By some accounts, Ward 7 Councilmember Vince Gray is in a slump. Over the past five months, Gray has lost a handful of hotly debated legislative efforts.

He’s twice tried and failed to stop a halfway house from opening in his ward. He carried water for Mayor Muriel Bowser’s unsuccessful efforts to meddle in a lucrative Medicaid contract. Along the way, he accused his fellow councilmembers of contract steering, and they returned the favor. In May, Gray asked his Council colleagues to pour more money into United Medical Center to avoid triggering a financial control board—a board that he himself created (with agreement from the rest of the Council) by reducing the cap on the subsidy D.C. provides to keep the hospital running. A narrow majority of councilmembers were unwilling to bail him and the hospital out.

As the D.C. Council finalized the 2022 budget, Gray whiffed again—this time in his yearslong quest to fully fix a problem with the D.C. Healthcare Alliance. The locally funded program provides health insurance for more than 15,000 low-income immigrants who don’t qualify for Medicaid, many of whom are undocumented.

For the past decade, D.C. has required Alliance enrollees to reapply for their health insurance in person every six months. Applicants would line up outside Department of Human Services locations as early as 3 or 4 a.m. to get appointments. About 600 to 700 people, roughly half of those up for recertification each month, fail to do so and lose their coverage, an effect of the requirement to reapply in person twice a year, advocates say. The onerous chore does not apply to traditional DC Medicaid applicants, who renew their coverage once a year.

The recently passed 2022 Budget Support Act does include some reforms to the Alliance program. But major changes don’t fully kick in until 2025. Alliance enrollees are currently still required to reapply every six months from now through September 2022, but won’t have to do so in person. From October 2022 until 2025, enrollees may complete only one of their two required reapplications in person. After March of 2025, they will only have to reapply once a year, but may have to go in person. First-time applicants are still required to register in person, according to Deputy Mayor for Health and Human Services Wayne Turnage.

During the public health emergency, Bowser allowed Alliance enrollees to keep their health insurance without reapplying. The public health emergency ended in July, but a general public emergency remains in place through Oct. 8.

Damon King, director of policy advocacy at the Legal Aid Society of the District of Columbia, believes the Council’s failure to build on Bowser’s pandemic-induced policy marks another lost opportunity. And Bowser shares some of the blame, King says.

“The administration has now had six years to fix this,” he says. “They did inherit the policy, but having inherited it and having heard testimony … year after year, they’ve had ample opportunity to address this on their own, and they’ve declined to do so.”

Gray sees the incremental changes to the Alliance as progress, according to a staffer familiar with his thinking. He pushes back against the notion of a legislative losing streak. “In the Fiscal Year 2022 budget, we secured significant investments for Ward 7, Birth-to-Three, and citywide health equity,” Gray says in an emailed statement. Among the highlights he included: $1.9 million for school-based mental health services expansion, $365.9 million toward building a new health care system east of the Anacostia River, nearly $127 million toward fair pay for child care workers, and $24 million for the Deanwood Library.

What is a simple solution to a major problem with Alliance has been complicated over the years, as lawmakers tripped over each other to fix it. A clusterfuck of legislation passed since 2017, a lack of funding, and what Gray believes is an overestimation by the CFO of the total cost of reforms have stood in the way.

Meanwhile, Alliance enrollees such as Selene Lara, who have had to line up outside DHS locations at ungodly hours just to keep their health insurance, are once again left waiting for reforms sought for the past decade.

Twice a year for the past eight years, Lara has stood in line before sunrise to apply to keep her health insurance. She recalls one particularly hellish rendezvous about three years ago.

It was January, the dead of winter, and she and her partner arrived at the DHS building on New York Avenue NE around 5 a.m. Others were already waiting, she recalls. They brought their own chairs.

Lara, 30, had her then-3-month-old daughter in tow. It was so cold that she and her partner took turns waiting with the infant in a nearby Starbucks while the other held their place in line. They weren’t let into the building until 8 a.m., she recalls. When it was her turn to see a caseworker, her daughter started to cry. The caseworker became angry and refused to help them until the infant quieted down, Lara says. She tried everything—talking, singing, rocking. At one point, her partner stood up to walk around, but the caseworker said he couldn’t leave the cubicle.

“It was really upsetting and sad,” says Lara, who is now a community health worker for La Clínica del Pueblo. “It’s a service that you need. Like, oh my god, I understand why people don’t come here. They really don’t care. At that point, I was crying.”

When the caseworker finally processed their application, Lara says she was told she was missing documentation and needed to come back. She says she had to return five more times before she was able to complete the process. On one visit, the system was down, so caseworkers couldn’t enter her information, Lara says. During another appointment, a caseworker entered her income incorrectly.

Rodrigo Stein, La Clínica’s director of health equity and community partnerships, says Lara’s experience is not unique.

Lara speaks fluent English, but many Alliance enrollees don’t, Stein says. Clients report that caseworkers rarely speak Spanish, and though DHS has translation services, they’re not always available, Stein says, and they’re sometimes ineffective. 

“We still have technology barriers, waiting a long time over the phone, and poorly translated documents,” Stein says. Enrollees “have to ask landlords for proof of residence. Imagine doing that twice a year. Lots of immigrant residences are doubling up, so they’re not necessarily signing a lease. It’s an excessive amount of documentation for an assistance program that should be [recertified] yearly like Medicaid.”

“There’s no reason for the Alliance to have a different level of scrutiny unless you see it through a lens of ‘we can’t trust the people applying for this,’” he says.

Alliance enrollees, by definition, don’t earn a lot of money. To qualify, residents cannot earn more than 200 percent of the federal poverty level, which is currently $2,818 a month for a two-person household. Many clients are hourly workers, Stein says. They must take unpaid time off work twice a year to reapply—more often if they don’t have all the right paperwork.

“Many people go without health insurance during the renewal process,” he says, including insulin users and those who are pregnant.

The barriers that Stein and King want removed were erected in 2011, at the beginning of then-Mayor Vince Gray’s administration. A staffer in Gray’s Council office explains that concerns about nonresidents enrolling in the program prompted the in-person reapplication requirements. D.C. was facing a budget gap of more than $322 million at the time. Requiring proof of residency every six months removed people from the program and lowered the cost.

King, who has been pushing for removal of those requirements since 2017 (his organization has been pushing for far longer), hasn’t seen nonresidents in the program.

“I don’t think that has been our experience when it comes to working with folks who need healthcare through this program,” he says. “I think the policy is a draconian response to that concern.”

The Council started its efforts to reverse the policy in 2017. A confusing puzzle of bills passed since then amended and reamended each other. Though the bills that will change the process are legally approved, some are “subject to appropriation,” meaning they don’t go into effect until the Council dedicates funds to implement them.

Therein lies the problem. Over the years, the CFO’s office has projected the cost of removing the recertification requirements at anywhere from $59 million to $105 million over the District’s four-year budget plan—not pocket change. The projections are based on the number of people expected to remain in the program if the stringent recertification requirements are lifted.

In a budget work session this cycle, Gray said he disagrees with the CFO’s estimates. But he still had to work within them. Through the Committee on Health, which he chairs, Gray proposed cutting more than 100 positions across three agencies to meet the approximately $59 million price tag for Alliance reforms.

Some of the positions Gray proposed cutting will support the District’s shift away from police response to emergencies, as well as mental health services in public schools.The recommendations did not sit well with pretty much anybody.

At-Large Councilmember Elissa Silverman said the cuts amount to a “gimmick,” and “are contrary to our goals of building a health equitable city.” At-Large Councilmember Christina Henderson asked simply, “What are we doing?” In a letter sent to the Council ahead of the budget votes, Bowser called Gray’s recommendations “reckless,” and said that they threaten critical programs.

Gray’s original recommendation wasn’t approved. The Council ultimately passed a budget that requires enrollees to recertify every six months, but doesn’t require them to do it in person. Starting in April 2025, enrollees only need to reapply once a year, but they may be required to do so in person. Gray also created a fund that will collect unspent money in the Department of Healthcare Finance’s budget in the coming years and direct it toward Alliance reforms.

Although King believes full reforms should come sooner than 2025, he gives Gray and Ward 1 Councilmember Brianne Nadeau, who has also worked on the issue, credit for their persistence. He notes that the budget process hampers legislators’ ability to fund expensive projects. Councilmembers must largely work within the budgets for the cluster of agencies under their respective committees. 

If an issue is high profile enough, legislators will move funding back and forth between their committees. But for programs that serve populations that are less visible or have less leverage, like the Alliance, it’s difficult to find money for big changes.

Turnage is beginning an 18-month study to determine how keeping the six-month reapplication requirement, but eliminating the in-person requirement, impacts enrollment. The results will help inform the projected costs of permanently removing barriers.

“It’s a situation in which this policy has been allowed to persist far longer than appropriate,” King says. “It really comes down to policy makers making the commitment to find the funds for it.”