Bazelon Center Mental Health Policy Reporter

Welcome to the Bazelon Center Mental Health Policy Reporter. Available exclusively online and to our email subscribers, the Reporter supplements the Bazelon Center's Action Alerts by providing a periodic bulletin on significant policy developments that affect people with mental illnesses.

Volume VII, No. 2, February 8, 2008

President’s Budget Proposal Slashes Mental Health

In this issue:

• Community Mental Health Services Hit Hard
• Efforts to Rein in Medicaid
• What You Can Do
• Legislation Imposing Moratorium on Medicaid Case Management Rules
• Mental Health and Criminal Justice Collaborations Bill Advances

Newsbytes:

• House Committee Hearing on ADA Restoration
• San Francisco Agrees to Create Supported Housing
• DC Promises to Upgrade Special Education

The President’s proposed budget for fiscal year 2009 has generated outrage on all sides, from states with revenue shortages to nonprofits working for low-income populations. People with mental disabilities would suffer greatly if the President’s proposals were enacted as presented. Community mental health services are hit hard and the Administration’s campaign to cut Medicaid is ratcheted up. Congress is reacting, however. It’s up to you and other mental health advocates to explain to Senators how the Administration’s proposals would create hardships for individuals and families…and ultimately cost the nation more.

Community Mental Health Services Hit Hard

The President’s $3-trillion spending plan for fiscal year 2009 drastically slashes community mental health services funding for the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA). The $144 million cut (nearly half of the discretionary budget) of CMHS’ Programs of Regional and National Significance (PRNS) would set community mental health services funding significantly below the levels five years ago, stifling innovation and severely restricting progress.

PRNS funds are used for programs that move the field forward, build new service capacity and translate research into practice at the community level. The following PRNS programs would be slated for elimination or significant cuts:

• the State Incentive Grants for Transformation to support the development of comprehensive plans to address fragmentation in a state’s public mental health system (to be eliminated);
• school violence prevention (to be cut by $17.8 million);
• jail diversion (to be cut by $2.9 million);
• seniors mental health (to be eliminated);
  post traumatic stress ($ 17.5 million cut);
• consumer support technical assistance centers (to be eliminated); and
  suicide prevention ($15.1 million cut).

The budget would freeze funding for the mental health block grant at $421 million (same as fiscal 2008) and largely level fund the protection and advocacy system at $34 million (a modest reduction of $.09 million). The only two programs with proposed increases are the children’s mental health services program, at $114.5 million (a $12.2-million increase) and the PATH program to address homelessness among people with mental illnesses, at $59.7 million (a $6.4-million increase).

Oddly, in light of the blanket cuts to important PRNS programs, the Administration chose to propose funding for two new initiatives in this discretionary portfolio: one that would provide for mental health drug courts ($2.2 million) and another to address mental health needs identified by state and local communities ($7.3 million) through a mental health targeted capacity expansion program.

Administration Continues Efforts to Rein in Medicaid Spending

In the budget plan, the Administration continues its effort to rein in federal Medicaid spending. The President’s budget would cut $1.7 billion in fiscal year 2009 and $17.4 billion over five years from a range of legislative initiatives. If approved by Congress, the cuts would affect vital services to numerous low-income beneficiaries, including people with mental illnesses, who rely on this federal safety net for health and mental health care.

Targeted case management
Among the proposals is reducing the federal contribution toward the cost of targeted case management for Medicaid recipients, including those with serious mental disorders. This is accomplished by shifting payment for case management from the service-matching rate to the administrative rate (50 percent). This slash is projected to save the federal government $200 million in fiscal year 2009 and $1.1 billion over five years. These “savings” would come at the expense of increase state costs and/or reduction of services for Medicaid beneficiaries. Medicaid targeted case managers serve as a vital link to medical, social, educational, housing and other necessary services that enable beneficiaries avoid crises that lead to costly hospitalization or incarceration. (See definition of case management.)

Targeted case management services have been in the Administration’s sights all along. Interim final regulations (72 Fed. Reg. 68077) issued in December 2007 to implement Section 6052 of the Deficit Reduction Act (Public Law 109-171) provided for reforms of case management and targeted case management. These rule become effective March 3, 2009 and would achieve federal savings of $1.28 billion over five years. They place an array of restrictions and limitations on case management and targeted case management services for Medicaid beneficiaries (see our summary).

Rehabilitation services
Additionally, the Administration issued proposed regulations on August 31 that would restrict allowable services under the Medicaid rehabilitation services category (summary). Rehabilitative services are the critical services that enable people with mental illnesses to live and thrive in the community, such as medication management, therapeutic foster care services and skills training that promotes recovery.

School-based administration and transportation costs
The Administration also followed through on its fy 2008 budget proposal by promulgating final regulations on December 28, 2007 to prohibit Medicaid reimbursement for school-based administration or transportation costs with respect to the Individuals with Disabilities Education Act (IDEA).

Nonetheless, both the Medicaid rehabilitative and school-based administration regulations were successfully delayed until June 30, 2008 by enactment of a moratorium in the Medicare, Medicaid and SCHIP Extension Act of 2008 (Public Law 110-173).

The President’s FY 09 budget proposal is available at: http://www.whitehouse.gov/omb/budget/

With large-scale reductions proposed, the Bazelon Center urges the mental health community to help thwart cuts that would further reduce service capacity within the public mental health system. Contacting Members of Congress throughout the appropriations process, can result in successful efforts that restore and increase funding levels for essential community based mental health programs and services.

What You Can Do

Contact your Senators and Representative and urge them to:

• Reject cuts to CMHS’ discretionary (PRNS) budget. The PRNS funds important programs aimed at translating research science into practice at the community level.
• Support increases in programs providing comprehensive community-based mental health services, such as the mental health block grant, PATH program and children’s mental health services program.
• Reject legislative actions that jeopardize access to Medicaid services for needy beneficiaries, including a reduction in the targeted case management administrative match.
• Continue to oppose implementation of harmful Medicaid regulations affecting rehabilitative services and school-based administration and transportation.

If your legislators are not on the Subcommittee on Labor, Health and Human Services, Education and Related Agencies of the Appropriations Committees, which have jurisdiction over funding for the Center for Mental Health Services, ask them to urge their colleagues to support mental health funding. (You can check www.congress.org to see the membership of these subcommittees.)

You can reach your Senators and Representative by calling the Capitol switchboard at 202-224-3121 or on their direct lines, available on www.congress.org.

When you call or email (and if you email, be sure to use the member’s own website so your message will get through), remember to identify yourself as a constituent, giving your address and zipcode.

Legislation Would Delay Medicaid Case Management Rules

In both House and Senate, legislation has been introduced in direct response to the interim final regulations on Medicaid case management and targeted case management services, promulgated by the Center for Medicare and Medicaid Services on December 4, 2007.

The legislation (S. 2578, H.R. 5173), sponsored by Senator Norm Coleman (R-MN) and Representative Keith Ellison (D-MN) would provide for a moratorium on the rules until April 1, 2009. (See sponsoring letter.)

People with mental illnesses who rely on Medicaid for their health care need a wide range of medical, social, educational, housing and other services and supports. Medicaid case management services help them gain access to these services--with their case managers serving as the vital link. Case management is thus essential in enabling many people to live successfully in the community despite serious mental disorders.

Legislation is necessary to delay implementation of the rules, which stray beyond the scope of the Medicaid statute, making fundamental changes that unduly restrict the ability of Medicaid beneficiaries to access needed care. The rules impose limitations on payment methodology and on units of service for case management. See analysis by the Council on Budget and Policy Priorities and letter from Senators Reid and Baucus.

The respective bills have been referred to the Senate Finance Committee and House Energy and Commerce Committee. The following Members of Congress have co-sponsored the legislation: Senators Lamar Alexander (R-TN), Ken Salazar (D-CO), Amy Klobuchar (D-MN), Pete Domenici (R-NM), Benjamin Cardin (D-MD), Bob Corker (R-TN), Patrick Leahy (D-VT), Robert Casey (D-PA), Jeff Bingaman (D-NM), Hillary Clinton (D-NY), Barbara Mikulski (D-MD); Olympia Snowe (R-ME), Edward Kennedy (D-MA), Ron Wyden (D-OR), Bernard Sanders (D-VT); Susan Collins (R-ME) and Sherrod Brown (D-OH) and Representatives Jim Ramstad (R-MN), Jim Cooper (D-TN), Timothy Walz (D-MN), James Oberstar (D-MN), Elijah Cummings (D-MD), Collin Peterson (D-MN), John Duncan, Jr. (R-TN) and Betty McCollum (D-MN)

What You Can Do

• Contact your Senators and Representative and urge them to co-sponsor S. 2578 and H.R. 5173.

Bills Advance on Mental Health and Criminal Justice Collaborations

Bipartisan legislation to reauthorize and improve the criminal justice and mental health collaboration grant program, administered by the Department of Justice, (P.L. 108-413, Mentally Ill Offender Treatment and Crime Reduction Act) is moving through the legislative process.

The Mentally Ill Offender Treatment and Crime Reduction Improvement and Reauthorization Act (H.R. 3992), sponsored by Representatives Bobby Scott and Randy Forbes passed the House last month (see January Policy Reporter). The Senate bill (S. 2304), sponsored by Senators Edward Kennedy (D-MA) and Pete Domenici (R-NM) is likely to be considered by the Judiciary Committee on February 14.

Although the bills are slightly different, they would renew the core MIOTCRA grant program and increase the authorization from $50 million to $75 million as well as renew the mental health courts grant. The bills also provide for new grants in need based areas, including greater law enforcement training, effective treatment of female prisoners with mental illnesses, statewide planning and outreach to coordinate the treatment of incarcerated individuals with mental illnesses, and would provide for new interventions, improved screening, identification and assessment of mentally ill inmates, and increased coordination of transitional, post-release services.

What You Can Do

• Contact your Senators and urge them to cosponsor and support S. 2304.

Newsbytes

House Committee Urged to Restore Intent of the ADA

A parade of witnesses came before the House Education and Labor Committee on January 30th to urge passage of the Americans with Disabilities Restoration Act (H.R. 3195). The bill would reverse Supreme Court rulings that have created a Catch-22 for people with mental or physical disabilities who are discriminated against because of their disabilities, but are then told that they are not sufficiently disabled for protection under the ADA.

Carey McClure, an electrician for 20 years who has a form of muscular dystrophy, presented a real-life example. He was offered a job by General Motors in Texas after passing both a practical and written test. He quit his existing job, sold his house in Georgia and moved his family to Texas. But after a company doctor “discovered” his muscular dystrophy, the job offer was revoked. He filed a complaint under the ADA. However, “even though GM revoked my offer because of my disability,” he said, “GM’s lawyer started arguing to the federal court that I didn’t have a disability at all. Well,” he added, “you can’t have it both ways—am I disabled or not? If I am, then the ADA should have been there to protect me. If I’m not, then I should be working…at GM right now.”

Among other witnesses was Representative Steny Hoyer (D-MD), who was chief House sponsor of the ADA when it passed in 1990. At that time, he said, “we could not have fathomed that people with diabetes, epilepsy, heart conditions, cancer and mental illnesses would have their ADA claims kicked out of court because, with medication, they would be considered too functional to meet the definition of ‘disabled.’” Hoyer, with Rep. James Sensenbrenner (R-WI), introduced H.R. 3195 last July. Read more about the ADA Restoration Act in our July 23, 2007 Action Alert.

San Francisco to Create 500 Supported Apartments

In settling a class-action lawsuit, the City of San Francisco (CA) has agreed to create 500 scattered-site apartments linked to community support for people with disabilities who live or have recently been discharged from the 1,100-bed Laguna Honda nursing home or who are awaiting placement there. Once the agreement is approved by the federal court and the city’s board of supervisors, the city will create a new program called “Success at Home,” described as a single door to independent living. It will coordinate residents’ transition through an individualized plan to match each one to subsidized housing, federally subsidized medical services and community supports, including, as needed, attendant and nursing care, vocational rehabilitation, substance abuse treatment, mental health services and assistance with meals. Read more about the landmark settlement of Chambers v. San Francisco.

DC School System Promises to Upgrade Special Education

As part of an effort to comply both with the IDEA and with settlement of the Blackman class action, District of Columbia officials announced that the city will make sweeping changes to its special education program to address the needs of thousands of students with mental or physical disabilities who await services. The District has committed to more than $6 million in new programs, including:

• Additional mental health services and coordination of these and other services by case managers.
• The introduction of nationally recognized models for helping students with disabilities in the classroom, including the SAM schools program, currently in place in California, Kansas City and New Orleans, and the Dawn Project, which coordinates services to students in schools in Indianapolis and Cincinnati.
• More support for parents, including expansion and reorganization of a parent resource center.
• Computers for students who have not timely received special education services.

DC’s school system currently spends more than $100 million annually on tuition for more than 2,000 special education students to attend segregated private schools. Officials are introducing these significant changes to the DC public schools so that these and other students will have better options in their neighborhood schools. Read more about changes to special education in Washington DC schools.

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