Bad News/Good News in Michigan’s budget wars

October 1st was the beginning of the 2020 fiscal year in Michigan, which meant that at least 16 different budget bills had to be approved to avoid a government shutdown. The intransigence of the legislature and the Governor’s office in finding a way to iron out entrenched differences was resolved by Governor Whitmer. She used the line item veto to achieve a balanced budget and a maneuver used by former Governor John Engler in the 1990’s to shift money around within departments. Governor Whitmer issued 147 line item vetoes totaling $947 million as a way to restart negotiations with the Republican legislature.

According to an email from DDAdvocates of Western Michigan,

“The bad news is that our Governor has vetoed $1 Billion in budget items. The good news is that Sec 298 was one of the items in the $80 Million MDHHS budget cuts. Presumably, a period of negotiations with the Legislature will commence; this is an opportunity to communicate with your Legislators about the need to delete the 298 funding permanently.”

“Section 298” has been a controversial section of state law that promotes the privatization of community mental health behavioral services, including the social services that allow people with disabilities to live safely in community settings. Medicaid funding that is now administered by local Community Mental Health agencies would be handed over to Medicaid Health Plans that manage the medical side of Medicaid but have little experience in providing residential and other services needed by people with disabilities.

I assume that all local and regional newspapers will be covering this in detail. Here is a summary of the main issues from "Bridge, Michigan's non-partisan, nonprofit news source".

From the Section 298 Team: More opportunities for public input in mental health reform

Total eclipse

August 30, 2017

From the Michigan Department of Health and Human Services, Section 298 Team:

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Dear stakeholders,

Over the last two years, the Michigan health care community has been engaged in a statewide discussion on improving the coordination of physical health and behavioral health services. This discussion is known as the Section 298 Initiative. This initiative is based upon Section 298 in the Public Act 268 of 2016. Under Section 298, the Michigan Legislature directed the Michigan Department of Health and Human Services to develop a set of recommendations “regarding the most effective financing model and policies for behavioral health services in order to improve the coordination of behavioral and physical health services for individuals with mental illnesses, intellectual and developmental disabilities, and substance use disorders.” MDHHS submitted a final report with recommendations for the Michigan Legislature on March 15, 2017.

The Michigan legislature approved a revised version of Section 298 as part of Public Act 107 of 2017. Under the revised Section 298, the Michigan legislature directed the Michigan Department of Health and Human Services to develop and implement up to three pilots and one demonstration model to test the integration of physical health and behavioral health services. The department will be working with stakeholders across the Michigan health care community to develop and implement the pilots and demonstration model over the next few years.

Under the revised Section 298 language, the Michigan legislature also directed the department to recruit a project facilitator to assist with the development and implementation of the pilots and demonstration model. The department has designated the Michigan Public Health Institute as the project facilitator for the Section 298 Initiative. The Michigan Public Health Institute will provide support to the department with supporting stakeholder discussions and managing the development and implementation process. Jo Anna Trierweiler will serve as the main project facilitator, and Jane Pilditch will serve as the co-facilitator.

The department will be working with the project facilitator to announce the next phase of the Section 298 discussion in September 2017. The next phase will focus on (1) the development of the structure of the pilot(s) and demonstration model and (2) the development of the evaluation process. The department will be also be contracting with one of Michigan’s research universities to support the evaluation process. The department will provide additional information about the next phase of the Section 298 Initiative in the near future.

We look forward to continuing to work with you on improving the coordination of physical health and behavioral health services for Michiganders. If you have any questions about this email or the Section 298 Initiative, please send an email to MDHHS-298@michigan.gov.

Sincerely,

The Section 298 Team
Michigan Department of Health and Human Services

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Background on the Section 298 Initiative

Michigan compromise budget for mental health: stalls complete takeover by medicaid health plans & funds pilot programs

In May 2017, The DD News Blog covered proposed radical changes to how services for people with developmental disabilities, mental illness, and substance abuse disorders will be delivered and who will be in control of the Medicaid dollars that pay for those services. The intent of proposed legislation was the eventual privatization of mental health services by “integrating” mental health and medical Medicaid services under the control of Michigan’s private Medicaid Health Plans.

The final budget compromise has at least stalled the complete privatization of the mental health system. The compromise preserves the current ten Prepaid In Patient Health Plans (PIHPs), regional administrative agency that distribute Medicaid funding for Mental Health services. There will also be as many as four pilot programs to test whether privatization, i.e. handing over control of Medicaid funding for mental health services to Michigan’s Medicaid Health Plans, can lower costs and expand services.

These are excerpts from an article in Crain’s Detroit Business, “Budget deal advances plan to test Medicaid mental health integration” by Jay Greene, 6/20/17.

“The budget deal allocates $2.8 million the first year to the fiscal 2017 budget to plan the pilots, and $3.1 million for fiscal 2018, which starts Oct. 1, to fund the pilots themselves. The $5.9 million funding includes $2 million in general state tax funds.

“The implementation of the pilots will be overseen by the state Department of Health and Human Services, which must hire by Aug. 1 an experienced project facilitator. The manager must establish performance metrics and pilot plans.”
…
“Over the past 18 months, Michigan's 11 Medicaid health plans have lobbied legislators and the public to try a semi-privatized approach. They contend they can run an efficient $11.6 billion integrated delivery system, save the state several hundred million dollars of administrative money and plow back the savings into expanded services. There are an estimated 350,000 people in the state's Medicaid program with mental illness, developmental and intellectual disabilities, and substance abuse problems.

“But mental health advocates, providers and families object to Medicaid HMOs taking over the system — even to test an integrated approach with which more than two dozen states are experimenting. They believe health plans have insufficient experience at overseeing complex populations and argue that private profit motivations of the health plans will trump public service.”
…
“[State Senator Mike] Shirkey, chair of the Senate health policy committee, has told Crain's the Medicaid HMOs will not be able to keep any savings. They must reinvest any savings into expanded services.

“Bob Sheehan, CEO of the Michigan Association of Community Mental Health Boards, said he is concerned that the budget language allows Medicaid health plans to contract outside of the several dozen established community mental health agencies and provider networks.

“‘Making the local community mental health (agency) only one of many providers in the pilot communities will immediately drain dollars from the community's mental health safety net ... leaving it unable to fulfill its statutory safety net role,’ Sheehan said Tuesday night in an email to Crain’s.”

Implementation of the pilot programs will include the following:

• That any changes made to a Medicaid waiver or Medicaid state plan to implement the pilot project must only be in effect for the duration of the pilot project.
• That the project is consistent with the stated core values as identified in the final report of the Section 298 workgroup in Public Act 268 of 2016.
• That updates are provided to the medical care advisory council, behavioral health advisory council and developmental disabilities council.

FYI: Background information on Michigan's infamous Section 298 regarding funding of CMH services

May 25, 2017

This is background information from the Michigan Department of Health and Human Services with links to reports and the text of the proposed FY18 budget. Opinions vary on the intent of the initiative and whether it will be a benefit to the people served:

Background on the Section 298 Initiative

The Section 298 Initiative is a statewide effort to improve the coordination of physical health services and behavioral health services. The initiative started with the publication of the 2017 executive budget, which sparked a statewide discussion on the best approach for coordinating physical health services and behavioral health services. In order to facilitate this discussion, the Lieutenant Governor called an initial meeting of stakeholders, which resulted in the formation of the original 298 Workgroup. This workgroup met five times from March 2016 to June 2016 and produced a final report. This final report included final language for Section 298, a set of “core values” for the initiative, and a set of “design elements” for future discussions.

The Michigan Legislature used the recommendations from the original 298 Workgroup to create a Section 298, which was approved as part of Public Act 268 of 2016. Under the new Section 298, the Michigan Legislature directs the Department to develop a set of recommendations “…Regarding the most effective financing model and policies for behavioral health services in order to improve the coordination of behavioral and physical health services for individuals with mental illnesses, intellectual and developmental disabilities, and substance use disorders.”

The Department convened a new 298 Facilitation Workgroup to assist with the development of the report. The Department and the 298 Facilitation Workgroup have also hosted a series of Affinity Group meetings across Michigan to inform the development of the recommendations. 1,113 Michiganders participated in this process during 45 separate meetings. The Affinity Group meetings included individuals, families, providers, payers and advocates. The Department and the 298 Facilitation Workgroup used the input from these discussions to inform the development of the recommendations.

The Department ultimately submitted two reports to the legislature. The first report was an interim report that was submitted on January 13, 2017. The interim report focused on recommendations for policy changes. The second report was a final report, which was submitted on March 15, 2017. The final report includes the initial policy recommendations and incorporates recommendations on financing models and benchmarks for implementation.

Michigan: Action Alert from CMH Board Association

May 25, 2017

The following is an Action Alert from the MACMHB regarding budget negotiations that affect Community Mental Health services for people with DD and other vulnerable populations:

Action Alert from the Michigan Association of Community Mental Health Boards

May 2017

As you know, both the House and Senate have passed their FY18 budget recommendations. Now legislative leaders will come together to mold their two separate budgets into one compromised budget bill for FY18. These discussions will begin to heat up again this week and should be finalized sometime over the next three weeks.

Now is not the time to ease up, we must have a strong finish to our advocacy efforts. Thanks to your help our last two ACTION ALERTS generated over 2000 emails to House and Senate offices – we need to do even better with this next one!!

REQUEST FOR URGENT ACTION: Please contact your House and Senate members urging them to make sensible changes to the final 298 boilerplate language. Timing is critical, we have roughly three weeks to put pressure on lawmakers as they finalize the FY18 budget. We are asking that you reach out to your lawmakers between now and June 2, urging them to remove the Senate language in Section 234 and to not include health plan run pilot programs in the final version of section 298.

We also need you to ask that the members of your Board of Directors, your staff, and your community partners make those same contacts – SIMPLY FORWARD THEM THE ACTION ALERT. These contacts are critical, legislators must hear from us in order to counter the efforts by others opposed to the public management of the state’s publicly sponsored behavioral health and intellectual/developmental disability services and supports system.

Below are quick talking points: 

REMOVE LANGUAGE – Section 234 of the Senate DHHS budget, specifically language referring to total Medicaid benefit and financial integration by 9/30/20, which would transfer all Medicaid resources to Medicaid Health plans.

This language predetermines the outcome of the process without any input from pilots or other measurables and completely ignores the 298 workgroup process and the will of the people.

INCLUDE LANGUAGE – Ensure that the policy and management role for Michigan’s Medicaid behavioral health and intellectual/developmental disability services and supports system remains public.

Concerns Regarding a Health Plan Run Pilot 

• Health Plans do not have a good track record managing behavioral health services 
• Mild/moderate services track record 
• Duals initiative 
• Less money available for services 
• Higher overhead cost 

What are we trying to accomplish? 

What are we measuring? Outcomes/metrics? 

Click the link below to log in and send your message:
https://www.votervoice.net/BroadcastLinks/3lZEXfKTU-pwR2WYUbnwpg 

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This is from an email I received with the names of specific legislators who will be making decisions as to changes in proposed wording for the FY18 budget:

Senate-Health and Human Services
Appropriation Sub-committee

Dave Hildenbrand (R), Full Appropriation Committee Chair, 29nd Distric-Conference Committee

Jim Marleau (R) 12th District-Conference Committee

Vincent Gregory (D), Minority Vice Chair, 11th District-Conference Committee

Peter MacGregor (R), Vice Chair, 28th District-Conference Committee ?

House-Health and Human Services
Appropriation Sub-committee

Laura Cox (R), Full Appropriation Committee Chair, 19th District-Conference Committee

Edward Canfield (R) Committee Chair, 84th District-Conference Committee

Sue Allor (R) Majority Vice-Chair, 106th District-Conference Committee

Pam Faris (D) Minority Vice-Chair, 48th District-Conference Committee