On January 17th, The Idaho Department of Health and Welfare (DHW) presented their budget to the huge joint meeting of the Finance, Appropriations, and Senate and House Health and Welfare committees. It is not a pretty picture. Based on the Governor’s proposed budget, DHW is expected to cut $25,000,000 in state funds from the amount they need to maintain services at the current level. This will result in the loss of about $59,000,000 in Federal matching funds, for a total cut in services of about $84,000,000 for 2012.DHW Director, Dick Armstrong, said that he believed that we could replace current Medicaid services for people with mental illness and developmental disabilities (DD) by relying on family members and volunteers from the community. Medicaid Director, Leslie Clement presented two scenarios to cut the budget. One involved completely eliminating adult Developmental Disability Agency (DDA) Services and Psycho-social Rehabilitation (PSR) for adults with mental illness. This scenario would preserve some Home and Community Based Services (HCBS) for people with developmental disabilities provided in Medicaid waivers. The only other scenario she presented, involves a range of serious cuts to a whole spectrum of community services for people with disabilities, including cuts to HCBS waiver services.
DDA services for adults include developmental therapy, adult day care, and some assessment services. These services have been the core of community supports for people with developmental disabilities for decades. Developmental therapy involves individual assessment and plan development and training programs designed to teach people with DD self care and independent living skills and to decrease problem behaviors. It requires the skillful use of applied behavior analysis and careful data recording, as well as professional review of the data to determine if the strategies being used are effective. It must be provided by agencies with qualified professionals supervising trained staff. It has never been provided by unsupervised volunteers even if volunteers were available.
PSR is a service which includes trained professionals visiting people with severe and persistent mental illness and insuring that they have what they need to stay safe in the community. This may include monitoring symptoms, monitoring compliance with medications, helping them through crises, helping them get to their medical and mental health appointments, and taking them to emergency rooms or hospitals when necessary. PSR is an evidence based practice which has been shown to help keep people with serious mental illness from relapses and re-hospitalizations. PSR providers are trained and certified professionals who deal with serious problems. It is not a service which can be provided by volunteers.
Each of these services plays a crucial role in the system of supports for people with disabilities in Idaho. Neither of these services has ever been provided on any regular basis by volunteers. While some family members have been devoted enough to gain these skills and provide some of the tasks associated with the services, most families are already doing what they can to support their family member with a disability. Most other family members cannot possibly step in to the role played by these services for their loved ones. The idea that families and volunteers will somehow develop the huge amount of resources, training, time and expertise to replace these services is sheer fantasy. Uncertified and unlicensed volunteers risk doing more harm than good. The use of untrained and unsupervised volunteers raises issues of liability, licensure and certification. Proper training, certification and professional supervision of volunteers would cost just as much as the Medicaid program which currently provides the services.
There are alternatives to these cuts.
A Cancer Society proposal to increase the tobacco tax would raise about $50,000,000 per year for the Medicaid budget. This would more than make up for the $25,000,000 shortfall produced by the Governor’s budget. A range of other possible revenue raising taxes would also eliminate the need for these devastating cuts. These include, a temporary sales tax increase, removing some tax incentives which have not produced the results they were supposed to produce, collecting taxes owed on internet purchase and reducing the number of sales tax exceptions.
In addition, the Governor’s budget is based on a prediction that revenue will rise 4.2% in fiscal year 2011, but will rise only 3% in 2012. This estimate is in direct contradiction of the state economists in the division of financial management who are predicting revenue growth of 6.9%. Accepting a revenue projection closer to the one supplied by the experts would also remove the need for cuts to Medicaid programs to balance the budget. Although a revenue projection which is too high would result in holdbacks, a revenue projection which is too low can force changes which cause unnecessary hardship and damage the infrastructure of community services for people with disabilities.
The Governor’s budget singles out Medicaid for the largest cut to any state agency in his budget (5% compared to an average of 2.2%). A more equitable distribution of cuts would relieve some of the shortfall in Medicaid.