State by State Data for Aged and Disabled: Institutional Bias? Information Bulletin #383 (October 2013) For the past ten years, we have tracked Medicaid funds by State by comparing community versus institution expenditures for people with disabilities. The FY 2011 data is finally available. This Information Bulletin will focus only on Older Adults and People with Physical Disabilities from both a six year (FY 2006-2011) perspective with a more detailed look at FY 2011. The “good” news is that in FY 2006, the national average of community versus institutional Medicaid expenditures was 29.6% to the community and 70.4% to the nursing homes. In FY 2011, it was 38.1% to 61.9%. Yes, it’s a slow, incremental change. And yes, inherent in the lethargy and pace are people being discriminated against in violation of the ADA. Without a serious national litigation attack, the arc of history will continue to bend, but very slowly. The nursing home industry is very powerful and contributes a lot of money to State elected officials. Given that most people want to live in the community and not nursing homes, the quid pro quo is obvious. The nursing home industry “contributes” to your elected State officials, who in return continue to raise the per diem nursing home reimbursements and continue to allocate Medicaid funds in a discriminatory manner. Unlike the for people with Developmental Disability, where 23 States spend more than 80% of their Medicaid expenditures in the community and only 7 States spend less than 50% in the community, for the Older Americans and People with Physical Disabilities only 1 State spent more than 80% in the community and 44 spent less than 50% in the community. Quite a difference! Here are the States that spent the least in the community in FY 2011 for A/PD, and therefore spent the most in the nursing homes. The worst/least Medicaid expenditures in the community was Rhode Island, followed by North and South Dakotas, Alabama, Delaware, Kentucky, New Hampshire, Mississippi, Indiana, Utah, and Pennsylvania. Six of these “worst” A/PD states either have an exceptionally strong nursing home industry or the State elected officials have a particular dislike of Old Adults and People With Physical Disabilities. Compare their community-based Medicaid expenditures for people with Developmental Disabilities versus Older Adults and People with Physical Disabilities. The following six states spent more than 72% of the Medicaid funds in the community for people with DD, while spending less than 22% in the community for people with A/PD: Alabama, Kentucky, Delaware, New Hampshire, Utah, and Pennsylvania. Quite a difference! Here are the States that spent the most in the community in FY 2011 for A/PD, and therefore spent the least in the nursing homes. New Mexico was far and away the best, followed by Minnesota, Washington, Alaska, Oregon, California, Texas and Wisconsin. These States are the winners. Advocates for Older Adults and people with Physical Disabilities should sit down in your State with the advocates for people with Developmental Disabilities to discuss their successful strategies. Advocates should ask their attorneys why they are not banging down the courthouse doors with lawsuits under the ADA and Olmstead. 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 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. Ext 227.

DOJ’s ADA Lawsuit Regarding Children in Nursing Homes. Information Bulletin #383 (8/2013) The U.S. Department of Justice, Disability Rights Section, filed a very important ADA/Olmstead lawsuit against the State of Florida on behalf nearly 200 children with disabilities. USA v. The State of Florida http://www.ada.gov/olmstead/olmstead_cases_list2.htm#fla. These children “entered nursing facilities as children and grew up in these institutions” and were “unnecessarily segregated from their communities.” This lawsuit also claimed that “children with significant medical needs who reside in the community” face “serious risk of unnecessary institutionalization” because of “repeated service reductions and lengthy and unduly burdensome recertification processes.” While the lawsuit focused on children, DOJ’s legal claims apply as well to adults in nursing facilities and at risk of institutionalization. Also, because many States have very similar ADA/Olmstead issues, we will point out some very important handles you might want to consider. 1. “Denial or Reduction of Medically Necessary Services.” DOJ asserted that Florida “in recent years unduly restricted the availability of many in-home services … through a state regulation that requires Medicaid services to ‘be furnished in a manner not primarily intended for the convenience of the recipient or recipient’s caretaker.” DOJ asserted that there were children in nursing facilities as a result of Florida’s limits on in-home services and/or a failure to provide such services. 2. “Stagnant Reimbursement Rates for Home Health Services.” DOJ noted that many people were unable to access home health services due to the low Medicaid rates paid for such services. One comparison that is very helpful was DOJ noting that the rate paid to nursing homes for these children increased in the last 9 years by 28%, but home health rates have not increased comparably. 3. “Insufficient Capacity in HCBS Waiver Programs.” After pointing out that most of these children are eligible for Waiver services in the community, due to lengthy waiting lists children have been forced to enter nursing homes. Even with additional State Waiver funds in 2013, more than95% of the people on waiting lists will not receive community-based services. 4. “Lack of Sufficient Community-Based Alternatives.” DOJ stated there were “very few providers of care to children with significant medical needs” in non-institutional settings. 5. “Failure to Offer Meaningful Opportunities to Move to the Community.” DOJ stated that “many of the Institutionalized Children remain in facilities for very long periods of time, even when it is apparent that their medical conditions would permit return to the community with appropriate supports. The continued stay of most of these children is the direct result of the State’s failure to actively identify more integrated service options for them.” Related to the ADA/Olmstead arguments and claims, DOJ noted that “providing services in integrated settings can be accommodated through reasonable modifications to the State’s existing services.” These five problems exist in many other States and cause adults (and children) to be unnecessarily segregated in nursing homes and other institutional settings, as well as to be at serious risk of institutionalization. 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 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. Ext 227.

HUD Issues Olmstead Guidance – Let’s Use It! Information Bulletin #382 (6/2013) On June 4, 2013 HUD released a “Statement … on the Role of Housing in Accomplishing the Goals of Olmstead.” Here is the link to HUD’s Statement: http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2013/HUDNo.13-086 Then click on “Read HUD’s new guidance” for the full Statement. This Information Bulletin quotes some points and suggests what advocates should look for and what can be done if your local and State recipients of HUD funds do not comply. HUD emphasizes the critical role housing plays in implementing the Olmstead and the ADA’s “most integrated setting” mandate by “increasing the housing opportunities for individuals with disabilities who are transitioning from, or at serious risk of entering, institutions, hospitals, nursing homes, adult care facilities, and other restrictive, segregated settings.” Advocates throughout the country have repeatedly testified that the lack of affordable, integrated, accessible housing is and has been a very significant barrier for people institutionalized (who cannot afford or locate housing because they have no money or their money goes to the institution) and people at risk of institutionalization (who, to stay out of an institution, must have accessible units in the community). Advocates know that HUD funded programs, in the past, have not focused on and have not required public recipients of HUD funds to focus on Olmstead and the ADA mandates for integration. The HUD Statement is intended to ensure compliance with Olmstead and the ADA. HUD recognizes that “a critical consideration in each state is the range of housing options available in the community for individuals with disabilities and whether those options are largely limited to living with other individuals with disabilities, or whether those options include substantial opportunities for individuals with disabilities to live and interact with individuals without disabilities.” HUD provides three examples of integrated housing: 1. “scattered-site apartments providing permanent supportive housing [that could be rented with Section 8 vouchers], [2] tenant-based rental assistance [a housing voucher authorized in the HOME Investment Partnership program, administered nationally at both the State and local levels] that enables individuals with disabilities to lease housing in integrated developments, and [3] apartments for individuals with various disabilities scattered throughout public and multifamily housing developments.” HUD told “public housing agencies and other HUD-assisted housing providers to work with state and local governments to provide integrated, affordable and accessible housing options for individuals with disabilities who are transitioning from, or at serious risk of entering, institutions or other segregated settings.” (Let’s hope they will work also with advocates and people with disabilities.) In another example [#4], HUD reminded both public housing agencies and other recipients of HUD assistance that “certain preferences [both with regards to actual housing and housing vouchers] that will enable individuals with disabilities … are permissible.” No more excuses that HUD-funded programs cannot establish preferences to assist institutionalized persons to return to the community or to prevent the institutionalization of people who are at risk of such institutionalization. A fifth example focused on “reasonable accommodations/ modifications (e.g., increasing the payment standard for Housing voucher for accessible units, or an extra bedroom for equipment or live-in aide). The Statement pointed out that “HUD requires recipients of HUD assistance [that includes public housing agencies, housing vouchers, the HOME tenant-based rental assistance vouchers, CDBG, and lots of other recipients] to take affirmative steps to further fair housing. The affirmative furthering fair housing (AFFH) obligation offers an opportunity for HUD and the recipients of HUD assistance to support Olmstead implementation by engaging in activities that will benefit individuals transitioning from institutions or at serious risk of institutionalization by providing integrated, affordable and accessible housing options in community-based settings.” What advocates should do to find out if HUD really means it. Here are a few possible strategies: 1. Do your local and state Consolidated Plans show that all of the above five examples are being implemented? Or even planned for the future? For example, are there “preferences” in both actual housing and housing choice vouchers (aka Section 8) for people institutionalized or at risk? 2. Do your local and/or State recipients of HOME Investment Partnership federal funds provide for tenant-based rental assistance for people institutionalized or at risk? Have any been actually provided in the past to end institutionalization? Are they needed in your State? 3. Has your public housing authority provided for scattered-site accessible housing throughout your community? Are more needed? Planned for? If there are people in institutions whom you, the advocates, know are institutionalized because of housing – either because they do not have funds for rent, security deposits, etc., or because they cannot locate accessible units they can afford, then your local and State recipients of HUD funds have failed to “affirmatively further fair housing.” These local and State recipients of HUD funds are in violation of the federal Fair Housing Act. HUD should be notified of these violations so it can remedy the situation and ensure people are not unnecessarily institutionalized. File a Complaint (be as specific as possible) with HUD Office of Fair Housing and Equal Opportunity in Washington, D.C. and send a copy of your Complaint to Jeanine Worden, Associate General Counsel, Jeanine.M.Worden@HUD.gov, or to Sara Pratt, Deputy Assistant Secretary for Enforcement, Sara.K.Prattt@HUD.gov. All italicizations are added. 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 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. Ext 227.

Managed Care Long-Term Services and Supports. Information Bulletin #381 (6/ 2013) The Center for Medicare and Medicaid Services, the federal agency that funds Medicaid on 5/20/2013 issued “Guidance to States using 1115 Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports Programs” (MLTSS). A copy of this important new federal guidance can be found at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf We are quoting extensively from this CMS document because, for those States contemplating using Managed Care as the mechanism for Medicaid Expansion, as well as for those States that already include MLTSS, this document provides important advocacy handles. Before a State can have a 1115 Demonstration or 1915(b) waiver, CMS must review and approve a State’s application. If your State does not include and really provide for the following, then advocates should let CMS know their opposition to MLTSS. Here are some points that disability and elderly advocates might want to keep in mind. 1. CMS points out that LTSS includes “both home and community based services and institutional-based services.” The guidance encourages states to include both home and community based services and institutional programs in the managed care capitation rate. If your State is contemplating MLTSS, make sure both home and community services as well as institutional services are included and are the responsibility of the Managed Care Organization (MC0). Make sure that institutional-based services are not “carved out” in any way. Our assumption is if a managed care agency is financially responsible for institutional-based services, the MCO will figure out how to serve the person in the community, where on average it’s less expensive. If the MCO is not responsible for institutional services, the MCO will have a financial incentive to dump people with disabilities, especially with severe disabilities, into the institution. 2. The ADA and Olmstead requirements for services apply to MLTSS. CMS points out that “under the law [ADA], MLTSS must be delivered in the most integrated fashion, in the most integrated setting, and in a way that offers the greatest opportunities for active community and workforce participation.” Such a setting “enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible.” CMS writes that “States are encouraged to include in their benefit packages supports to enable workforce participation such as personal assistance services, supported employment and peer support services, as appropriate and desired by the participant.” If these kinds of supports are not included in your State’s managed care program, then you should advocate with CMS and State officials to get your State to include them. If CMS is not responsive to your concerns, please let us know asap! 3. Under “alignment of payment structures and goals,” CMS requires States “establish rates that support the goals and objectives of their MLTSS program… In keeping with the intent of the ADA and Olmstead decision, payment structures must encourage the delivery of community-based services and not provide disincentives, intended or not, for the provision of services in home and community-based settings.” A number of advocates have voiced serious concerns that the more severely disabled persons will not be able to live in the community because the capitation rates (the dollar amount per person the MCO receives) are too low to cover all the community needs and supports. CMS requires that “State payment structures, systems and review mechanisms must ensure that participants at all levels of need and all types of disabilities have the opportunity to choose their MLTSS providers and have appropriate access to community-based services.” There cannot be any doubt that “States must employ financial incentives that achieve desired outcomes, [such a] provision of services in the most integrated settings and consumer satisfaction.” It is a failure for States not to set rates that ensure the most severely disabled persons have a meaningful choice to reside in the community. States that fail will have “financial penalties… or return of a payment if a MCO does not achieve required outcomes for the provision of services in the most integrated settings.” 4. The State Medicaid agency has the legal duty to “evaluate whether payment rates and structures are adequate to achieve participant access to quality providers for covered services.” 5. “Person-centered” needs assessment, service planning and service coordination are required. CMS urges that MLTSS “should encourage participant self-determination and provide opportunities for self-direction of services.” If your State provides self-direction in its existing fee for service Medicaid program, CMS states that the MLTSS “programs are expected to continue them,” and if your State does not currently offer self-direction, “it should consider providing the opportunity for self-direction within their MLTSS program. 6. “Stakeholders” [which includes us – disability and elderly advocates] must be formally involved, including cross-disability representatives, in the planning, implementation and oversight of the MLTSS. You must be at the table when the State Medicaid agency is developing the contract for MLTSS. The contract sets the enforceable requirements. ALL of the above five points are just words if the contract does not require the provision of these points. In addition to these six points, the State’s contracts with managed care organization should include requirements that managed care staff working with MLTSS programs receive Olmstead training to understand the importance of serving persons outside of the institution. 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 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. Ext 227.

Are Nursing Homes Referring People to the Community? Information Bulletin # 380 (May, 2013) Several years ago, the disability and elder communities and the Centers for Medicare and Medicaid Services worked to revise the Minimum Data Set questionnaires. The MDS must be completed quarterly by each nursing home for each resident and then electronically submitted to CMS. The famous “Q1a” was the focus of the revisions that very much concerned the disability and elder communities. One of the primary goals was to change the system to help people transition to the community. Here are some national findings for the 1,322,697 people in nursing homes on 3/31/13. The following data is from what CMS collected from the nursing homes. 1. MDS Questions 100A-C report on the percentages of people in nursing homes who “Participated in the Assessment and Goal Setting”. Nationally, 84.48% of the residents participated. Nationally 31.73% of “family or significant others” participated, and 10.08% had a “guardian or legally authorized representative” participate. 2. MDS Questions 300A-B focus on “Residents’ Overall Expectation” and the “Goal Established During the Assessments.” The results show that nationally 27.63% of the residents “expect to be discharged to community.” That means 365,461 nursing home residents wanted to leave and expected to live in the community. While we do not have a breakdown, we know that residents themselves made up 62.27% of these respondents and another 30.23% were family or significant others. 3. Proceeding to question MDS 400A, nationally there were 84.85% of these 365,461 residents (that equals 310,093 people in nursing homes) had an “Active Discharge Plan” in place to return to the community. We have no idea why the 15.15% (55,367 people) did not have a plan since they wanted to leave the nursing homes and had an expectation they would leave. But when asked in MDS 400 B, “What determination was made by the resident and the care planning team regarding discharge to the community,” no data is provided. CMS writes “please be patient. This may take a few seconds to load.” It never loaded. It is not clear what “determination” had to be made for the 310,093 people who had an “active discharge plan.” Nor is it clear whether a nursing home “planning team” could trump a resident’s decision to move to the community. Are community advocates present when such a determination is made? Does the nursing home “planning team” have any knowledge of what community-based services could be provided? 4. When the MDS goes beyond the “Active Discharge Plan” stage, it asks if the “resident asked to return to the community?”(MDS 500 A). Again, no data was provided. Also, we do not understand why the resident, who had an “expectation” to return to the community (MDS 300 A/B) and who has an Active Discharge Plan, is then asked (how many times are necessary) if the resident asked to return to the community. What if a family member asks? 5. Here’s the real kicker. When the nursing homes completed the MDS 500 B question, the nursing homes concluded that 86.55% of the people had no “possibility of returning to community.” A death sentence imposed! The nursing home concluded that only 5.75% of the residents - remember, this is according to the nursing homes – had even a “possibility’ to return to the community. What services did the nursing homes think could not be provided in the community? 6. As appalling as these numbers are, the nursing homes are supposed to refer people to a “local contact agency” which is supposed to come into the nursing home and is supposed to provide assistance for the nursing home resident to transition back to their homes and apartments with appropriate home and community-based services. 7. And now for the final blow: only 2.5% of the nursing home residents were actually referred to a “local contact agency” as reported on MDS 500B. We assume (and hope) that these 2.5% are from those residents whom the nursing home thought there was a “possibility” to return to the community. Disability and Elderly Advocates: Based on the above data, it might be hard to imagine but people in nursing homes are Not Dead Yet! What are advocates doing to help disabled and elderly in nursing homes move back into the communities? 1. Here is a link for the MDS data which is available by State. http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-Frequency-Report.html 2. There are a limited number of prizes for advocates who know the name of your “local contact agency.” There are more prizes for the local contact agency that has received the most such referrals. These prizes are time-limited so please send in your responses as soon as possible. 3. Can anyone explain why CMS’ nursing home office of “Surveys and Certifications” does not check on any of the above MDS questions? Is there any doubt that if CMS included these MDS questions in its annual surveys the percentages of people who wanted to leave would increase? Maybe even more people would transition back to the communities. 4. There is a very special prize for the advocates who can identify any person in a nursing home who could not reside and be cared for in the community with appropriate services. 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 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. Ext 227.

“Premium Assistance,” People with Disabilities, and Medicaid Expansion Via Insurance Exchanges. Information Bulletin #379 (4/2013) Do you reside in a State that has not agreed to expand Medicaid under the Affordable Care Act (ACA) to all persons whose incomes are under 138% of the federal poverty level? Has your Governor talked about using Medicaid’s “premium assistance” plan to purchase a health plan via an “Exchange” for people under 138% – the “Arkansas model”? This Information Bulletin attempts to clarify some of these concepts, particularly as they apply to people with disabilities. 1.The normal way most States are implementing the ACA Medicaid expansion is to provide all persons with incomes under 138% with defined Medicaid benefits delivered through one Medicaid system. The “Arkansas model” is different and is the outlier. It uses Medicaid funds as “premium assistance” payments with which a State will purchase a private health plan, through the health insurance exchange being created for each state under the ACA (run either by the state or by the federal government). This private health plan will be limited to specific covered health benefits and services. Based on the proposed federal regulations and guidance from the federal Medicaid agency, CMS, the additional benefits covered under Medicaid, and the cost-sharing protections under Medicaid, must still be provided, these are likely to be very difficult to access. However, absent a special waiver, with premium assistance payments, a State cannot mandate that anyone under 138% receive Medicaid expansion services via the private insurance market; they must all be offered the choice of traditional Medicaid. 2. There is one possible way your State may try to get around this prohibition on mandatory enrollment in premium assistance. The State may apply to CMS for a section 1115 demonstration waiver to provide premium assistance to purchase a health plan on an Exchange and to make participation mandatory. What is critical for people with disabilities to know is that, under such a waiver, “A State may not require an individual to obtain [Medicaid services and health care] benefits through enrollment” with premium assistance payments if the person fits into one of the following five categories. If you are in one of these categories, the State cannot force you into a private health plan even through a 1115 waiver. Instead, the State must provide the traditional Medicaid benefits and services that current Medicaid recipients who are disabled are eligible for and receive, and deliver them in the traditional manner. The exempted categories are: 1. Blind and disabled persons (or persons “being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits …on the basis of being blind or disable. Nationally, we estimated that 2,665,407 people with disabilities are in this category. See Information Bulletin #369 (1/2013) or http://stevegoldada.blogspot.com/ for a State-by-State breakdown. 2. Dual eligibles – i.e., persons who receive both Social Security disability and Supplemental Security Income benefits. 3. Persons institutionalized in a “nursing home, an intermediate care facility for the mentally retarded, or other medical institution, and required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs.” 4. “Medically frail and special medical needs individuals,” (as identified in accordance with regulations of the Secretary). 5. Persons who qualify for long-term care services. “The individual qualifies based on medical condition for medical assistance for long-term care services,” including Home and community-based services furnished under a 1915 waiver. These exempted categories are critical. These people are entitled to all of the Medicaid services and benefits currently available to existing Medicaid recipients who are disabled, through the existing delivery system. 3. Do you reside in a State that is considering using premium assistance payments for people on Medicaid? If you do, please make sure your State is fully aware that it will have to run two separate programs for the Medicaid 138% expansion population, even with a waiver allowing it to force some Medicaid enrollees into premium assistance. One Medicaid program will provide all the components in the State’s existing benefits and services for people in categories ## 1 -5 above, and for others who opt out of premium assistance if there is no waiver. A second and separate Medicaid expansion program will use premium assistance payments for people not exempted under a waiver, or who have not opted out if there is no waiver. We expect that most States using premium assistance without a waiver will try to convince people in categories ## 1-5 to receive services through private insurance in the Exchange paid with the premium assistance. Don’t do it! You are exempted from mandatory enrollment. Why are we so emphatic? There is no way a private insurance company that is paid to provide “Exchange” health services will provide the long-term care Medicaid services that people in categories ##1-5 need to live independent, integrated lives in their homes and apartments. Congress did not even require Exchanges to include long-term care services or benefits, and you can bet they will not. 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 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. Ext 227.

What are the Religious Communities doing in your State Re Medicaid Expansion? Information Bulletin # 377 (4/2013) Have the various religious communities in your State taken a public position with regards to Medicaid expansion for residents whose incomes are less than 138% of the federal poverty level? Last week in Pennsylvania, 1,350 Roman Catholic nuns, priests, and brothers, representing 19 different religious congregations, were individually identified, by name and religious affiliation, in a letter written to the Pennsylvania Governor in which they urged him to accept federal Medicaid funds to expand coverage to nearly 700,000 residents who lack coverage. These religious leaders noted that their “faith, tradition and justice teaching call us to advocate for the right of all human beings to have access to the basic necessities that enable them to live productive lives with dignity. Among those is the right to affordable health care.” They stated that a failure to accept these funds by the Governor would “breach the moral duty to those who are on the margins of society.” They requested a meeting with the Governor. These leaders pointed out the health benefits, cost savings on uncompensated care to hospitals, and economic stimulus which will occur with the Medicaid expansion. These religious leaders concluded that their “faith calls us to respond to the needs of the disabled, the impoverished, and the downtrodden. The Medicaid expansion is an unparalleled opportunity to provide affordable health insurance for uninsured Pennsylvanians.” In every State there are coalitions of religious congregations – Protestant, Evangelical, Jewish, Catholic, and others. Have they taken a public position regarding Medicaid expansion? Have they written to the Governor and state legislators? Have you asked them to? What have they done in North Carolina, South Carolina, Georgia, Alabama, Mississippi, Texas, Oklahoma, Nebraska, Iowa, Tennessee, Virginia, West Virginia, Kansas and Utah? Surely there are religious leaders and coalitions who recognize Medicaid expansion as a “moral duty.” 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 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. Ext 227.

One Strategy to Increase Monthly Income for Disabled Persons – Corrected!!!!!!. Information Bulletin #376A (3/2013) [Introduction – I apologize. In the above Information Bulletin, I made an error that a few people pointed out to me. The correction below regarding Medicare and Medicaid will significantly benefit people who apply, so I am rewriting this Bulletin with the corrections and thank all of you who pointed out my error. On a personal note, it is really gratifying that people actually read the Information Bulletin to the end. I must admit that I am never confident how many people read these, or do they float away in outer space. Thanks. Steve] There are more than 7 million persons who are disabled and who receive Supplemental Security Income because they have a disability. This Information Bulletin is addressed to a subset those 7 million -- whose disability began before they were 22 years old and whose parents receive or were entitled to receive Social Security retirement benefits. This Information Bulletin is to remind and or inform this subset of 7 million SSI recipients of a potential federal financial benefit that could increase their monthly incomes. This subset of 7 million disabled persons’ living arrangements differ: some live independently on their own; some live in group homes or with roommates; some are married and live with their spouses; and some still reside with their aging nondisabled parents. Some have physical disabilities, some intellectual and some mental disabilities. Some were born with their disability and some acquired their disability before age 22. If you are one of these 7 million or know people who are, you and they might be eligible to receive “Child’s benefits” – under the Social Security retirement system - based on the “earning record of an insured person,” your parent(s) Social Security retirement benefits, whether or not your parents are still alive. What this means in nontechnical terms is: 1.Is either parent receiving Social Security retirement benefits, Social Security Disability benefits, or has either parent died? If one of your parents has died, you may be eligible to receive benefits on his/her account if s/he had a history of working. 2.Don’t be misled by the term “child.” It does not mean your age, but refers to your relationship to your parent. For example, a 45 year old recipient of SSI has a 67 year old parent who collects S.S. retirement benefits. The 45 year old may be entitled to “child’s benefits” based on his parent’s earning record. 3.Did your disability begin before you were 22 years old? Here is concrete example of how this system works. A.You became disabled before you were 22 years old. This could have been at birth or any time before you were 22. B.You receive SSI (although that is not a requirement). It does not matter where you reside or with whom you reside. C.What is important is that one of your parents receives Social Security retirement benefits (a/k/a Social Security “Old-Age” benefits), Social Security Disability Benefits, or if either parent has died and that parent had a work history that would have qualified him/her for Social Security retirement benefits. The dollar difference between your SSI monthly benefits and the “child’s benefits” based on your parents earning record could be significant. You may receive up to one-half of your parent’s full retirement benefit or disability benefit while your parent is still alive, and up to 75 percent of your parent’s Social Security benefit when s/he dies. You must apply to the Social Security Administration, which can be done in person, or by telephone or on-line. It is worth your effort to find out the monthly benefits you may be entitled to, whether or not you decide to actually apply, and compare that sum with your SSI. Two additional points: 1.Normally “child’s benefits” end if the person marries. However, if a person with a disability marries another disabled person who receives disability benefits, then you are still eligible for “child’s benefits.” 2. A big issue is health care coverage and benefits. On SSI, you receive Medicaid. In many States – not all – if your “child’s benefits” are less than 138% of the federal poverty level ($1,285 a month), you will still be Medicaid eligible effective 1/2014. In many States, you can become eligible for Medicaid under “spend down” requirements. If you start to receive your parent’s social security benefits because of your disability began before you were 22, you will also be eligible for Medicare benefits after you have been eligible for your parent’s benefits for 24 months. Check out how this issue will specifically apply to you. Also, in 1987, a federal law was enacted that says that if you are receiving Medicaid (maybe because you receive SSI on your own account), and then you start to receive Social Security benefits from a parent’s account, the amount of your parent’s benefit will not be considered when your State is deciding if you are financially eligible for Medicaid. For example, let’s say you are receiving $715 a month of SSI and also have Medicaid. Then your father dies and you become eligible for $1,000 a month in Social Security on your father’s account. Your State cannot count any of the $1,000 a month from your father’s Social Security when deciding if you are eligible for Medicaid. Here is the citation, 42 U.S.C. § 1383c, or http://www.ssa.gov/OP_Home/ssact/title16b/1634.htm (Determination of Medicaid Eligibility). Is the Social Security Administration motivated to provide the maximum amount of income to which people with disabilities are entitled to receive? The SSA knows each of the 7 million SSI recipients, their age when they became disabled and their parents’ status. It cannot be too difficult to at least notify them of these potential rights. In fact the Social Security Administration requires that you apply for benefits on your parent’s account if there is a chance you might be eligible, in part because SSI is a “payment of last resort.” There are a number of wrinkles which this Information Bulletin does not discuss. Telephone the Social Security 800 number and make an application. 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 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. Ext 227.

One Strategy to Increase Monthly Income for Disabled Persons. Information Bulletin #376 (3/2013) There are more than 7 million persons who are disabled and who receive Supplemental Security Income because they have a disability. This Information Bulletin is addressed to a subset those 7 million -- whose disability began before they were 22 years old and whose parents receive or were entitled to receive Social Security retirement benefits. This Information Bulletin is to remind and or inform this subset of 7 million SSI recipients of a potential federal financial benefit that could increase their monthly incomes. This subset of 7 million disabled persons’ living arrangements differ: some live independently on their own; some live in group homes or with roommates; some are married and live with their spouses; and some still reside with their aging nondisabled parents. Some have physical disabilities, some intellectual and some mental disabilities. Some were born with their disability and some acquired their disability before age 22. If you are one of these 7 million or know people who are, you and they might be eligible to receive “Child’s benefits” – under the Social Security retirement system - based on the “earning record of an insured person,” your parent(s) Social Security retirement benefits, whether or not your parents are still alive. What this means in nontechnical terms is: 1.Is either parent receiving Social Security retirement benefits or either parent died but would have been eligible to receive those benefits? 2.Don’t be misled by the term “child.” It does not mean your age, but refers to your relationship to your parent. For example, a 45 year old recipient of SSI has a 67 year old parent who collects S.S. retirement benefits. The 45 year old may be entitled to “child’s benefits” based on his parent’s earning record. 3.Did your disability begin before you were 22 years old? Here is concrete example of how this system works. A.You were became disabled before you were 22 years old. This could have been at birth or any time before you were 22. B.You receive SSI (although that is not a requirement). It does not matter where you reside or with whom you reside. C.What is important is that one of your parents receives Social Security “Old-Age” insurance benefits, a/k/a Social Security retirement benefits, or either parent received those benefits before s/he died and would have been eligible for them now, were your parent alive. The dollar difference between your SSI monthly benefits and the “child’s benefits” based on your parents earning record could be significant. You may receive up to one-half of your parent’s full retirement benefit, or 75 percent of the deceased parent’s basic Social Security benefit. You must apply to the Social Security Administration, which can be done by telephone or on-line. It is worth your effort to find out the monthly benefits you may be entitled to, whether or not you decide to actually apply, and compare that sum with your SSI. Two additional points: 1.Normally “child’s benefits” end if the person marries. However, if a person with a disability marries another disabled person who receives disability benefits, then you are still eligible for “child’s benefits.” 2. A big issue is health care coverage and benefits. On SSI, you receive Medicaid. In many States – not all – if your “child’s benefits” are less than 138% of the federal poverty level ($1,285 a month), you will still be Medicaid eligible effective 1/2014. In many States, you can become eligible for Medicaid under “spend down” requirements. Unfortunately, you are not eligible for Medicare benefits based on your parent’s earning record. Check out this issue as it will specifically apply to you. Is the Social Security Administration motivated to provide the maximum amount of income to which people with disabilities are entitled to receive? The SSA knows each of the 7 million SSI recipients, their age when they became disabled and their parents’ status. It cannot be too difficult to at least notify them of these potential rights. There are a number of wrinkles which this Information Bulletin does not discuss. Telephone the Social Security 800 number and make an application. 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 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. Ext 227.

Why Private Employers Should Support Medicaid Expansion. Information Bulletin #375 (3/2013) Medicaid expansion is obviously critical for people whose incomes are less than 138% of the federal poverty level. However, the failure of States to expand their Medicaid program on January 1, 2014 will have disastrous impact on the private employers in your State. The Missouri Hospital Association recently released a report entitled “The Hidden Health Care Tax – How NOT Reforming Medicaid Could Lead to Cost Shifting.” www.missourihealthmatters.com/wp-content/…/Cost-Shift_Report.pdf This report presents data and arguments regarding how private employers will be negatively impacted if a State does not expand Medicaid and presents cogent arguments for advocates to use in urging Governors and State Legislatures to agree to Medicaid expansion. As you know from previous Information Bulletins, when Congress enacted the Affordable Care Act it significantly reduced the reimbursements that hospitals previously received uncompensated care the hospitals had been providing to low-income people. This reduction was because Congress had simultaneously mandated Medicaid expansion to all people who had been receiving this uncompensated care. With such expansion, the hospitals would receive regular Medicaid reimbursement for the newly Medicaid eligible people. Unfortunately, the Supreme Court invalidated the mandatory expansion, leaving States, hospitals and insurance companies with significant reductions in uncompensated care and no increase in Medicaid eligible persons. It has been reported that the growth of “uncompensated care is alarming,” from 2002 to 2011. Every State that does not expand its Medicaid program will suffer because the hospitals will continue to have high level of uncompensated care and no Medicaid dollars with which to pay for that care. Uninsured and uncompensated care account for a significant amount of costs hospitals must make up through other means. How will hospitals make up the lost Medicaid costs? Private commercial insurance payers will eventually (sooner than later) have to subsidize the cost of the loss in Medicaid reimbursements. The costs will be shifted from the loss of Medicaid patients to the private businesses that currently provide health insurance to their workers. This will happen regardless of their employees’ incomes. The above “The Hidden Health Care Tax” report presents the data quite starkly. The shifting of costs from uninsured/nonMedicaid low-income patients to employers of low-income workers are “hidden health care taxes” on commercial premiums and will increase what private employers will pay for the private health insurance of their employees. Otherwise, the hospitals will not be able to financially survive. Advocates: Has your State Hospital Association estimated the increase in costs to private employers’ health insurance premiums if your State does not expand Medicaid? Has your State Hospital Association publicly stated this increase? Has your Chamber of Commerce estimated this cost and the impact it will have on private employers’ insurance premiums? Are your Governors and legislatures aware of this ramification and increased costs if they refuse to accept 100% of federally reimbursed Medicaid expansion funds? Are your newspapers aware of these increased costs? 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 will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.comor call 215-627-7100. Ext 227.

Florida Opts Into Medicaid Expansion, Religious Leader, and 10 Year Data. Information Bulletin #373 (2/2013) This Information Bulletin deals with three aspects of the Medicaid expansion struggle: 1. Florida, 2. Religious leaders, and 3. Ten year data. 1.Another Republican Governor has announced his State will provide Medicaid services beginning January 2014 to all of its citizens with incomes under 138% of the federal poverty level. What should be a clear non-partisan issue, health care for the poorest people in a state, has unfortunately morphed into party politics. That’s one reason it is important that Florida’s Governor Rick Scott joined Republican Governors in Michigan, Ohio, Nevada, New Mexico, North Dakota and Arizona. Governor Scott had said quite emphatically that “Florida would not expand its program.” Why the reversal? What makes Governor Scott’s announcement particularly important is that he understood two points that many non-participating Governors apparently have ignored. First, Governor Scott said that “our options are either having Floridians pay to fund [Medicaid expansion] in other states while denying health care to our citizens or using federal funding to help some of the poorest in our state.” NYT, 2/20/13. Yes, if your State does not opt-in, your State’s taxpayers will be paying for health care for low-income people in participating States that have agreed to the Medicaid expansion. That’s neither a very smart business decision nor a sound policy decision. Second, “since Florida is legally allowed to opt out [of Medicaid expansion in the future], that’s the right decision for our citizens.” Yes, CMS has stated that a State that provides Medicaid expansion services can at any time decide to end its participation and there are no repercussions. Have you contacted your Governor? Will other Governors see the importance of these two points for their States? Will advocates follow the Florida advocates’ success? 2. Religious leaders are realizing the moral implications in Medicaid expansion. For example, the “Roman Catholic bishops of Salt Lake City and Little Rock, Ark., have urged state officials to expand Medicaid. “ NYT, 222/13. Sorry to add another item to your plates, but have you contacted religious leaders in your State? Are they doing anything to encourage recalcitrant elected officials to do the right and smart thing? 3. A separate third Medicaid expansion issue. In previous Information Bulletins and individual State Fact Sheets, we have provided (thanks to the Kaiser Commission) six year out data from 2014 through 2019 to show the amount of federal funds would be received by Medicaid expansion and the amount of money a State would have to spend as a match over the six years. A number of States are now arguing a longer time-frame, and they are suggesting/implying that over a longer than six years the federal funds may not be worth receiving. Therefore, we will provide for a period through 2022 (again thanks to Kaiser Commission) data for those states that have still not opted in to the Medicaid expansion. The results are the same as for six years. States make out like bandits!!!!! No business person in her or his right mind would turn down accepting the federal funds for the amount they must match over a ten year period. It makes no business sense. Isn’t it time that politics be put aside and rational business decisions take over? INCREMENTAL IMPACT OF MEDICAID EXPANSION 2013-2022 Federal funds and state matches over 10 years. Alabama $14,371 billion of federal funds with only a $1,081 billion Alabama state match. Alaska $1,458 billion of federal funds with only a $147 million Alaska state match. Arkansas $12,465 billion of federal funds with only a $922 million Arkansas state match. Georgia 33,711 billion of federal funds with only a $2,541 billion Georgia state match. Idaho $3,280 billion of federal funds with only a $246 million Idaho state match. Indiana $17,322 billion of federal funds with only a $1,099 billion In Diana state match. Iowa $3,909 billion of federal funds AND a $534 savings in Iowa state funds!!!!! Kansas $5,270 billion of federal funds with only a $524 million Kansas state match. Kentucky $17,832 billion of federal funds with only a $1,297 billion Kentucky state match. Louisiana $15,786 billion of federal funds with only a $1,244 billion Louisiana state match. Maine $3,124 billion of federal funds AND a $570 million savings in Maine state funds!!!. Mississippi $14,499 billion of federal funds with only a $1,048 billion Mississippi state match. Missouri $17,795 billion of federal funds with only a $1,573 billion Missouri state match. Nebraska $3,063 billion of federal funds with only a $250 million Nebraska state match. New Jersey $15,366 billion of federal funds with only a $1,492 billion New Jersey state match. North Carolina $39,638 billion of federal funds with only a $3,075 billion North Carolina state match. Oklahoma $8,561 billion of federal funds with only a $689 million Oklahoma state match. Pennsylvania $37,842 billion of federal funds with only a $2,842 billion Pennsylvania state match. Rhode Island $2,935 billion of federal funds with only a $250 million Rhode Island state match. South Carolina $15,827 billion of federal funds with only a $1,155 billion South Carolina state match. Soth Dakota $2,110 billion of federal funds with only a $157 million South Dakota state match. Tennessee $22,541 billion of federal funds with only a $1,715 billion Tennessee state match. Texas $65,619 billion of federal funds with only a $5,669 billion Texas state match. Utah $5,274 billion of federal funds with only a $364 million Utah state match. Virginia $14,665 billion of federal funds with only a $1,326 billion Virginia state match. West Virginia $8,744 billion of federal funds with only a $619 million West Virginia state match. Wisconsin $12,263 billion of federal funds AND a $248 million savings in Wisconsin state match!!!! Wyoming $1,353 billion of federal funds with only a $118 million Wyoming state match. Ten year data from Kaiser Commission, “The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis,” at Table 6 (November, 2012). 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 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. Ext 227.

If Texas can organize to expand Medicaid, what about your State? Information Bulletin # 372 (2/2013) Like many Governors, Texas’ Rick Perry has not committed to expand Medicaid for low-income people whose incomes are under 138% of the federal poverty level. However, Texas advocates have been doing their homework and are organizing the Trade Associations to explain to their Governor and elected officials why it’s essential that Texas agrees to Medicaid expansion. What follows is an excerpt from a newspaper article that explains what’s happening in Texas. These same arguments in this article are applicable in every State that is still sitting on the fence. You have to get to your Trade Associations and form a coalition. Trade Associations Lend Support for Medicaid Expansion by Becca Aaronson, February 5, 2013, in The Texas Tribune. “Despite the resistance of Gov. Rick Perry and many other Republicans to expanding Medicaid in Texas under the Affordable Care Act, some momentum seems to be building from outside of the Capitol in support of the expansion. “Texas’ two largest health care trade associations, the Texas Medical Association and the Texas Hospital Association, have announced support for extending Medicaid coverage to low-income adults. But both organizations also say that in order for the plan to work in Texas, lawmakers here also must implement reforms that will contain costs and bring more doctors into the Medicaid program to provide care for the additional patients. “ ‘The most viable path is to try to work with [the federal government] to create a reformed program that does meet the needs of Texas better,’ said John Hawkins, senior vice president of government relations at the Texas Hospital Association. He said the plan to expand must be bipartisan. Democrats must be flexible in considering “personal responsibility” reforms, such as requiring some new patients under the expansion to pay co-pays. And Republicans, he said, must “play ball” because the current system is fiscally inefficient. “We’re still providing this care at the local government level, but we’re doing it in a fragmented way that actually costs more and has worse outcomes,” Hawkins said. For an additional investment of $15 billion over 10 years, Texas could draw down $100 billion in federal funding to insure two million more Texans through the state’s Medicaid program, according to a report by Billy Hamilton, a nonpartisan consultant who was previously the state’s chief revenue estimator. [We can provide a 10 year comparison for your State. Just email me below and tell me what State.] The Texas Medical Association, which represents physicians across the state, announced on Saturday that it would support the Medicaid expansion if lawmakers can devise a way to give Texas “the flexibility to change the plan as our needs and circumstances change.” “You have the two major entities that represent the delivery of health care in Texas saying this is something that we definitely need to look at,” said Dr. Carlos Cardenas, vice president of the TMA board of trustees, adding the organization recognizes “there are issues within the present Medicaid program and that the Legislature is in a position to come up with some reforms to shore up the system.” *** Perry, who has the power to veto an expansion plan approved by the Legislature, also reiterated in his state of the state address in January that Texas would not expand Medicaid. “Gov. Perry continues to believe that Medicaid is an unsustainable, broken program that needs to be reformed, and he does not support expanding it under Obamacare,” spokesman Josh Haven said in an email. *** “The more people and organizations that come on board, the more likely there is to be a strings-attached proposition for the Medicaid expansion,” said state Rep. Garnet Coleman, D-Houston. As a proponent of expanding Medicaid coverage, Coleman said he would accept some reforms offered by Republicans, such as co-pays for expansion enrollees. “It’s hard to turn down $100 billion, so the question is what can be agreed upon to accept the $100 billion. And we have not gotten there yet.” To work around Perry’s veto power, state Sen. Rodney Ellis, D-Houston, has proposed a constitutional amendment that would allow Texas voters to decide whether to expand Medicaid. “There is a lot of political posturing going on, but the bottom line is that it makes no sense to reject additional federal health aid,” Ellis said in an email. “I believe we do millions of Texans a disservice — at a real financial and human cost — if we dither and delay implementing this common sense reform.” Whether Medicaid expansion happens in your State is up to you. Sure, it is not easy, but its doable and its critically important. 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 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. Ext 227.

HUD and HHS Award Housing Vouchers. Information Bulletin # 371 (2/2013) Yesterday, HUD and HHS jointly announced the award of 3,530 housing vouchers for people with disabilities with extremely low-incomes, i.e., less than 30 percent of the median income. These vouchers were competitive among States and are targeted to people transitioning out of institutional settings or at high risk of homelessness. Each State housing agency had to partner with the State’s Medicaid agency in order to identify and coordinate the transitioning out of institutional settings, in order ‘to identify, refer and conduct outreach to persons with disabilities who required long-term services and supports to live independently.” In announcing the vouchers, HUD noted that “today’s announcement reinforces the guiding principles of the Americans with Disabilities Act and the landmark 1999 Supreme Court ruling in Olmstead v. L.C., which require state and local governments to provide services in the most integrated settings appropriate to meet the needs of individuals with disabilities.” For the 13 States that were awarded these vouchers, advocates can find the specific program targets, populations, and targeted areas HUD approved -http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2013/HUDNo.13-024 Advocates should be in contact with your State Housing Agency that won the vouchers and work to make sure the vouchers really go to the people with disabilities and are in the most integrated setting. Here are the 13 States that won this competitive process. State Housing Agency # of units California Housing Finance Agency 335 Delaware State Housing Authority 170 Georgia Housing & Finance Authority 150 Illinois Housing Development Authority 826 Louisiana Housing Corporation 200 Massachusetts Dept. of Housing & Community Development 100 Maryland Dept. of Housing & Community Development 150 Minnesota Housing Finance Agency 95 Montana Dept. of Commerce 82 North Carolina Housing Finance Agency 562 Pennsylvania Housing Finance Agency 200 Texas Dept. of Housing & Community Affairs 385 Washington State Dept. of Commerce 275 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 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. Ext 227.

Jobs, Economic Development, and Medicaid Expansion. Information Bulletin #370 (2/2013). In the last three Information Bulletins, we discussed the Affordable Care Act’s Medicaid expansion which provides access to medical care for all people whose incomes are under 138% of the federal poverty level. We discussed the impact on people with disabilities and on hospitals. This Information Bulletin looks at the broader economic impact. Medicaid expansion’s extraordinary impact on State employment and economic development is true for all states, but the loss for those States that do not agree to expand will be devastating. Has your State agreed to Medicaid expansion (which begins in January 2014)? [Fact Sheets for States are available. Email address below and identify your State.] If your State is still struggling with high unemployment and remains stalled in post 2007 economic recovery, these federal funds unequivocally will increase employment throughout the State, reduce State taxes as more people become employed, and have a profound economic multiplier effect throughout your State’s economy. If your State has not yet agreed, your task is clear. There are no other new federal programs that offer your State 100% federal reimbursement for three years for providing health care to hundreds of thousands of low-income people, and then a federal guarantee of no less than 90% federal reimbursement in year six and thereafter. 1. Here are some examples of the new federal Medicaid funds that will come into these States for the next six years, if they agree to Medicaid expansion: Alabama $9.835 billion in new federal funds Florida $18.817 billion Indiana $8.057 billion Louisiana $6.936 billion Michigan $13.566 billion New Jersey $8.497 billion N. Carolina $19.683 billion Oklahoma $1.630 billion Tennessee $10.356 billion Virginia $9.131billion Show me the money? There it is - not play money, but real money! Some States have voiced concern with the reliability of the federal commitment. If sometime in the future the federal government changes its reimbursement level, then State governments could reconsider their commitment as well. We think the State governments have the federal government over-the-barrel. We do not buy the argument that “once a program begins, it cannot be ended.” Many States have terminated existing program. If your State is worried, make your State’s Medicaid expansion explicitly dependent on the federal commitment. 2. If your State thinks of itself in economic development terms, it should want to know the guaranteed federal rate of return, i.e, how much federal funds for each State dollar. Here are some examples: Alabama $21.90 federal dollars to $1.00 State dollar Kentucky $23.10 to $1.00 Louisiana $21.60 to $1.00 Michigan $20.80 to $1.00 Mississippi $23.00 to $1.00 New Jersey $16.90 to $1.00 Oklahoma $22.20 to $1.00 S. Carolina $23.10 to $1.00 Utah $23.70 tp $1.00 W. Virginia $23.10 to $1.00 We do not believe that any State can invest one State dollar and receive these returns anywhere else, and we believe that any good business person would jump at those rates of return. There is no rational business reason, and it makes no business sense whatsoever to not participate. Is your State concerned about jobs and employment? Let’s look at one example of the employment impact as a result of the increase in newly eligible Medicaid recipients. Medicaid expansion will result in hospitals hiring more personnel to meet the increased demand for Medicaid services. Because we’re talking large hospital increases in Medicaid reimbursements for health care, that means hospital employment at all economic levels. 3. Here’s the approximate one year increase in hospital reimbursements as a result of Medicaid expansion, which will translate into jobs. Florida $2.4 billion Louisiana $630 million Michigan $442 million Mississippi $593 million Missouri $881 million New Jersey $253 million N. Carolina $971 million Oklahoma $494 million Tennessee $359 million Texas $2.807 billion Virginia $411 million ADVOCATES: You can convince your State to participate. Ohio, New Mexico, Nevada and Arizona have recognized the extraordinary economic implications of Medicaid expansion and last month announced their States were signing on. You can convince your State to sign on. Here are a few suggestions. 1. We do not believe that the newspapers and other media have looked at and understood Medicaid expansion as an economic issue. Write letters and columns. Educate the media! 2. We hope your State Chamber of Commerce has reviewed Medicaid expansion as an economic issue. Telephone them. Ask them if they want economic development and employment, and if yes, what are they doing regarding Medicaid expansion? 3. Most legislators have so much on their plates that they cannot or do not understand Medicaid expansion from an economic perspective. Even though it will not require any state funds for three years, so the 2013-2014 budget may not be impacted, nevertheless get to your legislative leaders and explain Medicaid expansion from an economic perspective. 4. Each State has a hospital trade association. What are they doing? How about the Managed Care industry? Home health? Nurses? Pharmaceuticals? They all will expand their services, hire more people, and help your State grow. Get to them We realize every advocate has a long agenda. Medicaid expansion is the most important step in health care since 1965 and in economic recovery since 2008. Make sure your State joins in! 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 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. Ext 227.

The Disability Community and Medicaid Expansion: What’s At Stake. Information Bulletin #369 (1/2013). In 2010 Congress enacted the Affordable Care Act. One part of this legislation mandated that all States expand their Medicaid to all persons whose incomes are under 138% of the federal poverty level, which is less than $15,415 per year for a single person and less than $31,809 for a family of four. In June 2012, the U.S. Supreme Court held that Medicaid Expansion could not be a mandate, making Medicaid Expansion optional for States. This Fact Sheet explains why Medicaid Expansion is vitally important to people with disabilities. Based on data from the 2010 American Community Survey for people under 65 years old, 13.7% of non-elderly community residents with family incomes under 138% FPL have disabilities, compared to 6.7% of those with incomes above that level. So the disability rate among poor or near-poor Americans is more than twice that of those with higher incomes. For people with disabilities on SSI, they already receive Medicaid. Also, in many States that provide Medicaid Waivers for community-based services for people with disabilities, the income eligibility levels are above SSI. However, there are a LOT of people with disabilities in every State who are neither on SSI nor on a Waiver and who do not have any health coverage for basic health care – doctors, prescriptions, and hospitalizations. These are the people with disabilities for whom Medicaid Expansion is critical! What follows are the number of people by State who are at 138% of the federal poverty level and under, who are not currently receiving Medicaid, either based on SSI or Waiver, and are under 65 years. While a majority of States are opting into the Medicaid Expansion, a number have not yet decided it is in their economic interest or the interest of people with disabilities. [We also have separate Fact Sheet for the recalcitrant States. It makes an economic development argument why the States should participate. If you want it for your State, just email me with the name of your State.] Disability Advocates - here are the number of people with disabilities who will benefit if your State Expands Medicaid eligibility! # People with Disabilities under 138% FPL, under 65, and not currently on Medicaid Alabama 77685 Alaska 6550 Arizona 37366 Arkansas 44130 California 227747 Colorado 35162 Connecticut 16640 Delaware 5269 District of Columbia 3774 Florida 190073 Georgia 105420 Hawaii 5623 Idaho 16118 Illinois 80884 Indiana 67339 Iowa 19183 Kansas 24259 Kentucky 76619 Louisiana 67078 Maine 12465 Maryland 31616 Massachusetts 19008 Michigan 109828 Minnesota 24521 Mississippi 51235 Missouri 67885 Montana 10475 Nebraska 13643 Nevada 21158 New Hampshire 10237 New Jersey 41611 New Mexico 20393 New York 102793 North Carolina 105627 North Dakota 3453 Ohio 121348 Oklahoma 49336 Oregon 49213 Pennslyvania 108012 Rhode Island 10213 South Carolina 60840 South Dakota 5878 Tennessee 80742 Texas 237253 Utah 12641 Vermont 3383 Virginia 59705 Washington 49436 West Virginia 34953 Wisconsin 31285 Wyoming 4197 0 U.S. 2665407 Steve Gold, The Disability Odyssey continues Thanks to Steve Kaye, UCSF 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 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. Ext 227.

Nursing Home Residents and My Medicaid Matters. Information Bulletin #368 (1/2013) Over the next year, States may try to reduce community-based Medicaid-funded services for both disabled and elderly people. When they do, advocates should instead force them to focus money going to the institutional Medicaid-funded services, i.e., nursing homes, the flip side to the community. Nursing homes, unlike the community, continue to receive increased Medicaid reimbursements. People who have “self-care” needs, i.e., who need assistance with activities of daily living, trigger both an ADA/Olmstead and a fiscal issue, depending on where they receive these Medicaid services – in the community or in an institution. Based on data collected and analyzed by Steve Kaye, Director, PAS Center, UCSF, advocates can use the following points in your State’s My Medicaid Matters struggle to show how to reduce institutional expenses. The point of the data is to enable advocates to ask why your State has so many non-elderly and non-cognitively impaired persons unnecessarily institutionalized. What follows are ratios of two specific subcategories of nursing home residents (1. non-elderly and 2. non-cognitively impaired) to the total state population with self-care difficulties in 2010. First, nationally, there was an average of 6.3 non-elderly nursing home residents per 100 non-elderly people with self-care difficulties. The ten worst States with much higher rates than 6.3 national average are ranked as follows: Illinois (#1 with 14.5 non-elderly N.H. residents), Connecticut (#2 with 12.2), North Dakota (#3 with 11.7), District of Columbia (#4 with 11.3), South Dakota (#5, 10.1), and then Ohio, Iowa, New York, Hawaii, and Missouri. Why do some States have twice the national average of non-elderly persons with disabilities institutionalized? With appropriate scope and quantity of community-based services, many of these non-elderly people could and would want to live in the community. Many States have addressed this and significantly reduced non-elderly persons in nursing homes – e.g., New Mexico has 2.8 non-elderly NH residents per 100 total NH residents, less than 25% of the worst State. The number of non-elderly persons in NH is a matter of State policy. What is your State doing to reduce this institutionalized population? Rather than reduce community-based services, reduce much more expensive NH residents and provide services in the community. Second, nationally, there was an average 7.5 nursing home residents (all ages) without cognitive impairments per 100 with self-care difficulties. The ten worst States with high rates well-higher than the national average are ranked as follows: North Dakota (#1 with 23.4 N.H. residents), Iowa (#2 with 17.0), South Dakota (#3 with 16.4), Connecticut (#4 with 16.2), Rhode Island (#5, 15.3) and then Nebraska, Kansas, Wyoming, Indiana, and Minnesota. States have addressed this and many have reduced this institutionalized population including, e.g., Oregon with only 3.1 non-cognitively impaired NH residents per 100 population with self-care difficulties, less than 13% of the worse State. Others include Alaska (2.3) and Arizona (4.3). Here’s another unnecessarily institutionalized group who should be addressed before community-based reductions are implemented. Third, States which have “rapidly rebalanced” their state Long-Term Care Medicaid expenditures, i.e., shifted more than 10% of their Medicaid funds from institutional care to community-based care, have reduced the total number of long-stay nursing residents by 9% between 2002 and 2010. In States that have not rapidly rebalanced their LTC budgets, there has been an increase in nursing home residents. Advocates must know what’s happening on the institutional side of the ledger. Look at the institutional expenditures over the past eight years. Has the N.H. per diem increased? Compare it to the community-based services. Are there people in N.H. who could be more inexpensively served in the community? Has the total N.H. population increased or decreased? The NH industry is a powerful player, but we have the data and the way to save money. If your State is threatening to reduce community-based Medicaid Long-Term Care services, use these three items to argue why such reductions are wrong. 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 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. Ext 227.