Health Care Financing in the Community:
The Case of the State of the States in Intellectual and Developmental Disabilities
by Julie Ann Racino, December 31, 2015
On this New Year's Eve 2015, we are pleased to feature The State of the States in Intellectual and Developmental Disabilities, synonymous for most of our lives with the illustrious Dr. David Braddock (by the way a gentle, good-hearted man) and state reporting in the US. Now at the University of Colorado at Boulder, he forwarded his 2013 and 2015 editions for all of our use, especially with the American Society for Public Administration (ASPA).
Dr. David Braddock, whom I met prior to the formation of the Rehabilitation Research and Training Centers on Families and Community Living (with "his colleague" K. Charlie Lakin), was then a "Deinstitutionalization (versus Institutional) Leader" at the University of Chicago-Illinois. His first references in the book below are: Elizabeth Boggs, Braddock, Bruininks and Lakin, Gunnar Dybwad (See, Community integration in Great Britain and US, 2013), and Robert Gettings (with the late Gary Smith). Richard Hemp is still with him in 2015 and Glenn Fujiura is independently well known in the disability and demographics area.
The 1990 State of the States in Intellectual and Developmental Disabilities
In 1990, he and his university employees (Richard Hemp, Glenn Fujiura, Lynn Bachelder, and Dale Mitchell) published one of his Annual Reports (527 typeset pages, over 1000 double spaced pages) with "individual profiles" of every state (e.g., Arkansas, Montana, New Mexico, New York, Ohio, Rhode Island, South Carolina, Virginia, and Wyoming) in the US.
He was, and is proud that the 99th US Congress enacted new legislation in early intervention (PL 99-457) and supported employment (PL 99-506). In his introduction, he cited the 100th US Congress for its major reforms in nursing homes and "mentally disabled persons" (PL 100-203) and the Developmental Disabilities Act Amendments of 1987 (PL 100-146).
During that period, the struggle between an Institutional-Community Model was paramount with 70.6% of federal intermediate care facility funds still in institutions and only 16.1% in small homes (then 15 or less). Staffing ratios (1.88 in 1988, US total; 1.75 Washington; 2.20 Vermont), institutional per diems ($153.54, US; $164.47 Minnesota; $216.88 New York), and institutional closures (e.g., San Haven, North Dakota, 1922 TB sanitarium, closed, 1987; District of Columbia' Forest Haven, 1925 MR facility slated for 1992) dominated the discussion.
Many of us as community personnel were involved with the start of Community Initiatives, including Family Support Programs administered by MR/DD agencies and discrete initiatives (e.g., supported employment, early intervention and Aging and Developmental Disabilities). Virginia in FY 1988, like most of the states, was investing $0 in family support, New York at $0 (figures not yet reported of new programs), while Michigan was investing $9,429,251 and its nearest sister state Minnesota at $1,062,700 with Texas close behind at $1,000,000.
Community revenue in FY 1988 was reflected by total spending of $5.637 billion with 63.2% state funds and the Home and Community-Based Medicaid Waiver at only 4.4% and a Model 50 Waiver ("Katie Beckett Waiver") at only 0.1%. The total HCBS waiver funds were reported at $248,578,728 (e.g., $11,830,801, Maryland; $40,501,000, Pennsylvania; $502,803, Idaho; $6,000,000, Alabama) and $3,130,202 Model 50 waivers (e.g., Maryland, new, non-reported; $466,650, New York; $722,454, Oklahoma).
The State of the States in FY 2015: Intellectual and Developmental Disabilities
Dr. David Braddock, representing the American Association of Intellectual and Developmental Disabilities, announced on p. 40 that the Federal-State Medicaid was the majority of the total I/DD spending in FY 2013 with a 77.7% share of $61.46 billion. Long-term care spending in I/DD, however, was only 10.2% of the total federal Medicaid spending in the US in 2013. According to the National Association of State Budget Officers federal fund expenditures to states in the US (e.g., higher education at 3.7%, transportation at 7.7%, K-12 at 9.9%) were 51.0% Medicaid disbursements in FY 2014.
Public spending for intellectual and developmental disabilities for "Community Services" (categorical, on disability category) in the US was $53,235,790,070, an 8.5% increase from 2011. New Hampshire was at $277,181,929; Wisconsin at $1,234,424,509; state of Connecticut at $990,379,182; New York at $9,760,945,439; Maine at $439,111,984; Louisiana at $1,237,479,247; Montana at $157,188,442; California at $5,829,780,987; Iowa at $647,046,377; Kentucky at $603,706,311; Nevada at $150,226,860; and Ohio at $2,786,453,131. (p.10). Such an approach is considered to be likely to have claimed minimally all community service funds for a special interest group only (i.e., against the public good - breaks the taxpayer's purse, and community interest -not community for all ).
On the 50 state profiles and the District of Columbia, we'll look at Braddock's report (from the states itself) of the state of New Jersey (p.158). The HCBS waiver is now at $392.6 (millions of 2013 dollars) and intermediate care facilities at $308.3 (millions of 2013 dollars) and administration at $28.8 (millions of 2013 dollars).
State of New Jersey Individual and Family Support
In 2009, cash subsidies were terminated and many families began receiving "non-I/DD agency supports" (Division of Disability Services Information and Referral Services). While $72.9 (millions of 2013 dollars) were designated for supportive living in New Jersey as part of individual and family support, only 2,153 participants were on the chart; the total of participants in individual and family support peaked in 2006 at 20,000 and dropped to 4,564 in 2013 roughly equal to the number in 1996.
State of South Dakota Individual and Family Support
The number of participants in three programs (supported employment, supportive living, and family support) was 693 total for the entire state of South Dakota in 1996 up to 1,922 in 2013. In 1996, half million dollars was invested in family support and in FY 2013 that figure was at $6.3 million, $7.5 million for supported employment, and $3.6 million in supportive living (likely all one payor source only). Overall, for all I/DD spending in the state of South Dakota, $105.8 million was federal funds and $65.6 million state funds. Of the federal funds, 57% are HCBS waiver funds in which the state itself chose the service types.
State of West Virginia Individual and Family Support
West Virginia reported 2,140 family support participants in 1996 which marginally increased to 2,544 in 2013; supportive living increased from 1,642 in 1996 to 4,534 in 2013; and supported employment remained marginally the same from 408 to 462. Supportive living funding increased sharply concurrent with the increase in participants from $3.8 (millions of 2013 dollars) to $179.3 (millions of 2013 dollars). The state of West Virginia itself reported $332.8 million in federal and $113.6 million in state funds.
The comparative cost chart for individual and family support for all states can be found in Public Administration and Disability: Community Services Administration in the US (Racino, 2014) at http://www.crcpress.com/authors
Fiscal Context in 2015 in the US
Of importance at this time is that federal dollars have also influxed into states with modest growth of state funds due largely to the first year of Medicaid expansion under the Affordable Care Act (ACA) (NASBO, November 2015, State Expenditure Report).
We thank Dr. David Braddock and his personnel for the "annual statistical reports" minimally from 1990 to 2015, and look forward to working with him in a time in which corrections are increasing their budgets while estimated state fiscal effort for public assistance is expected to be well below zero and substantial Medicaid increases occur (Ibid, 2015).
In addition, for the public and professions, the federal debt is expected to climb to 77% of GDP (economic standard of a country's viability) by 2025 (Hall, October 2015).
Primary References for this Article
Braddock, D., Hemp, R., Fujiura, G., Bachelder, L. & Mitchell, D. (1990). The State of the States in Developmental Disabilities. Baltimore, MD: Paul H. Brookes.
Braddock, D., Hemp, R., Rizzolo, M.C., Tani, E.S., Haffer, L., & Wu, J. (2015). The State of the States in Intellectual and Developmental Disabilities: Emerging from the Great Recession. Washington, DC: American Association on Intellectual and Developmental Disabilities.
Hall, K. (2015, October 28). The Budget Outlook for 2018 to 2025. Presentation to the American Business Conference and the American Society for Public Administration. Washington, DC: Congressional Budget Office.
NASBO. (2015, November 19). Summary: NASBO State Expenditure Report.Washington, DC: National Association of State Budget Officers.
Racino, J. (2014). Public Administration and Disability: Community Services Administration in the US. New York, NY: CRC Press, Francis and Taylor.
Happy New Year 2016 and Have a Wonderful New Year's Eve Tonight
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ReplyDeleteHome HealthCare MainLine
home care Pennsylvania
Senior Care Bucks County
Home health care, respite and "in-home" services have needed an increased allocation by their governmental departments due to the aging of the population (right now in retirement gates). Government expectations, reflected by expectations of professionals, is for care first by family members and then "supplemental care" or services, including in aging after age 85 with increased risk of disability. Senior centers are alive and well in the US, but were targeted for population changes by the health care sector as opposed to growth in the number of senior centers or the "senior meals" being open to diverse age groups.
DeleteDelighted to hear that home health care, home care and senior care are vibrant and alive in Pennsylvania. Julie Ann Racino about.me/julieannracino
ReplyDeleteFor New York. Braddock's 2011 data indicates $10.10 billion public intellectual and developmental disabilties spending by revenue source: FY 2011. The "federal share" is 61% and the "state share" is $3.90 billion or 39%. The waiver services, designed to support the best in community services represented 53% of the federal dollars. Family support grew from 32,348 participants in 1994 to 52,632 in 2011; supportive living from 2,495 to 27,020 and supported employment reported as only 6,326 to 8,574 participants in 2011. Compared to total service funds,only $549.2 million was spent on family support, up from 1994 figure of $53.2 million (2011 dollars). Supportive living rose from $14.4 milion in 1994 to $374.90 and supported employment to $53.3 millions in 2011. See, http://stateofthestates.org Braddock, 2013 at the University of Colorado, Coleman Institute and Department of Psychiatry.
ReplyDeleteIn Idaho, supportive living increased from 1994 $14.1 millions in 2011 dollars to $33.6 in 2011; participants, however, only increased from 1,154 to 1,344. Family support stayed virtually at zero at the federal reporting gate ($.2 to $3.3 to o) with 535 participants to virtually zero in 2010. Total federal funds still at $177.4 million and state at $48.6 million with 41% of federal "related Medicaid". Idaho State School (only institution) was still open and a "residual population" was planned, in 2011 at a 49 average daily count of 16 plus institution. The "telling figure" on institutions also in New York is the $183 adjusted costs per day in 1977 to $603 ($1,430 in New York) public spending costs per day for the 16 plus state-operated institutions in 2011, US total. Also, reinstitutionalization on campuses is often not reported in that category and a new "corrections" industry is on the National Association of State Budget Officers pie charts on spending. New report of death penalty execution in that area (on wikipedia) after the death penalty off "for intellectual and developmental disabilities" and opposition to all death penalties in from President Carter. Thank you to all at the "support" work gates in the US and worldwide.
ReplyDeleteCost of care survey, the traditional home health and modernization:
ReplyDeleteReport by Genworth in 2013 on 15,0o0 long-term care providers. Annual cost of care reported at $45,760 for a homemaker, home health aide $50,336, adult day health care $19,800, assisted living $47,400, and nursing home, semi-private $120,498 and private $125,732. Otherwise, minimum wage, part-time, no benefits is another gate for home care wages as part of governmental planning!! Genworth expects 70% of people over 65 will need long term services and supports at some point in their lifetime.
Delighted to hear that home care and senior care are vibrant and alive in Pennsylvania. hope to see more in this.
ReplyDeleteLancaster, PA retirement community
As another aside, investigations on home care and senior care are still not in either, as one might expect with such a "grey market" on billions of federal funds.
ReplyDeleteAt the Presidential Campaign, a good lead in health care financing for an appointment would be Dr. David Braddock, now at the University of Colorado system, if he could be convinced for a term, too, to review community services development.
ReplyDeleteNext time I read a blog, I hope that it doesn't fail me as much as this one.
ReplyDeleteI mean, I know it was my choice to read, but I really thought you'd have something useful to talk about. All I hear is a bunch of complaining about something that you can fix if you weren't too busy seeking attention.
Rathbone Home. The state Commissioners, as appointees, are the lead per state on the home and community-based Medicaid waivers, though they can be "overruled" by the Governor and the public health department (or Division of Budget). Indivdiual and family support can be strengthened through the legislature, and it is the Commissioner's personnel or contracting agencies that are reporting the data to the university sector (for professional, their own, the government, now the public, and other uses). At the aging versus disability agencies, which largely control the nursing facility sectors, the industries involved are separate industries which do not have anything called individual and family support on the pie charts of taxpayer funds (called home health care). I'd suggest facebook instead; the banking industry suggests social media (marketing promotion) which obviously from your comments is a non-payment gate near the large cohort of paid government and contracting personnel.
ReplyDelete