Delivery of Care

Why did Dr. Nicole Alexander-Scott resign abruptly?

The simmering conflict over public health vs. political health between the Governor and the director of R.I.Department of Health burst into the open

Photo by Richard Asinof

Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, speaking at a Dec. 15, 2021, news conference. Four weeks later, Dr. Alexander-Scott abruptly resigned.

By Richard Asinof
Posted 1/17/22
The abrupt resignation of Dr. Nicole Alexander-Scott as director of the R.I. Department of Health raises questions about internal policy turmoil in Gov. Dan McKee’s administration, putting his election prospects at increasing risk.
Should the re-procurement of the managed care organizations for Medicaid membership be halted until there is an audit conducted of the current MCOs? Will there be an investigation of the continued use of Optum as the primary contractor for both UnitedHealthcare and Neighborhood Health Plan of Rhode Island, two of the state’s three MCOs? Will the apparent failure of the state’s turnaround plan for the Providence Public Schools under the leadership of Commissioner Infante-Green prove to be an Achilles heel for Gov. McKee? How can the interim director to be appointed by Gov. McKee to lead the R.I. Department of Health gain the confidence and trust of the hardworking staff at the agency? Why not allow policy debates around public health to be made transparent, to be shared in public, rather than hidden behind closed doors?
The province of Québec in Canada has instituted a unique approach to drive vaccination rates higher: new regulations that all purchases of liquor and cannabis products must be accompanied by proof of vaccination. In response, provincial authorities reported that the daily vaccination rates had quadrupled, moving from 1,500 to 6,000 a day.
While such regulations may not prove applicable to states in the U.S., the strategy points to a different approach to capturing the hearts of minds of consumers around vaccinations. Given that the R.I. General Assembly may finally pass legislation in the 2022 session legalizing recreational use of marijuana, the potential to add regulations around vaccinations perhaps should at least become part of the conversation.

PART One

PROVIDENCE – The unexpected resignation on Thursday, Jan. 13, by Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, who announced in a letter that she was departing from her post after seven years on the job, giving just two weeks notice, took many people by surprise.

The response by Larry Warner, who directs equity investments at United Way of Rhode Island, captured the dismay of many over Dr. Alexander-Scott’s abrupt departure.

“How did we lose an infectious disease expert/health equity champion/woman of color leading RI Health in the middle of a pandemic?” Warner asked.

“The fact that nationally recognized Dr. NAS, former president of ASTHO [the Association of State and Territorial Health Officials], with the right expertise and experience needed for this moment in time, was not provided the freedom and resources needed to lead the response to the pandemic, and joins the ranks of ‘former leaders of color’ in RI, is saddening and reveals how far we have to go on our equity journey as a state.

Warner then drew attention to the underlying conflict, which he called out as the privatizing of public health. “No, paying millions of dollars to consultants is not the same as providing the resources to RI Health. That’s privatizing public health.”

Warner continued: “Also, yes - Dr. NAS led RI Health, but she unfortunately hasn’t been in the driver’s seat of the state’s response, her team of public health and health equity experts not fully empowered to lead during this public health crisis.”

Warner concluded: “As a former firefighter, whether responding to a 4-alarm or 1-alarm fire, at all times the fire chief was in charge. We’ve been responding to a 5-alarm public health crisis for 2 years, and it’s clear that the public health chief has not been in charge. Let RI Health lead.”

Unraveling the thread of what happened
Seven years is a long tenure to serve in the position as the director of the state’s health agency, during which time Dr. Alexander-Scott led a remarkable sea change in direction, wholeheartedly endorsing the concept of Health Equity Zones, an initiative that was being coordinated by her then second-in-command, Ana Novais.

In one of her first major interviews following her appointment in 2015, after replacing Dr. Michael Fine, Dr. Alexander-Scott told ConvergenceRI that if she could, she would change the name of the agency to include “health equity”: “Thank you for sharing with your readers and with Rhode Islanders the directions that we are looking to go toward as a state and at the department, given our priorities, to truly focus on health equity.”

Dr. Alexander-Scott continued: “I like to say, if I could change the name of the department, it would be to the Department of Health and Health Equity, because we want to make sure that all Rhode Islanders have the opportunity to live in the healthiest communities and have the healthiest lives that they can.” [See link below to ConvergenceRI story, “One-on-one with Dr. Nicole Alexander-Scott.”

There are currently 15 Health Equity Zones operating in Rhode Island in 2022 [and most reporters and elected officials would have a hard time naming where they are]. One measure of her success in driving the move toward health equity, recognizing that research had shown 80 percent of health outcomes are determined mostly outside of a doctor’s or nurse’s clinical offices, has been the decision by the Rhode Island Foundation to focus on health equity and create its own equity division of investment. [See link below to ConvergenceRI story, “RI Foundation launches $8.5M Equity Leadership Initiative to tackle racial disparities.”]

Tackling the COVID-19 pandemic
For much of the last two years, Dr. Alexander-Scott has often served as the public face of the state government’s public health response to the coronavirus pandemic, first under former Gov. Gina Raimondo and then under Gov. Dan McKee.

That role was not without its tensions, alluded to in Warner’s tweet. Under the Raimondo administration, the R.I. Department of Health’s response to the coronavirus pandemic was being driven in large part by private business consulting firms, including the Boston Consulting Group and McKinsey & Company, who had created a shadow decision-making process focused on what was labeled by the Boston Consulting Group as “behavioral economics,” not public health. [See link below to ConvergenceRI story, “Getting stuck and then unstuck in time.”]

The fact Dr. Alexander-Scott had skillfully managed to navigate the delicate balance was a testament to her willingness to serve as a team player, even when she may have disagreed with the decisions being made, according to a number of sources.

What changed?
In the last few months, however, as palpable tensions mounted between the public health directives advocating for vaccine and masking mandates being urged by Dr. Alexander-Scott and Gov. McKee’s unwillingness to move forward with such mandates in a more aggressive fashion, the policy differences became much sharper – a divide apparent to anyone who was carefully listening to the different messaging being spoken moments apart from the same podium.

As ConvergenceRI reported in its Dec.13, 2021, edition, Gov. McKee had been considering making a 25 percent cut in spending on COVID-related activities by the R.I. Department of Health in his FY 2023 budget. [See link below to ConvergenceRI story, “It is all about public health, not political health.”]

As ConvergenceRI wrote: The current tension between the agency and Gov. Dan McKee has become palpable, as the Governor has so far resisted efforts to enforce masking mandates and vaccination mandates, all the while touting his efforts to keep the economy on a pathway toward recovery, citing statistics from Moody’s.

Most recently, word reached ConvergenceRI that Gov. McKee [was] seeking to cut some 25 percent from the current budget for COVID-related activities at the R.I. Department of Health, according to a number of sources. That effort to cut the agency budget would seem to be ill-timed, given the rising number of cases and hospitalizations and the emergence of a new variant, omicron.

At the news conference held on Thursday afternoon, Dec. 9, by Gov. McKee and Lt. Gov. Sabina Matos, the Governor sidestepped the question by ConvergenceRI if he was seeking to cut the Health Department budget by some 25 percent, while, at the same time, he admitted that his administration was seeking to return to the budget of pre-COVID days.

The rest of the news media, however, fixated on whether the Governor was going to issue a mask mandate in response to increasing pressure from hospitals to do so, seemed to ignore and disregard the budget issue altogether. [If they can get you to keep asking the wrong questions, they don’t have to worry about the answers, as Thomas Pynchon once warned in Gravity’s Rainbow.]

The story had featured an in-depth interview with Dr. James McDonald, medical director at the R.I. Department of Health, who framed the issue around the differences between achieving political health and public health.

“When you look at public health, public health is really about allowing everybody to have a decent life chance. It is public health, not political health. Public health is really about protecting and helping everyone,” McDonald said.

“If you have a healthy Health Department, you are more likely to have a healthy state. We need to make sure that the Health Department is free from political influence and that it has the tools it needs to succeed.”

The breaking point
The breaking point in the conflict between Dr. Alexander-Scott and Gov. McKee appeared to have occurred in the aftermath of the Governor’s news conference held on Dec. 15, 2021, at which Gov. McKee announced he was putting in place new masking policies to respond to a rapid increase in the number of COVID cases occurring throughout the state, which were overwhelming the hospitals.

As ConvergenceRI had reported, the news conference sought to create “the illusion that things were under control, carefully managed” by Gov. McKee, when the Governor announced “increased” measures around masking, even as the situation across Rhode Island appeared to be “quickly unraveling.”

At that news conference, held in the State Room at the State House, Gov. McKee had been flanked by the presidents and CEOs of the two largest health systems, Dr. Tim Babineau of Lifespan and Dr. James Fanale of Care New England, along with Dr. Elizabeth Lange, the president of the R.I. Medical Society, and Dale Venturini, the president of the R.I. Hospital Association, among others, to show solidarity with the change in masking policy. [See link below to ConvergenceRI story, “Changing the priorities of the ‘sick care’ industry.”]

However, the policy change to increase masking was apparently not supported by several key members of Gov. McKee’s staff. In the aftermath of the news conference, some had accused the Governor of being “weak,” apparently upset that Gov. McKee had decided to move forward with any increased masking policies at all.

In the two weeks following the news conference, as conditions around COVID worsened dramatically, and Gov. McKee was forced to respond with additional community testing sites after witnessing residents lined up on Broad Street in Central Falls, at the invitation of Central Falls Mayor Maria Rivera.

A second empathic break occurred when a confidential report written in November by the R.I. Department of Health, worried about the increasing number of COVID cases, was “leaked” to The Boston Globe – a memo that the McKee administration had apparently chosen not to make public.

A confidential government report obtained by the Boston Globe shows that while R.I. Gov. Dan McKee was saying the state was ‘ramping down’ its testing and vaccination efforts because of lower demand in November, he was warned that COVID-19 was spreading rapidly,” the Associated Press reported in its Jan. 5 story.

The internal memo, which had been prepared by the state’s medical advisors and was dated Nov. 16, warned of rising hospitalizations and deaths in the state in December, the AP story had continued.

On the same day as the internal memo was dated, Nov. 16, Dr. Alexander-Scott, speaking at a news conference, had said: “Now is the time, get your masks ready, your high-grade quality masks and make sure you’re wearing them, particularly indoors,” the AP story reported.

The Governor’s staff was said to be apoplectic about the leak, according to several sources. Even as the Gov. McKee moved forward with a mobilization of the R.I. National Guard, an increase in the number of testing and vaccination sites, and, most recently, the securing of some 400,000 additional COVID-19 rapid at-home rapid tests, the Governor’s staff was said to be busy conducting a computer forensics analysis of staff at the R.I. Department of Health in an attempt to determine who had dropped the dime on the Governor, according to sources.

The crisis at hand
The resignation of Dr. Alexander-Scott comes at a critical juncture for Gov. McKee’s 2022 election campaign, shining a spotlight on his alleged poor management of public health, health care, and public education. The health care industry in the state has been torn asunder by the continued COVID contagion, with hospitals overwhelmed, taxed by a flood of unvaccinated patients. Community health centers, the front line of defense in fighting the virus at the local level, are battling to keep their doors open, as their working staff is depleted by the rapid spread of the latest omicron variant.

The mental health and behavior health demands in the state keep escalating, with at least one community agency asking the Governor about deploying the National Guard to assist them. Some 30 staff members at the community agency had tested positive for COVID in December, and already, in the first two weeks in January, another 42 staff members had tested positive, creating an emergency situation.

More and more public schools in Rhode Island are being forced to move to remote learning, as the high transmission of COVID at the community level and through the schools have decimated the ranks of teachers and staff and students. The consulting contract engineered by the McKee administration to ILO, run by former members of Chiefs for Change, around school reopening policies has begun to look more and more questionable.

The continuing scandal around care for patients at Eleanor Slater Hospital, under the auspices of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals and its director, Richard Charest, keeps widening, under the glare of reporting by Providence Journal reporter Kathy Gregg.

However, the problems at Eleanor Slater Hospital are being driven by bigger issues around Medicaid budget shortfalls – the state’s failure to increase low reimbursement rates for providers, documented at hearings by the Senate commission on the future of R.I. Executive Office of Health and Human Services. At the same time, very much under the radar screen, the McKee administration is pushing forward with the re-procurement of the managed care organizations that cover most of the Medicaid membership in the state. [See link below to ConvergenceRI story, “Will Medicaid remain a part of R.I. EOHHS?”]

Translated, the release of the proposed Governor’s budget for FY2023 and, in particular, the planned spending on Medicaid – which represents roughly one-third of the entire state budget – will be revealing. Stay tuned.

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