Michigan 2018: Making Sense of the political landscape for people with disabilities, Part 3

This is a continuation of “Making Sense of the political Landscape…” based on a PowerPoint presentation by Alan Bolter, the Associate Director of the Community Mental Health Association of Michigan (CMHAM) and his oral presentation at a Town Hall meeting at Washtenaw County Community Mental Health on 11/15/18.

Here is how the CMHAM describes itself: 

"Community Mental Health Association of Michigan (CMHAM) is a trade association representing the 46 Community Mental Health Boards, 10 Prepaid Inpatient Health Plans, and more than 90 provider organizations that deliver services to adults with Mental Illness, children and adolescents with emotional disturbances, persons with Intellectual/developmental disabilities, and those with substance use disorders in every community across the state." 

"Part 3" gets into the nitty gritty of Medicaid funding for people with disabilities, some of which I do not understand, but then I am not alone. Many people dealing with this important benefit for people with disabilities are at times at a loss to explain Medicaid policies and why and how they are what they are. The following includes excerpts from the PowerPoint with a few notes of explanation thrown in and links to more information.

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Budget Issues/Medicaid Underfunding

Budget impact due to Medicaid enrollment shift – Shift of DAB Population

• Since FY16 our members have seen a significant shift in Medicaid enrollment involving individuals identified as Disabled, Aged, and Blind (DAB) moving to Healthy Michigan Plan (HMP) & Temporary Assistance for Needy Families (TANF) programs. Our members conducted a study that showed nearly 42,000 individuals in FY16 & FY17 categorized as a DAB and are now categorized as HMP or TANF, which has resulted in nearly $100 million in lost revenue to our PIHP system.  [This loss of funds reflects the difference in Medicaid reimbursement to CMH agencies under these programs. Reimbursement to a CMH from the state is much less if an individual is identified under the Healthy Michigan Plan (Michigan’s Medicaid Expansion for people with an income above the poverty level) than under the DAB program.] 
• The base rate amount for a DAB enrollee payment is $266.90, which includes state plan ($135.84) & 1915 (b)(3) ($131.06) (x age & gender x geographic region). The base rate for a Healthy Michigan enrollee is $29, while each TANF enrollees is $15.28. [Michigan has a modified managed care system that reimburses CMH's based on how many individuals are eligible for services under various categories plus other factors.

[See the PowerPoint on Budget Shortfalls not just a DAB issue - other Medicaid factors that describes a systemic funding problem creating a budget deficit of $133 Million "that is causing fiscal and client services difficulties across the state."]

Medicaid Funding Issues Moving Forward 

Community expectations and State requirements continue to grow.

• Increased requirements for independent living settings (HCBS) 
• more jail diversion and reentry requirements 
• housing and crisis stabilization programs 

Insufficient Medicaid funding

• Medicaid enrollment shifts (DAB issue) 
• 2-year look back for rates(does not allow for real time adjustments) 
• staffing costs continue to rise (minimum wage increases) 
• insufficient rates for both Healthy Michigan and autism have lead to an erosion of the Medicaid benefit in some areas. 

Failure to fund federally required contributions to PIHP/CMH risk reserves.

• ISF [Internal Service Fund - I think this has something to do with holding money in reserve to cover unexpected expenses?] Contribution - Late in the budget process we recommended to include, in the FY 19 Medicaid rates paid to PIHPs, revenue to support reasonable contributions, by the PIHPs, to their ISFs, as is done with any at-risk health plan. 
• Recent Medicaid rate certification letter indicates (for the first time in a certification letter) that a portion of the administrative costs provided to the PIHPs is intended for a risk margin, the amount (0.75% for DAB, the largest component of the PIHP’s revenue), this level of risk margin is far too low given the 7.5% risk corridor. If the ISF were never used, it would take a PIHP ten years to fund the 7.5% needed to share risk with the state. 

[For some unknown reason the amount of funding sent from the state to fund CMH services is $133 Million less than is actually spent. Mr. Bolter speculated that it may have to do with dollars being moved around within the Department of Health and Human Services, but he could not say for sure. In other words $$’s sent out from the state is less than what is actually spent. The deficit caused by this is $133 Million. in a system that is not allowed to have deficit spending.]

What does the Future Hold?

We would expect to see more of a deliberative (slower) process in Lansing.

• Budget process should slow down 
• Completed in June? Governor Snyder and Republican legislature completed all 8 budgets in June. 
• Return to [former Governor] Granholm vs Republican budget process? State budget process not completed until deadline 

Section 298 – what will Governor Whitmer do? [Under Section 298, the Michigan Legislature directed the department of HHS to develop a set of recommendations regarding the most effective financing model and policies for behavioral health services for individuals with mental illnesses, intellectual and developmental disabilities and substance use disorders - it has created a boatload of controversy.] 

• Regardless of 298 direction expect change 
• Too much $$ at stake and involved 
• National movement/trends in health care 
• In 2020 the Medicaid Health Plan managed care contract can be revised - Signed in 2015 – 5-year contract w/ three 1-year extensions available. 

Governor – Elect Whitmer’s To-Do-List (in the next 60-100 days)

• Hire executive office staff 
• Appoint cabinet members (Department Directors) 
• Write an Inaugural Address 
• Write a state of the state speech 
• Write/develop FY20 state budget 

Useful Information to stay informed

Michigan Votes – plain language descriptions of every bill, amendment, and vote that takes place in the Michigan legislature.

Michigan Legislature – copies of the bills, find the status, summaries, etc.

Michigan House of Representatives & Michigan Senate – find legislative contact information, committee and session calendars, and you can watch committees and session live.

Contact Information: Community Mental Health Association of Michigan 

• Alan Bolter, Associate Director  
• abolter@cmham.org 
• (517) 374-6848 

[Additional information: Work is under way to replace the Caro psychiatric facility in Tuscola County with a new facility that will increase the number of psychiatric hospital beds from 150 to 200.]

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See also MI Political Landscape 2018, Parts 1 - 3

Michigan's CMH system: Facts and Figures

Michigan 2018: Making Sense of the political landscape for people with Disabilities, Part 2

Information on "The Political Landscape..." comes from a Washtenaw County Community Mental Health Town Hall meeting on November 15, 2018. It is based on a PowerPoint presentation by Alan Bolter, the Associate Director of the Community Mental Health Association of Michigan (CMHAM). Most of the following consists of excerpts from the PowerPoint with some added notes based on Alan Bolter's oral presentation. 

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Part 2 on "Looking Back, Looking Forward and How to Make Sense of it All" 

The Lame Duck Session of the Michigan legislature, 

November 27 - December 20, 2018 (4 weeks/12 session days) 

What we [the CMHA of Michigan] are going to FIGHT FOR

• Direct Care Wage – Minimum Wage Funding 
• .50 cent wage increase for direct care workers is in the FY19 budget recommendation (.50 cent increase cost $64 million gross). 
• The Michigan Legislature passed the minimum wage increase on September 5, 2018 (to preempt the proposed ballot initiative). As a result, the state's minimum wage will increase to $10.00 per hour on March 1, 2019 and increase to $12/hour by 2022. 

Legislative leaders have indicated a desire to come back after the election and amend this, but what does that mean?

We are asking the legislature when they come back to recognize there is a Medicaid cost to that wage increase.

• .75 cent increase = $33 million GF (General Fund) increase/$100 million gross increase. 
• Coalition [groups supporting the wage increase] goal is $2 above minimum wage as a base salary for all direct care workers. 

[Note: this increase does not apply to Home Help Workers ]

CMHAM position statement on Direct Care Staff Wages

POSITION STATEMENT: Increased Wages for Direct Care Workers

• Direct care workers provide crucial personal care services and/or community living supports to people with disabilities in both licensed and non-licensed residential settings. These services and supports enable people With disabilities to work, attend school and fully engage with their communities. 
• Direct care workers receive wages which are clearly inadequate. Based upon recent survey data, their average starting wage state-wide is $10.46 per hour. By comparison, retail companies and fast-food restaurants generally offer a starting wage of $11 – $14 per hour. 
• As a result of low-pay, often coupled with a lack of benefits, a staffing crisis exists, which prevents people with disabilities from living the lives they envision. 

This is both an economic and a moral issue. 

• 2016 DHHS [Dept. of Health and Human Services] budget included the section 1009 report which recommended the following: 
• "The Michigan Legislature and Governor need to make additional investments into all the named Medicaid Covered supports and services to assure that: Direct support staff earn a starting wage of at least $2.00 per hour above the state's minimum wage. These investments and the starting wage rate should increase as the state's minimum wage increases." 

Legislators have been supportive, but we will see once it is compared to other priorities. 

Long Term Challenges Direct Care Issue

1. Very costly to increase wages (for state and employers) 
2. average starting wage state-wide is $10.46 per hour. By comparison, retail companies and fast-food restaurants generally offer a starting wage of $11 – $14 per hour. Increase wages only first step. 
3. No career path for direct care workers – need to look into certification process (Certified Nurses Assistants). View direct care as a profession 

What the CMHAM will FIGHT AGAINST:

• Rumors are swirling that MAHP [Michigan Association of Health Plans] will attempt to make changes to the Mental Health code or Social Welfare Act that could be damaging to our members and the people they serve during the lame duck session. 
• Removing the connection between CMHs to counties 
• Limiting/reducing the recipient rights process 
• Removing potential future barriers that could prohibit a total carve-in. 
• Language like 298 section 2(e) [this refers to plans to allow Medicaid Health Plans to manage behavioral mental health funding and services rather than public mental health agencies]. 

Next Steps / Follow up 

• Lame duck session – WHAT CAN I DO TO HELP? 
• Educate those running for office and those who win in November. 
• Invite them to learn more about your programs and issues. 
• Remember to be a resource. 
• Look out for ACTION ALERTS & be prepared to ADVOCATE! 

Key Pillars for public mental health system

• Local oversight 
• Addressing Social Determinants [transportation, housing, employment, nutrition] 
• Workforce - “must have the ability to retain and train competent staff across all levels…” 
• Funding - “must meet community expectations and obligations. NO unfunded mandates” 
• Information exchange… 
• Uniformity - “A consistent set of Standards and level of care across the state”

(to be continued...)

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See also,

Michigan 2018: Making Sense of the political landscape for people with disabilities, Part 1

CMHAM PowerPoint "Looking Back, Looking Forward..."

Michigan's CMH system: Facts and Figures

Michigan 2018: Making Sense of the political landscape for people with disabilities, Part 1

Alan Bolter, Associate Director of the Community Mental Health Association of Michigan (CMHAM), gave a presentation on 11/15/18 at a Town Hall meeting of the Washtenaw County Community Mental Health Association. A Power Point of his talk, “Looking Back, Looking Forward and How to Make Sense of it All” is available on-line. Here is a sampling of the topics he discussed: 

The 2018 Election

Democrats flipped ALL state constitutional officers (first time since 1938 one party flipped all statewide offices in a single election)

• Governor – Gretchen Whitmer (D) 
• Lt. Governor – Garlin Gilchrist (D) 
• Secretary of State – Jocelyn Benson (D) 
• Attorney General – Dana Nessel (D) 

Democrats picked up 5 seats in each legislative chamber

Republicans retained their majority in the State House of Representatives by a margin of 58 – 52 (currently the margin is 67 – 43).

Republicans retained their majority in the State Senate by a margin of 22 – 16 (currently the margin is 27 – 11).

All three ballot proposals were approved by voters (marijuana, gerrymandering, easier voting)

U.S. Senator Debbie Stabenow won re-election.

Democrats picked up 2 Congressional seats. Democrats Elissa Slotkin (D-8th) and Haley Stevens (D-11th) won their congressional races flipping two seats previously held by Republicans.

Democrats have won majorities on all statewide elected education boards, including the State Board of Education.

This is the first time in 16 years that the Governor in Michigan will have legislative experience.

2019 Michigan Legislative Leaders

Senate Republicans

• Majority Leader: Senator Mike Shirkey 
• Majority Floor Leader: Senator Peter MacGregor 
• Appropriations Chairman: Senator Jim Stamas (appointed not elected) 

House Republicans

• Speaker of the House: Rep. Lee Chatfield (R-Levering) 
• Majority Floor Leader: Rep. Triston Cole (R-Mancelona) 
• Speaker Pro-Tempore: Rep. Jason Wentworth (R-Farwell) 

Senate Democrats

• Senate Minority Leader: Jim Ananich 
• Senate Minority Floor Leader: Stephanie Chang 
• Minority Vice Chair, Appropriations Committee: Curtis Hertel 

House Democrats 

• House Minority Leader: Christine Greig 
• House Minority Floor Leader: Yousef Rabhi 

Committee assignments will not be announced until late January/early February.

The 2018 Lame Duck Session

A Lame Duck session occurs when one legislature meets after its successor is elected, but before the successor’s term begins.

The Michigan Lame Duck session runs from November 27 - December 20 (4 weeks/12 session days.)

Why Lame Ducks are dangerous:

• The Legislative process is in fast forward 
• Condensed timeframe so things move quickly, in many cases little if any public participation of legislation (committee / public meetings) 
• Bills do not have to go through the committee process, can get referred right to House or Senate floor. 

Three most important numbers 56, 20 , & 1 (votes needed to pass a bill). 

Article IV, section 26 of the Michigan Constitution states: No bill shall be passed or become a law at any regular session of the legislature until it has been printed or reproduced and in the possession of each house for at least five days.

A bill’s intent can be completely changed in lame duck as long as it still amends the same section of law…

Possible Lame Duck issues

• FY19 supplemental budget 
• Republicans looking for ways to tie Governor’s hand with spending State 
• Budget Surplus fund 
• Minimum Wage & Sick Time changes (from legislation passed in September) 
• Auto No-Fault reform 
• School Safety Grants - $30 million in FY19 budget 
• Implementation bills for proposals 1-3? 

(to be continued… )

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See also Michigan CMH Facts and Figures 

Making Sense of the Political Landscape... Part 2

Michigan's Community Mental Health System: Facts and Figures

Alan Bolter from The Community Mental Health Association of Michigan (CMHAM) gave a presentation on 11/15/18 at a Town Hall meeting of the Washtenaw Community Mental Health Association (more about that later). He distributed a flyer with basic information about the Michigan Community Mental Health system. It describes what CMH agencies do, how they are funded, and who they serve. The flyer does not appear to be available on the internet, but if it does become available, I will provide a link to the complete document.

These are excerpts from the flyer with a few modifications to make it easier to understand in the way I am presenting it here: 

How Community Mental Health agencies are funded

• $2.319 billion from “Medicaid Mental Health” 
• $299 million from “Healthy Michigan” [Michigan’s Medicaid expansion under Obamacare] 
• $175 million from “Substance Use Disorder” 
• $192 million from Autism funding 

These funds go to Prepaid Inpatient Health Plans (PIHPs), behavioral health managed care entities. These are the regional administrative agencies that distribute Medicaid funds to local CMH agencies.] PIHPs are responsible for oversight and compliance (Federal & State), Administration, and Utilization Management.

These funds are passed on along with $125 million from the State General Fund [GF] to Community Mental Health Centers and their provider network covering all 83 counties. CMHs are responsible for service provision, coordinating the local service network, and ensuring compliance (Federal & State).

Who Community Mental Health serves

• Children with Serious Emotional Disturbance [examples: Obsessive-Compulsive Disorder (OCD) or Attention Deficit Hyperactivity Disorder (ADHD)] 
• People with Substance Use Disorders [SUD] 
• People with Developmental/Intellectual Disabilities 
• Adults with Mental Illness 

Michigan is the only state that serves all 4 populations in a managed care setting.

How the Money is Spent

• 49% on People with Intellectual/Developmental Disabilities [45,000 people served] 
• 36% on Adults with Mental Illness [155,000 people served] 
• 9% on Children with Serious Emotional Disturbance [45,000 people served] 
• 6% on People with Substance Use Disorders [70,000 people served] 

Other pertinent information

The percentage of dollars spent on actual care in Michigan’s PIHP system has a statewide average of 6% spent on administrative Costs. This is a 94% “medical loss ratio”, an indication that Michigan Medicaid dollars are spent very efficiently for the actual care of the people served.

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Community Mental Health Association of Michigan (CMHAM) is a trade association representing the 46 Community Mental Health Boards, 10 Prepaid Inpatient Health Plans, and more than 90 provider organizations that deliver services to adults with Mental Illness, children and adolescents with emotional disturbances, persons with Intellectual/developmental disabilities, and those with substance use disorders in every community across the state. 

VOR Notes on the October 2018 Together For Choice Conference

I was unable to attend the Together for Choice Conference last month and appreciate hearing from others who were there. 

I'll start with the last paragraph of an article from the VOR Weekly News Update for 11/2/18 first. I have toured the Misericordia campus and encourage anyone who wants to find out about the Misericordia community to ask for a tour if they are in Chicago.

"The true highlight of the conference was the guided tour of the Misericordia campus, wherein attendees were shown an amazing array of services, residential models, and employment opportunities. Misericordia is a model for services for individuals with I/DD. Our warmest congratulations to Sister Rosemary and the thousands of family members, volunteers, Direct Support Professionals and donors who have made this facility such a beacon of hope for so many."

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from the VOR Weekly News Update for 11/2/18:

Notes on the Together for Choice Conference
Oct. 17 - 19, Chicago, IL

Nearly 200 advocates for individuals with disabilities from 30 states came together for the 2nd annual Together for Choice Conference held at Misericordia, a non-profit organization in Chicago Il. Among them were about a dozen members of VOR. There was a notable lineup of speakers at the conference. Here are just a few:

Sister Rosemary Connelly, Executive Dir. (Misericordia, Chicago Il.) delivered the welcome and opening statements She specifically exposed the “one size fits all” philosophy that has been going on since the 1970’s in which larger facilities are threatened with closure, simply because they are bigger. Sister said: “our purpose is to redefine what community really means. Within that definition, individuals and their families should have choice of where to live, where to work, and who their friends are.” As one of the leaders of Together for Choice, Misericordia led a group of providers, families and self-advocates to D. C. in November of 2017 to meet with their Il. Congressional delegation. One of the self-advocates in the group had previously lived in the larger community, but made the choice to return to a campus setting because she felt isolated. She asked one of the legislators: “How can I make you understand that we are not an institution, we are a community!” Sister Rosemary summed up her comments: “our families asked their elected officials to come and tour Misericordia. When they come, their response is: the bureaucrats don’t like you? You should be a model for the country!” In 2017, due their persistent legislative efforts, Misericordia received a continuum of care license from Springfield.

Melissa Harris traveled by train from her Baltimore office so that she could speak on behalf of Centers for Medicare and Medicaid Services. She told the family members in the audience: “My goal is to answer your questions or take them back and get an answer.” She also said: “you won’t hear from any of us that we know better than you.” Ms. Harris explained the Home and Community-Based Settings Regulation and she left her e-mail for further questions.

Bill Choslovsky gave an inspired presentation on the history of I/DD services from 1960 to present. He spoke of the early progress in development of ICFs and the problems that have arisen since the waiver was introduced. He noted that we should not balk at the definition of an ICF as an institution, that institutions are good, despite how our adversaries debase them. His Olmstead presentation was the centerpiece of his narrative, including Judge Kennedy’s prescient comment, “It would be unreasonable, it would be a tragic event, then, were the American with Disabilities Act of 1990 (ADA) to be interpreted so that States had some incentive, for fear of litigation, to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Olmstead, at 610.

Mr. Choslovsky singled out VOR’s Caroline Lahrmann as a shining example of advocacy at its best for her countersuit against Disability Rights Ohio for trying to close down ICFs in her state.

Rodney Biggert, of Seneca Re-Ads Industries, detailed the Kafkaesque persecution initiated by Disability Rights Ohio and the Department of Labor against his company for paying specialized wages under the 14(c) certificate. The judge in this case made some unbelievable pronouncements, including the determination that the workers must be proven “disabled for the work to be performed”, a concept that is literally impossible to prove in accordance with the judge’s own criteria.

Other speakers included Douglass O’Brien, the regional director for the Chicago area for the U.S. Dept. of Health and Human Services , David Axelrod, former campaign adviser to President Barack Obama,and Phil Peisch and Chris Lowther, lawyers who worked with TFC and others in standing up to CMS Settings Rule for the limits it imposes on choice in community settings. Representatives from Noah Homes and the Arc of Jacksonville spoke of their work in building intentional settings that stand up against the “Heightened Scrutiny: requirements of the Settings Rule. Congressman Peter Roksam of Illinois’ 6th Congressional District gave encouragement noting the importance of 1:1 visits to legislators and their staff. He said: “personal anecdotes are powerful; continue to build a network, and get them (the legislators) on campus.”
...

Patricia Peterson and Hugo Dwyer

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See also,

VOR Olmstead Resources

Disability Advocacy Alliance, Ohio