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Creigh Deeds: Medicaid and mental health

creigh deedsThe General Assembly reconvened on the 5th of April to consider the Governor’s amendments and vetoes of legislation from the 2017 Session. While it was a busy day, we saw few surprises. The Governor’s vetoes, which totaled 40 this year and made him the Governor who has exercised the veto pen the most often, were all sustained. Many of his budget amendments and other changes to bills were sustained, and his attempt to expand Medicaid was denied. The day also saw more members of the House of Delegates announce they were not running for re-election. All in all it was an unsurprising day.

The day before and the morning of veto session, we developed the 2017 agenda of the Joint Subcommittee on Mental Health Services. This past session, legislation was passed that has great potential to improve the delivery of mental health services throughout the Commonwealth. One bill rewrites the mandated services that public providers, CSBs, must provide. Another assured the Board of Corrections had oversight of jail deaths. A third effort put $5 million in funding for permanent supportive housing. Yet other changes addressed alternative transportation when a temporary detention order is made and the use of tele-psychiatry. Going forward, the subcommittee will be broken into two workgroups: Structure and Financing, chaired by Sen. Emmett Hanger of Augusta County, and Criminal Justice, chaired by Del. Rob Bell of Albemarle County.

The Structure and Financing workgroup has the task, as the title suggests, of determining the best configuration of our public system of mental healthcare and ultimately how to pay for the system. Presently we have a state Department of Behavioral Health and Developmental Services that oversees 10 public hospitals and 40 community service boards or behavioral health authorities. We need to figure out what resources are necessary to have a system of care that meets the needs of all Virginians regardless of where you live, and how best to balance the responsibility for the system between the state and the localities. The task will not be easy, but it is necessary work.

In 29 of the 40 CSBs, localities provide less than 50 percent of the funding. The CSBs are basically fee for service operations. Localities are required by the law to put up a 10 percent match of the General Fund appropriation. Only some localities meet that requirement while others put in significantly more than that minimal level of funding. In Fairfax County, for example, the local appropriation dwarfs state funding. All localities need to invest in mental health. We can do better.

In the criminal justice area, we know that the de-institutionalization of people from mental hospitals which began in the 50s, has resulted in re-institutionalization of many of the mentally ill in our jails and prisons. Somewhere between 16 and 24 percent of the residents of our state and local correctional facilities struggle with serious mental illness. There are many questions that Del. Bell’s workgroup will have to answer. How do we divert people from jail? How do we prevent them from falling into an encounter with the criminal justice system in the first place? For those who have to be jailed, how do we best provide services? In some regions the CSBs are totally integrated with the local jail, and in other areas, there is no relationship at all. The inconsistency and lack of accountability is part of what drives our discussion.

As I have written about before, I have been impressed by the jail diversion program in San Antonio. One of the major underpinnings of the program is a police force that is 100 percent trained in crisis intervention. The program has an active mental health court and wraparound services. The entire system produces a savings of nearly $10 million a year in corrections. Virginia can do better in this area as well.

One policy decision that could significantly help in our work to improve our mental health system, ties back to our work during the reconvened session. Since 2013, we have talked about and worked to expand Medicaid in Virginia. About 400,000 uninsured Virginians, more than 70 percent of whom work full-time or live in a household with someone who does, would be eligible for Medicaid if we expanded it under the provisions of the Affordable Care Act. Virginians who make more $200,000 a year, currently pay more than $1 billion a year in the surtax that was adopted back in 2010 to pay for Medicaid expansion. Ninety percent of the funding for the expansion costs would be paid by the federal government, so it only requires a 10% match from Virginia. The Governor again offered budget language for him to take the necessary steps to expand Medicaid. The language failed to pass on Wednesday. We have failed once again to thoughtfully consider expansion in Virginia.

Steven Stern at the University of Virginia has produced significant work that has shown among other things that around 60,000-70,000 Virginians who struggle with serious mental illness would be eligible for Medicaid if we expanded under the Affordable Care Act. Recently, the Commonwealth Institute for Fiscal Analysis issued a compelling report that indicated that upped that estimate to over 100,000 people if you include substance use disorders. The Institute also looked at data from Maryland, West Virginia and Kentucky, all of which expanded Medicaid, which demonstrated significant decreases of between 69-87 percent of those people who were hospitalized with substance abuse issues between 2013 and 2015. The report attributed that to increased access to outpatient treatment. During the same time frame, Virginia saw the number of hospitalizations increase by 17 percent. In rural areas, we are on the front line of the opioid crisis. We know firsthand the hopelessness that develops in people whose economic opportunities are few and who struggle to survive. This Wednesday we squandered another opportunity to help people.

Those who argue against Medicaid expansion point out correctly that the cost of the program has exploded. What they do not always point out however is that we have caused that explosion. By expanding the eligibility pool over the years to more than just the desperately poor, to the disabled and to low income elderly, we have already expanded Medicaid. Seventy percent of Medicaid dollars in Virginia are spent on those in nursing home care and those with disabilities. Those populations comprise roughly 23 percent of the Medicaid population. The remaining 77 percent of the population, which accounts for only 30 percent of the spending, are primarily pregnant women and children in very poor families.

The good news is that the Governor has vowed to use his remaining time in office, which will end in January 2018, looking for ways to expand Medicaid. We could in fact be in special session before the end of the year on this very important issue.

It continues to be my high honor to serve you in the Senate of Virginia. If I can be of assistance at any time when the legislature is not in session, please feel free to contact me at (434) 296-5491 or district25@senate.virginia.gov.

Creigh Deeds is a member of the Virginia Senate.

   
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