At MHAM, we depend on individual donors to support our mission to enhance mental health, promote individual empowerment, and increase access to treatment and services for people living with mental illnesses. You can help us by contributing to MHAM through Give to the Max Day tomorrow, November 14. What’s more, your donation will be matched by our Board of Directors up to $10,000.  Simply visit our page at GiveMN.org, enter the donation amount you’d like to make, and follow the prompts to complete the transaction. You will help people like Henry.

The sun shone brightly and the temperature was perfect as Henry made his way to visit family and friends in a nearby community. The world looked good, and Henry drove toward his destination with anticipation boosted by an elevated level of mania. With his history of bipolar, Henry suspected he was feeling so good because was he was becoming manic. He knew that mania often resulted in problems in his life, but he also knew that it felt a whole lot better than those days when he was caught in the grip of depression.

Henry’s good day went downhill fast. Suddenly, he saw flashing red lights behind him. He had stopped quickly at a stop sign and then made a right turn without signaling. A police officer approached Henry’s car. The flashing lights and the uniform caused Henry’s stress level and mania to increase. He started to talk fast and loud. Instead of staying in the car, he tried to exit to explain to the officer. The officer thought Henry had been drinking.

Henry was taken to a detox center where he was tested for alcohol and other drugs. They found he had a very low level of alcohol–well below the legal limit for driving. However, once he was admitted to the detox center, he was stuck there for the next couple of days. Henry had neither his medication for bipolar disorder, nor medication for a separate physical condition. He did not need to be in detox. Henry should have gone to the hospital where he could get treatment for his bipolar disorder.

Henry eventually called MHAM because he was billed by the detox center for his time there. Henry is on Social Security Disability and cannot afford a large medical bill. Moreover, the detox center should be covered under Medicare. Henry and his advocate contacted a Medicare representative, who told them that a bill was not submitted to Medicare for the detox center. The advocate then helped Henry set up some conference calls with the county and the detox center in an attempt to figure out what happened. As it turns out, a police transport brought Henry to a detox center from a neighboring county. The detox center did not bill Medicare, but instead billed the county that transported Henry to the center. The transporting county then billed Henry. After talking to staff in both areas, it was clear that the detox center needed to send the bill to Medicare and not to the transporting county. Henry was pleased that the issue of the bill was resolved. However, a larger issue still stands. This problem would not have come up if Henry had been treated for his bipolar disorder at a hospital or clinic rather than held in a detox center when no detoxification was needed.

As promised and expected, Gov. Dayton signed an executive order to expand Medical Assistance (MA) eligibility for single adults under %75 of the poverty line.  Federal law will expand eligibility even more in the future, but these changes are not scheduled to take place until 2014.  In the mean time, states are being given options to begin the transition early.  Under Gov. Pawlenty, Minnesota had declined these funds, but signed a compromise that would let the next Governor to take action.

Dayton’s signature on this is a major step forward.  MA, unlike the weakened GAMC plan that emerged last session, is a comprehensive plan.  It allows eligible individuals to seek treatment at any number of hospitals and clinics, not just a handful of locations in the Twin Cities.  Unlike Minnesota Care, it offers real coverage for expensive inpatient hospitalization for those least able to afford it.  While we are still waiting on information about how long the transition will take place and individuals are enrolled, we are very heartened to have good news to share.  Particularly for individuals who have lost work or housing and are living with mental illnesses, Medical Assistance represents a better hope for good quality medical care.

This is going to be a difficult legislative session, as the Governor and Legislature wrestle with a 6.2 Billion deficit.  Further cuts are all but inevitable.  With expanded MA, more low income individuals will be able to access resources they need to keep themselves healthy and safe.  For Minnesotans with mental illnesses, this is a victory.

Please stay tuned for further updates and stay in contact with your state legislators.  You can find out who represents you here.  They need to hear from you early and often as they consider the steps necessary to balance the State’s budget.  Let them know why your services are important to you and your community.

The 2010 Legislative session was an extremely active and difficult session.  While the primary goal was to pass a bonding bill for long-term projects, spending on health and human services came into sharp debate.  Looking back at everything that happened, what will be the impact on mental health services?

We see four areas of major importance.  GAMC was the big concern early and late in the session, and we expect more news to come soon.  For more detailed history on what happened, you can read our previous entries here.  Right now, letters are going out informing people that GAMC is changing and that they must select a hospital home for clinic care.  Otherwise, they will be restricted to emergency only treatment.  What we don’t know is how the proposed patient limits will affect this process, or how many previously eligible individuals will complete their paperwork.  We suspect that this will be a major barrier.  What we do know is that this is bad news for people living in outstate Minnesota.  The four hospitals that agreed to this plan are all in the Metro area.  People can still go to the ER, but only for emergency treatment.  We are working to find other resources for people who need assistance with obtaining medication or other non-emergency care, but the outlook is not great.

Guardianship law was one of the few “wins” we had this session.  You can read our summary here.  This change introduces a basic level of accountability for guardians and protects the rights of individuals to make long-term choices about their health care.  We believe that it is an important piece of working towards models of care that better involve and respect the person’s wishes.  In addition, it showed that we can still make important policy changes, as long as they do not require funding.

MA expansion was brought up several times in the session, and has an uncertain future, even though it is strongly favored by providers.  We view it as the best long-term solution to the GAMC issue and it is required to happen in 2014.  At the end of session, the final compromise budget did not include early expansion of MA, but authorizes the Governor to trigger entry at a later time.  Gov. Pawlenty has staked out a public position against federal health care reform and is unlikely to do so.  However, the next Governor may not be opposed or simply not have any choice to refuse so much federal money.  You can read about the candidates’ stances on MA expansion here.

Funding for basic mental health services came into jeopardy this session.  When the state invested an additional $34 M in spending in the mental health system in 2007, it was seen as a major move forward.  Yet, we are now seeing major cuts that will quickly dwarf that investment.  It’s hard to interpret this as anything but a step backwards.  Some of these cuts are set to expire in 2011, but we know that it will take a lot of political will in order to resist sustaining those cuts as the budget crisis deepens.  State Operated Services will be redesigned and face cuts, despite delaying the inevitable by refusing to follow legislative and community input.  MHAM is pleased to be included with other advocates and stakeholders in helping outline what SOS truly needs to deliver.  While the cuts will be significant here, we are hopeful that an intelligent redesign process will limit the impact on consumers.

As these conversations continue through the election season and into the next session, we think that the State needs to face facts about budget cuts.  We believe that many of these shifts and cuts do not really last.  Property taxes are up sharply as counties try to recover from reduced aid from the state, and cuts to low-income health care typically raise the rates for those with insurance.  Supportive housing, PCA services, drop-in centers, and other long term/lower intensity services have all been on the chopping block.  But hospitalization, crisis response, and police involvement are far more expensive.  When these services are cut, the trade-offs have both human and financial costs, and we will work hard to push back against the band-aid approach to budgeting in the state.

Working towards the next legislative session, a few things are going to be different.

• There will be many new faces.  We will have a new Governor, but we will also have many new legislators as well.  Many retirements were announced as the end of session, and many elections will be hotly contested.  We see this as an opportunity to educate and inform new lawmakers about why mental health services are important and can reduce long-term costs.
• The deficit will be larger.  The funding “shifts” for K-12 education will come due, one-time funding has been used up, and tax revenues are still lower than in previous years.  The new Governor and the Legislature will have difficult decisions to make about how to balance the budget.
• Lastly, we hope that more of you will join us in calling, writing, and staying involved.  We know that contact from constituents made a big difference in outcomes this session.  We will continue our outreach across the state to LAC groups and other communities, and we would love to hear from you about getting involved.

Once again, the future of mental health services are back in the hands of Gov. Tim Pawlenty. The House and Senate Conference Committee finally finished their negotiation of the final bill that would go to the Governor.  You can see the full details here.  These discussions have been long and tense, and many of the most important programs for our community were up for cuts.

The final bill is better than the Governor’s original proposal, and it is much better than the House proposal too.  But it still reflects the political and economic environment we’re in, and it will be a challenge to deal with in the coming year.  Please contact the Governor’s office and let him know what you think.  The compromise bill proposes:

• Restored funding for the Adult Mental Health grants supports community programs such as CSPs, drop in centers, and case management.  These grants were cut earlier in the session to pay for the GAMC compromise bill.
• Restored funding for ACT teams in rural areas.
• Cuts to housing with support for adults with serious mental illnesses.  However, these cuts are for 2010 and are not projected to continue at this point. All the major proposals have cut this amount.

We are particularly concerned for out-state Minnesotans at this time.  The Governor has taken it upon himself to modify the conditions of the GAMC deal struck with legislators earlier in the session.  When no hospitals would agree to participate, he  managed to convince 4 metro hospitals to accept a limited number GAMC patients.  There are two serious problems with this.  Patient limits were not part of the legislated solution, and may cut individuals off from needed care.  Secondly, four metro hospitals do not replace a state-wide safety net.  This is an unacceptable plan to people who do not live near the Twin Cities.

We would like to thank the members of the conference committee for hearing the needs of Minnesotans with mental illnesses.  We urge the Governor to do the same,

Yesterday morning, the Minnesota Supreme Court ruled that Gov. Tim Pawlenty’s unilateral unallotment of funds earlier in the biennium did not meet the statutory requirements for using that power.  The majority found that the language of the statute and the design of the State government do not allow for a Governor to use unallotment prior to agreeing to a budget.  Chief Justice Magnuson wrote for the majority (Link goes to PDF):

…we cannot conclude that the Legislature intended to authorize the executive branch to use the unallotment process to balance the budget for an entire biennium when balanced spending and revenue legislation has not been initially agreed upon by the Legislature and the Governor.  Instead, we conclude that the Legislature
intended the unallotment authority to serve the more narrow purpose of providing a mechanism by which the executive branch could address unanticipated deficits that occur after a balanced budget has previously been enacted.

The court chose to rule on narrow grounds, and it was a 4-3 decision.  They intentionally did not take up the question of the underlying constitutionality of the unallotment statute.  However, the implications represent a substantial shift in the balance of power at the Capitol.  Just hours earlier, Gov. Pawlenty had vowed to cut an additional $500 M from the budget if the Legislature failed to do so, invoking unallotment.  This decision makes that threat less credible.

Now, the pressing and serious question of how to balance the budget comes back to the Legislature. The full impact of this ruling is not yet known, but it is likely that it will create a substantial amount of conflict in the coming days.  The budget must be balanced, and Federal money that both Gov. Pawlenty and the Legislature was counting on has not yet arrived. They must agree to a  budget, but we do not expect the negotiations to be easy.  Deeper cuts and the potential for a government shutdown may be in the future, as Pawlenty as renewed his vow not to include revenue increases as part of the solution.

As the Health and Human Services budget is considered, this decision is going to play a significant role.  Many of the cuts made through the unallotment process were in this budget, and now must be renegotiated. We are already seeing strong signals that the Governor is unwilling to consider Medical Assistance expansion, even though hospitals have now refused to join in the replacement GAMC program.

Stay tuned and keep speaking up for mental health services in Minnesota.

Mental health services in Minnesota unexpectedly lost ground today, as the House Health and Human Services Finance Division introduced their proposed budget. The bottom line is that the House is aiming to take more away from mental health services than the Governor.

We find it hard to believe that the same Legislators that worked so diligently to try to find some solution for GAMC would abandon the critical programs that help keep Minnesotans independent and prevent hospitalization or other high-cost crisis situations. This news requires our immediate and strong response. Please call your Representative immediately, and tell them what mental health services mean to you and what you think about these cuts:

• Supportive long-term housing is important because it provides stability and a chance to recover. It is the single most important priority we have for our community.
• Instead, State Operated Services hospital system escapes unscathed from cuts. This rewards them for ignoring the Legislature, and refusing to deliver the services that we need.
• ACT Teams help defuse crisis situations, and find treatment for those who need it most.
• Cuts to county mental health grants attack the backbone of mental health services in Minnesota, delivered in the communities where we live. They provide services such as clinics, case managers, and housing that help us recover.
• These cuts come on top of 9 million of reductions to mental health grants in the GAMC compromise bill above and beyond lost reimbursement for services. GAMC was redesigned by cannibalizing the mental health system. In total, these grants will have been cut by over a quarter.
• Mental health services stand alone in receiving additional cuts beyond what the Governor proposed. Nursing Homes and Disability services stand to retain 100 Million that would have been cut. Mental health services are valuable, too. We can’t be the only target.
• Ultimately, this is a revenue problem. The dismantling of successful programs that help save money in the long-term is not an appropriate response to a temporary and politically exacerbated revenue shortfall.
• Expanding Medical Assistance may be a positive part of extending services to those who can’t afford them, but other cuts to hospitals and providers will weaken the system at the same time we’re adding more patients.

Tom Johnson, one of our client advocates, puts it well. You can treat a disease, and that’s part of the solution. But you also have to believe in people, too.

These cuts hit the very services that help Minnesotans with mental illnesses believe in themselves again and find recovery. At the same time, this plan will overwhelm and erode the emergency safety net that is supposed to treat them when they need it most.

The House plan is unacceptable to our community. It represents more hospitalization, less management of our conditions, and more costs.

Please call today, and send this information on to anyone who wants better lives for Minnesotans with mental illnesses.

As the SOS redesign continues, we have had many opportunities to speak about what is important to mental health consumers in Minnesota. Our refrain has been: long term care and housing with supports. We believe that supportive environments, aimed at long-term stability is what consumers need from the system. This puts the focus on the client and their independence, while hopefully reducing the need for acute services. In particular, we are hoping to reverse direction, and restore funding for CADI Waivers, and other options that put Minnesotans with mental illnesses back into their communities, and provide them with the support to stay there successfully. As Executive Director Ed Eide stated in a recent Star Tribune article, the alternative has been to warehouse patients indefinitely in restrictive settings.

We strongly believe that this kind of focus is what needs to be at the heart of the redesign process. Preserving jobs and programs are important but the provision of quality services at an appropriate level is paramount. We are calling for many of the cuts to be reversed, but we’re also showing the need to get better results with that funding. We can only really talk about appropriate staffing once we know what services we need.

We have continued our conversations with policy makers in St. Paul as well as consumers and providers around the state, seeking to build consensus around what are the best options for positively transforming SOS. As the legislative process to decide what to do with SOS continues, we will continue to provide ideas and feedback.

Another recent development has been around the revised GAMC system. As you may remember, patients are being shifted towards hospital-based care organizations that would try to move care out of the Emergency Rooms and towards clinics and less intensive settings. However, recent roadblocks have come up. The House Heath Care and Human Services Finance Division heard testimony last Thursday that many rural hospitals would refuse to participate because they did not think they could set up services quickly enough or have enough of their costs covered. Now, HCMC has signaled that it will also decline to participate. As one of the largest providers of GAMC services in the state, HCMC has played a critical role in this program. It is hard to imagine a successful care plan for low income Minnesotans that does not involve them.

Under Federal Health Care Reform, the state has the option of covering single adults with up to 133% of poverty level income under Medical Assistance (Medicaid). There are some issues with this plan, namely timely implementation and fully understanding the costs until 2014 when that expansion will be required. However, as more hospitals refuse the GAMC compromise, this option may require a second look.

As we’ve talked about previously, General Assistance Medical Care (GAMC) is changing dramatically this year.  This Friday, Governor Pawlenty signed SF 460 into law.  The state will pay hospitals, beginning in June, through block grant payments, for services to their GAMC patients.  The largest providers of services to GAMC patients, 17 hospitals, will become Coordinated Care Organizations (CCO).   Hospitals that served fewer GAMC patients will be able to receive funding, for six months, from an uncompensated care pool and will be able to later become a CCO.  They will be responsible for the entire health of the patients and some care will be delivered through clinics not the emergency department.

These payments to hospitals will be significantly less than they have been in the past, but do alleviate some of the uncompensated care costs they would have suffered under the Governor’s plan to auto-enroll GAMC patients into MNCare.  This bill also keeps the Health Care Access Fund intact.  Drug coverage will also be maintained for recipients, the majority of whom are mentally ill or suffer from chronic diseases and depend upon prescriptions to manage their illnesses.

While this solution is better than nothing, we are going to be working hard to identify opportunities in the recently passed federal health care reform bills for better models of care.

The compromise has preserved benefits though May, although current enrollees should expect a letter from the state that explains a timeline for benefit changes.  Prospective patients should apply through their county, and they will be directed to programs for which they are eligible.  More information can be found on the MN DHS website.

MHAM is relieved to see signs of progress after many setbacks.  Thank you to everyone who contacted their legislators and got involved: public pressure helps make sure that things get done right.

General Assistance Medical Care (GAMC) has passed both the House and Senate.  Given the Governor’s prior support of this plan, we expect it to be signed into law shortly before the plan is set to expire at the end of the month.  While we continue to have serious concerns about the effect of cuts to county mental health grants, we are thankful that some organized system of care will be available to those who have relied on GAMC.

Federal Health Care Reform appears to be moving forward, with the main bill signed and the addendum bill on its way.  Rep. Tom Huntley, chair of the House Health Care and Human Services Finance Division has noted that Minnesota is in good shape to capture additional federal dollars for Medical Assistance patients with chronic conditions (including mental illnesses).  While details are still coming out about the exact budget impact, we hope that as the pressure on the state is eased, some of the cuts to mental health services will be reconsidered.  Health Care Reform will have many other effects on our community, especially in terms of the availability of coverage.  We will post more here in the coming days.

Finally, the debate over State Operated Services continues.  There are no clear resolutions yet, but preliminary negotiations are underway to save some facilities by transferring operation to private companies or counties.  Your voices are still needed in making sure that the final redesign will reflect the needs of consumers. Our goals remain focused on ensuring the availability of appropriate services, transparency in how SOS is run, and the minimization of the state as a direct provider.  We have heard about many challenges and difficulties in the current system.  This is all the more reason that when we redesign SOS, we get it right.

Keep calling, writing, and staying involved…

That appears to be the question asked this past week at the Legislature.  In order to provide health care to the poorest Minnesotan’s, hospitals will have to develop a Coordinated Care Organization (CCO) for their GAMC patients.  GAMC recipients will have to learn to go to clinics instead of the emergency room.  Their health care will be “coordinated” in order to improve their health.  Can this system of health care work well with the homeless population once the new program begins in June?

There will be two levels of hospitals in this bill.  Level one are those who currently serve a substantial number of GAMC patients (approximately 17).  These hospitals will receive a lump sum reimbursement determined by the hospital’s recent share of GAMC business.  Currently level one hospitals serve 80 % of the GAMC patients.

The second level serves the other 20%.  They would receive funding for serving GAMC patients through an uncompensated care pool of $20 million for six months (June to November 2010) and then could become a CCO.

There are some positives with this new plan:

• Current GAMC recipients will be automatically eligible with no transition.
• It preserves access and affordability of prescription drugs.
• It preserves the Health Care Access Fund (HCFA).

Here are some questions and concerns to be alert to:

• What are the type of services to be offered?
• Will they be different depending on the CCO?
• Will hospitals opt in or out?

Part of the funding is taken from the Adult Mental Health grants to counties.  What services at the county level will be cut or eliminated? MHAM’s view of the GAMC funding bill is that it maintains a level of health care for our poorest Minnesotans.  But what will be lost in other mental health services provided at the local level with the shifting of dollars throughout the system?

State Operated System (SOS) Redesign

DHS has released their SOS redesign.  Here are some brief highlights:

• There will be Level 1 psychiatric care centers in regions of the state.
• There will be a new 24 hour psychiatric access service
• There will be a partnership process to involve service providers.
• Closure of the Mankato Crisis Center and transfer to St. Peter.
• Closure of the adult mental health residential facility in Eveleth.
• The development of Psychiatric Extensive Recovery Treatment Services (PERTS).

As we mentioned before, there is more to information to come and many more questions.  We will provide additional information on Wed. March 17^th following a presentation at Sen. Berglin’s committee Tuesday morning.