Third in a periodic series

Health and human services were barely blips on the screen of gubernatorial candidate Mike Leavitt's election campaign in 1992.

Today, after more than a decade as governor, Leavitt can't think of another issue that has taken more time, been more successful or caused him more grief.

"I came into office knowing there was some talk of health and welfare and child-protection reforms, but I can't say I was viewing them as huge parts of my agenda," Leavitt said in a recent interview.

The topics quickly took a prominent position on the governor's list of priorities: A month after taking office, Leavitt was sued over child protection in what has become the most protracted and among the most expensive legal actions in the state's history.

David C. vs. Leavitt was soon rolling across state government like a tank on the Capitol lawn. At the same time, welfare and health-care reform started picking up momentum. While Leavitt grudgingly acquiesced to dealing with the suit, he energetically embraced the national talk of health-care reform.

The self-described federalism geek viewed it as a rare-if-ever chance for his and other states to wrest away some control over federal programs that were overwhelming local budgets and just weren't being run all that well.

"The things we've done with health care and Medicare the past 10 years are satisfying," he said. "In human services, we had a child-welfare system that can only be described as in disarray and underinvested in. While today I can say children in foster care are safer, families are stronger and troubled kids are doing better, if I were asked, 'Name the biggest mistake you've made looking back over the past 10 years,' settling that lawsuit would be it."

Costly legacy

David C., one of the fattest files in Leavitt's stack of unfinished business, may also be the biggest bruise on the consummate "states know best" governor's tenure. It began in February 1993 when a set of attorneys from the Oakland-based Center for Youth Law came to call on the new governor.

Gracious but grave, the visitors told him that going to court, unfortunately, seemed to them like the only way to fix a state foster-care system that not only wasn't helping abused and neglected kids but also was putting them in harm's way.

More than 10 years later, legal action still isn't fully resolved, and its impressions on government are all over the place. It most recently induced a $1.9 million appropriation from the Legislature this year to hire 51 new child-abuse caseworkers.

As near as can be calculated, the state has spent about $52 million in new money since the lawsuit was filed to improve the system that looks after the 2,000 or so children in state custody at any given time, plus the more than $3.2 million spent on the lawsuit. A large chunk of that money, however, has been spent trying to undo a deal they wish they hadn't done, having petitioned the court to change or lower expectations or to stop court oversight immediately.

It's more than just the federal court telling Utah what to do, Leavitt said. The problem is that the agreement set up standards to evaluate child safety, permanence and well-being turned out to be impossible to meet, Leavitt said. "They were set too high, and a lot of those that were included were simply unmanageable. It was all about procedure and process but not about progress."

Leavitt and other state administrators now say Utah has one of the best child-welfare systems in the country. But that doesn't mean all the problems have been solved. In a high-profile case detailed this past week, Leavitt has been working with state officials and Idaho Gov. Dirk Kempthorne to resolve a case involving a 12-year-old Sandy boy with cancer. His parents, Daren and Barbara Jensen, are accused of kidnapping the child after they questioned the diagnosis and whether the boy needs chemotherapy (see related story).

'Two masters'

But that hasn't satisfied the law center or the federal court.

Despite having a series of specific steps to follow to wholeness in the original deal, the system still isn't right, law center attorneys say. The improvement plan has even been cut in half, and things still aren't much better, center attorneys say.

The state has made some repairs in the system, "but they have spent a lot of time and effort fighting this and going back to court or trying to avoid court-ordered rulings," said center lead attorney Darryl Hamm, adding that if the governor had spent that time focusing on what Utah said it would do instead of trying to get out of it, "this thing would be over."

The state has petitioned the court to end oversight, not because it's skirting improvement requirements but redundancy of effort, Leavitt said.

As proof that continued federal oversight is a waste of time and effort, Leavitt points to both federal and state reviews of the state system that found Utah outscoring other states and showing substantial progress in the overall quality of services and general safety of children in state custody.

"But we've got two plans so we've got two masters," Leavitt said. "We've got one of the better systems in the country now, and we could be even better if we didn't have to pay for a duplicate monitoring process."

Besides attorneys' fees, the state pays about $236,000 a year to the Alabama-based court-appointed monitor to keep tabs on Utah.

The Legislature tried to make the monitor just go away by removing the amount from the budget last year. The Center for Youth Law immediately sued, and the money was reinstated. Legislators didn't seem inclined to come up with the new money for caseworkers until U.S. District Judge Tena Campbell all but said in court she just might order them to if they didn't.

One national child-welfare observer, Richard Wexler, executive director of the National Coalition for Child Protection Reform based in Alexandria, Va., advises Lt. Gov. Olene Walker as she prepares to pick up the reins on the suit, to keep pushing for bare minimum federal standards as Leavitt has "would be absolutely ridiculous. To jump on the federal plan would be like studying the sky by replacing the Hubble telescope with a pair of backyard binoculars," Wexler said, adding he considers the federal evaluation that Utah likes as "virtually useless" for any state.

Summing up the suit, Leavitt said, "We got the point. We needed to fix the system. We did it and we've responded very, very well."

The people's health

Five years ago last week, Leavitt smiled for pictures with Redmond farm kids who were the first to enroll in the new Children's Health Insurance Program. The combination federal and state plan to get all children covered by medical insurance was the first of a dozen feathers in the health-care reform cap that Leavitt happily dons looking back over his 11 years in office.

He can leave office "feeling very good about that and what we've done in health care," Leavitt said. "Every child may not be covered yet, but every child has access to care, and a lot more adults, both the poor and and those with jobs who couldn't afford coverage, have health care. Those two things are true that weren't before."

Leavitt admits that it didn't hurt that a national debate on access to health care was already under way and that CHIP was laid in his lap by Congress.

But he is quick to point out that some of his own hard work helped Utah be a front-runner in the some sweeping changes to access to health insurance for both working and nonworking Utahns. "What we did was pretty innovative, actually."

About four months after taking office, Leavitt called for a mini-summit of every health-care provider in the state and advocacy groups. He brought a whiteboard, markers and a lot of questions.

"I told them, 'I don't know how you get anywhere in this business because anytime you put something on the table the interests come to bear and they drive everything down to the lowest common denominator and everything stays the same.'"

Leavitt, being an insurance guy himself, had believed for a long while that the health-care system had a kind of rust growing on it and that the times were calling for a wire brush.

He appointed a working group that developed a plan called Healthprint. Leavitt called it a blueprint for reform. It has been modified over the years, but he's pretty much stuck to it throughout his administration.

It expanded coverage under Medicaid, the joint state and federal insurance plan for the poor, for children, the disabled and single dependents.

The uninsured

Leavitt was invited by Congress to tell them about the effort, and as chairman of the Republican Governor's Association he became the lead trumpet in the call for block grants, in which the federal government gives states money for Medicaid and gives states the power to use common sense in how to spend it.

"Common sense was not permitted under that system," Leavitt said.

Leavitt reduced Medicaid benefits to be more in line with what the private sector offered and Utah ultimately put the Medicaid population into a managed-care plan, a decision that was criticized by some advocates for the poor who said the state was trying to balance its budgets on the backs of the poor.

"There are people who still believe that's the case," Leavitt said. "Money was saved by limiting services, but a lot more people are getting coverage."

The latest iteration of Leavitt's approach is the Primary Care Network/Covered at Work programs. Through a Medicaid requirements waiver in 2002 granted by U.S. Health and Human Services Secretary Tommy Thompson, Utah is offering either a limited medical benefit to many uninsured working adults, or a monthly subsidy to help them purchase their employers' coverage where available.

About 250,000 adults in Utah lack health insurance coverage. About 10,000 Utahns who cannot afford private health insurance are enrolled in the Primary Care Network. About 6,000 more should eventually get coverage under Covered at Work.

"The most underserved population in the state are those who are working two and three jobs and don't have enough money to buy health insurance," Leavitt said. "We provide it if they're not working, but we don't if they are, and I think that's wrong."

Many of those 250,000 will drive to emergency rooms to get health care. "We all pay for that, and it's less than an ideal health-care financing mechanism, but they're getting the health care when they need it. They are uninsured, but they are not uncared for."

The reformation

With surprisingly little grinding, the gears of Leavitt's states' rights approach also managed to mesh with the other major federal philosophical shift in welfare.

Leavitt created a new Department of Workforce Services, which merged Job Services with the Office of Family Support, forming an umbrella agency to help people look for jobs or sign up for public assistance. At the same time, Congress was implementing a national welfare reformation from entitlement to employment.

Instead of enforcing rules that simply gave people a paycheck with little incentive to find work, welfare would now operate on work, education and individual initiative.

Some advocates for the poor characterized it as a new real chance to give the poor some self-respect back while ending the cycle of government dependency. Critics said the reform was too punitive because it set time limits on assistance, made people work longer to get help and set up a Catch-22 of pushing people to get educated and get jobs without helping them find ways to watch the kids while they were out pulling themselves up by their bootstraps.

Although the lifetime limit on receiving benefits allowed by Congress was 60 months, Utah adopted a 36-month limit. Many states adopted shorter time lines.

While the U.S. Census and other local studies have shown a steep decline in the number of Utah families on welfare, there hasn't been much improvement in the lives of those who have been bumped off the system after three years.

Utah Issues, the state's leading research center on the poor, reports that long-term welfare recipients are leaving welfare with the same level of employability and the same barriers they had when they started.

This is the third in a periodic series examining the record of Gov. Mike Leavitt and his legacy of 11 years in office. Leavitt has been nominated as head of the federal Environmental Protection Agency and, if confirmed by the Senate, would leave Utah before finishing his third term. The series so far includes:

1st installment, June 12: Overview of Leavitt's tenure

2nd installment, July 20: Environmental record mixed

Today: Consumed by health and human services.