Wednesday, October 5, 2011

Meeting on "dual eligibles" in Washtenaw County

NOTE: The term "dual eligibles" is an awful-sounding label that categorizes people according to their health insurance status. Included in this group are the poorest, sickest, oldest, most disabled, and most vulnerable people imaginable. They are under scrutiny because they cost more than other people to treat and care for. They are among the easiest people to target for "cost savings", because it is so difficult for them and their families to fight back when the supposed savings come at the expense of the services they need to survive. We may have to use the same vocabulary that government agencies use so that we can enter into a discussion about government schemes to balance budgets, but it is our job to put a human face on the "DE's" and not allow government agencies and our legislators to forget who these people are.

Michigan's project on "Integrated Care for Dual Eligibles" applies to people who are fully eligible for all parts of Medicare and all Medicaid benefits. This includes about 204,000 people in Michigan. 40% are either people under 65 who are developmentally disabled or people with Mental Illness who started receiving SSI (Supplemental Security Income for low income people - this also qualifies a person for Medicaid in Michigan)  and then later qualified for SSDI (Social Security Disability Insurance)

Medicare, a federal health insurance program, covers most physical care. Medicaid, a joint federal and state program, covers almost all long-term care and specialty mental health services, including people with developmental disabilities.

The State proposal will move all Dual Eligibles (DE’s) into Medicaid. Presumably, private managed-care health plans would finance and manage physical and mental health services for DE’s, even though these managed care plans have little experience with developmentally disabled people under 65 or people with mental illness.  There is little competition among private managed care health plans and even less transparency into their operation.

It appears that the proposal would allow the state to redistribute funding to cover more long-term care for seniors at the expense of people with developmental disabilities and mental illness. No one can deny that more support for seniors is needed, especially for those who want care in their own homes or want to move out of nursing homes, but robbing Peter to pay Paul is a poor substitute for an ethically sound policy for serving both seniors and people who are now served by the CMH system who have developmental disabilities and mental illness.

The state legislature, through the appropriations process, has already signed off on assuming there will be savings of $10 million if the plan is accepted by the federal Centers for Medicare and Medicaid Services (CMS). The state wants to begin selecting health plans to cover DE’s by January 2012 and put the plan into effect by April 2012.

It is not necessary for the state to push this proposal through to implementation on such a fast track. The federal CMS expects states to refine and reconsider their initial proposals until the final plans are submitted in April 2012. CMS will approve selected plans submitted to them probably 6 months after that. Other states have submitted proposals that are far more nuanced and do not disrupt existing care arrangements.

The state claimed in its initial proposal that it does not need approval from the legislature and that the executive branch can implement the plan administratively. There is some doubt, however, about the legality of the proposal. There are regulations for Medicare and Medicaid that the plan may violate. There is also Section 400.109f of the Michigan Social Welfare Act that says:

"…Medicaid-covered specialty services and supports shall be managed and delivered by specialty prepaid health plans [regional Community Mental Health entities] chosen by the department of community health with advice and recommendations from the specialty services panel created in section 109g. The specialty services and supports shall be carved out from the basic medicaid health care benefits package…” 
Changes to these requirements in state law could only be made by the legislature . 

At the end of the meeting we discussed the best course of action for people affected by this proposal to express their views. The state needs to hear from people with developmental and other disabilities, their families, and friends.  Comments can be sent directly to the official Website for the Integration of Dual Eligibles by email, to state officials who are involved in the development of the plan for DE’s, and to legislators to make them aware of the proposal and to ask for legislative hearings on the Integration of Care for Dual Eligibles plan.

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