Since the MN Supreme Court decision reversing unallotment came down, we have known that budget negotiations would have to go into the final hours of the session.  But we are also facing new uncertainty about Federal funds that both sides were counting on to solve this biennium’s shortfall.

This means that the budget gap is now at about $3 B.  Obviously, this is a significant amount concentrated into the final year of the biennium.

The  plan proposed by the MN House and Senate majority addressed this new amount.  It would ratify certain parts of the unallotments, such as delays and shifts in K-12 Education funding and in local government aid.  What is significant about this plan is that it spreads the cuts more evenly that other proposals we have seen this yea. In addition, it plans on eventual restoration of the most important mental health related county grants and it raises new revenues through income taxes.  If the $400 M in Federal money does arrive, some money is put back into health and human services.

Passed narrowly last night, it met an almost instant veto from Governor Pawlenty.  There appears to be very little forward movement or compromise appearing.  Pawlenty has asked again for the Legislature to ratify his solution, but it was voted down by large margins in the House.

As we’ve said before, we hope that you will ask your legislators about what they have done to make a workable compromise possible.  There’s too much at stake to continue our present course of disappearing services and lost independence.

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.

As we continue to examine the House Health And Human Services budget, the worse the news gets.  We do not see an effective framework for managing costs or promoting the well-being of our community.  What we see are cuts to long-term programs that will lead to more crisis situations and worse outcomes for consumers.

Ways and Means will take up HF 2614 this Monday morning, and we need to make sure these Representatives get a lot more calls and emails in regard to these shocking cuts to mental health services before then.

Please call or email members of the Ways and Means Committee, or whoever is your Representative. Ask them to share with the Speaker that they do not support these devastating cuts to mental health services and will vote against this budget both in committee and on the floor if necessary.
Make sure you call your Representative regardless of their committee assignments, but in particular, members of the Ways and Means Committee need to hear about our concerns immediately.

Thank you to everyone who is helping make a difference in a very challenging time!

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.

Gov. Pawlenty signed HF 3128 into law on Thursday, providing critical reforms to the guardianship process in Minnesota.

This bill denies guardians the right to void advance health care directives, and restricts the circumstances in which a court may do so. It increases the rights of persons under guardianship who have formalized their concerns and wishes into a Health Care Directive. It also requires notice if a proposed guardian has been removed with cause in the past.

These changes allow persons with chronic mental health conditions to make decisions about their care when they are capable of doing so, and formalizing those wishes in a way that must be respected even if they are placed under guardianship in the future. At MHAM, we believe strongly that people have the right to be involved in creating their own care plan, and that these agreements can be an important part of staying healthy in the long-term. It also makes it easier for courts to spot proposed guardians who have not lived up to their duties in the past, so that they are not assigned to new clients. We know that it’s critical for appointed guardians to be held accountable for the decisions they make.

MHAM is pleased to see these needed changes make it into law, and thanks the sponsors of the bill: Sen. Mee Moua, Sen. Linda Higgens, and Rep. Debra Hillstrom.

For more information about advance health care directives and planning your medical care, please contact us at 612-331-6840 or 800-862-1799.

We’ve all heard about health care reform passing in Congress and being signed into law.  We’ve also heard a lot of conflicting reports on what will happen.  The reality is going to be somewhere in the middle of the rhetoric. At MHAM, we see the following as the key impacts on mental health services in Minnesota:

• Expanded funding and eligibility for Medicare and Medicaid.  Right now, this may be one of the big impacts: as federal money comes into Minnesota, we need to make a strong case for why some of those dollars should stay in health care and human services, and help ease the cuts we have seen in the past biennium.  As we’ve noted, DFL leaders in Minnesota are very optimistic about the state’s ability to conform to new standards for treatment of chronic illnesses, including mental health and concurrent conditions.  This may also help ease the continuing GAMC crisis, by moving more of that population onto federal programs.

• Moving towards more parity for mental health.  While the authors  clearly intended to end specific exclusions of illnesses and expand coverage of pre-existing conditions, insurance companies announced attempts to find alternate ways of denying coverage. The Administration pushed back, and the insurance companies have retreated on these claims.  We will be alert to future conflicts over the intent of the legislation: fighting enhanced coverage for children with serious conditions is widely unpopular, but other provisions may not attract such immediate condemnation.

• Broadens requirements for coverage of preventive health care.  Insurance companies will be required to fully cover (with no co-pay or deductible) services that are shown to be effective in improving public health. Currently, this would include screening for depression in many circumstances.

• Extends coverage under group plans to age 26.  Children can stay on their parent’s health plans until age 26.  For many young people, especially in a slow job market, it has been difficult to maintain health insurance.  While these are relatively healthy years for most people, it is also an age when mental health conditions may emerge or require treatment.

• Prohibits rescission.  Rescission is the practice of ending a health care policy retroactively when large claims are made on the basis that the person did not correctly apply for the policy, even if it has been a long time since coverage started.  If a person gets very sick, some insurance companies will review their application, searching for any mistakes.  While it is important that people are honest and pay in fairly for their coverage, this practice exemplified the lack of power individuals had when seeking health care.  This is also a critical reform for anyone who may encounter a period of higher claims, such as inpatient hospitalization or intensive services for mental illnesses.

These bills are quite complex, and as we’re already seeing, may have effects different than President Obama intended.  The debate has been extremely contentious, and companies with their profits at risk are not going to simply back down.  It is important for mental health advocates to continue to be visible in the ongoing debate about how health care reform is going to work. For instance, Medicaid is being expanded, but it will take action by the state to make sure that there are workers available for the program that assesses applicants for eligibility. MHAM will work to make sure the promise of these changes is not lost for Minnesotans with mental illnesses.

For more information, you may want to attend (or listen to the online audio) of the Minnesota Senate Health and Human Services Budget Division on April 8th.  Sen. Linda Berglin is holding a meeting focused on the effects of these bills on the state.

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…

Executive Director Ed Eide has been traveling the state, talking with LAC groups about how they can be a part of improving mental health services in Minnesota.

One of the question he’s been hearing a lot is: What will happen to services in the SOS redesign? He’s taken what he’s heard from LAC meetings in Hennepin, Dakota, Watonwan and Sherburne counties and other consumers and made sure you are being heard at the Capitol.

SOS is just one part of the picture for mental health services, but it represents the challenges we face.  Cuts are being made without transparency or consumer support.  We don’t have a lot of faith that the new SOS system will function better for patients.

Listen to Ed’s testimony here: look for the meeting of the Finance Health and Human Services Budget Division on March 23rd.  He testifies first at the beginning of the meeting.

Ed will be heading to Faribault tomorrow to work with the Rice County LAC meeting.  To learn how MHAM can help your LAC group become a better place for consumers to be heard, or if you have a personal story about SOS that would help the Legislature understand what is at stake in the redesign, please call Ed at 612-331-1630.  We’ll have more updates after he appears before the Health Care and Human Services Policy and Oversight Committee in the House on Thursday.

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.