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The nominee to be Montana’s next health director faced an unwieldy disease outbreak and pushed Medicaid work requirements — two issues looming in Montana — when he held a similar job in Kentucky.

Montana senators will soon decide whether to confirm Adam Meier, Republican Gov. Greg Gianforte’s for director of the state Department of Public Health and Human Services. He would earn leading Montana’s , which oversees 13 divisions and is a leader in the state’s pandemic response.

Gianforte is confident Meier “will bring greater transparency, accountability, and efficiency to the department as it serves Montanans, especially the most vulnerable among us,” Brooke Stroyke, a governor’s office spokesperson, said in an emailed statement.

For many Montana officials and health care industry players, the focus is on Montana’s future, not Kentucky’s past. But it can be instructive to see how Meier handled similar issues in his prior role, which he held from May 2018 through December 2019.

Some have praised the job he did in Kentucky, including his spearheading of a program that would have created work requirements in the state’s Medicaid program. But others criticized those proposed changes as well as his handling of a large hepatitis A outbreak that spread through rural Appalachia starting in 2017, ultimately sickening more than 5,000 Kentuckians and killing 62. The details of the state’s response to the outbreak came to light after in 2019.

“The hep A response is probably one of the darkest or most concerning things he did when he was in Kentucky. He also didn’t perform well in my eyes on other issues,” said , an assistant professor at Pennsylvania State University who studies politics, health care and public policy. “He didn’t do so well in Kentucky, so I don’t know how well he’s going to do in Montana.”

Dr. , a retired Kentucky physician who runs the national watchdog group Health Watch USA, is among those who said Meier and his team needed to do more early on to curb the hepatitis outbreak as it made its way into Appalachia. Kavanagh said Meier’s handling of the outbreak provides a window into how he might handle the covid crisis in Montana.

“But it could be a learning opportunity if failed strategies are corrected,” Kavanagh said. “The biggest question is: What did he learn in Kentucky?”

During Meier’s confirmation hearing before Montana’s Senate Public Health, Wellness and Safety Committee, the nominee said one lesson he learned was to invest in public health infrastructure. Because hepatitis A was spreading in rural Kentucky mountains, he said, standard outreach to vulnerable populations in settings like homeless shelters didn’t work. Instead, health officials started vaccinating people at convenience stores.

“One of the things I've learned there is, you have to be creative about how you reach folks,” Meier said.

Kentucky’s outbreak first centered in Louisville, where a more than 200-person health department was able to administer tens of thousands of vaccines against the highly contagious liver infection caused by a virus. The Centers for Disease Control and Prevention .”

But in spring 2018, the disease began to spread in Appalachia, which had thinly staffed county health departments.

Dr. Robert Brawley, then the state’s chief of infectious diseases, sounded the alarm to his bosses. Brawley asked state officials to spend $10 million for vaccines and temporary health workers. Instead, the acting public health commissioner, Dr. Jeffrey Howard, sent $2.2 million in state funds to local health departments. Brawley called the response “too low and too slow.”

In the months that followed, the outbreak metastasized into the nation’s largest.

Howard’s decisions at the time and the agency’s response. In Meier’s Feb. 10 Montana hearing, he said Kentucky lacked the infrastructure to buy $10 million worth of vaccines, and they would have gone bad anyway because the state didn't have the necessary storage. Brawley’s proposal had called for sending $6 million to health departments to buy vaccines, however, and $4 million for temporary health workers.

“The ‘too low and too slow’ response to the hepatitis A outbreak in Kentucky, reported in The Courier Journal, may be an albatross around his neck for a long time,” Brawley, who resigned in June 2018, said of Meier in an email.

Montana’s Democratic Party cited the hepatitis A outbreak when Meier was nominated for the Treasure State job in January, him as unsuitable.

The health department declined KHN’s request for an interview with Meier but provided letters from local Kentucky officials written in 2019. Allison Adams, public health director of Buffalo Trace District Health Department in Kentucky, defended the state’s actions in one February 2019 letter, arguing Kentucky’s leadership “made sound decisions regarding the support and known resources available.”

Meier has pitched himself as someone who works well with others, bolstered Kentucky’s family services and cut through the state’s bureaucracy.

Meier, an attorney, lived in Fort Thomas, Kentucky, near Cincinnati, with his wife and three children, where he served on the City Council just before being named deputy chief of staff for former Gov. Matt Bevin in 2015. After leaving Kentucky’s health Cabinet, he worked as a policy consultant with .

During Meier’s confirmation hearing before Montana lawmakers, Erica Johnston, operations services branch manager for the health department, said she was already impressed by his knowledge of the agency’s programs and ideas for changes. Past colleagues said he listened to those he oversaw. John Tilley, a former Democratic Kentucky representative who served as the state’s former head of Kentucky’s Justice and Public Safety Cabinet, called Meier a problem-solver.

“What I got in Adam was this refreshing take on government, this less than bureaucratic take,” Tilley testified.

While deputy chief of staff for Bevin, Meier oversaw the development of a Medicaid overhaul plan called Kentucky HEALTH, which would have required recipients who were ages 19-64 and without disabilities to work or do “engagement” activities such as job training or community service.

Bevin, a Republican who, like Gianforte, joined politics after making a fortune in business, described the effort as a way to ensure the long-term financial stability of Medicaid and prepare enrollees to transition to private insurance. In Meier’s Montana hearing, he said the goal was for Medicaid recipients to be linked to employment and training. Kentucky opponents said the program would have caused people to lose coverage and increase the state’s administrative burden.

That debate is familiar in Montana, where lawmakers approved work requirements for people who joined Medicaid under its expansion. The work rules are awaiting federal approval.

Kentucky’s requirements never took effect. They were authorized by a federal waiver but were tied up in legal challenges until the state’s current Democratic Gov. Andy Beshear rescinded the rules.

Still, Meier has said Medicaid’s enrollment dropped during his leadership and benefits remained steady for those who stayed on the rolls. That drop paralleled an in Medicaid enrollment that lasted through 2019.

Penn State’s Haeder, who observed Meier’s tenure, criticized Meier’s support for Medicaid work requirements, saying “excessive amounts of data show how detrimental they are to public health” because vulnerable people lose coverage.

, executive director for the Behavioral Health Alliance of Montana, said work restrictions aren’t a good model for Medicaid. But she said it isn’t surprising Meier has been in favor of those steps, given Montana’s recent efforts.

Even so, Windecker is optimistic when she talks about Meier’s confirmation. She said she’s thrilled he has experience with another state health agency.

“These are very complicated systems to run,” Windecker said. “If you understand health care, you stand a better shot at getting this.”

The Montana Senate has to take up Meier’s confirmation, which moved out of a committee Feb. 17.

While Meier awaits confirmation, he is already engaged in the state’s covid vaccine efforts and is working on the agency’s daily tasks, department spokesperson Jon Ebelt said in a statement. Meier is “focused on the job at hand,” Ebelt said.

Houghton, Montana correspondent, reported from Missoula. Ungar, Midwest editor and correspondent, reported from Louisville and formerly worked for The Courier Journal.

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