Friday, June 20, 2014
Olmstead 15th Anniversary [Part Four] - How Much Progress Has Your State Made? Information Bulletin # 394 (6/2014). In the previous three Olmstead 15th Anniversary Information Bulletins, we focused entirely on Medicaid-funded nursing homes and community-based programs. We have looked only at programs for people of any age with primarily physical disabilities of any age and who would meet the eligibility criteria for nursing homes. We saw that between Fiscal Years (FY) 2000 and 2012, there was a significant national increase in Medicaid community-based expenditures from 18.7% to 38.8%. That is an increase from $9 billion to $22 billion – not chopped liver! People with developmental disabilities also benefit from the Olmstead decision and the ADA’s “most integrated setting” regulation requirement. People with developmental disabilities do not meet the eligibility criteria for nursing homes and should not be in those institutions. We can make an independent comparison of institutional versus community spending for people with developmental disabilities. Historically, the two systems – one for people with developmental disabilities and the other for the aged and people with primarily physical disabilities – have responded to Olmstead and the ADA’s mandate quite differently. For example, for people with developmental disabilities between FY 2000 and FY 2012, there was a significant national increase in Medicaid community-based expenditures from 49.0% to 69.6%. That 20% jump is about the same as the increase in community spending for people with physical disabilities. Chart One presents 2012 Developmental Disabilities (DD) data by State in the community. What is particularly impressive is that 14 States in FY 2012 spent more than 90% of their total Long Term Services and Supports (LTSS) (i.e., the combined institutional and community expenditures) for DD in the community. See Chart One – 2012 % of LTSS Medicaid Expenditures Went to ID Community Programs. It is also fascinating is to compare by State the FY 2012 expenditure of LTSS for people with non-DD disabilities with the expenditure for people with DD. See Chart Two. Why, for example, does Alabama allocate 96.4% in the community for persons with developmental disabilities, but only 15.2% in the community for the aged and people with physical disabilities? Further, Michigan and Maryland each allocate 100% in the community for persons with developmental disabilities, but spend only 23% in the community for the aged and people with physical disabilities. Similarly, New Hampshire allocates 98% in the community for people with developmental disabilities but only 19% for the aged and people with physical disabilities, and Rhode Island spends 96% for people with developmental disabilities in the community but only 19% for the aged and people with physical disabilities in the community. We could go on and on – see Georgia, Connecticut, but you see the discrepancy. However, there are several big differences that may explain this discrepancy. First, in 2000, the institutional side (Intermediate Care Facilities/MR) and the community side (MR Waivers) each expended about $10 b. On one hand, $49b (80% of the entire LTSS) of Medicaid spending for the aged and people with physical disabilities went to the institutional side. On the other hand, institutions and community Medicaid spending for people with developmental disabilities started off nearly equal. It’s like a hundred yard dash with some folks starting at the mid-point and others starting far behind. Second, the institutional component of ICF/ID (Intellectual/Developmental Disabilities) in 2012 is quite different from nursing homes, the institutional component for people with physical disabilities regardless. That is, 58% of the institutions for developmental disability community were publicly owned in comparison to the nursing homes of which only 6% are publicly owned and nearly 70% are for profit. This difference results in political differences because, unfortunately, money and contributions to state-elected officials play an important role in how Medicaid funds are expended between the institutions and the community. Third, the exact opposite occurs on the community side for people with developmental disabilities. Since 2000, most people with developmental disabilities have moved from public institutions to primarily private provider-based group homes and most people with physical disabilities have moved from private institutions (nursing homes) to their own apartments and homes. The providers of community-based services are for developmentally disabled individuals very strong both financially and politically in the same way that institutional nursing homes proprietors are strong (regardless of whether the nursing home is “for profit” or allegedly “nonprofit”). Fourth, advocates actually need to go into institutions to encourage and help people transition out of the institutions. I am regularly amazed when I ask advocates for the aging and people with physical disabilities community about people in institutions who want to reside in the community and am told they do not know those people. Advocates should also encourage people to stay in their own homes and communities. “Closing the front door” before a person is institutionalized is an effective strategy to which your State Medicaid administrators should be receptive – if you push them. Neither the Olmstead decision or the ADA are self-executing. They are enforced only when advocates act. Chart One -2012 % of DD LTSS in the community Alabama 96.40% Alaska 98.10% Arizona 100% Arkansas 50.40% California 74.70% Colorado 89.60% Connecticut 74.20% Delaware 69.80% Florida 71.50% Georgia 90.30% Hawaii 92.10% Idaho 73.60% Illinois 47.80% Indiana 62.30% Iowa 56.10% Kansas 84.10% Kentucky 72.50% Louisiana 48.30% Maine 80.80% Maryland 100% Massachusetts 98.50% Michigan 100% Minnesota 86.00% Mississippi 14.00% Missouri 59.80% Montana 88.60% Nebraska 79.50% Nevada 79.90% New Hampshire 98.30% New Jersey 51.70% New Mexico 91.80% New York 62.00% North Carolina 56.90% North Dakota 58.00% Ohio 62.10% Oklahoma 71.10% Oregon 100% Pennsylvania 76.70% Rhode Island 95.70% South Carolina 65.30% South Dakota 77.60% Tennessee 72.80% Texas 50.00% Utah 74.90% Vermont 99.20% Virginia 66.90% Washington 83.80% Dist. of Columbia 68.00% West Virginia 82.80% Wisconsin 79.90% Wyoming 82.60% United States 69.60% Chart Two - 2012 % of A/PD LTSS in the community Alabama 15.2% Alaska 62.4% Arizona 42.0% Arkansas 31.7% California 57.1% Colorado 45.5% Connecticut 25.8% Delaware 21.3% Florida 23.0% Georgia 29.0% Hawaii n/a Idaho 43.5% Illinois 31.9% Indiana 18.7% Iowa 26.6% Kansas 31.5% Kentucky 14.4% Louisiana 30.0% Maine 32.3% Maryland 23.4% Massachusetts 44.7% Michigan 23.6% Minnesota 65.4% Mississippi 22.2% Missouri 37.4% Montana 36.2% Nebraska 23.6% Nevada 33.5% New Hampshire 18.8% New Jersey 15.7% New Mexico n/a New York 45.9% North Carolina 39.8% North Dakota 14.0% Ohio 32.4% Oklahoma 30.8% Oregon 60.7% Pennsylvania 24.7% Rhode Island 18.8% South Carolina 26.2% South Dakota 16.3% Tennessee 31.3% Texas 50.1% Utah 21.9% Vermont 44.7% Virginia 43.9% Washington 61.7% Dist. of Columbia 54.1% West Virginia 31.3% Wisconsin 47.9% Wyoming 20.0% United States 38.8% Again, thanks to Truven Health Analytics for the underlying data. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins posted after 10/2013 can be found only at http://stevegoldada.blogspot.com/ Information Bulletins before 10/2013 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 firstname.lastname@example.org or call 215-627-7100. Ext 227.