April News 2013 (Issue #7)
Issue 7, 4/19/2013
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Articles in This Issue:
- Legislature Enters FInal Weeks (Maybe)
- House Holds Public Hearing on Medicaid Expansion
- Senate Passes $42.8 million for Redesign
- HHS Budget Passes Senate
- Other issues of Interest
- Grassroots Advocacy Center Makes Advocacy Easy
- Bills of Interest
Legislature Enters FInal Weeks (Maybe)
With just two weeks left in the legislative session, legislators have not made much headway in finishing up discussions on the really tough issues that remain. We have heard there may be a breakthrough in the Education Reform discussion. You can see the differences between the House and Senate here. But no progress is being made on budgets, property tax reform, and Medicaid expansion. To top that off, we are hearing that decisions on the ongoing redesign of the mental health and disability services system will probably be put on hold until a decision is made on Medicaid expansion.
It does not at this time seem possible that the Republican-controlled House, the Democratic-controlled Senate and the Governor will all find a middle ground on these very complicated issues before May 3, when legislators stop receiving their expense money. After that time, legislators will be paying their hotel bills, mileage and meals on their own, and that can add up quickly. Usually that's when the legislature goes into a kind of hibernation. Leaders bring everyone to the Capitol for one day a week, and then send them home. Only leaders and the handful of legislators working on each issue will come to Des Moines to continue their work on negotiations.
It's a painful process, and one that isn't real visible to the public. Legislators often don't know what's going on, and that makes it difficult for them to advocate for their constituents. There are also rumors of adjourning without an agreement on property tax reform and Medicaid expansion, and coming back for a special session this summer to address those two issues. Either way, it sounds like we're in for at least another month of work at the Capitol.
House Holds Public Hearing on Medicaid Expansion
Less than half of the people that signed up to speak at a public hearing on Medicaid expansion Tuesday night (April 16) were able to make their points before time was up. House leaders set aside only 90 minutes to hear from Iowans - but there just wasn't enough time for the 72 people that signed up. Of those signed up to speak, 75% were in favor of expanding Medicaid and taking the federal government up on their offer to pay 100% of the costs for three years (reducing that match gradually until it ends at 90% federal funding in 2020). Those that were opposed said they didn't trust the federal government to put the money up as they face trillion dollar deficits, didn't think government should be paying for health care unless people take some personal responsibility (like making copayments), and didn't think Medicaid was very good at making Iowans healthier.
Those supporting expansion say it is the easiest way to make low-income Iowans (those earning up to $12,000/year) healthier without making them choose between rent, food, gas, and health insurance. Others say Medicaid could be made better using incentives that are proven to help make people healthier (like Health Savings Accounts). In the 90-minute hearing, only 15 opponents and 17 supporters were allowed to speak. You can watch some of the testimony here.
The five-member subcommittee working on Senate File 296 (Medicaid Expansion) and House Study Bill 232 (Healthy Iowa Plan alternative) met twice last week and had very good debates, but came no closer to an agreement on where they will start. Leaders say they'll try to get it into conference committee soon, so differences can be hammered out. Many say they don't see this issue being resolved by the end of June, and that it may require a special session.
If you have an opinion about Medicaid expansion or the Governor's Healthy Iowa Plan, contact your legislators, and one of the subcommittee members:
Rep. Linda Miller of Bettendorf has also been regularly attending and participating in the discussions. You can contact any legisaltor and the Governor using our Grassroots Advocacy Center.
Senate Passes $42.8 million for Redesign
The ongoing redesign of the state's Mental Health and Disability Services (MH/DS) system took another step forward this week, when the Iowa Senate passed the bill that funds the new county (soon to be regional) services system. The bill (Senate File 440) passed with bipartisan support on April 16, with 33 "yes" votes and 17 "no" votes.
The Senate boosted its commitment to local services by adding another $13 million to the pot of money available for non-Medicaid regional services (for a total of $42.8 million) But in adding money, the Senate also changed the distribution of these funds, which may be an issue with the House. Here's a quick rundown of Senate File 440 as it was passed by the Senate:
- Encourages regions to develop "research based practices" rather than "evidence based practices." Counties say that evidence based practices are very expensive (they are services that are proven successful and must be delivered exactly as they were designed) and not widely available in Iowa. DHS says that regions should try to meet this goal to make sure proven programs and services are available throughout the state. Counties gave the following example - Assertive Community Treatment (ACT) is an evidence based practice which must be overseen by a psychiatrist. If a region could not find a psychiatrist willing to locate in their area, and they choose to use an experienced Psychiatric Nurse Practitioner instead, it would no longer be considered an evidence based practice, even if the rest of the program were exactly the same. Rural areas say they need this flexibility to be able to design programs that work for their communities. House members may have some concerns about this change.
- Makes people living in community based corrections facilities eligible for regional MH/DS services if funding is made available. There has been a lot of discussion about mental health and substance use trreatment for prisoners, so that they are less likely to reoffend upon release. This change would allow those serving out their sentences in community-based correctional facilities to be eligible for the services delivered by regions, if money was available. Some legislators are concerned that this puts those in the correctional facility ahead of an already long list of Iowans waiting to be served by the regional system (such as children, people with brain injuries, people with developmental disabilities, and those earning between 150-200% of the federal poverty level). The House may consider taking this out of the bill.
- Clarifies that counties are allowed to continue to serve the populations they currently serve as they transition to a regional system. This makes sure counties are able to continue to provide services to the "non-target" populations they were serving before redesign - people with developmental disabilities, people with brain injuries, children, and people earning between 150-200% of the federal poverty level. There does not appear to be any concerns about this, so the House will probably keep it as is.
- Adds residential care facilities and work activity to the list of regional core services. In our community meetings, we learned just how much people love their jobs, whether in a supported employment setting or in a workshop. Those with jobs in workshops worried their programs would be shut down because they were not listed as a core service. DHS says that regions were still given the option of including that as a core service, even though it wasn't in the list. They didn't want it to be seen as a requirement for areas that have other types of work activities. This may be an issue in the House.
- Allows a county's current strategic plan to remain in effect until their new regional strategic plan is approved. Counties would have had to develop new three-year plans, at a time they are regionalizing and entering into new regional arrangements that will include a new regional plan. No one has expressed concern about this, so it will likely stay in the bill.
- Requires DHS to review options for MH/DS regions to coordinate detoxification funding provided by counties and report back by October 15, 2013. One region wants to coordinate funding for substance use disorder treatment with mental health treatment, and this is their requested language. It appears the House may have issues with this, and it may be removed.
- Requires DHS send counties their final Medicaid bills by June 30, 2013. All Medicaid costs after that time will be paid for entirely by the state. Counties stopped paying for Medicaid services July 1, 2012, but it takes DHS time to send out the bills to counties. Counties want to start off their regions with clean slates, so they have asked for a final date for Medicaid billlings. There do not appear to be any concerns about this.
- Continues the MH/DS Redesign Fiscal Viability Interim Committee to continue to work out issues with the ongoing redesign of the system. The Senate added at least four "public" members to this committee that was previously made up of only legislators. The public members are to include a supervisor, CPC, service provider, and person with a disability. There seems to be agreement on the continuation of the interim, but may not be agreement on adding public members.
- Makes changes requested by the Data and Statistical information Work Group and the Outcome and Performance Measures Work Group. These changes make sure computer systems of regions and state communicate, and make sure regions are tracking the same outcomes, in the same ways. There seems to be agreement on these.
- Establishes a Chldren's Cabinet to advise on the development of a comprehensive, coordinated system of care for children in this state. The Senate added several members to this Cabinet for a total of 16 voting members and 4 non-voting legislators. There was some disagreement about the focus of this group, the people serving on it, and the need for it (versus having the MH/DS Commission or other existing group do the work).
- Establishes a Center for Child Health Innovation and Excellence to suggest policies that improve children's health. This may be an issue in the House, as it may require funding that is not included in the House budget targets.
- Distributes $42.8 million to MH/DS regions to pay for non-Medicaid services. The Senate will distribute these funds in a different way than proposed under the "per capita equalization formula" passed last year, which allows each region to budget $47.28 per person living in the region. The counties that raise more than that amount through property taxes would have to lower their property taxes, and they will receive no state money. The counties that collect less than that in property taxes would be given an "equalization payment" to bring them up to the $47.28 per person spending level. Senators like Sen. Jack Hatch and Sen. Joe Bolkcom didn't think it was fair that 45 counties had to cut their property taxes and get by on less money, while the other 54 counties get additional money from the state. So they drafted a new formula that gets money to all counties, to make sure they have the money they need to build a strong regional service network without jeopardizing services to people living there. The plan adopted by the Senate subtracts a county's expenses from their revenues, and fills the difference with state funds. So the state money would first go toward filling the gap between the money they will have to pay for services, and the costs of those services. Then the Senate plan adds two payments (one in July, one in January) to pay for "growth" in the system. They also use a per capita (per person) amount - $8.25/person distributed in the first round, and $2/person distributed in the second round. This is a complicated formula, and spends $13 million more than the House had planned to spend, so this may be a problem in the House. Some members suggested doing the $47.28 distribution currently in law, but adding another $5 million for a risk pool to help out struggling counties (the Iowa State Association of Counties has identified a need of about $3.9 million).
The House subcommittee met on Thursday, April 18 to discuss the bill and identify areas where there may be concerns. The subcommittee members (Rep. Joel Fry of Osceola, Rep. Kevin Koester of Ankeny, and Rep. Mark Smith of Marshalltown) decided to set the bill aside for now, until they get direction from their leadership on the amount of money they will be allowed to spend, and a decision on Medicaid expansion vs. the Governor's Healthy Iowa Plan. As you may recall, the Governor uses $43 million in county MH/DS property tax levies to pay for his Healthy Iowa Plan, with no promise that it will cover an equal amount of services. In addition, DHS estimates that counties will save $60 million (which counties say is too high an estimate) if Medicaid is expanded. So now the MH/DS redesign discussion is tied into the discussion about Medicaid expansion and budgets - two things that may not be resolved until June (at the earliest).
Click here to see how your county or region fares under the Senate plan.
Click here to see how your county or region fares under the $47.28 "per capita equalization formula" passed last year.
Click here to see how your legislator voted on Senate File 440.
HHS Budget Passes Senate
The Senate passed a budget that spends $2.3 billion on various health and human services programs, including Medicaid. That's an increase of about 10%. Because the budget increase was larger than Senate Republicans wanted, they all voted against it. So the vote was along party lines (26 Democrats voting for, 22 Republicans voting against with 2 Republicans absent). Here are some of the highlights of the bill:
- $333.4 million increase for Medicaid, including:
- $11 million to eliminate or reduce Medicaid waiver waiting lists.
- 3% provider rate increase for Home and Community Based Services (HCBS) providers.
- 1.5% provider rate increase for most other providers (targeted case managers and consumer directed attendant care providers are not included).
- $3.3 million for a new autism support program to provide Applied Behavior Analysis and other treatment for children who do not qualify for Medicaid or private insurance autism coverage.
- $400,000 increase for the Regional Autism Service Program to create autism support programs in Child Health Specialty Clinics.
- $410,000 increase for brain injury services, including resource facilitators.
- $50,000 increase for epilepsy education and support.
- $55,000 increase for the Direct Care Worker Council and a new appropriation of $184,530 to establish a Board of Direct Care Professionals in the Department of Public Health.
- $25,000 new appropriation for the Children's Mental Health Cabinet if established in the MH/DS Redesign Bill (SF 440).
- $25,000 increase for the Prevention of Disabilities Council ($63,543 total).
- $1.6 million increase each for Glenwood State Resource Center and Woodward State Resource Center (but this just replaces lost federal funds when the Medicaid match rate went down this year).
- No change in funding for the following programs:
- Audiological Services to Children ($162,768)
- Youth Suicide Prevention Program ($50,000)
- Childhood Lead Poisoning, which is a preventable cause of intellectual disabilities ($537,750)
- Four Oaks Autism Spectum Services ($25,000)
- Dubuque County Autism Spectrum Services ($25,000)
- Polk County Systems of Care Program ($327,947)
- Cerro Gordo and Linn County Systems of Care Programs ($160,000)
- Connor Decree Training ($33,622)
Other changes include:
- Implements the standardized assessment (Supports Intensity Scale) for persons on the Intellectual Disability (ID) waiver (estimated to save $8.5 million).
- Requires the Department of Human Services to continue to administer the state Balancing Incentives Payment (BIP) Program, which requires the state to rebalance its long-term care system so that the state spends more money to support people in their own homes and communities, and less on nursing homes and other institutional care settings.
- Renames the Ill and Handicapped Waiver to the Health and Disability Waiver (but doesn't change who is is eliglble).
- Establishes in Iowa Code the Youth Suicide Prevention Program that requires teachers be certified in trauma informed care and suicide prevention, and the Applied Behavior Analysis Program for children with autism that do not qualify for Medicaid or have private insurance coverage.
Other issues of Interest
As reported earlier, the Legislature has really cleaned house and left very little on its "to do" list. There is little other than the big issues that remain - Medicaid expansion, MH/DS redesign, education reform, property tax reform, and budgets. There are two issues that may be of interest that are still trying to get enough momentum to put them over the top this year:
- Direct Care Worker Licensure: Advocates that support standardized training and credentialing for direct care professionals continue to push for a Direct Care Professional Board, but legislatotrs are now looking at an all-voluntary system. They plan to do this through an amendment that would make the 6-hour core training and the Direct Care Associate credential optional instead of required for all direct care professionals; all other advanced training and credentials were already proposed as voluntary. The plan right now is to put the amendment on House File 198 , which has passed the House and is ready for Senate debate. The bill allows providers to include the costs of training in their direct costs, so they can be reimbursed for it. Look for updates on Facebook or on our website.
- Mental Health Advocates (Senate File 406): When a person with a mental illness is being involuntarily committed,
the courts appoint a "Mental Health Advocate" to help them navigate the system, understand what is happening, and make sure their interests are being taken into consideration. These advocates are currently employed by the courts, but their salaries are paid for by counties. The DHS/Judicial Redesign Work Group recommended these advocates be conflict-free, and moved to the Department of Inspections and Appeals. The Senate passed the bill, but made them employees of the Department of Human Rights. The House wants to move them back to the Department of Inspections and Appeals, but the conflict over where they go isn't what is holding up this bill. It's politics. The House Republican leaders have taken a stand against "growing government." While the advocates are currently state employees for liaibility purposes, they are not included in the overall employee count. Making them employees of any state department means adding 40-50 positions to that agency, and growing government. Rep. Dave Heaton of Mt. Pleasant continues to work with his leaders to try to get agreement, but this bill may just end up stuck for the year. If the House passes the bill as is, it will go to the Governor. If they change it, it will need to return to the Senate for final approval.
Grassroots Advocacy Center Makes Advocacy Easy
infoNET has added a new tool to your advocacy toolbox - the Grassroots Advocacy Center. You do not need to know the names of your legislators, the Governor, or the people that represent you in the US Congress. If you know your address, our Grassroots Advocacy Center will match you to your elected officials, and automatically find their emails for you. All you need to do is write your message and hit "send." It's just that easy. So try it out - click here to get started.
If you need more help in crafting your message, make sure you check our new infoNET website for more information (www.infonetiowa.org) and ID Action's new Advocacy University website (www.advocacyuniversity.org). You will find lots of useful information and videos other advocates have made to help you get started.