June 2005 NACBHDD Newsletter
The monthly newsletter for the National Association of County Behavioral Health and Developmental Disabilities Directors
In this Issue...
The Campaign for Mental Health Reform Moves Into a New Phase with Executive Director Chuck Konigsberg
The Campaign for Mental Health Reform now has its first Executive Director, Charles S. Konigsberg. With previous service in the Senate, White House, and the national nonprofit world, he brings senior level, bipartisan experience to the Campaign. "NACBHD is excited about Chuck's appointment. Maeghan and I had the opportunity to meet him last week. His level of expertise is already apparent -- he has already answered numerous questions from us about the budget process. The Campaign made an excellent selection," says Melissa Staats.
Bill Emmet, who served as Project Director for the Campaign and is Project Director for the National Association of State Mental Health Program Directors (NASMHPD), has kept NACBHD informed about Campaign activities. He continues to work for NASMHPD and will help Konigsberg in moving forward with the Campaign.
NACBHD spoke with Konigsberg about his experience and the Campaign.
Konigsberg emphasizes his bipartisan work and his deep interest in health care issues, and especially, his work on Medicaid, Medicare, HHS, and appropriations issues. And, he says he is "coming on board at an important time given that Congress is considering significant cuts in Medicaid." Konigsberg and Emmet talked with NACBHD about Medicaid and other Campaign activities.
"We're at the beginning stages of looking at Medicaid options on the table to determine what type of impact they would have on the delivery of mental health services," says Konigsberg. With Congress expected to act on cuts in September, the Campaign is meeting regularly throughout the summer to discuss how best to relay concerns to Congress. The Campaign discusses the issues as a group - he emphasizes the Campaign's nature as a major collaborative effort of the 16 national organizations involved.
State-Informed Federal Policy Initiative - Call to Action: Release Planned for Late July
The Campaign's project to gather information on state and local transformation efforts and determine the implications for federal policy is in process, with plans to release the final document (not yet formally named) in late July. The report will include a number of proposals for federal action to advance the goals and recommendations of the New Freedom Commission. Congress is the primary audience, and a briefing or other event is in the planning stages.
Mentally Ill Offender Treatment and Crime Reduction Act
The Campaign continues to work on appropriations for this legislation; there is some support in both houses for it.
The Illinois Children's Mental Health Partnership recently released a report to the governor, which Emmet says is worth noting since Illinois seems to be the "bellwether" state on screening. The report emphasizes concepts the Campaign has recognized as important to screening, such as screening is voluntary and private and key to prevention and early intervention. To view the report, see www.ivpa.org/childrensmhtf/cmhpplan.pdf. For more information on the Campaign, including information on the Congressional screening briefing in May, see www.mhreform.org. Konigsberg is located at the Campaign's headquarters at the Campaign for Mental Health Reform, 1050 17th Street, NW, Suite 600, Washington, DC 20036, (202) 587-2983, firstname.lastname@example.org.
NACBHD Annual Meeting: Mark Your Calendars for October 20-22
The NACBHD Annual Meeting will take place October 20-22 in Portland, Oregon at the Benson Hotel. Please take a moment to mark this important event on your calendar, and check the website for more information on the meeting and for instructions on registering online.
NACBHD Board Meeting Scheduled for July
The timeline for Congressional activity on Medicaid; the Medicaid Reform Commission
Because Medicaid is a mandatory entitlement program, it is not part of the appropriations process. Instead, the House Energy and Commerce Committee and the Senate Finance Committee will develop legislation to find the $10 billion in savings over the next five years mandated in late April in the FY 2006 budget resolution. This reconciliation process takes place this summer and possibly into the fall (September 2005). (www.nami.org/Section=Policy_News_and_Alerts.)
At the same time, discussion of appointments, or refusal to participate in, the bipartisan Medicaid Reform Commission (appointed by HHS Secretary Leavitt) continues to make news. Most recently, Senator Gordon Smith (R-OR), who, along with Senator Jeff Bingaman (D-NM) sponsored the legislation for the commission, declined Senator Bill Frist's invitation to join the commission. A spokesman for Smith said that there are major differences between the commission and Smith's original ideas about it, and noted that Smith felt he could be more useful as a member of the Senate Finance Committee, which has sole jurisdiction over Medicaid. Shortly before that, Democratic lawmakers refused to join the commission after Leavitt said he will appoint the 15 voting members and that the eight members of Congress on the commission will be nonvoting members. (Kaiser Daily Health Policy Report, June 14, 2005, www.kaisernetwork.org/daily_reports/rep_index.cfm)
In addition, the National Governors' Association (NGA) has announced that it will not join the commission. While the group has elected not to be part of the Medicaid Reform Commission, it has offered to provide staff to the Commission for outreach and research as a linkage between the Commission and the NGA's work on Medicaid. The NGA just released to Congress its policy position on Medicaid. (See below.)
The NGA Position on Medicaid
NGA Chair Mark Warner (D-VA) and Vice Chair (Mike Huckabee (R-AR) released the NGA's preliminary recommendations to Congress June 15. The paper contains the NGA's recommendations for comprehensive Medicaid reform. To view the paper "Medicaid Reform: A Preliminary Report," or to view the governors' June 15 testimony before Congress, see www.nga.org.
NACBHD Supports Two Nominees to the Medicaid Commission
NACBHD has supported two nominees to the Medicaid Reform Commission:
Medicaid a Campaign Focus This Summer
Advocates are focusing on Congressional activity around Medicaid, and NACBHD will continue to distribute to members important information from advocates, as well as update members through the Washington Updates and the newsletter. And, NACBHD participates regularly in meetings of the Campaign for Mental Health Reform. Chuck Konigsberg, the Campaign's new Executive Director (see related article in this newsletter), says the Campaign is meeting regularly to determine the best way to relay the Campaign's concerns to Congress.
CBO document outlines possible Congressional Medicaid reductions
The Congressional Budget Office (CBO) recently released a document that outlines possible Medicaid cuts and options that Congress may consider. The Campaign for Mental Health Reform's new Executive Director, Chuck Konigsberg, provided the document to advocates, and the NACBHD Medicaid Committee believes members will find it useful. The link for the document was sent to members June 13. The link is http://www.cbo.gov/showdoc.cfm?index=6075&sequence=12.
For additional recent background information on Medicaid, see the May 27 Washington Update.
KCMU Report on Mandatory and Optional Spending Now Available
The Kaiser Commission on Medicaid and the Uninsured recently released three new policy reports covering the currently discussed issues of giving states more flexibility in coverage of optional populations and cost-sharing for beneficiaries. The following reports are available at www.kff.org:
The Center for Budget and Policy Priorities Releases Papers on Medicaid and Cost Sharing and Out-of-Pocket Expenses
The following information was provided to advocates by Families USA:
NEW STUDY FINDS POOR MEDICAID BENEFICIARIES FACE GROWING OUT-OF-POCKET MEDICAL COSTS
Increased Cost-Sharing Could Mean Less Care, Poorer Health for Vulnerable Families
OUT-OF-POCKET MEDICAL EXPENSES FOR MEDICAID BENEFICIARIES ARE SUBSTANTIAL AND GROWING
by Leighton Ku and Matthew Broaddus
Out-of-pocket expenses for poor adult Medicaid beneficiaries have grown twice as fast as their incomes in recent years; these individuals now spend more than three times as much of their income on out-of-pocket medical costs as middle-class adults with private health insurance.
THE EFFECT OF INCREASED COST-SHARING IN MEDICAID:
A Summary Of Research Findings
by Leighton Ku
The research indicates that higher co-payments cause low-income beneficiaries to cut back on essential care and higher premiums lead to fewer low-income people enrolling in health insurance programs.
CMS Sends Letter to State Medicaid Directors Re: Coverage of Excluded Drugs
On June 3, CMS sent all State Medicaid Directors a letter urging them to continue coverage for certain drugs under their Medicaid programs, including benzodiazepines, barbiturates, and other excluded drugs, that will not be covered under the new Medicare Part D benefit. States may continue paying for these drugs through Medicaid at the current matching rate or arrange for the medicines through Medicare health plans for full benefit dual eligibles. The federal government will share the cost with the states in either case. To view the letter, click here. MedicaidDir.pdf
More Transition Resources Available Online
HHS Secretary Leavitt , CMS Administrator McClellan, and the Access to Benefits Coalition, which includes the Alzheimer's Association, Easter Seals, the National Alliance for Hispanic Health, and the AARP, launched an outreach effort during a June 1 news briefing designed to ensure that low income beneficiaries know about the extra assistance available in obtaining coverage under Part D the Prescription Drug Benefit. To access McClellan's "Call to Action," click here. To access a statement from the Access to Benefits Coalition, click here
The following documents were also released during the news briefing and will be helpful to beneficiaries in obtaining coverage. The documents include steps they will need to take to receive in paying for prescription drugs.
Social Security Update
NACBHD will report on advocate concerns around the Social Security reform in the July newsletter. For the most recent information on advocacy concerns around possible Social Security reform, see the Consortium for Citizens with Disabilities at www.c-c-d.org.
Virginia Member Works with Advocates to "Put a Face on Substance Abuse Recovery" for State Legislature
Brendan Hayes, NACBHD member, and Program Manager for the Henrico Area Mental Health, Mental Retardation, and Substance Abuse Services Board (the community services board for Henrico, Charles City, and New Kent Counties in Virginia) has been working with individuals in recovery from substance abuse to "put a name and face on recovery" for state legislators in Virginia's General Assembly. The unique informal advocacy initiative involves individuals in recovery meeting with state legislators to emphasize that substance abuse is a brain disorder from which recovery is possible, and that treatment works.
Background: Why the need for those in recovery to directly advocate with legislators?
Hayes describes substance abuse as an underrepresented issue with the General Assembly, compared to mental health and mental retardation. General Assembly members are long accustomed to families advocating for group homes for the developmentally disabled, for example. And, he notes the nationwide problem of the stigma of addiction, with substance abuse still viewed through a moral lens, while the issue of the stigma of mental illness has come a long way. The concept of substance abuse and addiction as a brain disease has "a long way to go," he says.
In addition to the pervasive issue of stigma, substance abuse funding has been losing ground with state legislators. In recent years, considerable substance abuse money has been invested in the Virginia criminal justice system, with 60-75% of people in the criminal justice system with a substance abuse problem. Governor Mark Warner's Substance Abuse Reduction Effort put money toward substance abuse in the criminal justice system, but had the unintended consequence of making substance abuse a criminal justice issue. In the most recent legislative session, no new funding was designated for substance abuse, although almost $20 million in new money could be justified.
Convicted felons cannot vote in Virginia. On the other hand, Hayes says, "We know statistically that most people in the General Assembly know a family member or close friend with addiction." The issue was addressed at the May 2004 meeting of the Virginia Association of Community Service Boards (VACSB), with Executive Director and NACBHD member Mary Ann Bergeron directing that boards address the issue of supporting an effective advocacy initiative across the state of Virginia.
Process: Facilitating Advocates Getting the Message to State Legislators
There are 40 community services boards in Virginia; they may cover one county or as many as seven or eight counties. And, the Mental Health Council, the Substance Abuse Council, the Mental Retardation Council, and the Prevention Council are part of the Virginia Community Services Board. Representatives from substance abuse services from each community services board make up the Substance Abuse Council; Hayes is a member of the Substance Abuse Council, and serves as the liaison from the Substance Abuse Council to the VACSB Public Policy Committee.
These individual meetings between consumers in recovery and legislators demonstrated that there are a wide range of people in the community in recovery, and deemphasize the horror stories of addiction. Advocates took the following messages to their meeting with General Assembly members:
As Hayes explains, there is not always the gratification of something happening immediately with advocacy; it is a long-term process. But, he notes, it has taken NAMI 20-30 years to get its point across. For advocates from rural regions like southwest Virginia, which is over 300 miles from Richmond, advocacy can be a challenge and a frustration. They may travel a great distance to the State Capital during the legislative session and not even be called upon to speak.
The sense of stigma is still an issue for advocates relating stories of addiction and recovery. Hayes met with one professional group to discuss how they might advocate. While they were not comfortable meeting with delegates publicly, they did some "behind the scenes" advocacy. A high-level member of the organization met privately with an Assembly delegate to discuss recovery and treatment.
Other challenges Hayes mentions are having staff become more organized in the presentation of materials to the General Assembly and maintaining the advocates' motivation.
Hayes points out that it is useful to demonstrate concretely the benefits of treatment, mentioning tools such as the recent report, Economic Benefits of Drug Treatment: A Critical Review of the Evidence for Policy Maker (see May newsletter), which specifically outlines the cost benefits of treatment. He refers to the high health care costs and public safety costs associated with addiction; there are 200 treatment beds in his local jail because of the recognition of the huge cost to the community. Still, Hayes acknowledges that the funding decisions are extremely difficult when there is so much need among the mentally ill and the developmentally disabled as well. And, he says, the problem can be viewed in terms of "paying now or paying later," and he further notes the tendency is this country to inadequately address prevention.
Ohio's State FY 2006 Budget Likely to Hit MR/DD Services Hard
Dan Ohler, Executive Director of the Ohio Association of County Boards of MR/DD and a NACBHD member, recently spoke with NACBHD about the state budget situation in Ohio and its impact on the state's 88 local MR/DD boards. (Each county has its own MR/DD board.) The pending state budget is the most challenging in decades, says Ohler. In fact, one legislator was quoted as saying this would be "Ohio's most difficult budget in 100 years." Ohio's economy has not rebounded as quickly as other states in the Midwest, with more jobs lost over the past decade than any other state. In terms of behavioral health, the state budget includes a modest 4% increase for local mental health boards, but local MR/DD boards have not faired as well and local authorities are looking at the impact on consumers. A decline in state general revenue funding for the MR/DD service delivery system precedes the current budget crisis; MR/DD funding from the state has fallen from 20% to just 11% over the last 10 years. While previous losses have been offset by rising federal reimbursements via home and community based waivers, federal funding for the MR/DD population is also going to be reduced over the next two years as the state removes the habilitation center services program from its State Medicaid Plan. With local boards faced with revenue losses that are expected to exceed $60 million, many local boards have implemented hiring freezes, begun to lay off staff, and reduce the non-mandatory services that they have otherwise been able to provide. Ohler says that "At this point, a flat line budget with no further cuts from the general revenue fund for MR/DD boards would be a major victory." The recently passed Senate version of the bill indicates no cuts.
The governor must sign a budget bill prior to July 1; Ohio's constitution requires there to be a balanced budget. At press time, the bill was in a legislative Conference Committee where differences between the House passed version and Senate passed version are ironed out. Ohio's Governor does have line item veto authority in Ohio, which he has used it in past budget cycles.
To complicate funding pressures further, Ohio's MR/DD boards rely heavily on the local county property tax revenue. In fact, 70% of the funding in Ohio's system is raised at the local level.
What services might be impacted?
Ohler says the potential impact on services is a lot to absorb all at one time; any one reduction or cut is a significant challenge on its own. He lists the following areas of concern as the budget process nears completion.
In relation to this, several local school districts are suing the state of Ohio regarding the state's rights in this area. The Cuyahoga County Board of MR/DD attempted to intervene in the action; however, the judge denied their motion. At press time it appeared the schools and the State were finalizing a settlement, but neither side will comment until the matter is finalized. Ohler stated that his Association will lobby the state to ensure that MR/DD boards that operate schools have the same ability to access federal reimbursement as the local schools do.
Advocacy There has been a strong consumer and family presence at state budget hearings, and the media has definitely noted their participation, says Ohler. Individuals with developmental disabilities are living longer, often outliving their parents. This creates new demands within the service delivery system and differing opinions from stakeholder groups on how to address those demands. Some groups advocate for ICFs/MR because they believe it is better controlled and better prepared to deal with medical issues. On the other hand, parents who have taken care of their children at home would like to see them be able to continue living in the community, and person-centered waiver programs offer more options and frequently at less cost, thereby allowing limited local and state funding to stretch further and serve more people.
New Performance Measure and Management Tool Available Online
From a June 3 SAMHSA press release:
SAMHSA announced the online availability of its National Outcome Measures (NOMS) - a data resource to help federal and state substance abuse and mental health managers facilitate evidence-based decision making and ultimately improve services in the communities they serve.
"This new web-based tool is the very beginning of a data reporting system that ultimately will provide a comprehensive state-by-state picture of mental health and substance abuse service system results," said SAMHSA Administrator Charles Curie. "This is a powerful new tool that we can use to improve the management and performance of our programs and make the most of the limited dollars available to help people attain and sustain recovery."
Using maps and charts, the database will describe states' substance abuse and mental health prevalence, treatment and funding data. It will also provide substance abuse prevention data. As new data are collected, the website will also present cross-year data to help users examine program changes over time.
In collaboration with states, SAMHSA has identified National Outcome Measures for ten domains. The first area is abstinence from drug use and alcohol abuse. Also in this area is the goal of decreasing symptoms of mental illness and improved functioning. Four domains focus on resilience and sustaining recovery. These include getting and keeping a job or enrolling and staying in school; decreased involvement with the criminal justice system; securing a safe, decent, and stable place to live; and social connectedness to and support from others in the community such as family, friends, co-workers, and classmates. Two domains look directly at 1) increased access to services for both mental health and substance abuse and 2) retention in services for substance abuse or decreased inpatient hospitalizations for mental health treatment. The final three domains examine the quality of services provided. These include client perception of care, cost-effectiveness, and use of evidenced-based practices in treatment.
Data for reporting on the NOMs identified for the ten domains will come primarily from the states. States will be supported in their efforts by SAMHSA with infrastructure and technical assistance through a new State Outcomes Measurement and Management System (SOMMS), an umbrella activity in SAMHSA to implement NOMs. Through this new system, SAMHSA in partnership with the states will: Standardize operational definitions and outcome measures, and link records to support pre-/post-service comparisons; develop benchmarking strategies to determine acceptable levels of outcomes; produce routine management reports to direct SAMHSA's technical assistance and science-to-services program to implement interventions designed to result in improved outcomes; Achieve full state reporting on all NOMs by the end of fiscal year FY 2007. In the interim, each year more states will report NOMs using standard definitions until all states are on board. SAMHSA is using its State Data Infrastructure Grants program to develop and test the NOMS.
To access NOMS go to http://www.nationaloutcomemeasures.samhsa.gov/.
2005 Recovery in Action Summit Seeks Scholarships
Faces and Voices of Recovery, the national addiction recovery movement, is hosting the 2005 Recovery in Action Summit, September 6-8 in Washington, DC. Pat Taylor, from Faces and Voices, briefly spoke about this at NACBHD's March legislative conference, and the issue was covered in the April newsletter as well. Faces and Voices asks NACBHD members (if possible) to provide a scholarship to someone in their county or locality so that they may attend the summit.
The summit will bring together recovery efforts from across the country so that individuals may learn how to communicate the goals of the recovery movement in an attempt to gain national exposure and reduce stigma.
Please click visit http://www.facesandvoicesofrecovery.org/summit2005/index.php
to learn about the summit. Also, please complete a scholarship form if your county or organization is able to provide assistance.
Click here for the scholarship form.