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