Proposed Health and Human Services cuts create uncertainty across N.H.
By CASEY McDERMOTT Monitor staff
Sunday, March 22, 2015
(Published in print: Monday, March 23, 2015)
Today, members the House Finance Committee – the ones tasked with reviewing Gov. Maggie Hassan’s budget proposal – will meet to go over the plans they’ve come up with for their own version of the state’s financial roadmap for the next two years.
For the last week, the division that oversees funding for the Department of Health and Human Services has whittled away at a number of programs – in some cases, eliminating state funding entirely and jeopardizing the accompanying possibility of federal funding along with it.
In votes that were mostly split along party lines, with Republican representatives supporting the cuts and Democratic representatives opposing them, committee members opted not to renew the state’s Medicaid expansion beyond the end of 2016 and not to extend substance abuse coverage to the state’s traditional Medicaid population. They also completely eliminated Medicaid coverage for so-called optional services such as wheelchair vans, private duty nursing and hearing aids for people older than 21, resulting in an estimated savings of $8.6 million in general funds.
They voted to take away all state funding for ServiceLink Resource Centers – used heavily by the state’s elderly population, veterans and people with disabilities – to the tune of about $2.6 million, which will also likely result in the loss of additional federal funding. They also cut state funding for “social services for non-Medicaid eligible elderly clients” – such as home meal delivery and transportation services, for example – by about $10.5 million, or about half.
They decided to delay by a year the opening of a 10-bed crisis unit at New Hampshire Hospital, which was supposed to open in July. This unit was meant to allow people experiencing a mental health crisis to be admitted more quickly and to alleviate the days, sometimes weeks, of waiting many are otherwise facing in hospital emergency rooms across the state.
They reduced funding for the Division of Developmental Services by an estimated $52 million, half in the form of general funds and half in the form of matched federal funds.
They decided to cut funding for the state’s emergency shelters – which provide help to people who are homeless and in other crisis situations, such as domestic violence – in half, taking away an estimated $4 million over the next biennium.
In explaining these and other proposed reductions, House finance officials have said the state simply cannot afford to spend at the levels proposed by Hassan in her version of the budget. Lawmakers also point to increased spending required by two recent settlements, one involving the state’s mental health system and another involving the Medicaid Enhancement Tax, as major cost drivers that need to be balanced out with reductions elsewhere.
“A budget is a balance,” House Finance Committee Chairman Neal Kurk said in an interview Friday morning, following a week of deliberation over these and other proposed reductions. “All of us would like to make sure our fellow citizens get every possible service from the state to the extent that their lives have been transformed by congenital or accidental injury or disability, but it’s not always possible for all needs of all people to be fulfilled all of the time.”
The proposed budget, Kurk said, “provides at least for basic needs.”
An estimate for the total, immediate cost savings achieved by these and other actions was still being finalized heading into this past weekend. An update on the reductions will likely be released today.
But already, many – from Nashua to the North Country – are worrying that some of these decisions, if carried through, would have devastating consequences for the state’s most vulnerable residents.
‘My life . . . would be over’
For Jeff Dickinson, the most troubling of the proposed cuts are the ones that would eliminate “optional” Medicaid services. As advocacy director for Granite State Independent Living, he knows hundreds of people who might be affected by the state’s decision to no longer pay for these services – but he’s also worried on a personal level.
Dickinson has muscular dystrophy, and he relies on personal care attendant services – one of the categories that would be eliminated under the House’s proposal. This, he said, allows him to “remain independent, continue working full time, pay my mortgage and live where I choose to live.”
“Without these (personal care attendant) services I am not sure how I would get out of bed, get dressed, fix meals, toilet, shower, and do all of those regular activities that most people usually take for granted,” Dickinson wrote in an email. “Truth be told, I wouldn’t be able to. I would be forced to live in a nursing home where I do not want to be. It is not an exaggeration to say that my life as I know it would be over.”
The private duty nursing services – which, in Dickinson’s case, are necessary to monitor his use of a ventilator overnight in case the device would malfunction – would also be eliminated.
“For people that receive these services,” Dickinson wrote, “there is nothing optional about them at all.”
Without the support from the state, HHS Deputy Commissioner Marilee Nihan said, many families will be left with few alternatives for maintaining the care they rely on. According to the most recent data, provided by Nihan: About 10,000 people are currently using ambulance services that would be eliminated; about 3,000 people are using speech and occupational therapies, each; and about 2,500 are using audiology benefits, such as hearing aids.
“We’re talking about families who make $15,000 a year, they don’t have a lot of options,” Nihan said. “They certainly don’t have the resources to be able to fund some of these services themselves.”
In some cases, Nihan said, if families choose to forgo these services because of a lack of money, that could ultimately create more problems for the state – resulting in worse health for those residents and more pressure, or “downshifting,” onto local welfare offices.
Families face uncertainty
Earlier this month, Darienne McGuinness of Stratham attended the finance committee’s public hearing on the budget in Concord. There, the mother of three urged lawmakers not to reduce funding for developmental disability support services. Her oldest son, 11, has autism and receives services through the in-home support waiver program.
Those services, along with others provided through the state’s network of 10 nonprofit agencies that provide support to families caring for loved ones with developmental disabilities, would likely be affected by the reductions proposed by lawmakers last week.
On Friday, McGuinness was one of several family members gathered in Concord for part of an advocacy training workshop through the New Hampshire Leadership Series. She and several other families there – caring for children between ages 6 and 25 – watched lawmakers’ actions with trepidation about the ramifications of the reductions to developmental disabilities funding.
Consistency is especially important when you’re caring for a child with a disability, they said, and the support services that fall within the realm of the proposed reductions provide just that.
“Kids who experience disabilities need consistent support in order to maintain safety and skills throughout their lives,” said Jill Prakop, a parent from Derry who is on the waiting list for support services for her two children, ages 7 and 9. “That’s after 3 o’clock, you know, what they get in school. They need that at 4, 5, 6, 7 o’clock when they’re out in their communities with their parents.”
Thanks to the availability of those kind of supports, Michael Poulin said his son Brandon, now 25, is able to live independently in his own apartment in Nashua. It was “a long road to get him there,” Poulin said, but it was worth it.
“He wants to be independent, he wants to have his own life, he does have a job – it’s working minimal hours a week,” Poulin said. “He just loves going out into the community, and he wouldn’t have it any other way.”
To help make that possible for Brandon, his family relies on help from personal care service professionals – which might be cut under the House budget proposal.
“Our biggest fear is that, with the loss of losing that, it would be a step backwards,” Poulin said. “Our goal is to reduce his budget over time, and we’re really doing good in getting there – if it takes a step backwards, when we’re dead and gone, we just fear what would happen to him when we’re not here anymore and he doesn’t have them anymore.”
Jennifer Pineo, whose 6- and 10-year-old children are both on the autism spectrum, said she wishes legislators realized that reducing access to family supports has not only a significant financial impact on the families affected – it also affects the community, even the state, as a whole.
“We’re doing a lot of work with a little bit of funds,” said Pineo, who lives in LIttleton and sits on the board of the advocacy group ABLE NH. “And I know when you look at it all together it seems like a lot of money, but when you look at what it would cost if they were in other places or not within the family, it’s going to cost a lot more – supporting us so we can stay as family units and work through that is going to be more cost-effective than, you know, decimating our system.”
ServiceLink acts as lifeline
Paul Robitaille, manager for the ServiceLink Resource Center of Coos County, is similarly worried about what the elimination of state funding would mean for the future of his center. Located in Berlin, the Coos County facility logged about 15,000 contacts with clients – some of which included multiple contacts by the same people – last year.
“It would leave a tremendous hole,” Robitaille said. “I don’t know what goes on in a lot of other counties, but here in Coos County, we’re used to partnering with a lot of other agencies.”
The ServiceLink centers, he explained, act as a kind of “front door” for other support services in the community and the state at large. Older adults come in for assistance with making sense of their Medicare options, he said, while veterans can get help applying for benefits through the U.S. Department of Veterans Affairs. Low-income residents can connect with job training programs, housing assistance and more.
Many of the clients who seek help through ServiceLink are not computer literate, Robitaille added. Navigating through cumbersome, confusing online applications, phone menus or paperwork can get in the way of connecting people to the benefits they need, he explained.
“If ServiceLink is not here,” Robitaille said, “those questions do not get answered, and those people fall through the cracks.”
Rep. William Hatch, a Democratic lawmaker from Gorham, used to sit on the board of the Coos County ServiceLink. Particularly in rural regions of the state, he said, these centers are lifelines for people in need.
The loss of this program, combined with the potential loss of programs like at-home meal delivery for seniors, could make it more difficult for the state’s older population to remain independent in their communities, he said.
“This is real stuff,” Hatch said. “They do so much more than drop off meals three times a week. . . . This service enables people to stay in their homes, to not have to go to assisted living, to not have to go to a nursing home, which in many cases costs a lot more than having meals delivered.”
Cuts create HHS challenges
As lawmakers debated these and other proposed cuts, top department officials spent much of the week responding to questions and attempting to convey the potential toll of reductions.
The cuts, according to Nihan and other officials who were at the center of the budget discussions, will result not only in wide-reaching changes for the people who rely on the department’s services, but will also create significant administrative work for the department.
In some cases, the state will need to seek federal approval for proposed changes to its Medicaid program – something it’s had to do repeatedly in recent years, Nihan said. This, in part, has led federal officials to approach New Hampshire with increasing scrutiny, she said.
The state is also in the process of renegotiating contracts with the companies involved in its Medicaid managed care program, and those negotiations will also be affected – perhaps prolonged, officials said – by some of the representatives’ actions.
While Nihan hesitated to pick out one action that will have the most significant impact on the state – “I think they’re all egregious, contentious” – she said the decision to end the state’s Medicaid expansion is particularly disappointing.
Not only did the department and the state invest significant energy and resources getting the program off the ground in the last several years, she said, but now the 37,000 people who signed up for coverage through the expansion could end up “right back where they started” without access to affordable health care coverage.
And while Nihan and other officials have come to expect lawmakers to put forward some reductions, the outcome of last week’s votes was far more drastic than the department was expecting.
“There is virtually nothing in the work that DHHS does that went untouched,” Nihan said, “and nearly every single client who seeks services with DHHS is going to be impacted in some way.”