Faced with warnings there could be seven to 10 positions cut from the Cambridge Public Health Department within the next couple of weeks, but with health officials and the city manager unable to offer specifics due to ongoing discussions, city councillors took a rare step Tuesday in budget hearings: voting against a funding recommendation and replacing it with their own.

In proposals for the 2024 fiscal year starting July 1, the City Manager’s Office recommends  health funding of $7.9 million, slightly more than in past years. Before voting a negative recommendation for that, councillors passed a motion to instead “adjust the Health Alliance budget to ensure that all services provided to the City of Cambridge by the Health Alliance are fully funded.”

That motion by councillor Quinton Zondervan also called for adjusting the city’s capital budget to “ensure all necessary repairs” are made to the CHA’s Windsor Street Clinic in The Port neighborhood, which was called crucial to the lower-income residents surrounding it but in need of around $14 million in upgrades. 

Zondervan’s order was supported by all seven councillors present for the Finance Committee hearing. The follow-up order of a negative recommendation for the city’s recommended funding, on a motion by vice mayor Alanna Mallon, passed 6-0-1-2, reflecting a vote of “present” by councillor E. Denise Simmons.

“It’s not that we don’t trust you to work out the details,” Mallon told City Manager Yi-An Huang and health officials. “This is really the one place we get to kind of put our foot down and say this, these are our values.”

By the time the full council takes a final vote on the budget June 5, more information will likely be available.

Chief public health officer Derrick Neal said his department “can’t afford to lose any positions” but needs to do a “better job of integrating within our hospital system.” Roles needed a  “streamlining” Neal said, without being able to say what that meant.

On the other hand, Cambridge Health Alliance chief executive Assaad Sayah called budget impact “proportionately less” on the public health department. “We try to protect the public health department as much as we can, but they are part of the equation,” he said.

It was confusing, and councillors said so.

“Timing mismatch”

The phrase most heard during the hearing was “timing mismatch,” as Huang, Neal and Sayah struggled to present a budget request without being able to discuss its foundation. “For this budget cycle, it is going to be rough. We have not finalized all the details about how we’re going to make sure that the budget is going to be balanced,” Sayah said. “We have to be clear about what’s going to happen before we make it public.”

Sayah said he hoped the impact would be “minimal [but] significant. Everything’s on the table, and there will be some some reduction in force.”

In terms of the Windsor Street Clinic, “we’re going to need to come to the city with a real significant ask,” Sayah said, but it wasn’t clear what timeline was being discussed.

There would be a specific request around capital and the Windsor Street Clinic “as we move through this fiscal year,” Huang said, and a “larger, longer-term conversation about financial viability” between the city, state and CHA.

Complex relationship

Adding to the confusion as Huang cautioned councillors repeatedly against making big moves while other discussions were underway was the intertwined nature of the CHA and public health. Officials called the relationship unique: CHA chief executive Sayah is the city’s public health commissioner; and the Public Health Department is funded through a contract with the Health Alliance, currently locked in through 2028, and is not a freestanding city department. Yet the Health Alliance spends more on public health than what’s directly in the contract, Huang said.

“There have not been decisions made about how the Health Alliance is going to get through this fiscal year, which will impact the public health department, which sits under the Health Alliance,” Huang said.

In fact, CHA financial reports have shown for months that the Alliance was on track to lose millions more than it expected. The most recent report made public, for the period ending Feb. 28, said the health care system had lost $27.8 million during the first seven months of its current fiscal year, while it had anticipated a slight surplus of $860,000.

Fewer patients

The main reason for the Alliance’s financial problems was not inflation, as some councillors speculated. Instead, fewer patients than expected have been hospitalized or seen a doctor except for the emergency department, urgent care and some specialties such as outpatient psychiatry. And because of the shortage of medical workers, CHA has been forced to hire expensive temporary employees such as traveling nurses. Costs far exceeded expectations.

CHA chief financial officer Jill Batty told trustees on the system’s finance committee April 25: “It’s good news on the revenue side. The expense side is nearly as bad as the revenue was good.” The financial report actually said operating revenue for the seven-month period was $4.4 million more than expected, while operating expense more than wiped out the advantage, at $17.7 million more than budgeted. Batty said year-to-date figures were “much more negative than we have been experiencing in recent years.”

In a hint of possible staff cuts, Batty said she had just attended a meeting of “acute care service leaders” to discuss how to reduce staff as patient volume decreases.

More funds for Cambridge, not CHA

Though the fiscal 2024 budget document included some specifics about public and community health expenses, the city’s budget for the department is one line: the contracted city contribution of $7.9 million. The details showed that costs for public and community health that were not covered by grants would total $10.3 million.

Councillors had to clarify that their call for additional funding was for Cambridge public health, not for a Health Alliance that now serves Cambridge, Somerville, Everett and Malden.

While the Health Alliance has chronically difficult finances because of its mission of guaranteeing health services for the poorest and most vulnerable, “the city is not going through hard times, right? We just are about to approve over 50 brand-new positions – nine of them are in the City Manager’s Office,” Mallon said. “So it’s very hard for me to justify and understand where we are making cuts to our public health department and some of these really critical functions – coming out of a pandemic – when we are not making cuts to any other department in the city.”

“If we detect that this hospital system is dying, which it is, then because we have more money, we should spend more money on keeping it alive,” Zondervan said. “We are talking about actual people’s lives.”

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This post was updated May 18, 2023, to correct the number of new municipal positions referred to by vice mayor Alanna Mallon.