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BUDGET & FUNDING | MHAC in ACTION| LEGISLATION

Current Issues in Mental Health Advocacy

Background

More than 260,000 people in Cuyahoga County suffer from mental illnesses. Fathers and mothers. Sons and daughters. Grandparents and grandchildren. Your friends, neighbors or co-workers. Mental health services can help make a big difference in the lives of those affected by mental illnesses…Help them build healthier, happier lives. Help strengthen and empower individuals and families. And help them find and hold jobs, return to school and work, and stay out of trouble.

That's why the Mental Health Advocacy Coalition (MHAC) provides a unified voice around the continuous challenges to public policies and government funding of the mental health system. The MHAC joins together diverse organizations representing mental health providers, philanthropy, business, nonprofit, faith based, education and government organizations to address Cuyahoga County mental health issues.

Together, we have developed a two-year issue agenda designed to enhance funding for and expand access to mental health services, address multi-need consumers and improve awareness of mental health issues. We seek your participation in and support of our agenda to provide the best possible services to the members of our community affected by mental health issues. Through our collaborative efforts and voices, we our friends, families and neighbors—live healthier, successful lives while making our community stronger.

BUDGET AND FUNDING UPDATE

Read the MHAC's Press Release on the current economic situation and mental health services.

State Budget: FY 2010 - 2011

October 2009 - Although the FY 2010 - 2011 biennium state budget passed in July, there is still much talk about the budget and next steps.  With the Supreme Court decision on the Video Lottery Terminals (VLTs) impacting potential implementation and revenues, the Governor's office and the General Assembly are exploring alternative ways to generate approximately $850 million in revenues during the biennium.  During a recent press conference, the Governor announced his support for rolling back the last phase of the income tax cuts adopted in H.B. 66 which were implemented in January, 2009.  H.B. 318, which proposes postponing income tax reductions and reducing the salaries of General Assembly members, has been introduced in the House and is currently receiving hearings in the House Finance Committee.  Since the Governor's press conference, additional alternatives have been suggested, including an income tax increase on Ohioans who make over $200,000 annually.

The MHAC and other community mental health advocates continue to work with the Governor's office, leadership in the House and the Senate and ODMH to correct a drafting error in H.B. 1 which resulted in line item 408 for hospital operating and community mental health services to be erroneously cut by $14.7 million.  Advocates also continue to work to ensure that community mental health services are adequately supported and do not receive further cuts during the corrections process.  When you speak with a representative from the Governor's office or a member of the General Assembly, continue to stress that the community mental health system was significantly under-funded prior to the cuts starting in FY 2009 and the $111 million cut to community mental health services in the FY 2010 - 2011 budget brings the community mental health system to the brink of collapse.

July 2009 - On July 17th, Governor Strickland signed Am. Sub. H.B. 1, the State operating budget for FY 2010 - 2011, and vetoed 61 items from the bill.  (Vetoes included the language for a $1 million earmark for mental health treatment for kids under 7 and language that made it optional for ADAMHS Boards to use local levy dollars for Medicaid match.) This budget significantly cuts both the community mental health system and the community alcohol and drug addiction services system.  For a chart showing the funding levels since FY 2007, click here.  For a document showing the loss calculations, click here.

Community mental health (line items: GRF funding 404, 408, 419, 505 and non-GRF funding 609) has taken a $111 million loss over the biennium from FY 2009 after the three rounds of cuts.  This translates into a 12% decrease in funding for FY 2010 and a 10.5% decrease in FY 2011.   While we do not yet know the actual impact to community services, increases in hospital operating costs (approximately $31 million due to the 9% increase in hospital bed day per diem) will also reduce the funding available for community based mental health services. 

Community alcohol and drug addiction services (line items: GRF 401 and 404) has taken a $23 million loss over the biennium from FY 2009 after the three rounds of cuts.  This translates into a 31% decrease in funding for FY 2010 and a 29% decrease in FY 2011.
 
Residential State Supplement (funding for housing in Adult Care Facilities) funding was also decreased $7 million over the biennium from FY 2009 after the three rounds of cuts or 40.1% each year.

Although we currently do not know the specific impact of these cuts on community based services, including non-Medicaid services, these cuts will be devastating to the community alcohol, drug addiction and mental health services system. 

May 2009 - The Ohio House of Representatives passed Am. Sub. H.B. 1, the FY 2010 - 2011 State Budget, on Wednesday, April 29th.  The House version of the bill includes the following provisions for community mental health services: 

• FY 2010 - $487,655,769 for line items 404, 408, 419, 505, 636
  • All Federal Stimulus dollars (line item 636) were removed.
  • Local Mental Health System of Care (line item 505) was increased by $59,536,483The combination of line items 505 and 636 is $1,330,088 short of the introduced version
  • Children's Behavioral Health Services (line item 404) was increased by $1M designated for the care of children under the age of 7
  • A 0.5% increase in Medicaid reimbursement rate ceilings
• FY 2011 - $495,410,841
  • Federal Stimulus dollars (line item 636) was reduced by $52,047,570 to $27,697,699
  • Local Mental Health System of Care (line item 505) was increased by $53,308,856The combination of line items 505 and 636 is the same as the introduced version
  • Children's Behavioral Health Services (line item 404) was increased by $1M designated for the care of children under the age of 7
  • A 0.5% increase in Medicaid reimbursement rate ceilings

Language regarding elevating the Medicaid match to the state-level was amended.  The group established is now referred to as "The Medicaid Community Behavioral Health Elevation and Administration Group."  They are charged with the task of studying the administration and management of Medicaid.

Language was also added to create a group consisting of ODMH, ODADAS, ODJFS, ADAMH Boards, providers, and consumers to develop recommendations regarding the amount, duration, and scope of publicly funded community behavioral health services that should be available through Ohio's community behavioral health system, including recommendations regarding the conditions under which these services should be available. 

Am. Sub. H.B. 1 includes cuts to programs that help fund housing for individuals with mental illness. It cuts 20% of funding to the Ohio Department of Aging's Residential State Supplemental (RSS) program which helps pay for housing for individuals with mental illness.  This cut will eliminate more than 100 available slots for individuals with a mental illness in group homes. 

The Senate Finance Committee is currently hearing testimony on the State Budget.  Senate President Bill Harris recently said "The Senate will work very hard to meet the constitutional requirement of June 30, but we'll be prepared if we don't meet it." (Cincinnati Enquirer, May 3, 2009)

Specifically, the MHAC calls on lawmakers to:

• fund community behavioral health (general revenue funds) at the Ohio Department of Mental Health (line items 408, 404, 419, 525, 636) at $523.2 million in FY 10 and $523.2 million in FY 11 (this would require an additional $35.5 million in FY '10 and $27.8 million in FY '11).
• restore the 20% cuts to the RSS line.
• increase the Medicaid reimbursement rate ceiling by 3% for community mental health providers.

If you would like to view the entire text of Am. Sub. HB 1 as passed by the House, visit the General Assembly's website.  To view a summary comparison, visit the Legislative Service Commission's website. 

Dec. 2008 - On Friday, Dec. 19, 2008, Governor Strickland ordered 5.75 percent budget cuts to address the $640 million deficit in the state's current budget.  The Governor cut $180 million in state agency spending while finding another $460 million through Medicaid spending adjustments and cash management strategies.  A portion of the $460 million in savings comes from an anticipated increase in the federal share of Medicaid funding early next year.  If this increase does not occur, a 4th round of cuts will be needed before the end of the fiscal year.

Additionally, analysts estimate that even if all state agencies reduce their FY 2010-2011 budgets to 90% of current levels, as directed by the Governor, the next biennium budget could have a deficit of $4.7 billion. 

The Governor is hoping that a substantial federal bailout plan for state governments will be passed quickly after President-elect Barack Obama takes office.  A federal bailout plan could alleviate some of the potential funding deficits in the FY 2010-2011 budget.

With a bleak economic future and tough budget decisions ahead, it is important that advocates become involved in the budget process.  Some important dates to remember:
First week in February - Governor Strickland introduces his budget
Early February to Late March - House committees debate the budget and the House finalizes its version
Early April to Late May - Senate committees debate the budget and the Senate finalizes its version
Early June to Late July - Conference committee convened to reconcile the different versions
June 30, 2009 - final budget must pass both the House and Senate and be signed by the Governor by this date

County Budget

October 2009 - At the September MHAC meeting, County Administrator Jim McCafferty and Cuyahoga County Office of Budget and Management (OBM) Director Sandy Turk gave an update on the state of the county budget.  They reported that the general fund revenues are continuing to decline.  For example, in 2009 the County has $15.5 million less in revenues to operate than it did in 2001.  OBM is also projecting a $12.7 million deficit in 2009, a $29 million deficit in 2010, and a $46.2 million deficit in 2011 due to declining revenues, including significant declines in sales tax revenues.  To help establish a balanced budget for 2010, funding levels for many departments, including the Alcohol, Drug Addiction and Mental Health Services Board, for 2010 are expected to be 2% less than for 2009.  Cuyahoga County is also implementing other means to balance the budget, including no salary increases, continuing the Early Retirement Incentive Program but reducing the incentives, and implementing 5 furlough days during the 1st half of the year.  Both County Administrator McCafferty and Director Turk warned that there are several factors that could still create a need for budget cuts, including: additional state cuts, additional revenue decline, or unexpected staffing expenses.  Hearings on the budget will be taking place during October and November.  A 2010 budget will be adopted on December 3rd.  To download Director Turk's presentation, click here.

Dec. 2008 - At the Board of Cuyahoga County Commissioners meeting on December 11, 2008, the Commissioners approved the Administrator's Recommended 2009 Budget for Cuyahoga County.  The Administrator's budget recommended that both the CCCMHB and ADASBCC receive a 5.5% cut in County subsidy for CY 2009.

To view the Administator's Recommended Budget and other budget documents, as they become available, please visit the Office of Budget and Management's website.

Oct. 2008 - The September MHAC meeting was held in collaboration with The Alliance of Child Caring Service Providers, Council of Agency Directors, Human Services Advocates Network and Voices for Ohio's Children.  At that meeting Jim McCafferty, Cuyahoga County Administrator, Sandy Turk, Director of the Cuyahoga County Office of Budget and Management, and Rick Werner, Deputy Cuyahoga County Administrator of HHS, discussed the 2009 Cuyahoga County budget.  They reported that, regionally, the economy does not look good due to continued population loss, job loss and the decrease in housing values and that the County government is seeing an escalation in expenditures.  They also reported that the General Revenue Fund is expected to continue to decrease creating a need for the County to stabilize the budget.  They proposed a reduction in expenditures as the most effective way to stabilize the budget in 2009. 
Their proposed four tier budget approach is:
1. General Fund Agencies within budget will receive an 8% budget cut in 2009.  They will also receive a budget performance incentive based on additional savings they achieve in 2008.
2. General Fund Agencies that are over budget will receive an 11.5% cut in 2009.
3. HHS Levy Fund budgets will reduce expenditures by $27.5 million or 5.5%.
4. Self Supporting Funds budgets will be limited to their available resources.

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MHAC in ACTION:

Integration

Did you know that nationally individuals with a severe mental illness die 25 years younger than their peers without a severe mental illness?  Often these premature deaths are caused by preventable illnesses, such as diabetes, heart disease, and infection.  Why are individuals with a severe mental illness not receiving adequate physical healthcare?  Research has shown that it is for many reasons, such as transportation issues, being uncomfortable with new places, or not trusting a new doctor, among others.  However, research has also shown that if healthcare is provided at a mental health provider or if the mental health provider coordinates the care, individuals with severe mental illness see improved physical health outcomes.

Both nationally and statewide, policymakers and advocates are considering an integrated model as the future for healthcare.  Which raises the question of what the behavioral health system in Cuyahoga County and Ohio are doing to prepare.  Director Sandy Stephenson has begun holding stakeholder meetings to address some of these issues.  Dr. Dale Jarvis, a national expert retained by ODMH, believes that the behavioral healthcare system has a very short window to change their practices to provide integrated or, at the very least, coordinated care for individuals with severe mental illness.  He believes that if the behavioral health system does not take steps to integrate, then the behavioral health system will be left behind with regards to quality, funding and research.  Dr. Jarvis also believes that if mental health providers do not take steps to address the physical health needs of their patients, then the mental health providers are putting their patients lives at risk.

Dialogues are beginning across the state, facilitated by The Ohio Coordinating Center for Integrating Care, to encourage discussions about integration, the barriers to integration, and the potential solutions to these barriers.  Two of many conversations were held in Cleveland and Akron in September.  With national healthcare reform placing attention on quality healthcare, now is the time to integrate physical and behavioral healthcare.

DYS Settlement

July 2008 - In May, a Settlement Agreement was entered in litigation against the Ohio Department of Youth Services (DYS) relating to conditions in which youth were living while in the custody of DYS.  This Settlement Agreement requires DYS to improve services, including mental health services, provided to the youth in their custody.  The MHAC is working to ensure that these young people receive the mental health services many of them so desperately need.  To read the Settlement Agreement or the Fact-Finding Report, visit the DYS' website.

Transitional Youth

Dec. 2008 - The MHAC was part of a team representing Ohio at the 2008 National Policy Academy hosted by Georgetown University on December 8 - 11, 2008.  The Academy focused on developing systems of care for youth and young adults with mental health needs who are transitioning to adulthood.  Other team members represent ODMH, ODJFS, providers, young adult consumers, and family members.  Ohio was one of six states to be accepted for this year's program.

The goal was for the team to develop a statewide action plan for developing and implementing transitional aged youth policy in Ohio for 2009.  The action plan focuses on developing: 1) a state-level inter-agency committee responsible for developing policy for transitional aged youth and 2) an ODMH standard of practice to encourage the utilization of individualized plans, addressing all life domains, to assist youth with mental health needs in transitioning to adulthood.  The statewide action plan also addresses identifying funding constraints related to the transition from the child system to the adult system and developing possible solutions to those funding barriers. 

July 2008 - The Transitional Youth Project (TYP) is a partnership between the MHAC and Voices for Ohio's Children to develop strategies for improving supports for young people transitioning to adulthood in Cuyahoga County. TYP is currently creating action agendas for key issues including: education, health/behavioral health, workforce development, and housing and an operational plan for a "Youth Space" in Cuyahoga County.  For more information on the Project, please click here.

Medicaid Buy-in For Workers with Disabilities

Oct. 2008 - In 2007, Ohio took a step forward in helping individuals with disabilities work.  On June 30, 2007, House Bill 119 was signed into law establishing Medicaid Buy-In for Workers with Disabilities (MBIWD).  Enrollment began on April 1, 2008.  MBIWD is an Ohio Medicaid program that allows individuals with disabilities the opportunity to work while keeping their health care coverage.  For more information regarding MBIWD please visit ODJFS's website.
The MHAC is currently working with ODMH and other partners statewide to develop a business case for MBIWD and a webinar on MBIWD.  The MHAC is also engaged in other efforts to increase supports for consumer employment.  Additional information will be distributed as details are finalized.

Prior Authorization of Atypical Antipsychotic Medications

Oct. 2008 - The new state Medicaid rule requiring prior authorization of certain atypical antipsychotic medications will take effect as proposed by the administration.  A state legislative panel charged with reviewing the plan had no objections clearing the way for implementation (for more information read the Columbus Dispatch Story).
The administration estimates the rule change will save $6 million annually. However, there is concern that this plan will have significant unintended consequences.  The National Alliance on Mental Illness Ohio (NAMI Ohio) has released a study finding that not only will prior authorization of these drugs not save Ohio millions of dollars, but will actually cost the State millions annually in unintended costs.  These unintended costs include higher hospitalization, incarceration, and medical costs along with lost wages and increased homelessness among individuals with severe mental illnesses.  The unintended costs are associated with other fears advocates, consumers, and family members have over the policy change, namely, whether or not individuals with severe mental illness will continue to have access to the medications they need.  For more information regarding this issue, please read the Columbus Dispatch Story or visit NAMI Ohio's website.
NAMI Ohio is documenting Medicaid's denials of mental health medications for individuals with serious mental illnesses.  If a prescriber in your organization receives a denial from Medicaid for a mental health medication for a client with a serious mental illness, please contact NAMI Ohio.  For their contact information and more information, please read NAMI Ohio's memo. 

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LEGISLATION

State Legislation

S.B. 15 - Behavioral Health Parity: Senator Dale Miller introduced a comprehensive parity bill.  For bill language, click here.

H.B. 84 - Inmate Exams: Rep. Barbara Boyd introduced a bill which requires physical, dental and mental health exams upon arrival of an inmate to a jail and establishes procedures for intake for an individual on benzodiazepines (for example: xanax, ativan, valium). For bill language, click here.

H.B. 3200 - Aug 2010 - Federal healthcare reform is moving forward but is facing some opposition.  The President and Democratic leadership are still expecting to pass healthcare reform, America's Affordable Health Choices Act, this year.  Many provisions in the healthcare reform package will benefit individuals with a mental illness.  If you have the opportunity to speak with your Senator or Representative, stress the importance of healthcare reform.  Tell them that individuals need access to quality and affordable healthcare that includes mental health services, which are covered at parity to medical benefits, and primary care, including preventative and early intervention care.  Healthcare reform also needs to reduce the rate at which healthcare costs are increasing.

The Post-Deployment Health Assessment Act of 2009 (H.R. 2058/S. 711) would establish regulations that all members of the Armed Forces receive in-person mental health screenings prior to deployment and post-deployment in combat situations.  The bill would also establish the ability for the Department of Defense and the Department of Veterans Affairs to share screening results. Click here for more information.

SCHIP Passes with Mental Health Parity!

On February 4, President Obama signed legislation renewing and expanding the State Children's Health Insurance Program (SCHIP). For the first time SCHIP includes critical mental health parity benefits. It will remove higher co-pays and stricter limit on the number of treatment visits, creating parity between mental health services and medical and surgical benefits provided by the plans. Mental disorders affect about one in five American children. Mental health care is therefore a key component of the array of services needed for healthy childhood development. Without needed treatment, children with mental disorders are at increased risk for school failure, contact with the juvenile justice system and even suicide.

Federal Parity Passes!

The US Congress passed mental health parity on October 2, 2008. For more information, read Mental Health America's information sheet.

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