Many state programs will feel the crunch this year as the legislature struggles to make budgetary ends meet.
The budget proposal as it stands could be 50 to 100 million dollars out of balance.
The department of Health and human services alone faces cuts to dozens of programs.
Some services—like mental health care for people on Medicaid—may have to cut corners, forcing local governments and institutions to take up the slack.
The House finance committee sat down with the governor’s budget and decided that it wasn’t going to work.
Rodeschin: We don’t have the money to give everybody everything they want.
Newport Representative Beverly Rodeschin says the committee had no option but trim spending.
And one of those trimmed programs is Medicaid’s community mental health services.
Budget writers have proposed cutting the program’s increase by half.
Rodeschin: There’s some decisions you have to make. Nobody wants a sales tax, nobody wants an income tax—so where do you get the money? It was a tough tough year. You try to do the best you can. Nobody likes to have reductions.
Medicaid is already underpaying health care providers for the cost of services.
So when community mental health centers—which provide most of Medicaid’s mental health services—learned they may not get the raise they had asked for, it was another blow to an already crippled system.
Michael Coughlin, director of Genesis Community Mental Health in Laconia, says the centers have been working for years to be as efficient as possible.
Coughlin: I think this year will really be a telling year for most of the mental health centers because many of us have gotten as much as we can out of productivity gains. If there are no more productivity gains we know that there aren’t going to be any increases in reimbursement—what do you have to cut?
Coughlin says the center is already understaffed and people are waiting to get services like counseling and therapy.
Coughlin: The length of time it takes to come in to see somebody is longer than it was a year ago, and I would predict that it will be longer 6 months from now. Because our population continues to grow by some percentage every year…unlike our reimbursements.
Medicaid dollars constitute 80 percent of the center’s income.
Payment rates for certain services—like psychiatric assessment or individual psychotherapy—have not increased in over a decade.
And Coughlin says that costs have risen.
What makes the situation especially tough for community mental health centers is that they don’t have enough higher paying private patients to make up the Medicaid difference.
Coughlin: It’s hard to cost shift because the private insurers just barely cover our costs for those services anyways, so there’s not a lot of ability to cost shift.
Because of their financial struggles, community mental health centers typically suffer from high turn over of case managers and therapists.
Bachelors-level case managers make from about 23 to 25 thousand dollars a year, and often work over forty hours a week.
Mike Cohen, executive director for New Hampshire’s National Alliance for the Mentally Ill, says the regular staff turn over makes treatment difficult.
Cohen: Many times many of our families are telling their stories over and over again multiple times within a year to changing staff.
Cohen says this bruises the quality of treatment.
Wait lists and revolving staff mean patients aren’t getting the treatment they need—and the consequences reach beyond their personal well being and into the community.
Cohen: It’s not as if the illnesses go away. The costs shift to other places. These people will end up in some other service system. Two places where they end up are in emergency rooms and jails.
Genesis patient Susan from Laconia has been receiving treatment for major depression at Genesis for years.
Susan: With something like depression, when you get to the point where you’re making that call to the mental health center—if someone told you at that point that you needed to be put on a waiting list, I would think that probably in very short order you’d be in contact with emergency services and end up in a hospital.
And Laconia’s city prosecutor Jim Sawyer says he has seen criminal cases involving people not getting the treatment they need.
Sawyer: The small percentage of individuals that do become involved in criminal justice primarily because of their mental health issues, are always coming back. If they’re here once, they’re here two dozens times. They cannot be rehabilitated through the criminal justice system; they have to be made well through the mental health system.
Those who provide mental health services are confident that treatment works—and Michael Coughlin from Genesis says it’s cost effective.
Coughlin: Money that goes into the community mental health system can avoid money that goes into for example New Hampshire hospital where it costs a lot more for an in patient stay or a jail or the court system. A little bit of mental health help tends to pay back dividends very quickly.
Community mental health centers serve about 14 thousand Medicaid patients a year, at about five thousand dollars a person.
The county jail costs about four times that amount—and the full bill goes to county tax payers.
Medicaid is split between the state and federal governments.
One of Genesis’s patients, Dan, was hospitalized nine times for bi-polar disorder and schizophrenia+ before he got care through the center.
Since then he has completed a master’s degree and gone back to work part time.
But he required at home, individual care that centers may have to substitute for group options.
Dan says that would not have worked for him.
Dan: Them telling me, ok, here’s the services we have to offer: you can come to group once a week and we’ll help you that way. It’s not a matter of wouldn’t have done it, I couldn’t have done it. Without that kind of intervention I certainly would have ended up in the state hospital for a long time. I just couldn’t take care of myself, I couldn’t do it.
Representative Rodeschin on the finance committee says she thinks it’s unlikely the senate will restore the cut in mental health centers’ raise as it works through the budget.
She says the centers will have to tighten their belts and hope for better times.
SOQ
