At the last Washtenaw Community Health Organization Board meeting on 4/22/15, a packet of news articles about statewide problems with budget deficits and service cuts was distributed. These articles date from January 2014 to the present. Washtenaw County is its own special case, as the WCHO goes through a change from a "Community Health Organization" to a "Community Mental Health Agency" while also dealing with a $3.8million budget deficit. (More on Washtenaw County later).
The problems with state funding of Community Mental Health (CMH) services, including services to the developmentally disabled population, are complex. I am no expert on Mental health funding and it is likely that my take on it is not entirely correct, but this is what I think has happened based on news articles:
- Michigan's Medicaid expansion (Healthy Michigan) began enrolling participants in April of 2014;
- The State expected a large influx of federal funds to pay for health care to eligible citizens through Medicaid expansion and on that basis made large cuts to state Medicaid funding and to non-Medicaid General Funds that local agencies use to fill in the gaps for people not in the Medicaid system.
- The State also adjusted payments to counties to make funding more evenly consistent throughout the state, resulting in some counties receiving more Medicaid funding and some less than before.
- Large increases in people insured by Healthy Michigan and decreases in numbers insured by "regular" Medicaid have resulted in less funding for regular Medicaid mental health services, at the same time that the numbers served by the CMH system have increased. (Apparently, the two Medicaid systems are funded separately).
- The Governor's desire to use the increased Medicaid funding from the federal government as savings for future costs to the State, has made less money available to pay for current services.
- The legislature's expectation of increased federal funding to cover current and future costs was overly optimistic.
News Articles on State-wide Stresses on the Michigan CMH system
"Cuts likely necessary for Oakland’s Mental Health Authority, with $11M deficit", 4/7/15: $11million deficit...cuts to providers, programs, and layoffs likely…$14million reduction in Medicaid dollars from the state….some providers could go out of business…worst-case scenario - more cuts in 2016 fiscal year.
Kent County’s Community Mental Health authority Network 180 press release [no link available], 4/8/15: Board votes to implement agency-wide cuts…salary cuts…”adults with DD will see a dramatic reduction in daily support and services immediately”…new lower Medicaid rates in West Michigan to increase rates in other parts of the state…affected by unexpected drop in traditional Medicaid enrollment with introduction of Healthy Michigan (Medicaid expansion).
“Cuts threaten services for Oakland Co. disabled” 9/24/14: 2014-15 budget includes $20million in state aid cuts to general fund and $14million in cuts from Medicaid…Changes under the Affordable Health Care Act - “Michigan opened Medicaid to nearly 500,000 additional residents and moved their health care costs—including mental health care costs —off the state’s books and on to federal rolls”…..In anticipation of savings, state trimmed $75million from mental health spending for 2014-15 fiscal year…some cuts offset by federal dollars…number of people served by Michigan’s CMH system climbed from 184,708 in 2004 to 248,189 last year [2013]…
“Funding cuts send hundreds of mentally ill onto Detroit’s streets” 5/1/14: Detroit’s longtime round-the-clock homeless shelter turns out hundreds of people…no place to go…when state lawmakers passed Medicaid expansion, an infusion of federal funds was expected to make up for cuts based on anticipated savings…general fund dollars also cut…CEO of Detroit CMH on state plan: “It’s like, next month you need to pay the mortgage, and the state says, ‘Well your grandmother may die in the next six months and leave you the money.'”
“Local mental health programs face cuts” from Northern Lakes Community Mental Health Blog, 4/3/14 : “Community mental health groups across the state began to lose roughly 54 percent of their state-funded general purpose money on Tuesday, the same day enrollment in the Healthy Michigan Plan opened.” [General fund dollars, as opposed to Medicaid dollars serve people who do not qualify for Medicaid but nevertheless have needs served by the mental health system such as children, people on Medicare, and many people who are mentally ill.]
“Adult Foster Care Aid May be at Risk, Advocates Say” 5/30/14 from Kaiser Health News/Detroit News: “As part of major changes associated with the health care overhaul, also known as Obamacare, Michigan opened Medicaid to nearly 500,000 additional residents. That moves their health care costs — including mental health — off the state’s books and onto the federal government’s.”…state trimmed mental health spending for the current fiscal year [2013-14]by $75 million, Snyder wants to trim more…”The state’s not going to save as much as they think they are.”…Gov. wants most of the annual savings to cover future Medicaid costs…
“Michigan community mental health centers turning away patients, blame ‘flaw’ in Medicaid expansion” from mlive.com, 4/22/14 : “Local mental health officials say Gov. Rick Snyder's administration overestimated the savings from Healthy Michigan [Michigan's Medicaid expansion], resulting in a funding shortfall for CMH boards across the state.”…”While overall funding has increased, CMH programs are still left with funding gaps because the Healthy Michigan dollars can't be used to fund services for those who don't have Healthy Michigan coverage.”…”Vizena [from the association of CMH Boards] said he had hoped the state would have done a better job to make sure there wasn't a time gap between losing the general fund money and getting an influx of money through new Healthy Michigan enrollees”.
“Macomb, St. Clair County CMH cut services” 4/29/14: “Macomb County CMH is cutting services to about 1,350 people. St. Clair County Community Mental Health is cutting services to approximately 300 people. Sanilac County CMH is cutting services to about 90 people.”…St. Clair County uses the general fund money to cover people on Medicare...Medicare covers only about 80 percent of the cost of mental health services, the rest of which the CMH covers with general fund monies….general funds help cover “spend downs”, deductibles before insurance kicks in….
“Proposed mental health funding cuts could hurt Jackson’s uninsured, mentally ill population” from mlivd.com, 1/6/14: Maribeth Leonard, the CEO of Jackson County's mental health agency LifeWays - legislators are assuming too much under the expansion…In 2013, LifeWays served 2,780 patients who were uninsured or not covered under Medicaid with general fund dollars…
Many housing projects, including planned communities for people with developmental disabilities, have been built in recent years that use flexible Medicaid funding to provide services to people wherever they choose to live. Federal Medicaid law explicitly prohibits Medicaid waiver money or other Home and Community Based Services (HCBS) funding from paying for housing. Many family organizations, however, have built or found housing that is uniquely designed for people with very specialized needs and have then used HCBS funding to pay for services for the individuals who live in these homes.
A new rule from CMS, the federal agency that regulates Medicare and Medicaid, has set standards for what CMS considers to be suitable settings to promote integration into the community.
Consistent with the Americans with Disabilities Act and the 1999 Supreme Court Olmstead decision, states must administer the full array of home and community-based services in the most integrated setting appropriate to the needs of qualified individuals with disabilities. The new rule, however, threatens to limit Medicaid funds in settings that are deemed too institutional in nature by CMS standards and force individuals with disabilities to jump through hoops to justify their choices, if they want to live in settings that come under special scrutiny by the CMS. In addition, many advocacy organizations that ideologically support forced deinstitutionalization and oppose all congregate settings (settings that serve more than 3 or 4 individuals with disabilities together), are pushing to have states limit and eliminate settings that they do not like. This is a problem, especially for people with the most severe and complex disabilities who are also people who often need and benefit most from congregate care or services in congregate settings.
Disability advocates claim that their ideological opposition to congregate care is supported by the 1999 Supreme Court Olmstead decision, but that is a misrepresentation of the decision's mandate. The Supreme Court took a balanced approach, finding that unjustified isolation of individuals with disabilities is discrimination under the Americans with Disabilities Act, but they explicitly stated that they did not condone "termination of institutional settings for persons unable to handle or benefit from community settings." They also recognized "… the States' need to maintain a range of facilities for the care and treatment of persons with mental disabilities, and the States' obligation to administer services with an even hand." The Supreme Court held that states may move people from institutional care to community only as long as the individual does not oppose the move. And, “…the ADA is not reasonably read to impel States to phase out institutions, placing patients in need of close care at risk... ‘Each disabled person is entitled to treatment in the most integrated setting possible for that person — recognizing on a case-by-case basis, that setting may be an institution".
The Delaware Homes for Life Foundation sponsored a conference on October 31, 2014, called "Innovations in Residential Neighborhoods". Homes for Life was founded by Dr. Lanny Edelsohn and his wife Micki, the parents of an autistic adult son. The foundation has raised millions of dollars to build and furnish 27 homes for people with autism and other developmental disabilities.
The conference was covered in an article on Delaware Online on 11/1/14 entitled "Those with disabilities: Where should they live?" by Beth Miller. One of the speakers at the conference was from The Arc Village in Jacksonville, Florida, where ground will be broken soon on an $18.6 million, 97-unit community of affordable duplexes and triplexes to be rented by those with intellectual and developmental disabilities. Some of the discussion was about whether the new CMS rule on HCBS settings would allow residents who choose to live in planned communities access to Medicaid HCBS funding to pay for services where they live.
While the purpose of the conference was to showcase innovative housing ideas from around the nation, it was covered as a civil rights battle "simmering not far below the surface of local and national discussions on how and where people with intellectual and developmental disabilities... might live and work in the future."
Daniese McMullin-Powell, the Chair of the Delaware State Council for Persons with Disabilities, did not hold back when talking to the reporter about where she stood on the issue:
"…to Daniese McMullin-Powell, a longtime disability rights activist who has handcuffed herself to the White House fence to make her case against life in institutions, the day's discussions made her feel like she had been to a 'segregationist meeting.'
"McMullin-Powell uses a power chair because of post-polio syndrome. She has children and grandchildren with a variety of disabilities – including autism and Down syndrome, she said.
"She wants all of them to have access to full lives in their communities. But she does not want government money used to support segregated communities for people with disabilities. That money should go to those who can live in ordinary community settings and want to do so.
"'This would suck up every drop of Medicaid money there is,' she said. 'If they want to choose congregate living, then let CMS use only nursing home money. Don't suck it all up because you want to live in summer camp forever.'"
Dr. Lanny Edelsohn answered the "startling" remarks by Deniese McMullin-Powell in an opinion piece, "Delaware must be open to new ideas on housing" on 11/4/14 on Delaware Online:
"Beth Miller’s recent article… shines a most welcome light on an urgent issue in Delaware: the affordable housing crisis for adults with intellectual and developmental disabilities. In the state of Delaware, there are 2,900 persons living at home with parents who are 60 or older. These parents all ask the same question: 'What will happen to our loved ones when we are gone?'"
He goes on:
"In the article, I was startled to read the virulent comments by Daniese McMullin-Powell, Chair of the State Council for Persons with Disabilities, who had remained silent during the conference. While I disagree with each of her assertions as baseless, including her comments that she thought she was attending a segregationist meeting of rich white people (the conference was free, the attendees were clearly diverse and a tax return was not a requirement for admission), I am nonetheless most grateful for her finally revealing something that many in the disability community have long suspected but no one has yet had the courage or honesty to admit: that at the end of the day, this battle over the direction of the Medicaid waiver, while superficially clothed in the appealing rhetoric of 'rights,' is, like many things, actually about money. [emphasis added]
“'This would suck up every drop of Medicaid money there is,' she said. 'If they want to choose congregate living, then let CMS use only nursing home money. Don’t suck it all up because you want to live in summer camp forever.'
"By day, I am a neurologist who treats persons with autism, Down syndrome and other central nervous system disorders where there can be self-abusive behavior, PICA (eating foreign objects) or progressive early onset Alzheimer’s disease. Every week I treat patients who are in great need of safe and supervised environments. And I see families, struggling bravely and under great adversity, to care for them, often as their own health and welfare decline. I can assure you, from the patients I treat, that life is not a “summer camp”; rather, it more often resembles an exhausting challenge of relentless obstacles."
Thank you, Dr. Edelsohn. I couldn't have said it better myself.
This is from an editorial in the Miami Herald, "Floridians with developmental disabilities need more help " by the President of the Autism Society of America Ven Sequenzia, Jr., 9/25/14.
Rick Scott, the Governor of Florida, claims to be helping people with DD by increasing the state budget to reduce the "critical needs" waiting list for services. The truth is, according to Sequenzia, that:
- "The Medicaid Waiver budget for 2013-14 was $915 million, or $46 million below the 2008 budget. It was actually the third lowest budget in the last six years.
- "This while the waiting list grew from 15,648 in Sept. 2007 to 21,140 in June 2014.
- "Now the final straw. The Agency for Persons with Disabilities (APD) returned approximately $80 million 'unspent' from this fiscal year to the state treasury. Yes, you read that correctly. Gov. Scott not only reduced spending, the agency returned unspent money, while 21,000 people are languishing on a waiting list."
Furthermore, to add insult to injury, "[The Governor] allows the wait list to increase by almost 5,000 people in 2014, all the while taking thousands of families to hearings to deny needed services based on the iBudget rules and an algorithm that the District Court of Appeals threw out as illegal. He included $4.5 million dollars in the APD budget for legal fees to fight families, and those funds go to the law firm that his chief of staff is associated with."
Floridians should be fuming.
