Since Congress has shown no signs of passing legislation to reform Medicaid or welfare, the New York State Association of Counties (NYSAC) has proposed that some New York counties begin administering Medicaid programs through block grants in order to “improve the delivery of health and welfare services at an affordable cost.”
Counties should be given the opportunity to take more responsibility for the programs because they are on the front line of providing human services and have the expertise and knowledge to restructure how it’s delivered, said NYSAC Legislative Director Dave Lucas.
One key aspect of the proposed legislation includes recommendations to regionalize the experiment, allowing counties to combine their resources and expertise to improve delivery of services.
Counties have been instrumental in helping bring costs down, contributing to the state’s $450 million surplus in FY95–96, according to NYSAC. “Reduced welfare caseloads were the result of counties’ innovative up-front cost avoidance — making sure people are eligible before handing out checks — enhanced by extensive job search activities to assist people in finding jobs,” Lucas said.
In addition, counties reduced Medicaid costs by making greater use of managed care, increased utilization of “gatekeeping” authority in Medicaid personal care and crackdowns on Medicaid fraud, all resulting in a 1.5 percent decrease in county property tax levies, which were previously increased an average of four percent each year since 1990.
NYSAC hopes the legislation passes in order to correct current problems with the Medicaid program, including:
• Delivery of health and welfare services is fragmented — recipients and taxpayers alike are not effectively, nor efficiently served.
• Lack of accountability and responsibility. Many entities share the burden of financing and administering the social welfare system, with no single entity taking responsibility for the entire program. The result is the most expensive Medicaid and welfare programs in the nation.
• n the absence of federal Medicaid and welfare reforms and the state legislature’s reluctance to implement block grants even if federal authority existed, SIPs offer the state and counties an option to begin reforms now.
The major features of the proposed legislation, dubbed “Service Improvement Projects (SIPs),” include:
• maximum local flexibility — statutory and regulatory — including the ability to interchange funds between approved SIP program areas
• status quo funding based on prior years expenditures
• sharing of savings proportionate to state and county respective contributions
• state approval of demonstration plans with special incentives for regional projects, and
• four distinct demonstrations, including Indigent Medical Care, Home Care, Mental Health, and joint demonstrations that include any combination of health and welfare services as proposed by a county or region (which might be a group of counties working together).
According to NYSAC, there are certain criteria that must be met in order to make the program work in each of the four demonstrations.
In Indigent Medical Care, localities need the flexibility to design benefit packages, methods of service delivery and the ability to negotiate rates with providers. Counties also need the flexibility to focus their efforts on the four to five percent of the HR client population that consumes nearly 50 percent of all Medicaid HR resources.
For Home Care, the priority is to grant counties “gatekeeping” authority for the delivery of Certified Home Health Agency and Long-Term Home Health Care services.
“Funds must follow people, not programs,” the proposed legislation stresses, in order for the Mental Health demonstration to work. The consolidation of more than 70 state funding streams is necessary to end the practice of providing inappropriate and fragmented services. Also, extensive regulatory restrictions must be lifted.
An example of joint SIP demonstrations might include combining Medical Indigent Care with Mental Health services. The majority of HR costs are associated with a small percentage of that population, whom overwhelmingly require mental health and/or substance abuse services.
NYSAC says other “solutions” or advantages to be considered in the legislation include:
• providing statutory and regulatory flexibility to authorize a statewide demonstration which allows counties to implement health and welfare service improvement projects (small-scale block grants)
• a demonstration approach that will provide valuable insight to the level of savings that can be achieved by providing counties “gatekeeping” authority over a myriad of human services programs
• regional demonstrations that will alleviate concerns of statewide differences in implementation and create more uniformity, and
• counties to ensure that an adequate level of services the banding together of will be provided and curb fears of a so-called “race to the bottom.”
NYSAC has until July, when the state legislature adjourns, to get its voice heard.