Michigan groups sue to "Stop the Hamster Wheel" - Medicaid hearings that are never resolved due to lack of adequate funding

A press release from three legal advocacy groups, Including Michigan Protection and Advocacy Services (MPAS), alleges "Systematic Due Process Violations in Michigan Medicaid Program":

...Lansing, MI – Medicaid recipients have long had rights to “fair hearings” to challenge actions affecting their benefits. According to a new lawsuit, however, recipients in Michigan cannot get relief from those hearings, even when they win.

The suit, filed by attorneys for Michigan Protection & Advocacy Service, Inc. (MPAS), the National Center for Law and Economic Justice (NCLEJ) and Legal Services of South Central Michigan (LSSCM), says that the administrative law judges (ALJs) presiding over fair hearings lack the power to order the agency to grant the benefits it had wrongfully denied. All they can do is send the case back to the agency to “reassess” the recipient. And when the agency comes back with the same decision on reassessment—as it often does—all the recipient can do is ask for another fair hearing, where the same thing will happen again. This is the Michigan Medicaid “Hamster Wheel”: recipients run and they run and they run, but they never get anywhere.

Named Plaintiff Kevin Wiesner lives with various disabilities, and he relies on Medicaid-funded community living supports (CLS) to stay in the community. In 2019, he challenged the CLS budget provided by Washtenaw County Community Mental Health (WCCMH), and the ALJ held in his favor in every respect: The budget was insufficient to meet Kevin’s medical needs, it had been insufficient since at least 2015, and at least a certain, specific amount was required to make it sufficient. But the ALJ did not—because he said he could not—order a budget of that amount. Instead, he told WCCMH to “reassess” Mr. Wiesner’s needs. To no one’s surprise, WCCMH’s “reassessment” ignored the ALJ’s determination and denied Mr. Wiesner any increase at all.

“For more than 50 years, the Constitution and federal statutes have guaranteed public benefit recipients the right to an impartial determination of their benefits,” said Ed Krugman, a senior attorney at NCLEJ, “The Michigan Hamster Wheel makes a mockery of that right. Kevin Wiesner fought for the services he needs, and he won, but he got precisely nothing. That is a travesty.”

“The Medicaid Fair Hearing System is supposed to give recipients the right to challenge actions that negatively affect their benefits,” said Kyle Williams, legal director for MPAS. “If administrative law judges are only allowed to order reassessments, they can never win those challenges, because the reassessment decision is ultimately in the hands of the agency that took the negative action in the first place.”

Nick Gable, attorney for LSSCM, offered a similar thought. “The Medicaid fair hearing “Hamster Wheel” has been a problem for years, to the point that appeals challenging personal care or home and community-based support services denials are rendered futile. A legal challenge to the Hamster Wheel is overdue.”

The suit names WCCMH, Community Mental Health Partnership of Southeast Michigan, their directors, and Michigan Department of Health and Human Services Director Robert Gordon as defendants. The requested relief seeks to end the practice of ALJs remanding cases without ordering specific relief for Medicaid recipients.

Michigan Protection and Advocacy Service, Inc. (MPAS) is the independent, private, nonprofit organization designated by the governor of the State of Michigan to advocate and protect the legal rights of people with disabilities in Michigan.
www.mpas.org

Since 1965, the National Center for Law and Economic Justice (NCLEJ) has worked with low-income families, individuals, communities, and a wide range of organizations to advance the cause of economic justice through litigation, policy work, and support of grassroots organizing around the country.
www.nclej.org

Legal Services of South Central Michigan provides free legal advice and representation to low-income individuals, families, and older adults.
www.lsscm.org

###

For more information, contact:

Mark McWilliams
mmcwilliams@mpas.org

or Edward P. Krugman

krugman@nclej.org

Kerry Kafafian [kerrykafafian@gmail.com ], Kevin's mom, is also willing to provide more information about the lawsuit.

Michigan Update on Covid-19 Policies and More...

The ARC Michigan is the largest organization in the state advocating for people with developmental disabilities. As the parent of two sons with profound intellectual and developmental disabilities (IDD), I often disagree with the policies the organization has promoted over the years that ignore the real-life consequences of severe disabilities on the individual and his or her family. Along with many other disability advocacy organizations, the Arc attempts to promote public acceptance of disabled individuals by painting a rosy and unrealistic picture of life with a disability and applies it to all who fall under that category. I do give them credit, however, for making available information that individuals and families need to participate in effecting change in government policies.

The ARC Michigan e-newsletter update has timely information on legislation, other state and national policies, and recent court decisions affecting people with IDD. The archives for the newsletter are available on the website. You can also sign up to receive the newsletter by e-mail.
 
This is from the May 29, 2020, Government Affairs Update from RWC Advocacy, A Governmental Affairs Law Firm in Lansing, Michigan:

Emergency Authorities & COVID-related Legislation

The Michigan House of Representatives has yet to take action on Senate Bill 690, which provides $523 million in supplemental appropriations for Fiscal Year 2020 from the federal coronavirus relief fund for various purposes, most notable of which is the inclusion of a $3/hour increase for direct care worker wages. [emphasis added] We can likely expect the supplemental to move the first week of June.

[This appears on page 11 of the bill: DEPARTMENT OF HEALTH AND HUMAN SERVICES

Section 451. (1) From the funds appropriated in part 1 for pay enhancement for direct care workers, the department of health and human services shall provide sufficient funding to increase the wages paid to direct care workers described in subsection (2) by $3.00 per hour above the rates paid on March 1, 2020 retroactive to April 1, 2020 through September 30, 2020.
(2) The direct care wage increase shall be provided to direct care workers employed by the department of health and human services, its contractors, and its subcontractors who received a state-funded wage increase in April 2020. The total combined increase from the April 2020 wage increase and the wage increase outlined in this section shall be $3.00 per hour and shall be in effect from April 1, 2020 to September 30, 2020.
(3) A direct care wage increase of $3.00 per hour shall be provided to direct care workers employed by skilled nursing facilities, retroactive to April 1, 2020 and shall continue until September 30, 2020.
(4) Contractors and subcontractors receiving funding to support these pay enhancements shall be required to provide documentation of the wage increases provided pursuant to this section to the department of health and human services.
(5) Any payment enhancement above the hourly rate in effect on March 1, 2020 shall be of no effect in determining any employee's average compensation as provided by any contract or other provision of law...]
 
[The bill is 18 pages long and contains funding information on many other departments of state government. To find out more, read the bill.]
 
Stay Home, Stay Safe 

On Thursday, May 21, Governor Whitmer announced that she signed another iteration of the Stay Home, Stay Safe order – Executive Order 2020-96 – reaffirming the measures set forth in the previous order but taking the following new actions:

• Repeal of Executive Orders 2020-17 and 2020-34, which imposed a prohibition on elective dental, medical and veterinary services statewide, beginning on Friday, May 29 at 12:01 a.m.

• Allowing statewide reopening of auto showrooms, by appointment only, on Tuesday, May 26.

• Allowing statewide retail, by appointment only, starting on Tuesday, May 26. Stores will be limited to 10 customers at any one time.

• Allowing statewide gatherings of 10 people or less are allowed, but necessary health and safety measures should be used.
...

...Executive Authority Lawsuit
 
Judge Cynthia Stevens issued a ruling in the Michigan Court of Claims on Thursday, May 21 in Michigan House v. Whitmer upholding the Governor’s authority to declare a state of emergency under the Emergency Powers of the Governor Act of 1945. However, the judge also ruled that the Governor could not declare a state of emergency and disaster declaration under the Emergency Management Act of 1975 without legislative intervention.
 
[The Governor also has authority under the Emergency Powers of Governor Act of 1945 that does not require the intervention of the legislature.]

See more about Medicaid funding and the legislative attempt to direct funds from recent federal legislation to help the state get through the financial disaster that the corona virus has created.

Washtenaw County: Notes on the WCCMH Board Meeting for 5/17/19

I apologize for the use of so many acronyms, but I have tried to make sure to explain what they stand for at least one time for each. This is typical of administrative meetings where the acronyms fly fast and furiously. Their use is an understandable convenience for the people involved, but when they go unexplained, they add to the confusion of innocent bystanders.

Washtenaw County Community Mental Health (WCCMH) Board meetings are usually held on the third Friday of the month from 9:30 to 11:30 a.m. at the Learning Resource Center (LRC), 4135 Washtenaw Ave, Ann Arbor, MI 48108. Board materials for the 5/17/19 meeting are posted on line.

The current financial status report included a discussion of the continuing problem with the mysterious “migration” of consumers [clients of WCCMH] from regular Medicaid that covers DABS - people who are Disabled, Aged, and Blind - to the Healthy Michigan Plan (HMP). HMP is Michigan’s version of Medicaid expansion under Obamacare. Medicaid reimbursement rates to CMH for services are much lower for the HMP than for regular Medicaid. Later in the meeting, this came up again - when someone who has “migrated” to the HMP is re-identified as a DAB, there is no retroactive compensation to CMH for lost funding. Also, when someone is part of the HMP, they are limited to 3 years on that plan and a work requirement has been added for many of its beneficiaries. 

During the Executive Director’s report, an observation was made that 20 years ago CMH decided to “philosophically” oppose group homes in favor of supported living in one’s own or family’s home with an emphasis on “self-determination”. There are still group homes - my sons live in one of them. In my opinion, having decisions based on a philosophical argument from a public agency rather than on individual need is a mistake that is detrimental to people with DD and their families. “Self-determination” as a method of delivering services, can be helpful to people with DD, even for people with severe intellectual disabilities who are under guardianship, but often it is not. It sometimes amounts to a shift in responsibility, from the public agency to the family, for finding and supervising services. Adding these administrative burdens to the already relentless task of caring for someone with a severe disability can be crushing. “Self-determination”, in the usual meaning of having control of one’s life, is not always achievable, especially for someone with severe intellectual or behavioral disabilities.

The Community Mental Health Partnership of Southeast Michigan (CMHPSM) is the regional administrative agency that passes Medicaid funds from the state and federal government to a four-county area in Southeast Michigan. The CMHPSM is improving its administrative functions and is seeking a permanent Executive Director. It is also dealing better with personnel issues than had been previously reported. 

A presentation was given on the Direct Care Worker crisis by CMH staff and Scott Brown from Renaissance Community Homes. A Power Point presentation  accompanied a report called “Deconstructing the Direct Care Service Crisis” concerning a proposal to implement recommendations made three years ago by a legislative workgroup to improve wages and working conditions for direct care workers that was largely ignored by the state. The presentation emphasized how the crisis undermines care and support to CMH consumers and is imposing extraordinary costs on provider agencies causing many of them to go out of business.

I will be discussing these proposals in a future blog post.

***************************
At the June meeting of the WCCMH, there will be a discussion of services for people with developmental disabilities: 

June 21, 2019 
4135 Washtenaw Ave, LRC Room Michigan 9:30-11:30am
Ann Arbor  

Washtenaw County: Notes on the WCCMH Board Meeting for 4/19/19

Washtenaw Community Mental Health Board meetings are usually held on the third Friday of the month from 9:30 to 11:30 a.m. The timing alone may explain why there are so few members of the public who attend the meetings or take the opportunity to speak to the Board during the time set aside for public participation. Most of the attendees are Board members, WCCMH staff, or people who have been invited to talk to the Board on specific topics. 

At the WCCMH Board meeting on April 19, 2019, there were at least half a dozen members of the public who made comments during public participation, many of whom had participated in state House budget hearings on 4/11/19 in Lansing. Those hearings can be viewed on Michigan House TV. 

The April 11th Agenda for the House Appropriations Subcommittee on Health and Human Services included an Overview of the FY 2019 - 20 Executive Recommendation for Behavioral Health and State Hospitals by the DHHS (Department of Health and Human Services) and Public Testimony on the DHHS Budget Recommendation. Public comments begin at around 1 hour and 10 minutes into the video. There were a number of commenters from Washtenaw County, most speaking about the benefits of services for people with severe mental illness and a few representing people with developmental disabilities. A provider of services who is also a parent, said that Monroe CMH is far behind in reimbursing providers like himself for services and that this has a domino effect on families, clients, and employees. Some spoke against the privatization of mental health services and others bravely spoke of their experiences with severe mental illness and surviving seemingly hopeless situations, including childhood sexual abuse.

The agenda and other materials for the 4/19/19 Board meeting are available on the Washtenaw County website. The public part of the meeting was cut short for a closed session to discuss pending litigation that challenges the State’s underfunding of Community Mental Health agencies. As I understand it, these agencies are put in the position of having to either cut services that they are mandated to provide or to violate mandates against budget deficits that they are unable to cover with funding reserves because they have been depleted by underfunding. In current state budgets, there has been a slight increase in general appropriations that can include spending on services to people who are not eligilble for Medicaid.

A notable development is that Jane Terwilliger has resigned as the Executive Director of the 4-county Community Mental Health Partnership of Southeast Michigan (CMHPSM). This followed the results of a survey that was highly critical of her performance. The COO (Chief Operating Officer) is now heading the organization and there will be a search for a new Executive Director.

Another part of the meeting focused on Board Committee structure and planning for services funded by the 2017 Washtenaw County millage to improve mental health services and safety. As I have said before, my interest is usually in subjects connected with services to people with intellectual and developmental disabilities. If you are interested in how the WCCMH is funded and spends available resources, the Agenda package includes detailed financial information on this subject.

Wayne County, MI, Advocates for IDD: Workshops on Medicaid, employment, and housing

This is an announcement of events in Wayne County, Michigan, from parent/advocate Ed Diegel:

During the last several election cycles I heard only Barack Obama mention that in addition to providing Medical services to the needy, Medicaid also provides funding for the intellectually and developmentally disabled, the mentally ill and persons suffering with substance abuse. Furthermore, in my state district during the 2018 election,  the Michigan Republican Party flooded the district with fliers suggesting that extending Medicaid would only extend Medicaid fraud, inferring in effect that all Medicaid recipients are lazy and fraudulent. 

My friends, it is you and I who are responsible for allowing politicians and our friends and neighbors to harbor the idea that Medicaid is BAD. We need to do a much better job of being honest and effective and speaking out about the tremendous benefit to our individuals and communities that this program delivers. In addition there are issues being discussed in Lansing and Washington that have potentially severe impacts across the board and specifically on funding and on group home and workshop settings that need our attention.

Community Opportunity Center together with STEP and MALA is sponsoring the legislative issues and advocacy training workshop described below. Persons ready to speak up are encouraged to sign up for the workshop. Position papers of current issues, tips on effective lobbying and legislator town hall and in district coffee schedules will be provided.

Two workshop dates are available. Please see the following for detail:

++++++++++++++++++++++++

You Are Encouraged To Attend A Family Advocacy Training Session

Sponsored by: Community Opportunity Center and Services to Enhance Potential

Two Sessions Offered:

February 12, 2019 5pm-8pm

February 16, 2019 10am-2pm

Location: Community Opportunity Center
14147 Farmington Rd., Livonia, MI 48154

Educating legislators about the importance of Medicaid funding and about the needs and circumstances of our loved ones is essential if we wish to influence legislation and funding sources for their benefit. Issues related to housing and employment are under review and new legislation has been created at the federal level, which may have an impact on services our loved ones receive. For this reason, COC and STEP would like to meet with interested families and other support persons to discuss these issues and create an advocacy group, which in turn can share information with local, state, and Federal legislators regarding the impact of these legislative changes. 

If you wish to attend one of these sessions and to learn more about these issues, please contact Joyce Franks at, 734-422-1020 or jfranks@cochomes.net by Friday February 8, 2019. 

+++++++++++++++++++++++

Thanks, I hope to see you at the session. It's up to us to spread the word!!! 

Ed Diegel,

Advocates for Persons with Developmental Disabilities in Wayne County.
ddadvocates@gmail.com

Michigan: Law affecting minimum wage and sick leave is undermined by lame duck legislature

December 3, 2018

What the legislature giveth, the Lame Ducks taketh away...

The Michigan Community Mental Health system that provides services to people with developmental and other disabilities is in a crisis caused in part by the low wages of direct service professionals who provide care to people with disabilities. Whether an individual lives in a licensed setting or unlicensed home of their own or shares a home with others or with their family, the help they need to survive is often provided by a caregiver paid for by Medicaid.

Before the November 2018 election, hundreds of thousands of signatures were gathered to support a ballot initiative that would raise the state’s minimum wage to $12/hour by 2022 and allow employees to accumulate sick leave of 1 hour for every 30 days worked. The ballot initiative proved to be extremely popular which prompted the legislature to pass a law that would do exactly what the ballot initiative would do, but with the intention of amending the law during the lame duck session to scale way back on its requirements. This is exactly what happened. A bill scaling back the promises of the ballot initiative has passed the Michigan Senate and is now in the Michigan House of Representatives.

According to the Community Mental Health Association of Michigan (CMHAM) and other state organizations, a wage increase above minimum wage for direct care workers is needed to stabilize the work force that now has a 37% turnover rate. The difficulty and responsibility of the jobs these workers perform should be recognized and supported with better pay and working conditions.

Further complicating the CMH crisis is the necessity for the legislature to assure adequate Medicaid funding to pay workers to provide the services needed for people with disabilities. An increase in the minimum wage overall should bring an upward pressure to raise wages for direct care workers and to acknowledge the importance of adequate Medicaid funding to provide services. 

**********************

More on the need to raise direct care workers wages above minimum wage...

See also, "Michigan state senators on Wednesday dramatically scaled back two citizen-backed laws to raise the minimum wage and require paid sick leave."

And furthermore, this is from a Detroit Free Press column by Brian Dickerson on  12/2/18: 

• Lock 148 elected representatives in a couple of large rooms.
• Remind those assembled that more than a third of them will be out of their jobs in 30 days.
• Sit back and enjoy the fun as dozens of lawmakers with nothing left to lose take the $57-billion-a-year enterprise called the State of Michigan for one last, wild spin around the block.

"What could possibly go wrong?"

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.

***************************************

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.]

********************************

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. 

************************************** 

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...)

******************************
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's Direct Care Worker Staffing Crisis

Michigan’s Community Mental Health system serves people with intellectual and developmental disabilities, mental illness and substance use disorders. Crain's Detroit Business featured an article on 10/21/18 on the "Staffing Crisis of direct care mental health workers faces clients, families" by Jay Greene. The article covers a Crain’s health summit panel that was chaired by Robert Stein, the general counsel for the Michigan Assisted Living Association (MALA). MALA represents providers of assisted living and similar services including mental health services to people with developmental and other disabilities. [note: direct care workers are also known as Direct Support Professional or DSPs.]

According to Stein, “We have a real crisis with support services to people with disabilities…Wage levels are not competitive with retail companies, fast food restaurants and others. The funding levels have been constrained for many years.”

A MALA survey found “the average turnover rate for agencies providing staff is 37 percent, the starting wage is $10.46 per hour and the average number of open positions for full-time staff is 12 percent, 20 percent for part-time staff.”

Although the legislature “approved $64 million in additional funding in the fiscal 2018 budget to increase the average hourly rate by 50 cents..”, the panel characterized this as a “drop in the bucket”.

The article quotes Robert White, a parent advocate who has two adult sons with autism, as commenting that "Paying [direct service professional] $2 above the minimum wage (of $10 per hour) prevents more people from leaving the system. …We also need a supplemental budget in the lame duck session and future budgets to come [that] must have non-negotiated budget items. We can't kick the can down the road. It is an infrastructure requirement, a civil and constitutional right to have these services like good roads, good education and clean water to drink." [emphasis added]

Here is a quote from State Rep. Christine Greig, D-Farmington Hills, the Michigan House Democratic Floor Leader:

"I get really frustrated by state government and how we fund things,…We talk about integration. We should be talking about great quality care, not about money. You start from an outcomes standpoint. What does the provider, patient need in services. The money flows from that."

[I agree, and I wish more legislators and advocates would support this approach to funding services, rather than promoting the idea that full inclusion in the “community” is the highest and only worthwhile goal of our our system of services.]

The panel also discussed the kinds of things that direct care givers do:

Robert White says in response: ”My older son has high medical needs, 24-7 supervision, in taking the meds he needs, bathing ... nutrition, safety, socialization in the community…The home he is in is currently understaffed. Managers are actively taking shifts. Many caregivers work many shifts. There is mental and physical fatigue, possible errors. It is not their fault. They are truly their lifeline."

John Williams, executive director of Progressive Lifestyles Inc., pointed out that "A lot of staff work two and three jobs. It is unattractive to get involved. …in many cases, it is a very physical job with wide spectrum of disabilities. One day you will lift somebody from a wheelchair to a bed. (The next day) help people move in, repair a stove, fix a washing machine. It's a very demanding job."

According to the article, Stein said MALA and others are “starting a grass roots effort to lobby state legislators to add a line item in the Medicaid supplemental budget that would amount to an increase of 75 cents per hour.”

Michigan: The Burden of Funding Crises should not be borne by People with Disabilities

Some Michigan Community Mental Health Agencies and administrative regional entities called PIHPs (Prepaid Inpatient Health Plans) are facing diminishing revenues in combination with demands for more services that they are required to provide. Washtenaw County appears to be having difficulties similar to those in Western Michigan, though not as extreme (yet). 

When the response to these fiscal crises is to reduce services to people the agencies are obligated to serve, families and their disabled family members need a refresher course on their rights while demanding that local and state agencies sort out how these shortfalls in funding will be resolved. 

This is a note from DD Advocates of Western Michigan with some good advice on what to do when service reductions are contemplated:

“Note that a Medicaid recipient is entitled to services ‘appropriate to their needs’, not subject to available (or reduced) budgeting. It is the CMH's responsibility to provide all of those appropriate services. It is the state's responsibility to provide adequate funding. The Regional Entity [the PIHP] is the intermediary in this process, possessing the contract for providing eligible Medicaid services through it's provider network and CMH agencies. If the Region does not have adequate funding, then it must press the state to allocate more funds for these needed (required) services. Oversight of individual CMH agency funding and the region's budget is a critical component of its mandate. … Encourage the prohibition of ‘rationing’ in any shape or form. ‘Utilization management’ can just be a buzzword for rationing, and is what the medical insurance business uses to limit their financial exposure. The more they restrict or make difficult to access, the better their bottom line. If a service is appropriate and needed, is Medicaid allowable and requested via the PCP [Person Centered Plan], then insist on its delivery, or challenge any such failure to provide it via the Medicaid Fair Hearing process. Demand what is your entitlement. It's their job to figure out how the provide it.” [emphasis added]

The Disastrous Privatization of Medicaid in Iowa

See more on Iowa's managed care disaster here.

Iowa: Managed Care and Privatization of Disability Services Create a Crisis

https://www.desmoinesregister.com/videos/news/2018/01/17/disabled-iowans-struggle-managed-care/109548320/

What's the matter with Iowa? Managed care and privatization of Medicaid for the State's poor and disabled have created a crisis in the delivery of Medicaid services. The Des Moines Register features over 60 articles from 2015 to the present reporting on the rocky road to the takeover of Medicaid by private health insurance companies.

Michigan should take note. We have a modified managed care system that so far preserves services provided by public Community Mental Health agencies and (at least theoretically) ensures that all medically necessary services will be provided to people with developmental and other disabilities. The move to privatize all services under private Medicaid Health Plans (MHP) is underway, however, with the implementation of three pilot projects and one demonstration program in the state.

Here is a sampling of articles from the Des Moines Register:

The Register’s Editorial: Medicaid plan is gift for private firms, 3/22/15

The Des Moines Register foresaw problems with the idea of privatized managed care for Iowa’s poor and disabled citizens. The editorial board encouraged the public to be skeptical, especially when the state throw’s out numbers, out of context, to show how expensive Medicaid is. It turns out that in 2015, Iowa was doing pretty well in serving people with disabilities and other low income citizens and keeping costs down in comparison to other states:

“In fiscal year 2013, a Medicaid recipient in this state cost an average of $5,491 — less than the per-person cost in 29 other states and much less than people insured by private coverage. For an adult who is not a senior or disabled, Iowa spent an average of $2,000 on health care, less than that spent in 47 other states, according to research from the Kaiser Family Foundation. Health insurance for a state lawmaker costs Iowa taxpayers about $9,000 per year.”

...“Administrative costs are low because the program is largely managed by the government, which is not beholden to stockholders or obligated to pay huge CEO salaries. The cost of operating the program is currently 4 to 8 percent, according to the Iowa Department of Human Services, which oversees Medicaid. When privatized, the cost could grow to as much as 15 percent. Those are dollars not spent on actual health care.”

...“In its comments to state officials, the Iowa Hospital Association noted that managed care companies reduce costs by denying coverage for services, including emergency room visits. The association is 'deeply concerned' that the private model could reduce access to care and reimbursement rates for providers.”

Branstad touts Medicaid contracts, but few hospitals signed

by Tony Leys, tleys@dmreg.com, 11/19/15

Signs of trouble. The takeover of Medicaid by private health plans was scheduled to go into effect January 1st, 2016 [the starting date was later moved to April 1, 2016], but by November 2015, most hospitals and physicians had not signed contracts to participate in the new system.

“Gov. Terry Branstad, who is pushing to shift management of the state’s Medicaid program to private companies on Jan. 1, said Thursday that the firms have signed more than 12,000 contracts with pharmacies, doctors and other health care providers.

“But most Iowa hospitals and physicians have not signed contracts to participate in the new system, according to the Department of Human Services. The issue is important, because the managed-care companies are supposed to show they have broad networks of health care providers willing to care for the new plans' members."

…"None of the four managed-care companies reported signing more than 17 of the 118 Iowa hospitals now participating in Medicaid. One of the companies, WellCare of Iowa, said it hadn’t signed up any hospitals. Another, AmeriHealth, said it had signed up just two.”

…”Branstad contends the shift to managed-care companies will save millions of dollars for the state and federal governments while offering flexibility and coordinated care to Medicaid recipients.

“Critics fear the change to for-profit management will lead to service cuts. They say Iowa’s 560,000 Medicaid recipients are being put in the impossible position of choosing a managed-care plan next month without knowing whether their doctors, hospitals and other health care providers will be participating in any of the networks.”

Iowa Medicaid payment shortages are 'catastrophic,' private managers tell state

by Tony Leys, tleys@dmreg.com 12/21/16

By December 2016:

“The for-profit companies running Iowa’s Medicaid program have been complaining to state administrators that the controversial project is 'drastically underfunded' and that the situation has been a 'catastrophic experience,' newly released documents show.

"One managed care executive wrote that Iowa’s recent offer to give the companies an extra $127.7 million in state and federal money this budget year 'is not acceptable.' He added that without major changes, the privately run Medicaid program could be unsustainable.”

…”Gov. Terry Branstad last year ordered the shift to private Medicaid management, which took effect April 1. Branstad, a Republican, predicted the private companies could allow the state to save tens of millions of dollars by helping the program’s 600,000 poor or disabled participants stay healthy. Critics are skeptical of the savings estimates, and they say the main effect of the switch has been to tangle Medicaid recipients and care providers in red tape.”

….”During a Statehouse hearing last week, a Democratic legislator asked executives of the three companies if they planned to ask for big raises in their payments for next fiscal year. They declined to answer.

“We really just don’t discuss those things in public settings,” Cheryl Harding, who is Iowa president for AmeriHealth Caritas, told Sen. Joe Bolkcom of Iowa City.”

Nevertheless, the health care plans complained that the plans were vastly underfunded and unsustainable. 

State should hold managed care accountable 

by Michael Bugeja, Iowa View contributor, 7/29/17 

This is the editorial viewpoint from a conservative Republican: The writer refers to a teenage “victim” of Medicaid who has a severe mental illness. Medicaid is pressuring treatment facilities to shorten the length of treatment regardless of the recommendation of the professionals involved. 

“As the former director of the Greenlee School at Iowa State University, I know Gov. Terry Branstad. I usually sat next to him at the Iowa Newspaper Association convention head table. I have the utmost respect for Gov. Branstad. His service to the state of Iowa is exemplary. But he made one colossal misjudgment in privatizing services for the mentally ill and others dependent on Medicaid services and managed care. 

"As a fiscal conservative Republican, I understand why he did it and why he believed that privatization saves the state millions of dollars. It may appear so on the surface, but savings in one area often results in expenses in others, and Iowa communities are paying the price.” 

AmeriHealth's exit should curtail disabled residents' suit against Iowa, state lawyers say

by Tony Leys, tleys@dmreg.com 11/6/17

A class action lawsuit was filed in June 2017 by Disability Rights Iowa on behalf of 6 disabled Iowans, “who argue that the state’s shift to private management of Medicaid led to illegal cuts to their in-home care services. The plaintiffs say without those services, they could be forced to move into nursing homes, violating their constitutional rights.” The class action is on behalf of about 15,000 Iowans with disabilities.

Meanwhile, Amerihealth Caritas, one of the Managed Care Companies announced that it is dropping out of the state’s Medicaid program, “because of a contract dispute. The state lawyers noted in a court filing last week that AmeriHealth oversees Medicaid benefits for all six initial plaintiffs in the Disability Rights Iowa lawsuit. None have had their benefits overseen by the remaining two managed-care companies, UnitedHealthcare and Amerigroup.”


By its very design, managed-care Medicaid discriminates against severely disabled Iowans

by Bill Dodds, Iowa View contributor, 1/26/18

"By its very design, managed-care Medicaid discriminates against disabled Iowans who require costly, long-term treatments simply to live in their communities. It’s the only way today’s managed-care organizations (MCOs) can deliver on their promise to slow the growth of Medicaid spending and generate profit for shareholders.

"Iowa, like many states, has sought to gain control over the increasing costs of its Medicaid program by doing away with a state-run system in favor of managed care. This has resulted in state contracts with multiple managed-care organizations in an attempt to incent these companies to compete in Iowa for Medicaid members by offering services that best meet their needs while simultaneously reducing costs.

"This might sound good in concept but is difficult to achieve in reality, especially for recipients who have severe mental illness and disabilities. At Optimae, we have seen this play out daily in the lives of the more than 5,300 Iowans we serve."

…"It is virtually impossible for an MCO [Managed Care Organization] to determine which of the millions of units of services provided each year is truly 'medically necessary,' given that more than 600,000 Iowans receive services under Medicaid. To compensate, the companies focus on managing the most expensive services, especially those that are long-term. This includes longer term inpatient and outpatient services, including home health and home- and community-based services for individuals with disabilities, and nursing and residential care facilities."

…”Additionally, the MCOs in Iowa and most other states are publicly traded, for-profit companies. Their management is under pressure to constantly produce better financial results for shareholders, meaning taxpayer dollars that previously paid for Medicaid services are now set aside for profits. This puts the most expensive services at even greater risk for reductions by the MCOs regardless of the outcome."

Iowa House passes Medicaid cleanup bill in effort to address managed care woes 

by Brianne Pfannenstiel, bpfannenst@dmreg.com, 3/8/18

“The Iowa House of Representatives approved legislation Thursday that lawmakers said would begin to fix some of the problems that have plagued the state's Medicaid system. "

...“The Iowa House of Representatives approved legislation Thursday that lawmakers said would begin to fix some of the problems that have plagued the state's Medicaid system. “

Iowa privatization of Medicaid generates complaints

As Iowa experiments with the privatization of its Medicaid program, complaints have spiked. Is Michigan paying attention?

*************************

As Medicaid Managed Care Proliferates, So Do Complaints


by Clay Masters, Iowa Public Radio | November 6, 2017

Iowa is one of 38 states that radically changed the way it runs Medicaid over the past few years. The state moved about 600,000 people on the government-run health program into care that is managed by for-profit insurance companies.

The idea is that the private companies would save the state money, but it has been a rocky transition in Iowa, especially for people like Neal Siegel.

Siegel is one of six Iowans with disabilities suing the state, alleging that Medicaid managed care, as it is known, deprives thousands of Iowans with disabilities the right to live safely in their homes.

Medicaid serves people with disabilities, low-income people and people in nursing homes. A combination of federal and state funds pays for it. It covers 74 million people across the country these days, about half of whom are in Medicaid managed care.

Siegel, a former financial consultant, was in a hit-and-run bicycle crash four years ago that left him with a severe brain injury. He uses a wheelchair and can barely speak.

“I would probably put Neal at about 98 percent cognitive (awareness) of what’s going on around him, but unfortunately (he’s) not able to articulate it,” said Siegel’s girlfriend, Beth Wargo. “So it’s being trapped inside your own body.”

After the accident, Siegel qualified for Medicaid. He lived in a rehabilitation center for a while, and the lawsuit, filed in U.S. District Court in June, says he was the victim of abuse and neglect while living there.

Eventually he moved home with Wargo, where he’s totally reliant on caregivers to assist him with all activities of daily life.

Then last year, Wargo said, they got a letter in the mail from AmeriHealth Caritas, the company that manages his care. Siegel’s budget for home help had been slashed by 50 percent, Wargo said. Siegel’s face lit up as Wargo talked about the lawsuit, and he managed to say, “Oh yeah,” when she mentioned how happy they were that they could be part of it.

Cyndy Miller is the legal director with Disability Rights Iowa, the advocacy group that spearheaded the lawsuit.

“The system is too stressed right now with the way it’s being managed, and it’s not healthy for individuals with chronic or serious disabilities,” said Miller.

According to the lawsuit, the company claimed that spending on Siegel’s case was cut because it had exceeded a limit set in state policy. A spokesman for AmeriHealth Caritas said the company could not comment on ongoing litigation. The state has asked for the lawsuit to be dropped.

In addition to the suit, complaints about Medicaid from hospitals, doctors and patients have spiked in Iowa.

Iowa’s Department of Human Services Director Jerry Foxhoven defended moving the entire Medicaid population to managed care. He said more taxpayer dollars will be saved under private management.

But he said his agency is willing to make changes, especially for people like Neal with serious disabilities.

“Everything’s always on the table. We’re always looking at everything to say, ‘How do we best serve the people we’re trying to serve and be the best stewards of taxpayer dollars?'” Foxhoven said.

For their part, the three companies with contracts in Iowa said in statements that the first 18 months of Medicaid managed care have been successful. But they also have said to state officials that reimbursement rates were based on deeply flawed cost estimatesprovided to them before the project began.

They are now negotiating to get millions of dollars more in state funding.

So where’s the savings? So far, no state has actually done a comprehensive review of whether private companies actually save Medicaid dollars, said Kelly Whitener, an associate professor with Georgetown University who studies managed care.

“You’d really need to be able to see, are you saving money overall or not, and if you are spending less money, are you suppressing services that are needed? Or are you really finding efficiencies and only delivering care that families really need?” said Whitener.

For the moment, those questions don’t have definitive answers.

Meanwhile, Iowa has to balance its books. Republican Gov. Kim Reynolds had to tap more than $260 million of the state’s reserve fund this year, and officials expect next year’s budget will be even tougher to negotiate. Medicaid funding is likely to continue to be a large part of the discussion.

This story is part of a reporting partnership with NPR, Iowa Public Radio and Kaiser Health News. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.