I am a registered nurse, so I thought, well, I know the system. But when [my adult son was injured]... I needed every bit as much help as anyone else. It was unbelievable, some of the bridges that we had to cross.
(C.L.)
Improving the quality of life for people with disabilities — through higher levels of inclusion and involvement in work, social and community life — is a challenging task. We know that the lives of many Ohioans with disabilities have been enhanced in the past three years, but we can be sure that a much larger number of people with disabilities have not yet felt the benefits of the Ohio Access efforts.
There is still much ground to be covered and many advances to be make. But that is what the Ohio Access vision is all about and that is the undertaking that lies ahead.
It will not be easy. In fact, there will be significant challenges — most importantly limited funding, federal policy constraints and the task of sustaining critical health resources — that will stand in the way of continued progress. The following section creates a realistic picture of the challenges going into the SFY 2006-2007 budget.
Funding Constraints
Without question, resource availability remains the greatest ongoing challenge to fulfillment of the Ohio Access vision. Although the state's revenues have rallied somewhat during the last few months, continuing national economic uncertainty and the proposed repeal of Ohio's temporary sales tax will be critical questions as policymakers develop the next biennial budget. It is possible that the state's next budget development process will be even more difficult than the last due to a combination of rising costs and sluggish or declining revenues.
The distribution of scarce resources is a related challenge. During SFY 2003, funding for primary and secondary education and Ohio's Medicaid program comprised nearly half of Ohio's annual spending. These two areas of government will continue to require the commitment of a substantial portion of the state's available resources, thereby limiting the amounts available for new initiatives (including those within Ohio's Medicaid health care delivery system) and the ongoing operational costs of the rest of state government.
Statutory requirements regarding Medicaid reimbursement for nursing facilities and ICFs/MR also prevent the state from providing the community-based capacity demanded by elders and people with disabilities because the first priority for new dollars are the institutional providers covered by statute. In the mental health delivery system, this was resolved by controlling institutionalization and by permitting resources to follow individuals from institutional settings to community settings. Ohio does not have a provision in law that allows money to follow the person from a facility-based setting to a community setting, although this does occur on a regular basis in the home and community based waiver programs. To assist with the closing of two Developmental Centers, ODMR/DD has instituted a policy to allow residents who choose to live in the community to have their service dollars follow them. During the last two biennial budget development processes, Governor Taft proposed to slow or freeze the growth of reimbursement for nursing facilities and intermediate care facilities for the mentally retarded (ICFs/MR) to redirect some new resources to expand community resources throughout the state. The Administration continues to believe that reimbursement reform is essential to community system growth as well as to slowing the overall rate of growth of the Medicaid program.
Inflation creates additional challenges for non-entitlement services and supports for elders and people with disabilities, including programs such as non-Medicaid behavioral health services, Alzheimer's respite services, Early Intervention for children, and human services subsidy payments to local governments. Even if budgets are not reduced, these programs are affected adversely by flat funding. The cost of providing these services is increasing each year, but the funding is not and there is no automatic rate adjustment such as in the nursing home reimbursement formula. As a result, state and local agencies must identify new resources or implement administrative efficiencies, create (or increase) waiting lists for services, narrow eligibility requirements in order to reduce the number of people receiving services and/or reduce the amount, duration or scope of the services that are being provided.
The failure to achieve real parity of private coverage for behavioral health has resulted in a greater reliance on publicly financed behavioral health services for individuals who do not qualify for Medicaid. "Medicaid crowd-out" is a term used by some local boards of MR/DD, mental health, and alcohol and drug addiction services to describe federal and state requirements that result in the obligation to fund Medicaid entitlement services for all eligible individuals prior to meeting any non-Medicaid payment obligations. In short, board systems address financial shortfalls by reducing or eliminating services provided to individuals who are ineligible for Medicaid. This is a particular challenge in Ohio's behavioral health system, where matching funds for community Medicaid benefits are the responsibility of local boards.
Given the fiscal challenges detailed above, resources from local levies are critical for the continued provision of many long-term services and supports. When authorized and renewed, levies provide valuable support for services to individuals who may be quite seriously ill but not Medicaid eligible, and for services Medicaid cannot reimburse, such as housing, employment supports, respite and prevention. Additionally, some parts of the Medicaid delivery system rely on local levies to help finance services. Unfortunately, in recent years voters in many board areas have decided against authorizing new or expanded levies for these and related purposes. For example, during the past 10 years, only three out of 48 attempts to pass a new levy in the behavioral health system were successful. [1] Additionally, levy resources are not distributed based on statewide need but on local support. Most Appalachian counties do not have alcohol, drug addiction, and mental health levies although the need for care in these communities is high.
The Administration remains committed to the vision and goals of Ohio Access; however, the financial challenges detailed in this section will leave scarce resources to make significant new investments during the next biennium. To the extent possible, the SFY 2006-2007 Executive Budget recommendations will prioritize resources in areas that will provide improved outcomes for the greatest number of Ohioans and focus on ways to provide Ohio Access agencies with flexibility to increase community capacity if that can be accomplished at no additional cost to taxpayers.
Federal Policy Constraints
The original Ohio Access report summarized how federal policy constrains Ohio's flexibility to implement new programs in home and community settings. Community services for people with disabilities are funded through a variety of federal, state and local sources, but it is federal Medicaid policy that shapes program design.
The federal Medicaid program has a long-established institutional bias, which makes it more difficult to serve eligible individuals in home and community settings. Eligible people with disabilities are "entitled" to facility-based care, but home and community services are "optional." States are required to apply for a "waiver" of the institutional requirement in order for federal dollars to follow people into home and community settings. Similarly, using managed care tools (e.g., controlling referral of individuals to expensive services, or capping the number of providers) requires obtaining a "waiver" of federal requirements.
Fragmentation in funding and policy exists among federal programs. There are a number of different programs and funding sources that are used to provide services to persons with disabilities, including Medicare, Medicaid, Supplemental Security Income, Food Stamps, Social Services Block Grant, the Ryan White Care Act, Maternal and Child Health Block Grant, and the Older Americans Act. This complexity makes it difficult to coordinate programs and funding and can be overwhelming for individuals to manage all of the benefits for which they are eligible. As an example, the President's New Freedom Commission on Mental Health reviewed federal programs that might fund services to a person with mental illness or their family, and found 42 such programs.
The federal Medicaid program is administratively cumbersome, particularly regarding Medicaid waiver authority. It takes a significant amount of staff time, in some cases months or years, to get approval from CMS for a Medicaid waiver. This has prompted states to call for an end to the current system of Medicaid waivers in favor of increased flexibility in state plan amendments to create flexibility without the bureaucratic limitations of the current system.
Three years after the original Ohio Access report was published, Ohio still faces all of the same federal constraints and Medicaid's institutional bias remains. During the intervening time period CMS has sent mixed messages by allowing some additional waiver flexibility and creating grants to encourage states to develop new home and community based alternatives to institutional care, while at the same time generally tightening CMS' interpretations about how Medicaid is to be managed by the states. As Ohio continues its discussions with CMS regarding federal interpretations of upper payment limits, payments to public providers, targeted case management and administrative claiming, the state remains well prepared to compete for the grants (because of Ohio Access). So far Ohio has received $3,510,000 grant funding to support Ohio Access activities.
Until Congress reforms Medicaid, Ohio will pursue available opportunities to improve services and supports for people with disabilities. In the short term, that involves pursuing federal grants that are strategic to changing the system and, over time, fundamentally altering the system to provide services and supports in home and community settings that most people prefer.
Local Resource Sustainability
Ohio's publicly funded mental health system is at a critical juncture today — a national model of community based care facing considerable resource challenges.
Compared with a decade ago, mental health services are more community based and locally managed than Ohio's other delivery systems. The Mental Health Act of 1988 enabled Ohio to reduce the size of its state hospital system so that funding could be used to provide more appropriate and cost-effective services in the community. Throughout the 1990s, state hospital downsizing and numerous state hospital closures resulted in a "devolved" system managed at the local level (including shared funding responsibility) and oriented strongly toward community care. The average daily inpatient census at state-owned psychiatric hospital facilities has decreased from 3,800 to 1,100 (71 percent) since 1988.
While this has been very good news for community based care, fiscal challenges now threaten the system's hard-fought progress. Hospital downsizing and consolidation has run its course as a source of new community funding. Local boards are experiencing significant financial stress from a combination of flat or reduced state and local revenue, inflationary growth, increased demand for services and escalating Medicaid match obligations. These factors reduce individuals' access to the array of safety net services they need in order to lead independent, productive lives. The problem is exacerbated by cutbacks in private sector mental health care and services paid through the mainstream Medicaid program. Particularly troubling is a pattern of closures in private hospital psychiatric units, with shorter lengths of stay and high levels of readmissions occurring after downsizing of public hospitals was completed. The burden on emergency rooms, community mental health agencies, local law enforcement, and nursing facilities is increasing. The community mental health system is caught in a vicious spiral, with increased demand, increased Medicaid match responsibilities, and decreased resources. Placing a priority on stabilizing mental health funding is necessary. Additionally, addressing Medicaid's impact on community mental health care is an urgent priority. As recommended by the President's New Freedom Commission on Mental Health, gaining federal flexibility (e.g., in Medicaid's requirements) may be necessary to prevent the elimination of mental health care for individuals with serious mental illness who are not eligible for Medicaid.
In the case of mental health, the cost of not providing treatment is often much greater to Ohio taxpayers than the cost of providing treatment, but these secondary costs are hidden:
- Severe, untreated mental illness often causes people to lose their job or never have the opportunity to pursue a career. Federal disability payments to people disabled by mental illness are estimated at $850 million annually, far more than the General Fund budget of ODMH.
- Although most of the common crimes charged to person with mental illness are not violent crimes, persons with mental illness are overrepresented in jails and prisons, and responding to minor disturbances by people with mental illness takes up a significant portion of police officers' time.
- Children with a serious emotional disturbance are less likely to be successful in school than all other categories of disability.
- Increasing numbers of individuals with mental illness are now receiving treatment in nursing facilities, particularly because of the scarcity of appropriate housing options for this population.
In addition to reducing inpatient costs, the successful provision of appropriate community based services ultimately saves taxpayer dollars by enhancing individuals' employment opportunities, reducing criminal activity, and increasing family reunification in the child welfare system. Reversing the decline in support for community behavioral health care and sustaining the minimal levels of public psychiatric acute hospital care remaining in Ohio is an urgent priority.
[1] Source: Ohio Association of County Behavioral Health Authorities