Here two detailed articles from the Detroit Free Press on the vote by the Michigan Senate to expand Medicaid to cover people earning up to 133% of the poverty level. The first article, "Medicaid expansion passes after heated politicking; 470,000 more Michiganders to get coverage", 8/27/13, covers the nitty gritty and sometimes unseemly wheeling and dealing that it took to get the bill passed. The second article, "Delay in Medicaid expansion to be costly" deals with the consequences of the failure to get a two-thirds majority of the Senate to agree that the bill should take immediate effect. Both articles are by Kathleen Gray from the Detroit Free Press Lansing Bureau.
The passage of Medicaid expansion allows the state to take advantage of extra federal funding available under the Affordable Care Act to cover low-income people. Although the Michigan Senate voted to approve Medicaid expansion, there's a catch. The bill will not take effect until April 1, 2014. This could change after the Michigan legislature comes back in September, if two-thirds of the Senate can agree that it should take effect immediately (meaning on January 1, 2014). If the the legislature fails to pass the bill by a two-thirds majority, the state will have to forgo an estimated $7 million per day in federal funds that would have covered health care for this low-income population.
The effect of Medicaid expansion on adults with developmental disabilities will not be as great as the effect on people with mental illness, although low-income families with disabled children would be likely to benefit from Medicaid expansion. The vast majority of adults with developmental disabilities already meet the eligibility criteria for Medicaid, but many people with mental illness who can work, at least sporadically, have a harder time qualifying. Medicaid expansion will provide Medicaid to mentally ill people who meet the income criteria and also make them eligible for Medicaid-funded mental health services. It should also have a significant impact on low-wage caregivers who do not currently have health insurance.
One reason the bill won enough Republican support to pass was offered by State Senator Kahn: “This bill is about reform. It is a national model,” Kahn said. “The taxes in the Affordable Care Act are billions of dollars. And for us in Michigan, it will be $2 billion siphoned from our people, and we’re going to bring that back to the state.”
Here is addtional information on Medicaid expansion, according to the Detroit Free Press:
Federally-funded Medicaid expansion will cover 320,000 low-income Michiganders next year and 470,000 people by 2020.
"The bill requires the additional recipients [of Medicaid] to contribute 5% of their out-of-pocket medical costs. After 48 months, that co-pay would increase to 7% or the recipient could purchase insurance on the health care exchange...if a person who falls in that poverty level is determined to be “medically frail” — either with a chronic disease, mental illness or are unable to complete the daily tasks of life — they would remain at the 5% co-pay."
The federal government will have to grant waivers to Michigan for two of the provisions of the bill, the creation of health savings accounts for Medicaid recipients and language that allows recipients to choose between a health care exchange or Medicaid benefits after 48 months.
The Medicaid expansion will be fully paid for by the federal government through 2017. The federal contribution would drop to 90% by 2020.
An opinion piece in the New York Times, (8/3/13) by Christine Montross entitled "The Woman Who Ate Cutlery" illustrates the point that trying to save money by making care and treatment for people with mental illness less accessible, does not save anything. Emergency rooms become the only available treatment venue in a crisis - a poor substitute for preventive care before a crisis develops, hospitalizations increase, and sometimes lives are lost.
Problems in the the system of care for people with mental illness often parallel those for people with developmental disabilities. There are many people with developmental disabilities who have unusual and sometimes dangerous behaviors, with the added complication that the person's capacity to communicate their frustrations make it even more difficult to know how to relieve their distress. There are also people with DD whose medical problems, when not addressed early or treated appropriately, can land them in the emergency department with the result that the person receives too little or too much treatment that is almost always more costly than it needs to be.
In "The Woman Who Ate Cutlery", "M" is an extreme case - a woman who ingests knives and forks and other sharp objects and inserts objects and substances into her body to relieve stress caused by mental illness.
According to the article:
"If M had insurance, or enough money to pay out of pocket, she might see a therapist every week for an hour and a psychiatrist once or twice a month. Instead, she’s treated by an overextended, publicly funded mental-health center where she sees a psychiatrist for 20 minutes, four times a year. Not surprisingly, her symptoms persist and she is hospitalized again and again."
"…Our failure to provide a critical, basic level of outpatient psychiatric care to the mentally ill creates a volatile cycle in which uninsured or underinsured patients avail themselves of treatment only when they are in crisis. This is analogous to refusing to treat hypertensive patients — or to monitor their blood pressure — unless they show up in the E.R. after having had a stroke."
"…If M had a regular outpatient psychiatrist, she could call him or her in these moments of distress, schedule an urgent appointment, and obtain treatment and care from a simple phone call. But M does not have a relationship with a provider; she has a relationship with an institution. And the institution requires that M be in imminent danger in order to be treated."
"…According to Dr. E. Fuller Torrey, president of the national nonprofit Treatment Advocacy Center, 'Assisted outpatient treatment has proven to reduce psychiatric hospitalizations by more than 70 percent.'"
Montross concludes, "…we will need to place new societal value on the importance of mental health. Until accessible, affordable mental-health care is a universal right, too many psychiatric patients will continue to receive the reactionary, crisis-driven care that is all our emergency rooms are equipped to provide."
It can be cold up here, even in August. As we were sitting huddled around the fireplace, throwing logs on the fire, this song from the 1970s came to mind. Here it is sung by Tompall Glaser. Lyrics are by Shel Silverstein. This has nothing to do with my personal life, but parts of it ring true for people I know.
This is from the August 2013 newsletter, The Advocate, from The Area Agency on Aging 1-B. AAA 1-B is a nonprofit agency serving the needs of older adults in Livingston, Macomb, Monroe, Oakland, St. Clair, and Washtenaw counties.
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Three Medicaid Reform Proposals Move to Full Senate for Consideration, Vote Likely in Early September
On July 24th, the Senate Medicaid workgroup convened by Majority Leader Randy Richardville (R-Monroe) and led by Senator Roger Kahn, M.D. reported three Medicaid reform proposals; HB 4714 as passed by the House on June 13 with minor changes, SB 422 (Caswell) known as the Michigan Low-Income Health Plan Act, and Senate Bills 459 and 460 (Colbeck) known collectively as the Patient-Centered Care Act. All three bills were sent to the Senate Government Operations Committee and were voted out of committee on July 31st to be sent to the Senate for full consideration, debate and a likely vote will happen in early September.
The decision to move all three Medicaid proposals out of committee for a full senate vote was made by Senate Leader and Government Operations Committee Chair Randy Richardville citing that all three bills have their own merits. Supporters of HB 4714 worry the additional proposals may strip potential votes in favor of SB 422, or 459 and 460.
HB 4714 (S-7): The Healthy Michigan Plan reforms Medicaid to cover individuals with incomes up to 133% of the federal poverty level for up to 48 months with a requirement that the newly insured would pay no more than 5% of their out-of-pocket medical expenses. Following the 48 month period, the newly insured could then remain on Medicaid with an increase in their copayments up to 7% or they could choose to purchase health coverage through the Federal Health Care Exchange.
SB 422: The Michigan Low-Income Health Plan Act would essentially create a state funded alternative to Medicaid. The Act would provide tax credits to those between 133% and 100% of Federal Poverty Level (FPL) to enable the purchase of insurance on the healthcare exchange established by the Affordable Care Act. This bill establishes a Michigan Low-Income Health Plan which would provide health coverage to persons who meet the following criteria; Not eligible for Medicare, Medicaid, or MIChild; Household in-come under 100% of FPL; Under age 65; Not eligible for veterans health benefits; and have no other health insurance coverage.
SB 459, 460: The Patient-Centered Care Act would require the state to license private health exchanges, create the Low-Income Trust Fund, and “migrate” Medicaid recipients to individual health savings accounts from which they could purchase a qualified health plan. The Low-Income Trust Fund would be used to fund the deductibles of former Medicaid or MIChild recipients until the balance of their health savings account is adequate to pay their deductibles.
HB 4714 S-7 closely mirrors the version passed by the house in June and is likely to draw the majority of bipartisan support. Both alternative plans SB 422 and SB 459, 460 are receiving criticism as too costly to the State’s general fund, or as unfeasible given the knowledge and personnel requirements needed to administer the program. Contact your Senator to share your opinion on reforming Medicaid in Michigan
This is from an article in Disability Scoop, "Disability Spending Drops for the First Time in Years" by Michelle Diament, 7/22/13, based on the 2013 State of the States in Developmental Disabilities, a report from the University of Colorado:
"Overall government spending on people with intellectual and developmental disabilities for 2011 — the most recent year for which data is available — was $56.65 billion, the report found.
"Of the funding distributed nationwide that year, about 20 percent went toward programs providing family supports, employment services, personal assistance and similar aid.
"Almost 60 percent went toward residential settings for six or fewer people while 5 percent funded living environments with seven to 15 residents. State-run institutions with 16 or more residents received 11.5 percent of total spending and 3 percent went to institutions that were privately run.
"Nearly 80 percent of government spending on people with intellectual and developmental disabilities was funneled through the Medicaid program in 2011, the report found. Other funding came from the states and federal programs like Social Security."
More information on the State of the States Report was presented here in a Webinar on Feb. 27, 2013, hosted by the American Association on Intellectual and Developmental Disabilities (AAIDD). The presentation shows some disturbing trends:
"Current Trend: Support Services Waivers Characterized By:
"A low dollar cap on the total amount of HCBS Waiver services authorized for each beneficiary
"Flexibility in the selection of services within the dollar cap
"Expectation that unpaid family caregivers will provide significant support to Waiver participants [emphasis added]"
"An Estimated 853 Thousand Persons with I/DD Live at Home with Aging Caregivers"
Intellectual and Developmental Disability (I/DD) spending per $1,000 of state aggregate personal income, shows that Michigan ranks 26th at $3.75, a reduction in spending of 0.2%
In addition is this from another 2013 report from UCP, "The Case for Inclusion":
"Waiting lists for residential and community services are high and show the unmet need. More than a quarter of a million people (268,000) are on a waiting list for Home and Community Based Services. This would require a daunting 44% increase in states' HCBS programs! However, 20 states report no waiting list or a small waiting list (requiring less than 10% program growth). This measure has gotten much worse over the life of the Case for Inclusion. Since the 2007 Ranking, the size of the waiting list nationally has almost doubled from 138,000 to 268,000."
In Summary: Less money is being spent on people with DD. Waiting lists for services have almost doubled since 2007. 853,000 people with DD live at home with aging parents. The expectation is that unpaid family caregivers will provide "significant support" to waiver recipients. And there don't appear to be any plans to relieve the burden on families by expanding residential options for people with DD.
This is a video of a TV news report from WMTV in Madison, 7/18/13, about a violent 26-year-old felon with developmental disabilities who is locked in a house in the city of Baraboo, Wisconsin. Neighbors are frightened and don't know why he is there, local politicians are raising questions with the state about him, and the police are making crisis plans for what to do if the man escapes.
According to the report, "Neighbors fear violent felon locked in Baraboo home" by Phil Levin, on the WMTV Madison website:
"The home has fortified windows, a padded cell and doors that lock from both sides. Staff carry panic buttons and wear bite sleeves, but since the man was moved to the facility in February at least ten staff members have suffered injuries in altercations. Police reports indicate employees sustained broken bones, bites, scratches and other injuries trying to contain the man."
It goes on: "[The residence] is sparsely furnished with a locking cell in its interior..many of the altercations begin when the man is assigned a 'time-out' in the padded room. Reports and staff indicate the man has broken doors and windows and sometimes maneuvers behind staff in apparent attempts to try and strangle them."
A politician weighs in: "'Any time you can get someone with disabilities into a community setting, that's the best thing for everybody, it's a win-win for everybody,' said [State Senator Jon] Erpenbach. 'In this particular situation with the violent nature of this individual, and I can't stress this enough this individual requires four staff members within this house dressed in kevlar so they are not harmed to deal with this particular individual, there might be a better way to deal with the whole situation.'" Interesting that the politician and a former staff member interviewed on TV do not question the underlying idea that living in the community is always the best thing that can happen to people with developmental disabilities even though everyone acknowledges that in this case it is not working to anyone's benefit. The only person who expresses any real concern for the man who is being subjected to imprisonment "in the community" is Police Lt. Rob Sinden who asks, "'If we have ten incidents where this individual has sent people to the hospital, how many times has he [the resident of the home] been injured?" Indeed. What is happening to that poor man who tries to strangle people when he is "assigned" to the segregation cell? Home Sweet Prison Home.
Why is the ARC Michigan, an advocacy group for people with developmental and intellectual disabilities, having a hissy fit over two family-initiated projects in southwest Michigan? The ARC Michigan is of the opinion that if the state allows Medicaid funds to pay for services to people with DD who choose to participate in these projects, the state will be going against current trends, departing from current thinking on disabilities, and possibly violating the Americans with Disabilities Act.
This "warning" was issued in two letters from Dohn Hoyle, the Executive Director of the ARC Michigan, to the MDCH. [For an explanation of abbreviations and links to the full text of both letters and the MDCH response, see the end of this post.] The ARC Michigan receives most of its funding from federal and state government grants. [See the ARC's 2012 Annual Report ] Of course the state does not have to ask the ARC for permission before allowing the expenditure of Medicaid funds.
The two family-initiated projects targeted by the ARC Michigan are Benjamin's Hope and AACORN (Autism Agricultural Community Option for Residential Needs). Benjamin's Hope, near Holland Michigan, is a planned community for people with autism spectrum disorder. It is described here on the website of LTO Ventures, a non-profit company that develops communities for people with autism:
"A 40-acre campus designed as a community-based model to provide housing, recreation, vocation and support for 24 residents in six custom-designed homes. It is a private/public model, built with private dollars, and utilizing public funds for direct care. They received 62 applications for the first 8 available residential slots. [emphasis added] The first two residences have been completed, and the community building is nearly done." Four women moved into a licensed group home at Benjamin's Hope in June, 2013. AACORN Farm is still in the development stage but has received non-profit status and is looking for property in Kalamazoo County, Michigan. While residential options are being developed, AACORN has started a vocational program. According to the AACORN website, "Tillers International of Scotts, MI has generously offered to let us use their farm and help care for its animals and gardens, and to have arts and crafts indoors while we are raising funds for a farm of our own…The program will run three days per week with just a few participants while we are breaking it in. In September, the program will be offered four days per week and we will be adding more participants." Here is an article from the Kalamazoo Gazette, 4/8/13, with more about AACORN Farm. It is clear that the years of thought, energy, and planning invested by these families of autistic children are approaching fruition. It is also clear that these two programs have broad community support and plans for residents to be fully engaged in what the broader community has to offer them. So why is the ARC in such a huff?
The ARC is right that these projects go against the current trends and thinking prevalent among government-funded advocacy groups and the government agencies that fund them. Creative ideas for providing services and residential options for those with the most severe and complex disabilities may well be thwarted by misguided and potentially harmful government policies with the support of mainstream government-funded advocacy groups. [See CMS rules limiting choice].
For decades, advocacy groups such as the ARC Michigan have been railing against institutions for people with DD [e.g. Intermediate Care Facilities for Individuals with Intellectual Disabilities or ICFs/IID], despite the fact that such settings are a legitimate choice for people who need that level of care. For years the ARC Michigan has been chipping away at services and residential options provided in settings that serve more than three or four people with disabilities. The basis for this bizarre policy appears to be the faulty assumption that only by limiting the number of disabled people that associate with each other in one place, can we assure their integration into "the community". Not only is this assumption based on tunnel vision, but it is also predicated on a special interpretation of what constitutes a "community" [See "Integration or Isolation? Defining Community Beyond Bricks and Mortar"]
To these advocates, where and with whom one associates is not a matter of free choice or individual need, but is instead a matter of policy applied generally to all people with disabilities and enforced through government mandates:
"We don’t believe that hiding behind language regarding supporting the housing preferences and choices of people with disabilities (or those of their parents or guardians) would shield any new, additional, segregated developments or its funding from being considered discriminatory as segregating persons with disabilities." …Dohn Hoyle, ARC Michigan, 4/30/13
The ARC Michigan claims that using Medicaid funding to pay for services at Benjamin's Hope, AACORN, and similar programs may violate the 1999 U.S. Supreme Court Olmstead decision interpreting the Americans with Disabilities Act. However, the ARC Michigan's reading of Olmstead is faulty. Olmstead does not support the view that congregate settings are automatically discriminatory against people with disabilities. Instead, it supports individual choice. It does not specifically focus on congregate settings in the larger community, such as group homes. Even if one lumps such settings together with larger facilities and assumes that every licensed setting is an "institution", Olmstead still does not prohibit them:
“We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings...Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.” 119 S. Ct. at 2187.
Stated another way:
“As already observed by the majority, 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" [quoting VOR’s Amici Curiae brief]
Personal choices and needs are the governing factors, not the oversimplified criterion advocated by ARC Michigan.
For families living with a severely disabled family member, a utopian vision of a world where everyone, regardless of the nature or severity of their disabilities,can live independently, engage in competitive employment, and live fully integrated lives in "the community" (whatever that means), makes as much sense as a vision of a world where severe disabilities don't exist at all. We need realistic solutions, not over-simplified utopian notions that only serve to limit the range of choices. Creative family and community-based projects that provide specialized services and residential options to people with DD should be encouraged, not prevented from getting the assistance they need to succeed.
*************************** Information on the ARC Michigan: Executive Director: Dohn Hoyle President: Donald Teegarden Board of Directors Contact Information
***************************** Letters from Hoyle to MDCH and MDCH to Hoyle: A short lesson in MichiganSpeak will make reading the letters easier: a CMHSP is a Community Mental Health Service Provider - a local CMH agency that provides services to people with DD and other disabilities. A PIHP is a Pre-Paid Inpatient Health Plan, a regional CMH agency that distributes funding to local CMH's and performs other administrative functions. The AFP is the Application for Participation that assures that PIHP's comply with all relevant federal and state requirements.
Links to full text of Letters: (a) Letter to MDCH from Dohn Hoyle dated 4/10/13
(b) Letter to MDCH from Dohn Hoyle dated dated 4/30/13
(c) Letter to the ARC Michigan from MDCH dated 4/25/13
