NAMI Minnesota Legislative Update – August 17, 2011

Senator Berglin to be Honored

The Minnesota Mental Health Legislative Network will hold a reception on Friday, August 19 from 5:00 PM to 7:00 PM at the Dorsey Ewald Conference Center (1000 Westgate Dr, St. Paul, MN 55114) to thank her for all that she has done to improve the mental health system. As many of you know, she has retired after 39 years in the legislature. If you would like to attend the reception, please let us know at . If you cannot attend and would like to send a note of thanks, send an email to that address.

Adult Foster Care

NAMI Minnesota has formed a working group to look at the issue of adult foster care, particularly corporate foster care. There are 4, 786 foster homes in Minnesota, totaling 16,921 beds. 72% of these homes are corporate foster homes, meaning that the individual who is licensed does not live in the home. Many families and individuals with mental illnesses mistakenly believe that these are “group homes” and that there are strict requirements. The truth is that there are mainly environmental regulations (water temperature, space, etc.) but no requirements that a person be a mental health professional to run the home or that the staff have training on mental illnesses or de-escalation techniques. If you or a family member have been in an adult foster care home and would like to share your experience and thoughts, feel free to send an email to .

Continuing Care Cuts

The Department of Human Services issued a bulletin yesterday outlining which continuing care providers will receive a 1.5% rate reduction on Sept. 1, 2011.

Programs affected include:

• Alternative Care (AC) Program

• Community Alternative Care (CAC) Waiver

• Community Alternative for Disabled Individuals (CADI) Waiver

• Developmental Disabilities (DD) Waiver

• Elderly Waiver (EW)

• Traumatic Brain Injury (TBI) Waiver

• Nursing services and home health services

• Personal care services (PCA)

• Private duty nursing (PDN)

• Epilepsy Living Skills Programs

• Semi-Independent Living Services (SILS)

• Intermediate Care Facilities/Developmental Disabilities (ICF/DD)

• Aging Grants

• Consumer Support Grant (CSG)

• Disability Linkage Line grants

• Family Support Grant (FSG)

• Housing access grants

• Self-advocacy grants

• Technology grants

New Administrator at St. Peter

David S. Proffitt has been named the new Administrator for State Operated Services’ Forensics Services within the Department of Human Services.

As administrator, David will oversee Forensic Services which serves individuals under commitment as mentally ill and dangerous or who are under a criminal court order for evaluation or treatment. Forensic Services includes the Minnesota Security Hospital, Transition Services, the Forensic Nursing Home, and other specialty services in St. Peter.

David brings to this position a well-rounded background in a full range of behavioral health care services, including child, adolescent, and adult mental health, substance abuse and both facility based and community forensic services. David also has a passion for the recovery movement and bringing those principles into forensic services.

David most recently was president and chief executive officer of The Acadia Hospital, a behavioral health services provider in Bangor, Maine. He previously was chief executive officer for Riverview Psychiatric Center, a public psychiatric hospital, out-patient clinic and forensic transitional program in Augusta, Maine. Earlier, he held leadership positions for Northern Nevada Adult Mental Health Services, Montana State Hospital and Wyoming State Hospital. He holds B.S. and M.S. degrees in therapeutic recreation and has a doctorate in health administration.

HHS, Treasury take new steps to help states build Affordable Insurance Exchanges

Tax credits to help millions of middle-class families

Health Insurance Exchanges

The Departments of Health and Human Services and Treasury today took the next steps to establish Affordable Insurance Exchanges – one-stop marketplaces where consumers can choose a private health insurance plan that fits their health needs and have the same kind of insurance choices as members of Congress. Among other policies, the proposed rules describe how middle-class families will gain access to unprecedented tax relief that will dramatically reduce the cost of coverage.

HHS awarded $185 million to 13 states and the District of Columbia to help them build Affordable Insurance Exchanges and, with Treasury, posted three proposed rules that will provide a simple, streamlined, and affordable path for consumers to use the Exchanges to purchase private health insurance.

The Minnesota Department of Commerce was awarded $4,168,071 to build on the Limited-Competition Exchange Planning grant it received in February 2011. Minnesota will focus on developing its Exchange information technology infrastructure. Minnesota also will establish an initial governance structure within the Minnesota Department of Commerce with full-time staff dedicated to the development of Minnesota’s Exchange. The state will also create and maintain an Advisory Task Force to provide guidance on the establishment of an Exchange. The state is requesting funding to develop and execute work plans, timelines, and budget and cost-allocation estimates through 2014. Minnesota will also designate a Chief Financial Officer to create and execute detailed work plans related to financial management, program integrity, and Exchange financing mechanisms.

What the Debt Limit Agreement Means for People Living With Serious Mental Illness

Two weeks ago a major economic catastrophe was averted through the agreement put together by President Obama and congressional leaders to increase the current debt limit and bring about significant deficit reduction over the coming decade. As is being widely reported in the press, the agreement will increase the debt ceiling by $2.1 trillion and allow the government to continue meeting all current obligations. The agreement also includes a 10-year cap on discretionary spending and formation of a new bipartisan congressional committee charged with identifying an additional $1.5 trillion in deficit reduction through changes in entitlement programs and reforms to the tax code.

In terms of assessing the impact of this agreement on people with mental illness, it is important to note that the increase in the government’s borrowing authority will ensure NO interruption critical safety net benefits such as monthly cash assistance under the SSI and SSDI disability benefits. While media coverage was largely focused on a government default and protecting AAA bond ratings, failure to raise the debt limit would likely have placed these cash benefit programs at risk. In addition, the higher debt limit will ensure that quarterly matching payments to state Medicaid agencies and payments to housing agencies for rental assistance programs (tenant-based and project-based Section 8) will continue uninterrupted. Even a short-term disruption to these programs would have had a dramatic impact on people living with mental illness who depend on these programs (SSI, SSDI, Section 8, etc.) for basic supports.

As noted above, the agreement creates a new 12-member bipartisan joint House-Senate Committee that will be charged with identifying $1.5 trillion in additional deficit reduction over the next decade. This panel will be on a fast track and must produce recommendations by November 23, 2011, with a required "up or down" votes in the House and Senate by December 23.

This $1.5 trillion in savings will come from changes in entitlement programs and reforms to the tax code.This new special congressional committee will be made up equally of Democrats and Republicans from the House and the Senate. As a result, few expect the committee to come to an agreement on cuts to major entitlement programs before November. Therefore, the "sequestration" enforcement mechanism becomes critical and it is here that critical protections for Medicaid will kick in.

So, in the strong likelihood thatCongress fails to approve the committee’s recommendations (or if the recommendations fall short of the $1.5 trillion goal), the agreement contains an "enforcement mechanism" designed to impose automatic cuts, known as a "sequester." This "trigger" mechanism for spending reductions would begin in 2013 and would split reductions evenly between defense and non-defense programs. If this automatic "trigger" mechanism is imposed, it would exempt from reductions Medicaid and Social Security (including SSI and SSDI). As with the new special congressional committee, the "trigger" mechanism can limit payments to Medicare providers (health plans and hospitals), but not Medicare benefits or cost sharing. In addition, any reductions in payments to Medicare providers are limited to 2% of total Medicare spending.

Bottom line: The agreementdecreases the possibility ofdeep cuts to Medicaid, the largest source of funding for treatment and supportive services for people living with serious mental illness. At one point during the difficult negotiations over the past month, as much as $1.2 trillion in cuts to Medicaid over the next decade were under discussion. Exempting Medicaid from cuts--through the "sequestration trigger"--will help ensure that this agreement meets the test of protecting the most vulnerable.

The agreement does impose new constraints on the growth of federal discretionary programs that Congress funds through annual spending bills. Imposition of a 10-year limit on federal discretionary spending will generate as much as $900 billion in savings over the next decade – that is, $917 billion below the baseline established by the Congressional Budget Office (CBO). This will reduce discretionary spending to its lowest level since the Eisenhower Administration. While President Obama had proposed freezing discretionary spending for 2012 and 2013, this new agreement puts these limits in statute and extends them through 2021.

The agreement does impose "firewall" protections between defense and domestic discretionary programs. It also walls off "homeland security" spending that will not be subject to the discretionary spending limit. This means that Congress will not be able to raid domestic discretionary programs to fund critical defense, homeland security and veterans’ medical care needs. For FY 2012 and FY 2013, the agreement puts into place discretionary limits of $1.043 trillion and $1.047 trillion respectively.

For NAMI’s priority discretionary programs, this could have far reaching implications. Keeping current funding levels in place for a decade will mean that mental illness research, services and housing programs are almost certain to stay in place. In order for Congress to increase funding for a domestic discretionary priority, a corresponding equal reduction must be made in another program(s) in order to avoid breaching the cap. Fortunately, homeland security (including veterans’ medical care) are exempt from the cap.

At the same time, keeping a tight enforceable limit on discretionary spending will have significant consequences for NAMI priorities:

Mental Illness Research

The current (FY 2011) budget for the NIMH is $1.477 billion (.9% below FY 2010 level). Keeping this level in place for the coming decade would seriously erode the capacity of the NIMH to invest in "new and competing" grants, while still maintaining "out year" commitments to large scale clinical trials and longitudinal studies that take years to design, recruit and complete. Each year that the NIMH budget is frozen in place, the capacity of the agency to undertake new studies and clinical trials will be eroded as "biomedical research inflation" (the annual increase in the cost of research) means fewer and fewer new grants. This year, the NIMH "pay line" (the percentage of accepted and validated grant proposals the agency can fund) is at risk of dipping below 15%. In other words, 85% of the proposals and applications NIMH will receive in 2011 that meet standards for sound and valid scientific discovery will not be funded. Level funding NIMH over the coming decade will inevitably send that "pay line" even lower.

Mental Illness Services

As noted above, the vast majority of publicly funded mental health services are financed by the Medicaid program, a joint state-federal entitlement program that operates outside of the new 10-year cap on discretionary spending. There are now a range of smaller discretionary services programs operated by SAMSHA (the Substance Abuse and Mental Health Services Administration) that will be subject to the discretionary cap. These include:

Mental Health Block Grant - $421 million,

PATH (outreach and engagement services to homeless people with mental illness) - $65 million,

Children’s Mental Health - $121 million, and

Projects of Regional and National Significance (various discretionary grants and demonstration programs) - $361 million.

Housing

A 10-year cap on overall discretionary spending will likely have a dramatic impact on HUD’s rental assistance programs. These programs, including Section 8, Section 811 and permanent housing programs under the McKinney-Vento Homeless Assistance Act depend on the discretionary budget for ongoing renewal of existing rental and operating assistance. The out year costs of these programs are driven by a complex set of factors such as tenant income and rental markets. Any increase in these costs is certain to erode the capacity of HUD to invest in development of new supportive housing units that serve people with disabilities (including serious mental illness). This is especially the case with McKinney-Vento and Section 811.

Veterans

The agreement follows the Obama Administration’s definition of "homeland security" funding that is exempt from the 10-year discretionary funding cap. This means that veteran’s medical care will not be subject to the discretionary spending limit. However, other functions of the VA, including medical research will be subject to the cap.