Some of the most vulnerable Mainers are about to get hit with a one-two sucker punch from DHHS director Mary Mayhew and Governor Paul LePage that, if approved, will decimate life-saving services, eliminate healthcare jobs and force people back onto the streets and into the emergency rooms.
Given the absence of a budget crisis that might justify such belt tightening, the draconian $65 million in cuts that target those most desperate for help is not only puzzling, but cruel.
The first punch will be a 23-26% cut in the MaineCare reimbursement rate for providers of targeted case management and community support services, as recommended by Phoenix, Arizona-based consulting firm Burns and Associates. The initial proposed cut of 33% that Burns floated last year was met with outcry and an emergency moratorium by the legislature on rate changes by DHHS. When that moratorium expires in April, DHHS can move forward with the cuts, effective with the start of the next fiscal year, without legislative approval.
The second blow will be the changes in the LePage budget that boot 19- and 20-year-olds from MaineCare and block out parents making between 40-100 percent of the federal poverty level (FPL) to 40%, a $9.6 million chunk of the overall effort to cut $102.7 million from DHHS. That means a single parent with one child will be on her own for health insurance without access to an ACA plan if she earns more than a paltry $6,496 gross income annually ($561 per month) and less than $16,240 ($1,353 per month). In other words, even if she managed to find a minimum-wage job that gave her 39 hours a week sans overtime, she would be out of luck.
And she would be far from alone. With the unknowns in Washington surrounding the ACA and no guarantee of Medicaid expansion, more than 25,000 low-income parents and young adults, a quarter of whom are receiving treatment for mental health and substance abuse, would lose coverage.
Like all those high-paying, full-time jobs with benefits that supposedly exist in abundance, equally mysterious is the LePage administration’s rationale for the necessity of such drastic action when he’s angling for more tax cuts for the wealthy and on national TV touting a $200-million (or is it $1-billion?) rainy day fund as a result of “tough management.”
Mainers are dying
The human cost of such management is mounting. More than 40,000 Mainers have already lost health coverage due to cuts in recent years.
“We don’t have a fiscal crisis. Yet we’re making cuts with people dying,” said Malory Shaughnessy, executive director of the Alliance for Addiction and Mental Health Services. “Maine’s infant mortality rate and food insecurity for children is rising. One Mainer dies every day from untreated opioid addiction.”
“I’d say it’s raining. It’s pouring.”
The Alliance is comprised of 35 provider members that employ more than 5,000 people, and they have served 85,000 Mainers with over 6 million service hours. Though Shaughnessy said that the total impacts of the LePage cuts are still being tallied, a similar Harvard/NYU study that analyzed the effects of losing the ACA in Maine paints an equally grim outlook.
“Several of our agencies have grave concerns about the impacts on the youth they serve with the 19-20 year-old cuts, and many more have concerns about the reduction in coverage for parents down to the 40 percent FPL,” Shaughnessy said.
One agency that will be hit hard right away is Day One, a South Portland-based nonprofit that works with behavioral and substance abuse issues for teens and young adults primarily between the ages of 13-21.
“Cutting 19- and 20-year-olds from MaineCare would put 69 of our clients out of service immediately,” said CEO Caroline Raymond.
Day One provides residential services, including continuing mental health and six-month treatment programs for a variety of abused substances, until a client turns 19. At that point, the focus changes to transitioning him or her to adult life with assistance finding stable housing, employment and continued care.
“Our goal is to prevent children from needing higher, more expensive care,” Raymond said. “We want to identify the issue and get them help early. Vulnerable youth and adolescents need access to services.”
However, the cuts would widen the care gap that already exists for low-income 20-26 year-olds by two years, with the only discernible solution to “get a job.” That’s easier said than done for someone with mental health challenges and/or a history of substance abuse and who is likely from a less than stable home situation. A full-time job with health insurance is hard for even a well-heeled recent college graduate to find, and is a near-impossibility for a young adult with immense personal challenges.
Cuts on top of cuts
The proposed reimbursement rate cuts from DHHS would double down on their struggle by forcing cutbacks in transition services.
“If they relapse, they have no place to go,” Raymond said. “They’re already behind developmentally. They feel lost in adult services. Already we have young adults begging to come back to our program after they turn 19, but we have to tell them no.”
The best bet for unemployed or underemployed low-income twenty-somethings to find access to necessary care and treatment is in the penal system, such as the successful pilot program at the Charleston Correctional Facility. Incentivizing incarceration as the only means for desperate young adults to get care is a precarious position for the state to put itself in, and surely a more expensive one, but the LePage administration seems adamant on paying a lot later for problems that can be solved with much less right now.
Donna Galluzzo, executive director of the Frannie Peabody Center, which serves Portland and surrounding areas with targeted case management, was hopeful that the Burns study commissioned by DHHS would confirm the need to raise the reimbursement rates, which have been unchanged since 2009.
“With real estate prices going up and the cost of doing business rising, it would have made sense,” she said.
The opposite happened. Although the original 33 percent first proposed last year was revised down to 26 percent in the updated study released last month, the loss of a quarter of the nonprofit’s operating budget will cripple its ability to deliver services.
“We’ll have to lay off staff, terminate services and change our model,” Galluzzo said. “There’s no budget shortfall, there’s no reason to do this but to ‘get the rates right.’ It’s not compassionate. It’s not fiscally responsible.”
The center’s caseworkers provide a critical link between vulnerable individuals and health providers. Its clients include the unhoused, refugees, asylum seekers, members of the LGBTQ community, and persons living with HIV and AIDS. According to Section 13 of the MaineCare manual, the goal of target case management is to help meet the “medical, social, educational and other needs (including housing and transportation) of the eligible member, identify the services necessary to meet those needs, and facilitate access to those services” of these populations.
For these services, the state has been reimbursing $21.52 per quarter-hour that a caseworker spends directly with a client (time spent on paperwork, travel and training are not billable). The adjustment drops this rate to $15.92 per quarter-hour, a 26% cut.
Axing community support services
An interrelated but separately-funded program facing cuts is community support services. According to Section 17 of the MaineCare manual, these rehabilitative services are “provided in the context of a supportive relationship, pursuant to an individual support plan that promotes a person’s recovery, and integration of the person into the community, and sustains the person in his or her current living situation or another living situation of his or her choice.”
The state has been reimbursing $20.86 per quarter-hour for these services; the adjustment drops this rate to $16.11 per quarter-hour, a 23% cut.
With a staff of 20 and only eight caseworkers who are already stretched thin by the combination of face time with clients and keeping up with the immense amount of paperwork required to keep tabs on their cases, taking on more clients or hiring more staff is an impossibility. The center is already scrambling to accommodate those shut out by the City of Portland’s controversial closure of the India Street Public Health Center last year.
“These cuts will mean a six-figure hit to our budget and leave us with difficult decisions. Many would have to close their doors, especially in rural areas,” Galluzzo said.
Many of the center’s HIV- and AIDS-positive clients have coexisting health conditions and need help with medical paperwork and keeping appointments, in addition to behavioral health issues. Without a case manager to help them navigate the system, the risk of their falling out of care – and into homelessness or the emergency room – rises dramatically, costing taxpayers more in the long run. And the consequences could be even more dire.
“When they are staying in care and on their meds, the system works well,” Galluzzo said. “It suppresses the viral loads in the general population and protects the public. But we would be risking a worst-case scenario, another epidemic, by pulling away care.”
Even that concern has fallen on deaf ears at upper levels of DHHS.
“I’ve asked them what their plan is to make up for it, and have received no answer,” Galluzzo said. “I asked DHHS to visit. We’re transparent about our budget. We’re fiscally responsible, but we’re not even breaking even at the moment. We’re already doing a tremendous amount of fundraising. We have no endowment to fall back on. We’d love to do more, but we’re busy caring for clients.”
Galluzzo isn’t the only nonprofit health administrator who has noticed an increasingly adversarial attitude toward providers by DHHS under the LePage administration. Mary Haynes-Rodgers, who has worked in community health in Maine since 2000 and has been the executive director of Shalom House in Portland for the past eight years, remembers a time when the relationship – and the health outcomes for Mainers – was much better.
“There’s been a culture of lack of care and little teamwork with DHHS for the past six years,” Haynes-Rodgers said. “The philosophy of all of us being together has changed. The administration is choosing deserving and undeserving populations for care, and the unhoused and mentally ill are always considered undeserving. I used to be proud of the system we have here, but now I’m embarrassed by it.”
Shalom House, which provides both targeted case management and community support services, would be hit hard by both the DHHS reimbursement rate reduction and the LePage budget cuts. At least 300 clients with mental and physical health needs would be shut out, Haynes-Rodgers said, and the community integration program and its associated jobs would have to be eliminated. It’s a recipe to put even more people out on the streets without a lifeline.
Given the well-documented link between severe mental illness and homelessness, the wholesale elimination of MaineCare eligibility for 19- and 20-year-olds is especially cruel. “Most people who are at risk of developing schizophrenia have their first break as young adults, right at that age,” Haynes-Rodgers said. “It tells the most vulnerable people that they’re on their own.”
More questions than answers
Perhaps most frustrating to her and the other directors is the accusations in the Burns study that they are providing unnecessary services: “In certain instances, providers may have been providing services that are neither required nor expected by MaineCare policy. DHHS expects that the reduced rate will require that providers more closely align services they deliver with MaineCare requirements.”
When providers pushed for an explanation, none was initially given. Only after more than 100 public comments were made did DHHS respond in the Burns follow-up report, released on Dec. 31, in which it cited these excesses:
– Support to individuals receiving inpatient care,
– After-care support,
– Arranging travel,
– Coordination efforts with new clients before billing begins,
– Sitting in a waiting room or waiting for a meeting to start, and
– Employee breaks.
It is yet unknown if providers were notified or ordered to correct any of these supposed inefficiencies prior to the release of the study. If the state thinks providers are guilty of caring too much for their clients, perhaps DHHS officials could have a conversation with them about finding better ways to meet client needs rather than instinctively reaching for the hatchet.
Ignoring providers’ concerns also seems to be a favorite weapon.
“When they did the [Burns study] re-do, they didn’t even talk to providers,” Haynes-Rodgers said. “Then they told us these cuts aren’t budget-driven. So, what is driving it?”
That’s a question that many providers are asking and have been asking for over a year, to no avail. Given the speculation about LePage’s senatorial ambitions, a fat rainy day fund at the end of his reign of obstruction would be a pretty feather in his cap for his conservative base come primary season, even if it comes at the expense of our state’s most vulnerable citizens now and all of us later when the emergency rooms start filling up again. But he’ll be out of office by then, so he’s not obligated to care.
“This is about letting people have a life,” Haynes-Rodgers said. “We have people out there homeless and children are starving, and we’re worried about padding the state’s bank account?”
It’s raining in Maine, and there’s a flood coming. If only the governor would believe it.
The 60-day public comment period for the MaineCare reimbursement rate changes is closing soon. Contact DHHS to submit your comments, and contact your legislator to voice your opinion about the proposed budget changes.
Photo via Andi Parkinson.