2010 MA Data -Progress Since the 1999 Olmstead Decision - How Is Your State Doing?

2010 MA Data -Progress Since the 1999 Olmstead Decision - How Is Your State Doing? Information Bulletin # 245 (11/2011).

In 1999, the U.S. Supreme Court Olmstead decision held that “unjustified isolation is properly regarded as discrimination based on disability.” The Court wrote that “institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.” In the decision, the Court noted that a State’s efforts should “not be controlled by the State’s endeavors to keep its institutions fully populated.”

Okay. So how much progress has been made in your state between the 1999 Olmstead decision and FY 2010 (the last year for which we have data) regarding people in nursing homes?

Here is what we found using Medicaid’s long-term care expenditures in both 1999 and 2010 for the nursing facility institution versus the comparable Medicaid LTC community services. This comparison looks at how States allocate MA expenditures for persons with disabilities and the aging communities. The higher the percentage expended on nursing homes, the less on the community.

FY 1999 - Olmstead decision - the benchmark:

Nationally, in 1999, 80.4% of the relevant Medicaid’s long-term care institutional expenditures went to nursing facilities and 19.6% went to community-based services:

1. 13 states spent more than 90% of their Medicaid LTC expenditures institutionally on nursing facilities (D.C, HI, IL, IN, LA, MS, NH, ND, PA, RI, SD, TN, and UT) and therefore less than 10% in the community;

2. Only 4 states spent less than 70% of their MA LTC on nursing facilities (AR, NC, OR, WA), and therefore spent more than 30% in the community. .

3. The median state expenditure to nursing facilities was 84.7%. Median means half the states spent more and half less on nursing facilities.

FY 2010 - Eleven years later - how much progress has been made:

1. Nationally, 64.3% of Medicaid’s long-term care institutional expenditures went to nursing facilities. That’s a “drop” of 16.1 percentage points from 1999 to 2010.

2. Viewed from the Olmstead community-based perspective, in 2010 nationally only 35.7% of States long-term care expenditures went to the community – even though States had large numbers of persons in nursing homes who have stated they want to live in the community. Remember that in 1999, it was 19.6%

3. First the worst states in 2010:

5 states were still spending more than 80% of their LTC on nursing facilities (ND, DE, AL, MD and MS), even though the national average was reduced to 64.3% in 2010; and

4. And now, the best states in 2010:

7 states spent less than 60% of their Medicaid LTC on nursing homes (the national average was 71.4%)(AK, CA, ID, NC, OR, TX and WA), therefore spent more than 40% in the community;

5. The best states, i.e., those that spent more than 50% of their LTC MA expenditures in the community, in order are: NM, WA, MN, OR, AK, CA;

6. States that made the most progress since 1999 are

12 states (only includes non-managed care States) had a “drop” of more than 15 percentage points from 1999 to 2010 in institutional/nursing facility expenditures. (AK. CA, CO, DC, ID, IL, LA, MO, OK, PA, VG, WA) and therefor spent the savings in community. This reflects change – not where the State started in 1999.

7. So what’s up with the rest of the States:

Two States - Delaware and Kentucky - actually increased their NH institutional expenditures from 1999 to 2010. Quite unbelievable.

8. Four states had a “drop” of less than 5 percentage points from 1999 to 2010.(AL, AR, NJ, SC). No bragging rights in these states.

9. Tem states had a “drop” of more than 5 but less than 10 percentage points in the eleven year period. (CT, GA, KA, MD, NH, ND, OK, SD, WV). Still hard to believe so little in 3l3lven years.

How do we explain such minimal changes over eleven years. What would the racial movement for equality and women’s movement have done if their movements had made so little progress – especially when we know there are about 25% of the people in nursing homes who want to reside in the community?

Why are the disability and older American advocates in the “worst states” not outraged that eleven years after Olmstead their states are doing so badly? Why are there no “Occupy” movements in those states focused on the lack of civil rights of unnecessarily institutionalized people? What are the advocates doing in these “worst states?” Where is the next generation of advocates?

What about the 14 states where the “improvement” was so small - less than 10 percentage points? Aren’t there disability and older American advocates in those states who are upset with the extremely slow Olmstead progress? What should we tell the brothers and sisters unnecessarily institutionalized about their civil rights?

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects. To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100.

The following data does NOT include managed care data for AZ, FL, MA, MN, NM, TN, TX, VT, and WI. We have reviewed that data but it’s available only for 2008 and 2009. Also, HI and RI 2010 data does not include managed care programs that provide long-term services and supports.
FY1999 vs FY 2010: Decrease or Increase

Alabama .....................88.2 % vs 83.7% -4.5
Alaska ........................74.8% vs 40.9% -33.9
Arizona ...................... 88.5% vs 90.4%MC ???
Arkansas.....................68.7 vs 68.5 -0.2
California................... 81.6 vs 45.4 -36.2
Colorado.....................73.7 vs 55.9 -17.8
Connecticut.................83.8 vs 74.6 -9.2
Delaware.....................85.5 vs 86.0 +1.5
D. C............................ 91.4 vs 52.4 -39.0
Florida........................ 88.3 vs 78.7MC ???
Georgia....................... 84.7 vs 74.8 -9.6
Hawaii........................ 90.9 vs 79.7 MC -??
Idaho........................... 78.4 vs 50.6 -27.8
Illinois.........................92.8 vs 73.8 -19.0
Indiana........................ 92.5 vs 80.0 -12.5
Iowa............................85.1 vs 72.0 -13.1
Kansas........................69.3 vs 61.0 -8.3
Kentucky....................79.1 vs 82.5 +3.4
Louisiana....................91.7 vs 69.5 -22.2
Maine.........................80.5 vs 74.8 -5.7
Maryland....................87.4 vs 79.5 -7.9
Massachus..................84.6 vs 62.5MC -???
Michigan....................86.5 vs 71.6 -14.9
Minnesota.................. 80.2 vs 40.2MN -??
Mississippi.................94.7 vs 82.5 -12.2
Missouri.....................81.7 vs 65.4 -16.3
Montana.....................75.6 vs 61.9 -13.7
Nebraska.................... 85.5 vs 73.1 -12.4
Nevada........................ 81.9 vs 67.1 -14.8
New Hampshire.......... 91.1 vs 81.4 -9.7
New Jersey................. 79.8 vs 76.0 -3.8
New Mexico............... 88.7 vs 13.5MC -???
New York ..................70.3 vs 57.3 -13.0
North Carolina............ 67.7vs 56.9 -10.8
North Dakota.............. 95.5 vs 87.9 -7.6
Ohio............................ 88.5 vs 76.1 -12.4
Oklahoma................... 86.5 vs 68.1 -18.4
Oregon....................... 55.3 vs 44.8 -8.5
Pennsylvania............... 96.9 vs 79.5 -17.4
Rhode Island............... 92.7 vs 99.3MC -???
South Carolina............ 79.8 vs 74.8 -5.0
South Dakota.............. 94.7 vs 84.9 -9.8
Tennessee................... 99.2 vs 73.4 MC ???
Texas......................... 74.6 vs 53.9MC -???
Utah............................92.5 vs 80.2 -12.3
Vermont..................... 82.5 vs 92.4MC ???
Virginia.......................82.6 vs 61.6 -21.0
Washington ................62.5 vs 38.9 -17.1
West Virginia..............77.0 vs 85.5 +8.5
Wisconsin ..................72.2 vs 73.0MC -???
Wyoming ...................83.3 vs 72.4 -10.9

National .....................80.4 vs 64.3 -16.7


Special thanks, again, to Thompson Reuters and CMS for compiling and making this data available.

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins are also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100.

Medicaid 1115 Waivers and People With Disabilities.

Medicaid 1115 Waivers and People With Disabilities. Information Bulletin #344 (11/1/11)

I will bet anyone out there a Philadelphia pretzel (with mustard) that over the next few years there will be major structural and funding changes in the Medicaid program. These changes will happen regardless of the recommendations of the Congressional “Super Committee” or who wins the 2012 Presidential election. States are pressuring for more flexibility to make changes in Medicaid. We have no doubt that these changes will determine who will be eligible for and will receive Medicaid services, how much and what services they get, and the way these services are delivered.

Many States are submitting or have already submitted what are called “1115 Medicaid waivers” to get out from under some of the existing federal Medicaid rules. (California is just the latest state getting their waiver request approved.)

Section 1115 of the Social Security Act allows the Secretary of the Department of Health and Human Services (HHS) to suspend certain federal laws or regulations that govern programs authorized by Medicaid and SCHIP, in the context of an alleged state “research and demonstration project.” A Section 1115 Medicaid and SCHIP demonstration project/waiver are supposed to “promote the objectives" of the Medicaid program.

Some 1115 Waivers are statewide, comprehensive demonstrations that affect the majority of people who receive Medicaid in the state. These include waivers that require people to enroll in a managed care plan or that expand coverage to all state residents with incomes below a certain level. Other demonstration projects are more limited in scope. Examples of these include waivers that provide family planning services to low-income women who would not otherwise qualify for Medicaid, or those that allow certain people with disabilities to manage their health care purchasing (e.g. Cash and Counseling waivers).

Section 1115 waiver projects are generally approved to operate for a five-year period and must maintain “budget neutrality.” The budget neutrality requirement means that the waiver program cannot cost the federal government more than would have been spent on Medicaid for people covered by the waiver if the waiver didn’t exist.

1115 waivers can be written in to resemble what we called “block grants”. Most Governors and their Medicaid Directors are looking for any way to control their Medicaid budgets and they see the 1115 waiver process as one way to make this happen. We can “hope” that the current Administration (HHS/CMS) would not approve any waiver that would harm people’s services. However in this economic and political environment nothing is certain.

Remember if in the November 2012 election change administrations, there will be a new Secretary of Health and Human Services who may be more open to more state flexibility and “block grant” proposals.

Another aspect of the current 1115 waiver process that should send up red flags in our community is the limited federal requirement for stakeholder/consumer input into the design of the waiver. Literally the state (Medicaid Director) can substantially change the way Medicaid services are funded and delivered without holding one public hearing (CMS has new rules in the process to change this but they are not yet final.)

We are very worried that people with disabilities, especially those with more severe disabilities – you know, expensive – will not have their needs adequately addressed. The ADA applies to States that apply for 1115 Waivers and also applies to private managed care agencies that may apply to administer the 1115 Waiver. For people with disabilities, living in “the most integrated setting” must continue as a priority!

The hell with: NOTHING ABOUT US WITHOUT US!

Suggestions of things we can do now:

1. In the follow up to the historic DC “MY MEDICAID RALLY, reach out to other organizations in your state who have members that would be effected if Medicaid funding is reduced or if the program was drastically restructured. Form a Medicaid Action coalition (Texas is starting a Texas - MY MEDICAID MATTERS Campaign);

2. Meet with your Medicaid Director and/or your Director of Health and Human Services and find out what plans your state has in regard to Medicaid and especially an 1115 Waiver application.

3. Demand that the state establish a statewide public input process BEFORE for any proposed 1115 waiver process begins;

4. Develop an Action plan through 2012 to include: monitoring Medicaid funding, cuts in services, all new waiver submittals and renewals, outreach to the community and educate folks on Medicaid issues, develop a media strategy, potential legal action and Direct Action activities.

“We must not fiddle while the sky is falling because we can’t put Humpty Dumpty back together again” I always get these sayings mixed up!!!

Don’t Mourn...ORGANIZE, REGISTER and VOTE

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com

with a searchable Archive at this site divided into different subjects.

As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/

To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100.