Longtime AIDS and LGBT health advocate David Munar will take over the troubled Howard Brown Health Center ( HBHC ) as its new president and CEO starting April 1.
The selection follows a long and sometimes stalled 18-month national search process.
In an exclusive interview with Windy City Times, Munar, who was accompanied by board chair Duke Alden, spoke at length about his goals in his new post. He will replace interim president and CEO Karma Israelsen.
Munar, an openly gay, HIV-positive, Latino is also a longtime Chicago resident and activist. He will step down from his post as president and CEO of AIDS Foundation of Chicago on March 31 to take over the helm at HBHC. He will start at an annual base salary of $205,000.
Munar will be the first leader of HBHC, in recent memory, with experience in healthcare.
He has a storied reputation in Chicago and Illinois, and has been a national leader in policy efforts around HIV/AIDS. Munar joined AFC in 1991, and over the years since has moved up the ladder to his current position. John Peller will serve as the interim president and CEO of AFC until the board finds a replacement, and he spoke of his colleague in glowing terms to WCT, even as he also described himself as "sad" at seeing his colleague leave.
"David leaves AFC, where he practically grew up, in excellent shape, and Howard Brown will benefit tremendously from his expertise and leadership," Peller said. "It's an exciting change for him and really outstanding for Howard Brown, the LGBT community and, ultimately, it's a good thing nationally."
Peller's words echo the respect accorded to Munar over the years, for his work and credentials. His appointment at Howard Brown comes at a crucial juncture for the organization, which has frequently been rocked by scandals in its 40-year history. Most recently, it almost closed after a series of controversies centered around finances, which eventually resulted in its losing the prestigious MACS AIDS research grant.
Like every other healthcare organization, the agency is poised at the brink of an unprecedented era of changes in its field, with the implementation of the Affordable Care Act ( ACA ). Controversial on all sides, the ACA presents uncharted territory and has so far been a landscape of complicated new procedures and regulations, daunting even to long-time professionals.
For that reason, Munar's appointment is especially significant, given his experience with healthcare reform. Peller describes him as "a giant in the healthcare reform field; David has a really tremendous understanding of the changes that are happening with Medicaid, the transformation to managed care, and the national trends that are taking place."
Addressing his own history with AIDS organizing and policies, and his decision to move to Howard Brown, Munar spoke of the personal and career matters that formed his decision. In one sense, his taking over of Howard Brown is a cyclical event: in 1994, he received his diagnosis with HIV there, when it was still located on George Street.
Windy City Times interviewed Munar and Alden at the offices of PCI Inc., a communications firm, Feb. 6. A representative from PCI was present during the interview. PCI resigned from its position as HBHC's communication handler during the tenure of Jamal Edwards, but has since returned. What follows are excerpts from the session; video excerpts are available with the online version of this story, and on the Windy City Times YouTube channel. The answers and questions have been edited for clarity and space.
Windy City Times: You've been with AFC since 1991. What made you decide to take this job?
David Munar: I'm excited about this opportunity. My work in HIV since I joined AFC has been around health and inequality. And now there is such a huge opportunity with the Affordable Care Act ( ACA ), for us to expand and improve health, by expanding access to health insurance. That work is exciting, and will require us to be deliberate in reaching populations that are medically underserved, and Howard Brown is a critical partner in that work. Its longtime experience in working with the LGBT, the greater Lakeview and North Side community is an opportunity to help the whole system to improve its delivery of care to our community and our allies. I want to leverage what I've learned in the AIDS fight to help the 16,000 patients that we have at Howard Brown.
I also think that Howard Brown and AFC and many historical AIDS organizations will be under new pressures to realign their business models with the ACA. And it's a real opportunity to ask: How do we maximize the ACA? How do we reach people who are vulnerable because of their sexual orientation and their gender identity, because of their income, race, ethnicity, their diagnoses, or their trauma?
WCT: As for the ACA, what is that going to mean for an agency like Howard Brown?
David Munar: The ACA means that many of our uninsured patients will receive insurance for the first time. That means that their ability to afford a comprehensive integrated care should be improved, but it's about making sure that care is high quality and compassionate and non-judgmental and meeting their unique needs. Having insurance will not necessarily mean that people's health is going to improve. We have ample experience with people who are mistreated in public healthcare systems because of their sexual orientation or their gender or their race; they won't come back to care and their healthcare suffers. This is why the work of Howard Brown and our ally organizations is so important; we have to be part of the system.
WCT: At a trans health forum held in March 2013, several healthcare organizations and activists spoke about the implications of the ACA for the trans community in particular. When asked what the ACA might do to for specific trans needs, such as hormone therapy and surgery, the response from professionals seemed to be: unfortunately, not a lot. [WCT report can be found at the link: www.windycitymediagroup.com/lgbt/UIC-holds-trans-health-forum/42130.html .] What can Howard Brown do to advocate for better trans healthcare?
David Munar: Trying to figure out how to maximize these tools for affordable care, for our folks, our transgender men and women is going to be so important. I don't believe the ACA is going to meet all of our needs and it's our duty to try to maximize those opportunities and advocate for solutions. I think you're right: we are going to face some challenges with the ACA, for good transgender health. I think we have some better opportunities on the Medicaid side to make sure that individuals have access to hormone therapy, have access to some of the behavioral health needs like counseling, psychiatry as well as good internal medicine, family practice, women's health; but we are going to struggle, I believe, particularly in the commercial marketplace side of the ACA.
The ACA is really going to help people whose income is 138% of poverty or below, if they're legal U.S. residents who have access to Medicaid. Medicaid is going to be the insurance provider for low-income people so we're going to have some opportunities there to meet the medical needs for low-income people. People above that level are going to have access to an array of commercial insurance products and it's complex.
WCT: But [commercial plans] are not required to cover certain types of healthcare options for trans people.
DM : They do have to meet some federal standards, but they're pretty broad. We've already encountered this in HIV. For example, we found that many of the commercial plans were not covering single tablet regimen so formulated medication, where three drugs are formulated into one, they were not covering them at all or in some cases covering them at 50% co-insurance, which means that the insurance recipient is paying 50% for most single tablet regimens in HIV, that's $6000 per year, of the deductible on top of a co-pay, on top of a premium.
WCT: NYC instituted an LGBT cultural competency requirement for all healthcare providers in 2011. [See report at the link: www.windycitymediagroup.com/gay/lesbian/news/ARTICLE.php .] Howard Brown has been around since 1974, but hasn't actively pursued such an active policy to improve care for LGBT people everywhere, not just at its locations, and trans people in particular have felt discrimination and stigma at area hospitals and agencies. Advertising itself as one of the places to give culturally competent care actually gives Howard Brown a certain amount of power and actually leaves trans people more vulnerable, if you're not engaged in actively training other organizations. What can and will Howard Brown do to improve care provision for LGBT people across the city?
David Munar: It's my understanding that there is a nurse whose job is to work with healthcare workers around LGBT culturally competent care. I think that's important. I think we have to pursue this issue in multiple ways. Training is very important and we should continue to do that, but I'm also personally cautious about an over-reliance on training. We see this a lot with HIV. Folks come to us saying we want to be culturally competent in HIV, and we want AFC to come and talk to our case managers about that for an hour. Well, guess what, in an hour, we can only explain the difference between HIV and AIDS.
It's gratifying that health systems want to provide their workers a baseline of information, but at a certain point, we also know that people with HIV are going to get better care from an expert on HIV. The same is probably true with transgender health. We have to make sure that we're working with providers who have demonstrated a commitment to that population and are really on the cutting edge of competent, state-of-the-art trans healthcare. We've got to lobby, and fight on the policy front, make sure that the payer sources have the requirements are feeling the pressure to respond to the needs of our community.
WCT: Given its complexity, it seems like the ACA will require organizations to take on a larger number of administrative positions, so that patients can be guided through the process. Will that be true for Howard Brown?
David Munar: Your question about the complexity of the ACA is much bigger than Howard Brown. I think anybody who needs healthcare services or is insured is going to have the same set of questions: What is the coverage to meet my healthcare needs today and tomorrow? What's the best value?
Duke Alden: As an agency, we have a really great supportive network of case managers that have already been acting as navigators for our patients to answer questions about the ACA.
David Munar: [laughs] Funded by the AFC.
Duke Alden: Right! That exists not only to keep people adhered with their insurance but to keep them adhered to their care. We have a network for keeping the opaque ACA as clear as possible for our patients.
It's really a fact of life that even with the ACA, we're going to be seeing a portion of the population that won't have healthcare, whether they be trans or whether they be experiencing HIV or other issues. The charity care that clinics like Howard Brown provideswe've become even more important because every dollar that goes into our bottom line, whether we're billing Blue Cross, Blue Shield, Sigma or Medicaid, goes to help support our charity patients.
David Munar: One of the biggest gaps with the ACA is that it's not extending these benefits to the undocumented [immigrants]. The charity care is going to be a lifeline for people who are undocumented so they can enjoy good healthcare coverage. Community-based healthcare clinics are going to be the frontline for them.
WCT: The Lesbian Community Care Project ( LCCP ) used to be more service oriented and now they do more training. What will LCCP's role be in the structure of Howard Brown, moving forward?
Duke Alden: We're very aware that 25% of our patient population is female, five percent is lesbian. The question is how do we continue to provide culturally competent resources for our lesbian population while also expanding women's health.
The ACA makes economically viable our ability to pursue certain aspects of female services we weren't able to afford, so we're in very serious conversations about what the full breadth and width of our women's services will look like.
WCT: Does the ACA require community health organizations to work more collaboratively?
David Munar: Yes, but not in the way that you would assume. There's nothing in the ACA that mandates collaboration. The whole healthcare system in the U.S. is very dynamic and changing rapidly. Now there's going to be a lot of competition, and that's good for consumers. If we're going to be a destination for care, we're going to have to provide better customer services, better high-quality services. We can partner with hospitals and specialty practices and provide a total continuum of care, through the lifespan, which is good for our mission, our patients, our community.
We are anticipating that there's going to be a decline in availability of public and private grants for healthcare services. Increasing the dependence or the utilization of insurance revenue for models of care, that are provided by Howard Brown and our partners, is putting pressure on every health organization, whether those dealing with LGBT health, or HIV, or other specialized resources. Last year, the state cut a program to help low-income women get mammograms by about 50%. So that sector has been scrambling to figure out, how do we continue to get mammograms for low-income women?
This trend is beginning. In the five- or 10-year window, we may have fewer grant opportunities for the kind of services that we need to provide the community. We have to be more innovative in maximizing insurance. The sector is really changing. There are good things about that. We should all feel pressure to provide better customer service and quality for our patients. The dark side of this is that big hospital systems may have more power in the marketplace, and may put community-based organizations that have historically been serving vulnerable populations in a vulnerable position.
What that means is that organizations serving communities of color, LGBT, people with HIV, people who are in and out of prisonthose organizations may go away. Where are those people going to find healthcare and social service providers who are kind to them and that are serving them? This is my biggest concern. We've got to make sure that nonprofits and organizations serving those populations survive this transformation. Because the lives of our communities depend not just on having insurance, but on having high-quality, culturally competent care.
WCT: What is going on with the Broadway Youth Center, and what are Howard Brown's plans for its future?
David Munar: I breathed a sigh of relief when I found that the zoning appeal board had granted special-use license for the location at Wellington [church]. I'm relieved that we can continue that work at that location. My short-term priority is to make sure that we comply with all of our zoning requirements, that we're good neighbors and that we serve our young people who rely on BYC. Long-term, I have no clue if that location is optimal for the young people. My commitment to the population is complete. We have to serve the LGBT population across the lifespan and we know that there is a crisis for LGBT young people who are struggling with homelessness and unemployment and trauma.
WCT: Our understanding is that the current location is not suitable, and that it's almost run as a temporary structure. And there have been questions about Howard Brown's commitment to the program.
Duke Alden:I don't disagree that the Wellington location is not great. We've consulted with real-estate experts throughout the entire North and West side, and the challenge has been with real estate and cost. We have incredible partnership with Wellington Avenue Church of Christ, but we have been looking actively for months to find the kind of location that meets a litany of criteria. It has to be close to transportation, it has to have a specific kind of zoning, it has to have certain kinds of plumbing because we need showers, it needs kitchen functionality and gas lines, it has to have certain types of allowances for medical care: it's really, really hard to find a space where we can check all those boxes.
The board is going to give David a lot of maneuverable room to make sure that mission remains stable. Just prior to David's hire, we wrapped up a BYC Task Force group, that included not just BYC and Howard Brown but our partners like Night Ministry. We got together and asked, "What do we do to make sure we're sustainable?" The one thing that everyone agreed to is that the mission has to be alive to perpetuity.
David Munar: Wherever BYC goes, those decisions have to be aligned with the needs of the clients. At the end of the day, we could find the perfect space but if it's not geographically accessible or safe for our clients, it's not going to work.
Duke Alden:We really thought we had found that space about six months ago. And we did a walk through to see what a client would face to transport themselves through that area, and it's just too much. So we're still searching.
WCT: Howard Brown has a long history of research, but in recent years its research profile has dwindled, especially with the loss of the MACS [Multicenter AIDS Cohort Study] grant. What changes does Howard Brown envision in terms of either reincorporating that level of research or a different sort?
David Munar: That's something the institution is going to have to really discuss internally. I'm interested in knowing what the providers' perspectives might be, in terms of gaps in research and needs for our patients. I guess I'm not exactly sure what research opportunities we should be pursuing but I do know that the opportunities there will lie in us providing high-quality competent care and improving patient retention. If we can reach more of the medically underserved population, then we can augment our services with research opportunities. All research starts with a good question, such as: Why is it that this segment has higher rates of smoking? Why are there high rates of heart disease in this other demographic? We're trying to improve medication adherence for this group, and why is that not working?
WCT: What made you take this job, given the difference between the rocky history of Howard Brown, which has earned a lot of distrust in the community, and your own much better reputation? What were the significant factors that made you think the organization can move forward?
David Munar: I was really impressed by the people. I got to talk to some of the physician assistants, our doctors, folks in different positions including on the board, and saw the dedication and commitment and the values that I share. That was phenomenal. I also know so many people that received their care at HB, and some of them were dissatisfied with their care at Howard Brown. But, to a person, there was an aspiration that Howard Brown should be a stronger, more viable organization. So that's exciting to be part of that mission. Even when there was disappointment, people felt it because they thought the organization had not lived up to its full potential.
From my policy lens, there are tremendous opportunities for Howard Brown to rise to the occasion to become a stronger destination for good quality care. Our community needs it; I'm concerned that if we don't lean in to the challenges and support Howard Brown, we could lose this investment of 40 years.
WCT: What did you have to do to satisfy yourself? What convinced you that the ship could be righted?
David Munar: I see a lot of potential. I know that we have to build and have some struggles financially. I saw that the board really leaned into the work of the organization. As a CEO you don't want the board to be that involved in the day to day, you want the board to govern but in this case it was a necessity. In the last 18 months, it was a real test for the board. I think it was really healthy, for them to contend with the needs of the patients.
WCT: The relations between the board and the leadership of the organization have been controversial for a number of years. The last two CEOs had close ties to the board, and those relations have been criticized as unhealthy for the organization. Moving forward, what will shift significantly to prevent such controversial decisions?
Duke Alden:What has changed is that we made a commitment to the community 18 months ago that we would go through a very deliberate professionally led and national process [Kittleman and Associates conducted the search] to find a leader like we have in David. David's understanding of Chicago dynamics is important because it's a city that you really need to understand really well to operate well in. What changed is our approach to hiring. We did everything to make sure we did it right. This process was structured. We are very ready, as a board, to step back and put the organization wholly in the hands of an executive like David.
DM : I had an incredible, incredible board at AFC and through that have worked on matters like board recruitment, engagement; it's experience that I hope to bring to Howard Brown to make sure that the board is utilized for high-level strategy, and to fulfill its fiduciary responsibilities like fundraising and fiscal management.
WCT: But there has been a lack of transparency both internally and externally, along with a recent series of dismissals. Were those attached to your entrance as CEO? Did you have anything to do with them?
David Munar: Speaking from my experience still running AFC: it's just good practice to not talk about personnel issues, to maintain the bond of confidentiality.
That said, I'm excited to meet many of the people I've not met through my vetting process. I'm going to dedicate the first part of my term to meeting and learning from the great people at Howard Brown. I will be learning because my skill set is in particular areas and there are some areas I'll be learning about.
I'm not afraid of smart people. I thrive on people who are committed and who bring their big brains to the work. I know a lot of people on the HIV side but a lot I've not met yet, including the retail side [the Brown Elephant stores].
WCT: What would you describe as your vision for Howard Brown in light of both the changes in healthcare and its history?
David Munar: One is to meet the highest standards of a community-based healthcare clinic. Right now, we have a designation of a Federally Qualified Health Center Look-Alike, so we have all the requirements and none of the financial incentives [laughs]. Not only is it important for the operation to be a full grant-earning FQHC, but it's a stamp of approval. It's when the federal government says it's thoroughly assessed your strategies in the community and determined that you're meeting all those standards; that is an important, important goal of mine. It's a part of maturing the organization and demonstrating that we can provide good care.
Part of that mission is earning accreditation as a patient-centered medical home, which is another way of demonstrating the quality of services that we provide. And work is already underway on that.
The organization also has to meet the highest standards of non-profit operations. Rebuilding the financial stability of the organization, so we can make it more nimble and more responsive to community needs, requires a business plan. The financial health of the organization is an enormous goal because as we find gaps in our community we should be doing more on, we're going to need the ability to respond, and you can't do that if you're struggling to make payroll.
WCT: What is it like for you on a personal and political level, as an HIV-positive Latino, gay man who has been working on HIV/AIDS for so long, to take on this position?
David Munar: It's all intertwined. At AFC, all my identities can coexist without having to hide any part of my identity. It's at the core of why I believe so passionately in social justice: so many people are harmed by racism and xenophobia. One of my dear friends died in 1986, of HIV/AIDS, he was 27 or 28 years old. Everyone knew him as Luis, but it was only when his sister came from Mexico for his funeral that we found out that his real name had never been Luis: he had to assume a different identity so that he could get charity care. He didn't survive and died a very lonely, sad … and had too short a life.
I also believe that social justice is enabled by strong institutions. The LGBT community deserves community-based institutions. I'm thrilled that we've crossed the barrier to marriage equality, but there's no equality without health, there's none. If you're sick and you're out of the system, guess what, you're not equal. We're not done. We mustered so much energy to Springfield and saw a well-deserved victory and we should celebrate, but we can't for a moment believe that the lives of LGBTQ people have been forever improved. Not without racial justice, ethnic justice, economic justice and assistance for the poor. Too many of our folks are in those conditions [of need], and they deserve for our community to be rallying for them too. That's at my core.
With Additional Reporting by Tracy Baim
SIDEBAR: HBHC By the numbers
Information Supplied by Howard Brown
Demographics ( July 1, 2012 - June 30, 2013 )
Number of Unduplicated Patients Throughout All Services: 13,173
Breakdown by Patient Gender:
Transgender F-M: 5.3%
Transgender M-F: 8.4%
Patient Orientation Mix
American Indian/Native Amer: .4%
Plus smaller numbers of other races
Patient Payer Mix
Commercial Insurance Mix: 40%
Sliding Scale: 35%
Videos below by Tracy Baim, interviewers Yasmin Nair and Tracy Baim.