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Bazelon Center Mental Health Policy Reporter
Volume VIII, No. 2, February 26, 2009 Show Me the MoneyFrom Medicaid dollars to the fiscal 2009 Omnibus Funding billIn this issue:
Newsbytes New Funding Will Boost Many Programs Affecting People with DisabilitiesRecovery (of the fiscal variety) is on the way for states to assist people with disabilities. The American Recovery and Reinvestment Act of 2009 (HR 1, H. Rept 111-16), signed by the President on February 17 as Public Law 111-5, provides $787 billion in spending and tax relief. The law is designed to create and save up to 3.5 million jobs, aid struggling families and stimulate a downward-spiraling economy through investment in various sectors, including health, education and infrastructure over the next two years. This issue of the Mental Health Policy Reporter summarizes some of the law’s provisions that will benefit people with mental disabilities and create new advocacy opportunities—for example, to shift state support from institutional services to community integration for people with disabilities. A new federal website, www.Recovery.gov, will show how the funds are being distributed to states, congressional districts and even federal contractors. Also welcome, although not yet enacted, are two House-passed bills. The aptly numbered H.R. 911 would protect teens in residential treatment facilities from physical, mental and sexual abuse and help parents make informed choices about services for their children. The other is the 2009 Omnibus Budget appropriation, to fund a plethora of programs in the current fiscal year. It would notably increase support for many initiatives of importance to individuals with mental disabilities, including housing and homelessness prevention. The Recovery Act Improves Access to MedicaidMedicaid is administered by the states and jointly financed with the federal government. It is the primary funder of community-based mental health services for people with mental disabilities and the nation’s healthcare safety net for low-income Americans, including those with disabilities.
This week the Administration announced the release of the first $15 billion of the Recovery Act’s Medicaid Federal Medical Assistance Percentage (FMAP) fiscal relief funds to the states. (See http://www.hhs.gov/recovery/statefunds.html for a chart of funding by state.) These temporary funds will help states avoid cutting eligibility and services for Medicaid beneficiaries due to the economic crisis. The Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services will administer release of the funds. See the February 23 White House press statement. FMAP amounting to $87 billion over 27 months is available through December 31, 2010. These funds provide a 6.2% across-the-board increase in the federal match (65% paid out on a flat basis for expenditures between October 1, 2008 and December 31, 2010, and 35% distributed based on increases in unemployment rates due to the recession). While states can decide how to allocate the new funds, rules in Section 5001(f) of the Recovery Act require them to maintain their eligibility requirements and sustain state Medicaid funding to qualify for the increased federal dollars. States may not use FMAP funds “directly or indirectly” to meet other needs. However, these funds offer an important opportunity for states to expand community-based Medicaid services for people with mental illnesses and thus reduce their use of institutional care. Advocates should press for use of FMAP to end their state’s waiting list for community programs. Under Section 1931 of the Social Security Act, states must continue Medicaid coverage temporarily for low-income families with children when wages or child-support make the family ineligible for traditional Medicaid. The Recovery Act extends this program, called Transitional Medical Assistance (TMA), beyond the current expiration date of June 30, 2009, to December 31, 2010, at an estimated cost of $1.3 billion.
Extended until July 1, 2009 is the moratorium on Medicaid regulations that would reduce access to rehabilitation and targeted case management, school-based administration and transportation services, and provider taxes. These rules had been delayed by the Supplemental Appropriations Act of 2008 (Public Law 110-252) until April 1, 2009. (See the Bazelon Center’s July 7, 2008 Action Alert.) The Recovery Act also includes a new moratorium through June 30, 2009 on final regulations (issued November 7, 2008, 73 Fed. Reg. 66187) relating to clarification of the definition of outpatient hospital services under the Medicaid program. Through “Sense of Congress” language, the HHS Secretary is prohibited from issuing in final form proposed rules on Medicaid rehabilitative services (issued August 2007, 72, Fed. Reg. 45201) as well as others concerning graduate medical education and cost limits for certain providers and intergovernmental transfers. The estimated cost of the two-month extensions is $100 million. A Start to Healthcare ReformPresident Obama is scheduled to kick off the debate on healthcare reform this week with a significant “down payment” budgeted for control of costs and expansion of coverage. The Recovery Act, in the meantime, addresses some immediate needs.
Recovery Act funds will be used to help approximately seven million people who have lost their jobs between September 1, 2008 and December 31, 2009 to keep their health coverage. The legislation authorizes temporary subsidies to help these individuals pay the premium for COBRA coverage. COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985) allows people to keep coverage when they leave a job by paying the total premium for the group insurance they had through their previous employer. This is quite expensive, averaging about $1,000 a month and unaffordable by many laid-off workers. The Recovery Act will provide a 65% premium subsidy for up to nine months to individuals who were involuntary terminated and whose incomes are no more than $125,000 (single) or $250,000 (family). This option is available regardless of any preexisting health condition.
The Act provides $19 billion to begin modernizing the healthcare system, spurring adoption by 2014 of health information technology (HIT), including electronic medical records. Of that amount, $17 billion is dedicated to Medicare and Medicaid incentives (entities serving Medicare and Medicaid patients) and $2 billion for state grants that would promote HIT, including funding for infrastructure, training and dissemination of best practices. Community mental health centers are among the list of entities available for the HIT funds. The law includes privacy protections that would provide notification of unauthorized disclosure or use of health information, secure rights to audit trails for disclosures of health information and ban the commercial use or sale of personal health information, along with other meaningful privacy safeguards.
A $1 billion Prevention and Wellness Fund includes $650 million for community-based prevention programs to address chronic disorders, including obesity, smoking and other health risks. Advocates will need to work with HHS to ensure that mental disorders, such as depression, which has a high co-morbidity with cardio-vascular disease are included in the list of chronic disorders eligible for grants. Recognition of the high proportion of individuals with mental illnesses in the public system who smoke (roughly 50%) should be among considerations for smoking-cessation programs.
The Recovery Act invests $1.1 billion in comparative-effectiveness research. This will better inform patients and providers about the relative risks and effectiveness of different clinical treatments. The law also establishes a Federal Coordinating Council for Comparative Effectiveness Research to help federal agencies (HHS, Veterans Administration, Defense Department and others) to coordinate and conduct their research.
The Recovery Act provides $500 million to support a primary healthcare workforce. $300 million will focus on the National Health Services Corps, which places providers in underserved communities, and $200 million will go to primary care training programs authorized under Titles VII and VIII of the Public Health Services Act. Payment to Social Security RecipientsSupplemental Security Income (SSI) is a mean-tested income assistance program providing a minimum cash income to aged (65 and older), blind or disabled individuals with low incomes and limited resources. The Social Security Disability Insurance (SSDI) program provides benefits to individuals who have paid into the Social Security system and meet minimum work requirements. SSI and SSDI beneficiaries will receive an extra one-time payment of $250 by late May of 2009. Railroad Retirement beneficiaries and veterans receiving disability compensation and pension benefits from the VA are also eligible for this one-time payment. To learn more about this one-time economic stimulus payment visit http://www.socialsecurity.gov/payment, and access the Frequently Asked Questions section for information about children receiving SSI or adults who have a representative payee. The law also provides $1 billion to the Social Security Administration (SSA) to upgrade its computer systems and address the problematic backlog in claims for SSI/SSDI eligibility. Support Added for EducationThe Title 1 (Elementary and Secondary Education Act) formula grants supplement state and local funding to help provide additional academic support and learning opportunities to disadvantaged students. The program will receive $10 billion under the Recovery Act, with $3 billion for school improvement during the 2009-2010 and 2010-2011 school years (section 1003(g) of ESEA). Each educational agency receiving funds is required to submit to the state education agency by December 1, 2009 a school-by-school listing of per-pupil educational expenditures from state and local sources during the 2008 and 2009 academic year. The Title I LEA Allocations of Recovery Act funds are live on the web at http://www.ed.gov/about/overview/budget/titlei/fy09recovery/index.html.
A total of $12.2 billion is authorized for special education, of which $11.3 billion is for Individuals with Disabilities Education Act (IDEA) Part B grants to states (3-21 year olds) and $500 million for Part C infant and toddlers program (birth to 2 years old). $400 million is reserved for preschool services for 3-5 year olds (Section 619). IDEA Part B grants pass through states to local education authorities to provide services to children who meet the federal definition of a “child with a disability” and who, because of their disability, need special education and related services in order to benefit from a free and appropriate education. Mental health services are among the related services that can be provided.
Vocational Rehabilitation (VR) Title 1 formula grants assist individuals with disabilities in preparing for and engaging in gainful employment. The VR program provides a wide range of services and job training to people with disabilities, including job counseling and help in locating employment. The VR program in the Rehabilitation Act of 1973 is funded at an additional $680 million, of which $540 million is allocated for VR state grants (part B, Title I of the Rehabilitation Act) and $140 million for Independent Living programs. An investment of $15.6 billion is allocated to Pell Grants for individual students attending higher education institutions. The funds will support an increase in the maximum award. Pell grants do not have to be repaid. The Department of Education website includes tables showing how states will benefit from the Recovery Act education provisions. To view, visit http://www.ed.gov/about/overview/budget/news.html#FY2009action and click on State Tables. The department has also created a website specific to Recovery Act provisions at http://www.ed.gov/policy/gen/leg/recovery/ To Prevent HomelessnessThe Recovery Act includes $1.5 billion for homelessness-prevention activities, including short-term rental assistance, housing relocation and stabilization services for families who may become homeless due to the economic crisis. The Act also allocates $2 billion to provide full-year payments to landlords participating in the Section 8 Project-Based rental assistance program. An investment of $70 million is made available for the Education for Homeless Children and Youth formula grant to states. This grant assists school districts providing services to homeless youth. Child Care, Head Start, TANF and Community ServicesThe $2 billion investment in the Child Care Development Block Grant will help fund child care assistance for low-income families who, due to the downturn, are struggling to afford care. The Recovery Act also suspends for two years a provision in the Deficit Reduction Act that reduced funding for the child care enforcement program. This will help parents continue to receive child-support payments and avoid widespread cuts to child-support services. An investment of $1 billion for Head Start and $1.1 billion for Early Head Start programs is included, along with $1 billion for the Community Services Block Grant. The Community Services Block Grant enables states to make grants to local nonprofit anti-poverty agencies that serve low-income individuals and families. Typically, services are provided to individuals who are unemployed or on public assistance, seniors, high-risk youth, public-housing residents, homeless individuals and people with disabilities. The Temporary Assistance for Needy Families and Children (TANF) Program will receive a $5 billion boost for an emergency fund to help states with demanding caseload activities (including monthly cash assistance and subsidized employment). TANF is designed to move welfare recipients into work and to self-sufficiency through services and cash assistance for a limited time. Criminal JusticeThe Recovery Act allocates $2 billion to the Edward Byrne Memorial Justice Assistance Grant Program. The Byrne program provides formula grants to states and local governments to support a range of activities to prevent and control crime and improve the criminal justice system. Byrne Competitive Grants to state and local law enforcement are allocated an additional $255 million over current support to improve the criminal justice system’s functioning to assist victims of crime and provide mentoring to at-risk youth. An investment of $1 billion is allocated to the Community Oriented Policing Services (COPS) Program, which grants to tribal, state and local law enforcement agencies funds to hire and train community policing professionals, develop and test innovative policing strategies and develop cutting-edge crime fighting technologies. The COPS funds will be available until September 30, 2010. The bill waives the $75,000 per officer cap and the 25% local match requirement.
You can access the Recovery Act’s legislative text and see the progression of the plan at http://thomas.loc.gov/home/approp/app09.html#h1 and http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.txt.pdf House Passes Bill to Protect Youth in Residential ProgramsOn February 23, the House of Representatives overwhelmingly passed (295-192) the Stop Child Abuse in Residential Programs for Teens Act (H.R. 911), sponsored by Education and Labor Committee Chairman George Miller (D-CA) and Healthy Families and Communities Subcommittee Chairwoman Carolyn McCarthy (D-NY). The legislation protects youth enrolled in residential programs from physical, mental and sexual abuse and increases transparency to allow parents to make safe and informed choices about services for their children. A 2007 Government Accountability Office (GAO) report revealed thousands of allegations of child abuse and neglect and nearly a dozen tragic deaths at residential treatment facilities in recent years. Facilities such as wilderness camps, boot camps, therapeutic boarding schools and behavior modification facilities house thousands of teens each year. Their stated purpose is to help children and youth struggling with behavioral, emotional, mental health or substance abuse problems. A subsequent GAO report released in May 2008 found major gaps in regulation and oversight of residential treatment programs fostered by a weak patchwork of state and federal standards. Further, some private and government-operated facilities have been exempt from state or federal licensing requirements. H.R. 911 aims to keep teens safe by setting new national standards for residential programs. The bill would ban disciplinary techniques that involve the withholding of a good or service essential to the child’s mental, physical or emotional health, such as food, water, clothing and medical care. It would also ensure that children in these facilities are free from physical restraint and seclusion and are not humiliated or degraded in any way. During investigations, the GAO also discovered examples of deceptive marketing and dubious practices in the private residential program industry, such as fabricated statements and even fraud. Parents are often not given a clear picture of program policies, staff qualifications and safety guidelines before entrusting their children to facilities that supposedly offer a certain standard of care. To combat such deception, H.R. 911 includes standards for hiring and training staff at covered residential programs and would require facilities to fully disclose the roles, responsibilities and qualifications of all staff. The legislation would require program staff to know what constitutes child neglect, the procedures for reporting abuse and neglect and the signs, symptoms and appropriate responses to heatstroke, hypothermia and dehydration. The bill would also require programs to notify parents or legal guardians of substantiated reports of child abuse or violations of health and safety laws at that facility and, within 24 hours, of any changes to their child’s medical treatment or any missed dosages of a prescribed medicine. Importantly, H.R. 911 would provide vital access to resources outside of the facility walls. It would guarantee that youth in these facilities have reasonable access to a telephone from which to make and receive private phone calls. In addition, the child must be aware of and have access to an appropriate child abuse hotline. Passage of H.R. 911 is a critical first step toward protection of the safety and well-being of youth in residential programs. The Bazelon Center applauds the sponsors of the legislation and the Representatives who ensured its success. The text of H.R. 911 is at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h911eh.txt.pdf. See also the press release from the Education and Labor Committee. Omnibus FY 09 Appropriations LegislationOn February 25, the House passed by a vote of 245-178 the remaining fiscal year 2009 appropriations bills, which the last Congress extended at fiscal year 2008 levels in a continuing resolution. FY 2009 began on October 1, 2008. Nine spending bills are wrapped in the $410 billion bill (H.R. 1105, Omnibus Appropriations Act for Fiscal Year 2009). The last Congress had cleared only three appropriations bills: Defense, Homeland Security and Military Construction, and Veterans Affairs. It is unclear when the Senate will consider the remaining appropriations. The continuing resolution for the nine spending bills is set to expire on March 6. The bill includes level (=) or increased (+) funding of various programs that particularly interest people with mental disabilities:
The President released his fiscal year 2010 budget priorities today (February 26). The preliminary budget focuses on the Administration’s top priorities for each department, including mandatory spending programs and tax policies, with details to be released in late March or April. In Tuesday’s address to Congress, the President outlined energy, health care and education as three budget areas critical for investment in the economy. The budget is expected to include creation of a $634 billion, 10-year “reserve fund” to partially pay for expansion of the U.S. healthcare system. Newsbytes On February 24, the Institute of Medicine released a new report, America’s Uninsured Crisis: Consequences for Health and Health Care,on policy implications of the growing number of uninsured Americans—45.7 million as of 2007, including nearly one in 10 American children and one in five non-elderly adults. The report points out that high rates of non-insurance can have spillover effects, creating problems with access to effective health care services by people who are insured. This report follows six prior IOM reports that established principles for expanding coverage and reiterates the call for efforts to ensure access to effective healthcare. It underscores the urgent need to begin now, given that coverage continues to decrease as more people lose their jobs and employer-based plans. To learn more visit http://www.iom.edu/CMS/3809/54070/63118.aspx. For ideas about integrating mental health services in healthcare reform, see the Bazelon Center’s series of issue briefs on the subject at http://www.bazelon.org/issues/healthreform/. On February 19, 2009, a federal court in New York issued a tentative order finding that people with mental illnesses now housed in large private facilities have a right to be fully integrated in the community. The order came in a lawsuit maintaining that the state is violating the American with Disabilities Act (ADA) by administering its mental health service system in a way that isolates thousands of individuals with mental illnesses in large, for-profit board and care facilities in New York City, known as "adult homes." The Bazelon Center and local advocates filed the case in the U.S. District Court for the Eastern District of New York in 2003. The court’s order dismissed motions for summary judgment and set the stage for a trial of the class action lawsuit, Disability Advocates, Inc. v. Paterson. The state had asserted, among other contentions, that it cannot be held responsible under the ADA for segregating people in adult homes because the facilities are privately owned. In its order making clear that a state violates the ADA when it operates a mental health system that unnecessarily segregates people with disabilities, the court explained that the state cannot evade its obligation to comply with the ADA by using private entities to deliver its services. For more on the case, including a link to the order, see http://www.bazelon.org/newsroom/2009/2-19-09DAI.htm. |
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