Comparing Olmstead Implementation Among Disabilities. I

Comparing Olmstead Implementation Among Disabilities. Information Bulletin #322 (9/2010).

For years, we have reviewed and compared Medicaid expenditures for people in institutions and in the community. For quite a number of these years, advocates for people who have an Intellectual/Developmental Disabilities have consistently used the Medicaid’s Home and Community-Based systems far better than advocates for older and younger people with physical disabilities, dementia.

To analyze how well the Olmstead's ADA mandate to end unnecessary institutionalization of people with disabilities has been accomplished, it is necessary to separate these two groups, ID/DD (previously MR/DD) vs. A/D(Aged/Disabled) (these are CMS designations). The reason this is necessary is, because depending on the disability label people have affixed to their heads, this label determines the institution into which you may be unnecessarily institutionalized and the funding stream you can access in the community.

Under the federal Medicaid statute, people with a ID/DD label are institutionalized in State Centers and ICF-MR (Intermediate Care Facilities for Mentally Retarded), and older and younger people with, for example, physical disabilities, dementia or anything other than the ID/DD label, are unnecessarily institutionalized in nursing homes.

These institutions, though similar in how they treat people, differ dramatically when measured by per person spending which carries over directly into the Medicaid Home and Community-based Waiver system and therefore into the amount and package of services a person will receive. Therefore, the label triggers the institution which triggers the amount of Medicaid community-based services one receives.

This long-winded explanation is necessary to understand that when one compares Medicaid community vs. institutional expenditures, the label determines both the institutional and community-based expenditures.

With this background information, we can now compare Olmstead's ADA mandate by looking at the Medicaid expenditures for the two groups. Here's what we find:

* In FY 2004, nationally the distribution of Medicaid Long Term Care expenditures for MR/DD services spent 42.4% in the institutions (State Centers and ICF-MRs) and 57.6% of the total LTC in the community. In dollars, $12 billion went to MR/DD institutions and $16 billion for services in the community.

* In the same year, FY 2004, nationally the distribution of MA LTC expenditures for A/D services spent 74.9% institutions (nursing homes) and 25.1% in the community. In dollars, $46 billion went to A/D institutions and $15 billion for services in the community.

Let's see what changes occurred in five years. Was there a leveling and how much progress was made?

* In FY 2009, nationally the distribution of Medicaid Long Term Care Expenditures for ID/DD services spent 34.4% in the institutions (State Centers and ICF-MRs) and 65.6% in the community. In dollars, $13 billion went to MR/DD institutions and $26 billion for services in the community.

* In FY 2009, nationally the distribution of expenditures for A/D services spent 66.2% institutions (nursing homes) and 33.81% in the community. In dollars, $50 billion went to A/G institutions and $26 billion for services in the community.

The FY2004 data and statistics were only five years after the Olmstead decision. However, the FY 2009 data is ten years after Olmstead. Though there has been a lot of improvement, there is still a significant institutional bias if one has the A/D label.

Let's compare the two funding groups over the five years:

The good news is that between 2004 and 2009, both groups had increased the distribution of Medicaid expenditures in the community as compared to their respective institutions.

But the inexplicable fact remains: people with a ID/DD label have a significantly better chance of residing in the community than people with an A/D label.

Just the facts!

There were 17 States in FY 2009 that expended more than 80% of their Medicaid funds inthe community for people with ID/DD. Congratulations!
There were only 2 States in FY 2009 that expended more than 60% (that's correct) of their Medicaid funds for people with A/D in the community! Wow.

Here are a few examples: Why in FY 2009 would Michigan spend 99.2% of Medicaid funds for people with ID/DD in the community but only 21.5% in the community for people with A/D? Similarly, New Hampshire spent 98.1% for ID/DD in the community but only 17.7% in the community for A/D; Alabama spent 87.8% for ID/DD in the community but only 14.9% for A/D in the community.

Why are there such marked differences based on a label?

Are the ID/DD advocates better than the A/D advocates?

Do younger and older people with physical disabilities prefer nursing homes over community services?

Why can State administrators (Medicaid Directors) continue to shift Medicaid funds from ID/DD institutions to the community while at the same time increase significantly faster the pace of shifting the A/D Medicaid funds to the community?

If the goal is to rebalance the entire long-term service and support system, then we need to look at how each of the funding streams are faring and develop rebalancing strategies to meet our overall goal of a total community integrated system.

Disability advocates - whether older or younger are people with disabilities. Whether your label is A/D or ID/DD or MI or....... , we all want services in the most integrated setting. The Olmstead decision was about all of us. Isn't it about time we confront the labels and the different funding streams?

The people united will never be defeated. El pueblo unido jamás será vencido!

Thanks to Thompson/Reuters for compiling the above state MA expenditures data.

Steve Gold, The Disability Odyssey continues

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