Malloy has mental health agencies 'reeling' over proposed budget cuts

Feb. 22--hartforD -- As Jack Malone listened to Gov. Dannel P. Malloy's budget address last week, he recalled a headline that reverberated in New York City in 1975.

The New York Daily News wrote: "Ford to City: Drop Dead," when President Gerald Ford denied federal assistance to keep it out of bankruptcy, something he later agreed to.

Malone said Malloy has delivered a "drop dead" message to the nonprofits who provide the behavioral health and substance abuse services for Connecticut residents.

To close a projected $2.2 billion deficit in the next two fiscal years, Malloy has proposed a $39.9 billion budget that cuts $1.3 billion in expenditures, while adding $914 million in new revenues.

Malloy left millions on the cutting room floor for health care and social service programs, as well as reduced reimbursement to Medicaid providers totaling $143.2 million over the biennium.

The proposal is now in the hands of the legislature which will likely ameliorate the cuts to a certain extent, but the deficit is a sobering factor that they have to work into the equation.

The governor's plan also has $2 million in cuts to school-based clinics and the state projects saving $126.7 million by switching some 34,000 adults earning up to 201 percent of the poverty level out of Medicaid coverage.

"It doesn't take courage to make cuts. What would take courage is to properly fund a system of care that Connecticut has come to rely on," Malone said. "This budget will decimate that system."

Malone is the executive director of the Southeastern Council on Alcoholism and Drug Dependence, a 49-year-old organization that offers residential, outpatient, halfway houses and acute detox facilities, employing 144 workers at 14 facilities.

He said the state has cut $33 million to the Department of Mental Health and Addiction Services since 2012, one of its main sources of income.

Since the December 2012 murder of 20 first-graders and six educators at the Sandy Hook Elementary School, the state has been engaged in a dialogue about improving mental health programs, particularly those that address the behavioral health needs of children and young adults.

Alice Forrester, the executive director of the Clifford Beers Clinic in New Haven, is a member of the Sandy Hook Advisory Commission, that spent two years looking at the issues of gun safety, secure school buildings and reaching children and adults in a holistic model of health care.

"How much sense does this make given the Sandy Hook experience?" she asked of the proposed cuts.

The various studies on the massacre tried to determine "what could have been different for Adam Lanza," Forrester said.

The advisory commission recommended integrating mental and physical care, early intervention for children at risk and a focus on prevention, as well as treatments.

Lanza was the shooter at Sandy Hook and the Office of Child Advocate found numerous missed opportunities where red flags about his deteriorating mental health were not addressed by the schools, his doctors or by his parents, who were in denial as to the seriousness of his condition.

"The lack of sustained, expert-driven and well-coordinated mental health treatment, and medical and educational planning, ultimately enabled his progressive deterioration," the Office of Child Advocate reported on Lanza, who was diagnosed with severe anxiety, obsessive-compulsive disorder and autism spectrum disorder.

The most detailed mental health workup by the Yale Child Study Center when he was 14 was not shared with Newtown High School and his mother failed to allow the recommended treatments for him, the report found. Nancy Lanza was the first person Adam Lanza killed, before he drove to the Sandy Hook school and found 26 more victims.

Under the present system, Forrester said Clifford Beers, like all programs dependent upon Medicaid reimbursements, lose about $100 in each patient encounter.

She feels this budget, rather than being punitive, could be an opportunity for innovation to reach a more holistic approach to health care.

"We need to invest more in innovation. Connecticut can be the center of health care innovation," Forrester said, given its high-quality hospitals, Medicare and Medicaid programs. "We could turn the curve" on health care costs, she said.

Clifford Beers is an innovator.

It serves 18 towns with its emergency mobile psychiatric services; it is part of two school based clinics and the New Haven Trauma Coalition where 700 school staff members have been trained on what stress does to the developing brain and how to recognize signs that children are in crisis. It sees 1,600 in its out-patient clinic and its staff saw 14,000 visits last year.

It has contracted with the Department of Children and Families over three years with the help of a competitive federal grant to coordinate care for some 2,250 New Haven area residents with other healthcare providers with the goal of saving $12 million in Medicaid costs.

Barry Kasdan, the recently retired CEO of Bridges, a full service mental health clinic serving Milford, Orange and West Haven, said he was "flabbergasted" that the $25 million in a reduction to grants that the nonprofits were counting on through DMHAS in 2013 was again eliminated in the governor's proposed budget.

The assumption by the state two years ago was that more people would be enrolled in healthcare insurance through the exchange and this in turn would benefit the providers. DMHAS determined however, that they would be left with costs because of low-reimbursement by Medicaid.

The legislature and DHMAS found a way to cover the $25 million for the current fiscal year, although $5.4 million ultimately will not be paid because increased provider rates have yet to be approved by the Centers for Medicare and Medicaid Services.

"The type of planning that is taking place for the highways, the trains, the buses needs to take place for mental health and substance abuse services," Kasdan said. He predicted that more clinics will shut down for lack of sustainable funding.

"I'm sorry I came up here. It's a sad day," he said of attending the governor's budget address on Wednesday.

Heather Gates, the CEO of Community Health Resources, the largest clinic network in central and eastern Connecticut with 18,000 visits, nine outpatient sites and over 700 employees, said she can't understand why the state continues to develop budgets based on the prediction that they will make more money from the newly insured given the inadequate Medicaid payments.

"We haven't been able to make a dent in that logic," she said.

Ben Barnes, Malloy's budget chief, Wednesday said the 34,000 adults who will no longer be covered by Medicaid can get federally subsidized insurance through Access Health Ct, the state's health exchange, which has a robust network of providers.

This was rejected two years ago by lawmakers who argued the premiums, co-pays and deductibles make it too expensive for this demographic. The advocates continue to predict it will lead to more uninsured and more emergency room visits, at a greater cost to the state and hospitals.

Barnes said that Connecticut now has the country's second highest Medicaid income eligibility levels for parents with minor children, which is up to 201 percent of poverty level. The proposed budget drops it to 138 percent of the poverty level.

Gates said the 8,000 adults they serve are "the most seriously mentally ill. They have no place else to go."

She said it is "unconscionable" if the cuts remain in place, in addition to two earlier cuts this fiscal year.

Gates said the state would find it unacceptable to tell a group of people with a medical need that they would no longer have access to care, but that is the message to the mentally ill.

"Providers are in a horrible situation to say no to people they have served. We have been all about providing more," she said.

Gary Steck, executive director of Wellmore, which provides outpatient and residential services at 13 sites in the Greater Waterbury area, also weighed in.

"Frankly, we are concerned because it is so inconsistent with all the data," Steck said of the need for more money, rather than cuts.

"State officials know our rates are upside down," Steck said. "OPM (Office of Policy and Management) is perfectly aware of this."

"We can't do any more. We will be doing less. We are already rationing care," he said.

Steck, whose agency was one of the first responders to the Sandy Hook killings, said there is a tremendous push now to identify children at risk early, but the capacity to do this hasn't increased.

Malloy and Barnes have acknowledged that the $1.2 billion in cuts over two years will be tough.

"The vast majority of these cuts are choices that, under ideal circumstances, Connecticut would not have to make. But as our economy continues to recover, tough choices are needed ...," Malloy said in his address, as he outlined the priorities of balancing the budget and living within the spending cap. The other priorities include funding for public education, as well as cities and towns and protecting the "middle class."

He has proposed a small sales tax decrease, but put off restoring the tax exemption on clothing purchases under $50, as well as changes in the Earned Income Tax Credit, while maintaining the surcharge on the corporation tax, and increasing other business costs and the hospital tax.

State Rep. Cathy Abercrombie, chair of the Human Services Committee, said she was "devastated" by the $2 million to school based clinics.

"The clinics are the most cost effective way to reach young people," she said.

As for removing low income adults from Medicaid, she said her committee will look for some alternative, exploring whether the state could instead pay the premiums on the exchange for this group.

Sue Peters, director for the school based health clinics has in New Haven was equally concerned. New Haven clinics in 17 schools in a district with 20,000 students.

"The most vulnerable population of kids here needs and deserves these services," she said. "I think everyone is reeling from the news."

Peters said many of the services are not reimbursable, including those for undocumented students, for which the clinics are often their only healthcare option.

"We have become a safety net," she said. The clinics had more than 10,000 visits from the beginning of this school year.

Peters said the clinics and their physical and behavioral services "have a huge impact on educational outcomes," by providing children who are asthmatic a place to get treated and then return to the classroom. She said students having control issues have a place to de-escalate.

She said that hard to reach adolescent age group will often avail themselves of the clinic. They also work to reduce health disparities for children already at risk for obesity, asthma and diabetes.

Martin Morrissey, executive vice president of Continuum of Care and Continuum Home Health, said they provided 160,000 visits to vulnerable patients in a year, a service that keeps this population out of nursing homes, emergency rooms and jails.

They are mission based and depend 100 percent on Medicaid reimbursement where they always lose money, he said.

"Any cut, any reduction would be very detrimental to us," he said.

Not everyone was panicked by the potential cuts.

Rob Rioux, spokesman for the Hill Health Center, said if the cuts are instituted, they will come up with solutions to continue with their services. He said they revamped their business model in recent years and now have a cushion of funds they can fall back on when needed.

They have an extensive network of mental health clinics in New Haven and are the largest provider of behavioral health services in South Central Connecticut, he said.

But that wasn't where he had concerns. Rioux said they are contracted to work in six school based clinics in New Haven and that could be an issue.

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