Alex Briscoe on Medicaid Reform, Youth Mental Health and EMS Corps

Lisa Lawson:

Hello and welcome to CaseyCast, the Annie E. Casey Foundation's podcast, where we explore how to create a brighter future for children, youth, and families. I'm your host, Lisa Lawson.

Today, we're diving into how public systems can better serve young people and communities. Our guest is Alex Briscoe. He's a principal at the Public Works Alliance. He has decades of experience designing and leading transformative public health initiatives.

He's championed using Medicaid to drive systemic change and is a leader in innovative workforce programs like EMS Corps. EMS Corps trains young adults, many with child welfare or juvenile justice system involvement, to become emergency medical technicians. By combining training, mentorship, and support, EMS Corps creates career pathways while empowering participants to serve their communities.

Alex, I'm so thrilled to have you. Welcome to Casey Cast.

Alex Briscoe:

Thank you, Lisa. It's really nice to be here.

Lisa Lawson:

Why don't we start by just talking about your work. It often connects health, education and social systems, and uniquely, you use Medicaid as a tool. So, could you talk a bit about your work? What drew you to Medicaid as a tool for transformation, and how it led you to this innovative EMS Corps program?

Alex Briscoe:

I wish it was a romantic story. It's a practical one. Medicaid is where the money is, and it's the essential financier of safety net systems. In California, Medicaid is a $140 billion program. I learned Medicaid making payroll, trying to keep clinics open and ambulances running and hospitals from shutting down.

Lisa Lawson:

So your experience really grew out of running a public health program, a hospital system.

Alex Briscoe:

Medicaid is the tie that binds child-serving systems. So, when you think about the juvenile justice system or the foster care system or the public education system or the early childhood system, you will find that in every one of these systems, Medicaid has a footprint for paying for special ed, for paying for home visiting, for paying for wraparound supports, for paying for residential care. To change these systems requires money and influence. And Medicaid provides both.

Lisa Lawson:

That's great. Thank you so much for helping people understand the role financing can play in system change. We always hear “follow the money.” Tell us what you understood about how the financing worked. What then inspired you to think of, well, how can I be creative with this? What led you to the EMS Corps?

Alex Briscoe:

I was a therapist in the Oakland Public Schools. I worked in juvenile detention and foster care, in sexual assault units in high acuity settings. And then for 12 years, the last eight of which I led one of the state's largest health systems.

I was appointed in 2008 when we had a horrible financial crisis, which really constrained the revenues of big systems. And so, I had to keep things open and make things work. And one important one to think about was our juvenile hall. We had like 486 kids in there, which is way, way too many, and our probation department couldn't afford to staff the thing. So, I mean, part of this is luck, and so we were able to say to our partners in public safety, "Hey, we got all kinds of opportunities. All these young people are low income, all of them qualify for Medicaid. How about these?" And we reduced the population in juvenile hall from 486 to 34.

Alex Briscoe:

And the same thing, in foster care, we had 6,600 children, and we got that down to 1200. The primary funder of those system changes was community-based mental health services funded by Medicaid.

Lisa Lawson:

You are very passionate and talk a lot about mental health.

Alex Briscoe:

Yeah, I mean, this is a uniquely difficult time to be young in America. Before the pandemic, we saw a doubling of inpatient admissions for self-injury. Twice as many kids hurt themselves so bad that they had to be admitted to the hospital. And then the pandemic poured gasoline on that fire. And we got to this unfortunate place where suicide leapfrog cancer as a cause of death, where 42% of young people report persistent feelings of sadness and hopelessness. I really believe this is the issue of our time-

Lisa Lawson:

Time, yeah.

Alex Briscoe:

Because Medicaid covers half of all children in the nation, any solution at scale requires we get that part right. I met you, Lisa, at the White House where I was talking about these changes we've been making in Medicaid to try to make it more relevant and effective. And one of those is the workforce. My beliefs in this space are really borne of my experience. I've seen a lot of human suffering.

And so, I think those of us who've done this work for a long time really know that there's a beauty and a wisdom and intelligence in this struggle that low-income folks have. And that's not only a personal quality, but it is also likely the solution to our systems’ challenges.

So, when we flip our frame and see the people we serve as essential actors, then it leads you to: Wait, who's eligible to bill for Medicaid? What are those rates? What do they have to do?

Lisa Lawson:

So really trying to change who could be paid for their services.

Alex Briscoe:

One of the essential changes we made was to create new types of providers in Medicaid: like community health workers, like doulas, like wellness coaches, like certified peers.

Not only is that an economic justice issue. Most of the people I serve needed a good job more than they needed therapy. So, there's a truth to that. But it also is a delivery system reform and quality issue for the healthcare system, because we know when you're treating professional shared or lived experience, outcomes are always better, from heart disease to cancer to mental health. And then we also in mental health have a fundamental workforce shortage.

Lisa Lawson:

We do. I don't think there's anyone listening who's ever tried to get mental health care, especially today for a senior, a young person, an adult, and hasn't faced the inability to find a provider with any availability.

Alex Briscoe:

It's an economic justice issue, it's a delivery system, reform and quality and access issue. That's why the EMS Corps is so important. So, we were running a very busy 911 system, 150,000 calls a year, one of the busiest in California and a good one. But we had trouble staffing our rigs.

Lisa Lawson:

When you say a rig, what's a rig?

Alex Briscoe:

An ambulance.

So, we are having trouble with our staffing.

And we decided to train a handful of young people to be EMTs. We did everything possible wrong. But I mean-

Lisa Lawson:

What does it take to train an EMS technician?

Alex Briscoe:

It's the same test across the country. It's called the National Registry, and you need a high school diploma and 180 hours. And we trained our first handful of young people and about half of them got re-arrested.

Lisa Lawson:

Oh, no.

Alex Briscoe:

And we asked, we're like, "Yo, what did we do wrong?" And they were like, "You didn't pay us. You didn't guarantee us a job. The people who trained us didn't look like us. You didn't help us with the things we really needed help with." So we dug in, that's why when I tell this story, I really want to make sure folks understand.

Lisa Lawson:

You listened.

Alex Briscoe:

Yeah, listen carefully and persist. So, 12 years later, across three sites, two in California and one in Albuquerque, we've trained over 600 young people. And what we did was take the program from six weeks to six months.

Young people needed longer. So, we wanted to give them the chance to bond as a group and prepare for entry into a workforce which is dominated by really good people.

Lisa Lawson:

And so how old were these young people? Are they over 18?

Alex Briscoe:

Yeah, 18 to 26. You have to have a high school diploma, and there's certain offenses that disqualify you. So, we do a background check and blah, blah, blah. But we decided early on that 180 hours wasn't enough. So, we changed our curriculum and made it 480 hours, and we added a $1,500 a month stipend.

Lisa Lawson:

So, they have some stability while they're in the program. We hear that from young people all the time, "Our basic needs are the foundation for us to do other things. It's lovely that you're planning all these programs for us, but if we don't know where we're going to sleep, if we don't know how we're going to eat, we can't participate and certainly can't focus." So yes, great solution.

Alex Briscoe:

And then the third leg of that stool, if you think stipend, enhanced training, and a bunch of mentorship and experiential learning, and then comprehensive wraparound support. And by wraparound, we mean things like formal mental health care, healing circles, care coordination and case management, cognitive behavioral training.

Lisa Lawson:

All things that really helped them heal from the experiences that they'd had prior to this.

Alex Briscoe:

So yes, yes, yes, full stop. And young people who've overcome things, big things make incredible superheroes.

Lisa Lawson:

I think that's one of the most beautiful things I've ever heard you say. That's wonderful.

Alex Briscoe:

EMS is not for everybody. All right?

Lisa Lawson:

What is the work?

Alex Briscoe:

Yeah. I mean, you're going to everything from a senior falling down to a mental health call to a strained ankle, to a trauma on the freeway, to a gunshot, to a young person in one of our interviews saying, "You're with people at one of the worst moments in their life. And the compassion and the care you show them is like," he says, "it's a gift to provide."

Lisa Lawson:

It is.

Alex Briscoe:

Opened him up to purpose and empathy. And let's just get really practical for a second. EMS systems across the nation face a crippling staffing shortage.

Lisa Lawson:

What's behind the crisis?

Alex Briscoe:

We're competing with Starbucks at entry, $18 to $24 bucks an hour kind of stuff. It's not for everybody. And sometimes you don't know until you try it, and it's physical labor and you are in and around real human suffering. And the key thing about EMT, there's about a 30% turnover annually.

You don't stay in EMT long, and this is both a blessing and a curse. If you persist for three years, you become a paramedic, and the systems you work in pay you to do that and you can make a hundred grand.

Lisa Lawson:

Oh, wow. So, it's really a great on-ramp for young people.

Alex Briscoe:

There is no other pathway in the American workforce economy where someone with a high school diploma and persistence and a desire to serve can make a hundred grand within four years.

Lisa Lawson:

What's a paramedic do compared to an EMS technician?

Alex Briscoe:

An EMT is literally 180 hours. It's very much patching them up and get them to the hospital staff, a paramedic... So, what we call, we have what's called basic life support and advanced life support or services, BLS and ALS. And ALS means there's a paramedic on scene, and a paramedic is like 3,000 hours in training, more akin to a nurse than an EMT, which is basically an advanced first aid practitioner.

Now, they work together. But a paramedic takes significant training and a lot of field experience to qualify, and it's also an important pathway to fire. So, this is really important for folks who maybe don't know how EMS works because fire is a foundational provider. About 80% of what fire services do nationally is 911 EMS. But if you're going to go into fire now, you are basically working in 911. So that's the kind of pathway-

Lisa Lawson:

Pathway.

Alex Briscoe:

You pass the national registry, you get your EMT, you go to work for a private ambulance company or maybe in a public EMS system, you earn your hours, you study to be a paramedic, you get into fire. There's a bunch of different on and off ramps there.

Lisa Lawson:

And the fire system in and of itself has pathways forward as well.

So, I'm really curious to hear what young people's experiences were as they participated in this program.

Alex Briscoe:

My heart is open to you for that question, and it's way better to hear it in their voice and story, because I don't want to speak for them. And when I'm sad, I have a series of three and five minute interviews saved in my favorites, and I listen to young people talk about the transformation they went through, the changing of their life trajectory and their family's life trajectory. Some of our early EMS Corps grads are now captains and lieutenants in fire services and-

Lisa Lawson:

Awesome.

Alex Briscoe:

What makes the EMS Corps so amazing is that you only got to get the first two or three years and then your graduates come back and become your skills instructors and your mentors. So we're-

Lisa Lawson:

Nice circle.

Alex Briscoe:

And I should state it, we are expanding the EMS Corps to 14 new communities in America.

Lisa Lawson:

Did people just hear about it and call you or were you purposeful in where you wanted to take it?

Alex Briscoe:

So, any EMS system, if you read their plan, the number one problem they will have on their plan is workforce. So, I would like to tell you... In Albuquerque, New Mexico, where half of our participants are from Sovereign Lands, which is amazing. A friend of ours became the child welfare director in New Mexico and was like, "I gotta have it." So that's how that one happened.

But New Orleans, I love this story because a leader in the EMS system there, I think he's a captain, he was a teenager in New Orleans living on the fringes, and the hurricane came and after the hurricane, they offered free training and he just signed up to be a paramedic, worked his way up the EMS system.

And he saw one of our videos of young people talking about their experience, and he called us and was like, "We got to have it." The New Orleans EMS Corps is starting in two weeks. And that's a great one, because the young people become city employees from day one.

Lisa Lawson:

Wonderful.

Alex Briscoe:

So, that's a great one. We started planning in Atlanta. There's 11 communities. I mean, Lisa, I will say this just so it's not all roses and peaches and roses. I am a Medicaid guy and I'm now learning how to be a workforce guy.

I'm familiar with the complexity of public financing, and I thought Medicaid was messed up. And it is, okay. Public workforce funding is somewhere as in the equal dysfunction.

Lisa Lawson:

Well, just for listeners, they're just all these very unique financing streams for things that don't always align with the reality of how anything practically works. And so while appropriations thinks that they are doing the right thing to say, "This is the money for this and this is the money for that."

In reality, it's like in your budget, if you only got your salary, this is the money you can use for food and this is the money you can use for housing. None of us could manage our own budgets. We're forcing public systems to do the same thing, so I sympathize, emphasize, with you in that.

Alex Briscoe:

And I think that some of the work, Lisa, we're doing with you and your team is thinking about the sort of nexus of public workforce financing and healing.

Lisa Lawson:

I want to ask what you've learned about engaging young people, particularly those who have faced adversity as agents of change in their communities. I mean, here you've taken young people who could be described as on the margins, really marginalized in their community, and really made them essential workers in their community. What does that mean for them? What's that mean for the way their communities see them and value them?

Alex Briscoe:

In one of our early cohorts in Oakland, we had a poster up in the bus stop of Carl Bolz, one of our first graduates. On one side of the bus stop was a picture of him and jeans and a T-shirt saying, "Hey, my name is Carl. I'm not who you think I am." And on the other side of the bus stop was him in his EMT uniform saying, "I'm going to save your life."

I think for those, again, I think anyone who has done this kind of work for a period of time, people are amazing. It is their birthright to heal and connect and live and improve and seek meaning and purpose, but we constrain those opportunities in low-income communities. When you're hustling to make rent or get your kid food or off to school, it's hard to see.

To your point earlier, when you provide that opportunity and see people recognize that and pursue, it's intoxicating for all parties. And to link it to Medicaid, the reason EMS Corps is so important to us is it tells this story in such a tangible way that people aren't a problem. There are the solution, that there's beauty and wisdom and intelligence to lived experience that can be leveraged to the benefit of all of us.

Lisa Lawson:

It's very practical, very practical, very scalable. I mean, that's the beauty of what you've done is you have just talked about what we might want. You've created an infrastructure to do that. It makes me ask you the question of how are you training these young people?

You talked about having a graduate come back to be an instructor, but what's the infrastructure that's to do this? I assume we were already training EMS technicians. This is a little different than how you do that. How are you putting the infrastructure together to scale this?

Alex Briscoe:

What we say is every community already has everything they need to run an EMS Corps.

Lisa Lawson:

Oh, good.

Alex Briscoe:

They have an EMS system who needs workers desperately. They have amazing young people who don't even know this is a thing, like rural kids and kids from the hood, they don't know EMS is EMS. They think it's the cops. You got to just teach them.

And they have community-based organizations that know how to support young people. And what we do is like peanut butter and chocolate. We bring them together. And so, our role is literally to go into a community and find the certified trainers, find the right CBOs, engage with the EMS system, put those people in a room, and man, it doesn't take much.

Lisa Lawson:

And you've already got a curriculum, what do these six months look like?

Alex Briscoe:

And we don't talk about replication because it's unique to you.

Lisa Lawson:

Because the community-based organizations are all different in the places where you're going.

Alex Briscoe:

We learned some hard lessons. Everyone wears a uniform, you come correct. You say a mantra. We have an approach, but when we come to a community, we are not like a franchise. We don't buy a building and drop staff in.

Lisa Lawson:

You're building the local capacity.

Alex Briscoe:

The economic benefit of EMS Corps derives to that community. It's for those people by those people, and it benefits them. And one of the most important public services. Now, the cost issues are real. EMS Corps costs about a million bucks a year, 900 grand a year for two cohorts of about 20 young people. So, it works out to be 15 to 20 grand.

Lisa Lawson:

Per young person.

Alex Briscoe:

Per young person, which is roughly what twice if not more than what most employment and training programs. And we are uncompromising. That's what it costs, we're not going to cut it-

Lisa Lawson:

It costs $100,000 to lock them up. That's great. That's great to hear. And talk about persistence. Do most of the young people who enter the program, are they able to persist to graduation? Because you said they've got a job when they graduate, so I don't even have to ask about the hiring rate after they finish.

Alex Briscoe:

Yeah. We have a 90-plus percent graduation rate. We outperform the state average and pass the national registry.

Lisa Lawson:

Fabulous.

Alex Briscoe:

Not every young person decides to stay at EMS.

Lisa Lawson:

Sure. It sounds hard. I mean, it's emotional, challenging work, but you've given them a start, even if they decide not to persist in it.

Alex Briscoe:

And there's obviously a reflective thing that happens. We have trained you to save lives. You are now a lifesaver. And so young people have gone on to be firefighters. We have four physicians now, 10 years later.

Lisa Lawson:

Wow. That's awesome.

Alex Briscoe:

It's pretty amazing. Lisa, as I think you know, I'm like a policy person. I work with Medicaid in large systems. I don't talk very often about individual programs, but this one's different.

Lisa Lawson:

You said that, "I'm not a workforce person," but you darn sure have turned yourself into one. I'm curious what lessons you've learned that you've maybe shared with other workforce programs so that they could have similar success.

Alex Briscoe:

I think a really strong and deep understanding of the systems you're trying to impact. You've very skillfully asked me about Medicaid and youth mental health and how it all fits together. And a lot of my work is focused on how do emergency departments handle this influx of young people, and how do we expand access to services in schools and how do we make managed care plans pay for services in schools?

So, I do a lot of that. So when we were designing EMS Corps, we knew very intimately, because I was running the system, the challenges the EMS system was facing. And so I think there's understanding both the current reality of obviously who you're training people to work in, but also the needs of that system to evolve and improve. You're not just providing cattle, you know what I mean?

Lisa Lawson:

These are people, talent.

Alex Briscoe:

Yeah, talent and to whatever future state you are aspiring to. So again, this is really important for the new provider types in Medicaid, community health workers, doulas, wellness coaches and peers, states across the country are doing it. As we think about integrating these new provider types, you have to bring some sophistication in the delivery system reform you envision.

Like how does a community health worker work with an LCSW, and what does that note look like? How do they keep their records? How does payment work so they both can cover their cost? That would be my recommendation to the workforce world is dive deep in the operational policy and future state needs of the system you're serving.

Lisa Lawson:

And I think that's what's powerful about what you've done. The innovation came from inside that system. It wasn't an outside workforce provider agency telling you what do you need and how can we build it for you? You were creative and thought about how we can do this differently?

And the innovation absolutely starts on the inside, but you're also, your deep commitment to trying to open doors of opportunity to new groups of people that you knew were going to be needed in this field also is an important part of that innovation. So, I think those are important lessons for other workforce development programs to consider.

Plus, things you said initially about how do you help people sustain themselves while they are in this transition, how do you help them resolve trauma or mental health challenges that are often barriers to people persisting and succeeding in new roles. All those supports and services people don't think about.

They think, "I just need to provide the training," and not think about the humans that they are trying to connect to it. It's not workforce development, it's human development in lots of ways.

Alex Briscoe:

Amen. That's very much it, exactly.

Lisa Lawson:

Well, let's go a little bigger. Thank you for all of that insight into EMS Corps.

But EMS Corps does tie into broader Medicaid reforms that you've championed. I'm curious how this ties to that with things like making schools in-network providers and rethinking access to mental health services.

Alex Briscoe:

I mean, at the risk of losing listeners who don't want to go down the Medicaid rabbit hole, Medicaid is a deeply troubled program, even though I love it and think it's sexy and essential to our future. But there's some changes that we need to make to unlock its potential.

Lisa Lawson:

To solve other problems, like you're solving an EMS problem. Talk about the other challenges we've got to solve.

Alex Briscoe:

And states across the country are waking up to these changes, because they're all within their regulatory authority. I'm about to give you a list of five things, but none of them haven't happened. Sorry, double negative. But they're all within the regulatory authority of a state Medicaid agency.

Lisa Lawson:

Already?

Alex Briscoe:

Already.

And these have been pioneered in places as disparate as California and Georgia and New Mexico and New York and people are all... None of these things are that revolutionary. But the first is we have to rethink access criteria and remove diagnosis as a prerequisite for care.

Lisa Lawson:

Say more about that. For those of us who aren't in the medical field, you got to be diagnosed with something to get resources to-

Alex Briscoe:

So here I am, a therapist in Oakland. In order to get paid, I have to give a kid a qualifying DSM-5 diagnosis.

Lisa Lawson:

You got to have depression, you got to be bipolar, you got to have a diagnosis. Even though this child might be struggling for many, many reasons, they need a diagnosis to get help.

Alex Briscoe:

And I would argue that of the hundreds of millions of dollars of services I provided, probably 20% of the kids I served were mentally ill, and 80% of the kids, something bad happened to them that they didn't choose.

Lisa Lawson:

But they still need mental health services.

Alex Briscoe:

So, I think we're coming to an understanding in our culture that kids didn't get twice as pathological, despite the fact that twice as many kids need crisis care. So, this idea of rethinking qualifying criteria, and Dr. Nadine Burke Harris, and the ACES work is really helpful there, like help us rethink that.

The second is this whole workforce bubble. There aren't enough people anyway, so we've got to create new provider classes and make it easier for people to participate as providers.

The third is we have to have a way for caregivers to get mental health when they take their babies to the doctor. So low-income people interact with the health care system the most frequently in the first three years of their child's life.

Lisa Lawson:

How can we use that as a platform to get people the support they need?

Alex Briscoe:

But Medicaid only sees the kid as the patient.

Lisa Lawson:

How do we expand who it can serve?

Alex Briscoe:

You have to create a way for really amazing things like Healthy Steps or parent-child interaction therapy. It's kind of technical, but it's a big deal.

Lisa Lawson:

It's just saying serve the whole family, not Just the child.

Alex Briscoe:

It distills to letting a caregiver get a mental health service on their kid's ID. That's a technical trick, but a big, big one.

Lisa Lawson:

Gotcha.

Alex Briscoe:

The fourth is this idea that California just launched. It's not going well, but big things are slow, which makes schools the same as emergency departments in the eyes of managed care plans.

Lisa Lawson:

Wow. Say more about that.

Alex Briscoe:

Yeah, this is a big one. Children 8 to 18 use the health system the least.

Lisa Lawson:

Really?

Alex Briscoe:

But that's when 75% of mental illness manifests. So, everybody knows schools are the essential setting for a response at scale to the mental health crisis, and most kids in America now are covered by a health insurance plan with a mental health benefit. But for a school or a provider working in a school to sign up individually with all the plans is impossible.

So what we did in California, and now lots of states are looking at it, is we leverage something called portability, which means when you go on vacation, Lisa, your health plan still works if you need care in the emergency department because all essential services must be paid for. So, we made schools an essential provider, and it applies to Medi-Cal and commercial. And what it basically says is for a very defined set of services, any service delivered in a school is automatically in network for any managed care plan.

Lisa Lawson:

Wow.

Alex Briscoe:

So, it's a really big deal and it'd be worth talking to you in a year about how it's working.

Lisa Lawson:

But it's a fundamental change in perspective that's already allowed that would enable millions of children literally to get the care that they need where they are.

Alex Briscoe:

They all work together though, even if you make schools automatically a network, but there's no new workers to provide the care, and then if you make them have a diagnosis before they need it, it's too late. So, you have to think of these as the building blocks of systems change.

Lisa Lawson:

Great.

Alex Briscoe:

You work them together. The final one is basically you got to be really creative with how you finance things. And I won't go into that on this call, but there's tricks to Medicaid that help you get federal matching funds. And so you think about these five things together, and that's what states are looking at and we're doing a lot of coaching and supporting and explaining.

Lisa Lawson:

That's awesome. But what you've really done is help our listeners understand what it takes to create system change. So often, we talk about it and we say things need to run differently in order to help people at the scale where the need is.

People don't always understand all the mechanisms to do that, and though they don't need to understand all of it, you help them appreciate that it is these little things about how the rules work that can unlock resources, can unlock workers, can unlock care for millions and millions of people. So while wonky, I appreciate it, because I think it will help many people get what they need, and that's exactly what we want and inspire innovation in other ways.

Any final words of wisdom or inspiration to our listeners before we close?

Alex Briscoe:

I'd just like to maybe emphasize the last thing you said, which is you have to understand the systems you want to change. So, embrace the complexity of them. Don't be the person in the room that's always about your understanding, but don't quit until you understand it, persist. You're smart. You can read, dive into the details and really unpack it, because find all kinds of opportunities for love and connection and healing.

Lisa Lawson:

That's wonderful. Well, thank you for every single thing you are doing to bring that vision to life, not just in California, but across the country.

Alex Briscoe:

Thank you for having me, Lisa.

Lisa Lawson:

And I want to thank all of our listeners for joining us on Casey Cast. If you liked our conversation, please recommend or rate us on your favorite podcasting app. To learn more about Casey and our guests, check out our show notes at aecf.org/podcast. Until next time, wishing all of America's kids and all of you a bright future.