Winnebago Mental Health Institute a Threat to Patients

More problems have surfaced with the use of the Winnebago Mental Health Institute for Dane County residents and others suffering from acute psychotic episodes.   Two Madison police officers drive two hours each way to escort a person in great stress to Oshkosh.  The person likely deteriorates and the officers spend time that could be better used in policing.

Mental health advocates, family members, and criminal justice professionals have all urged a better approach to the problem of getting care for a person who could be a danger to himself or others.

A recent article suggests that the trip might be the least of the problems with the use of Winnebago.  Read “Feds Sanction Winnebago Mental Health Institute” by WSJ reporter David Wahlberg to learn about a series of horrific incidents that threatened the lives of patients and put Medicare funds in jeopardy.

In December and February, federal inspectors issued 48 citations for violations of important Medicare rules including  improper patient care, inadequate nursing staff, poor oversight of medical staff, and an unsafe physical environment.

Even more shocking are some of the incidents Wahlberg reports.

“After a patient fell and hit his head, it took more than 14 hours before he was sent to an emergency room, where he needed surgery for a brain bleed.”

“Before another patient was discharged, he told a nurse he would jump out of his father’s vehicle on the way home. After his father picked him up, the patient ran onto a highway. He was readmitted.”   The patient had initially been admitted for a suicide attempt and had tested positive in a suicide screening the month he was released.

At 10 a.m. Oct. 15, [a] patient was seen hitting his head on the floor. Afterward, he lay unresponsive in a day room for about 12 hours, including at least two hours after urinating on himself and not being cleaned up, before nurses returned him to his room, inspectors said.   A doctor working at Winnebago temporarily assessed the patient twice that day and said there were no concerns, including no brain bleed. Nurses said they didn’t move or change him earlier because of short staffing, though a nursing supervisor told inspectors other nurses were available to help. After “neurochecks” were done on the patient at 11:10 p.m., and another doctor on call said he should go to the ER, he was taken there at 12:30 a.m. the next day.”

Poor management and callousness at Winnebago are obvious.  However, the difficulties of getting help for people with severe mental illness go beyond that institution.  Wahlberg also reported on violations by Strategic Behavioral Health, the company approved to open a psychiatric facility in Middleton.  Click here to read his article.

The solution is both simple and complicated.  We need more public money for mental health services.  Rallying support for that money and figuring out how to spend it are the complicated aspects.

A first step is passage of a bill that would have provided funds for the establishment  of mental health crisis centers throughout the state.   The bill was supported by county governments, criminal justice organizations, and the League of Women Voters.

Click here to read a letter to the editor describing that bill and the diverse support for it.    This legislative session has ended, but we have an opportunity in November to elect representatives who will support the use of public money to help those who need it most.

UPDATE:  The man who fell and was left on the floor for 14 hours later died.  Click here to read an article about the investigation.



Cuts to Mental Health Block Grant Program Could Wipe out Progress in Wisconsin

Trump’s budget proposal for the Mental Health Block Grant program calls for a cut of about 25 percent.  Wisconsin’s Department of Health Services has been instructed to assume that it will receive $2.3 million less than it received the previous fiscal year.  DHS will submit its budget this week.

Wisconsin Health News interviewed advocates and providers of mental health services to gain an idea of the impact of the cuts.  Here are excerpts from those comments:

Barbara Beckert, Milwaukee Office director for Disability Rights Wisconsin, said that the grant had played a key role in increasing access to community services and decreasing reliance on crisis and inpatient care.  She mentioned employment opportunities for people with mental illness and early interventions for at-risk children.

Mental Health America would lose $125,000 from its suicide prevention program.  The National Alliance on Mental Illness Wisconsin could lose $52,000 or one staff member.  Family Ties of Wisconsin, which provides peer support to parents, could lose about $58,000.

Other cuts include:  access to mental health services for people who are homeless; training for providers and efforts to reduce inpatient readmissions;

The federal House of Representatives has approved the cuts.  Wisconsin’s Senator Tammy Baldwin sits on the Senate Appropriations Committee, which has yet to approve the cuts.







Parity Regulations in AHCA Give Boost to Mental Health Services

An article in the Milwaukee Journal Sentinel shows how an entrepreneurial approach can   produce a healthy bottom line and increased access to mental health services.  Click here to read “Rising need for mental health care spurs growth in Rogers Behavioral Health System.”

Rogers Behavioral Health System provides care to more than 11,000 people a year, including more than 10,000 in the Milwaukee area.  In the past five years, the system’s revenue has doubled.  It is continuing to expand its services and geographic reach.

Here are key excerpts from the article by Guy Boulton.

“Its recent growth stems partly from changes in federal laws that require health insurers to provide the same benefits for behavioral health as for other medical care.

It also is driven by the increasing acceptance that behavioral health conditions, such as obsessive-compulsive disorder and bipolar disorder, are no different than other medical conditions, such as diabetes or heart disease.

That has helped lessen the stigma long associated with mental illness, resulting in more people seeking treatment. More effective treatments also have contributed to the increase in demand for behavioral health care.”

Although Rogers Behavioral Health had been criticized for treating few patients covered by Medicaid, about one-third of its patients now are funded through Medicaid.   It also helps fill the urgent need for in-patient psychiatric beds.   An average of 500 patients a year are sent to the system when Milwaukee County’s hospital is at capacity.



Stop Wisconsin’s Medicaid Waiver: Take Two

Governor Scott Walker submitted a request to the federal government for a waiver that would permit changes to the state’s Medicaid policies and requirements.   Because waivers can change eligibility for benefits, federal law requires that members of the public have 30 days to register their opinions.  The state must respond to concerns and may then forward the revised application to the federal government.  The federal government allows another 30-day period for comment.   That period ends on July 15.

More than 1,000 comments were received by the state.  Less than five supported the waiver.  State representatives had agreed to make all comments public as a part of its application.  Instead, they were released only after the state was forced to do so because of a reporter’s request through the Open Records Act.  The state had submitted only an 8-page summary of comments and its responses to them.   Likely the unabridged  comments depict more serious concerns and potential damage than the summary.

The state resisted notifying the public about the process for involvement or its own activities.   As a result, there appears to be much less protest directed to the federal government.  Nevertheless, Bobby Peterson, executive director of ABC for Health, submitted an extremely well-researched and comprehensive letter to the federal Department of Health and Human Services outlining the flaws with the waiver and the state’s process.  The letter includes research results from states that have implemented variations of Wisconsin’s proposals.  No state has implemented any version of drug testing as a condition for receipt of Medicaid benefits.

Click here to read the letter.   Click here to enter a comment.   Review the letter to develop your comments or check out  “Wisconsin’s Medicaid Waiver Can Be Stopped”  on this blog.

There are other ways of stopping the waiver.  The legislature’s Joint Finance Committee passed a resolution stipulating that the waiver could not be implemented without its approval.  We can review any version approved by the federal government, identify flaws using Peterson’s research and analysis, and begin a campaign to lobby members of the committee.

That lobbying effort could be helped by statements from Wisconsin’s own Legislative Fiscal Bureau.  It has questioned whether Medicaid programs can charge premiums for people who are under the poverty level or remove them from the rolls for non-payment.   It also questioned the imposition of a time limit on benefits for enrollees who have not found work.

Lobbying efforts could also remind the co-chair of the Joint Finance Committee, John Nygren, of his own more enlightened views about the best means of combatting drug abuse.  Rather than punitive measures, such as testing for drugs and denying benefits, he supported the expansion of treatment options.

He and Lt. Governor Rebeca Kleefisch, co-chairs of the Governor’s Task Force on Opioid Abuse, wrote, “We’re not talking about the ‘Just Say No’ campaign of the 80’s and 90’s…As the drugs on the street have changed, our policy and policing frameworks must catch up to shifting trends.”

Peterson identified legal grounds to challenge the waiver.  In particular, he pointed out court cases in which drug testing was ruled unconstitutional when used as a condition for receipt of benefits.

It appears that the entire application is a violation of the intent of the legislation. Waivers are to be “demonstrations of innovative ways to expand eligibility and Medicaid services to improve access to care and reduce costs.”  State officials claim their first objective is “ensuring that every Wisconsin resident has access to affordable health insurance to reduce the state’s uninsured rate.”  But, in its waiver proposal, it projects an enrollment decrease from 150,050 beneficiaries in CY 2016 to 146,407 in CY 2018.

Finally, we can always vote.   This struggle could be only a painful memory when we have a different governor.

UPDATE:  The League of Women Voters of Wisconsin issued an action alert with concise talking points about the hazards of the waiver and instructions about how to comment.  Click here to read it.

UPDATE:  Click here to read an article from USA Today, which reports comments from organizations that challenged Indiana’s request to include work requirements in its Medicaid waiver.  The federal government accepted the state’s request as complete even though time for public comments had not been allowed at the state level.

UPDATE:  United Health in Wisconsin submitted a letter opposing the waiver, citing continuity of care and other issues.  Click here for the letter.

UPDATE:  Click here for a letter from the Wisconsin Society for Addiction Medicine.

UPDATE:  Click here for a story from Politico that describes the increasing importance and popularity of Medicaid.  Wisconsin is out of step in its waiver request and refusal to accept Medicaid expansion funds.



Wisconsin’s Medicaid Waiver Can Be Stopped

Wisconsin earned national headlines when state officials announced plans to request a waiver from the federal government allowing it to restrict access to Medicaid benefits in new and devilish ways.

Those officials want Wisconsin to become the first state in the country to require applicants who are childless adults to submit to a drug test and undergo treatment if results are positive.  The request would also add time limits on coverage and require co-pays and work requirements.

The severity of the proposals galvanized local advocates.  Newspaper articles throughout the state pointed out that the waiver would result in loss of access to health care for many of the state’s most vulnerable citizens.

More than 1,000 comments were received by the state’s Medicaid director during the 30-day comment period required by the federal government.   The Department of Health Services, which had planned to submit the waiver on May 26, announced a delay in order to review them.  The legislature’s Joint Finance Committee passed a resolution stipulating that the waiver could not be implemented without its approval.

The federal government offers other methods of challenging the waiver request.  The application must show that comments have been reviewed and concerns acknowledged in the request.   After the submission is accepted as complete, the federal government requires a 30-day comment period during which advocates can register opposition.

They have many sources of information from which to draw.  One of the most comprehensive is a comment letter from Mike Bare of Milwaukee’s Public Policy Institute.  He makes points rarely included in the most common critiques.  Click here to read the full letter.

Bare wrote that such waivers by law are to be “demonstrations of innovative ways to expand eligibility and Medicaid services to improve access to care and reduce costs.”  Officials claim their first objective is  “ensuring that every Wisconsin resident has access to affordable health insurance to reduce the state’s uninsured rate.” Instead, writes Bare, the health care system has large affordability gaps and the waiver would make them worse.

The second stated objective is creating “a medical assistance program that is sustainable so a health care safety net is available to those who need it most.”  Bare points out that  charging fees and premiums to low-income participants reduces enrollment.  In addition, Wisconsin is requesting permission to disenroll a participant for non-payment of those premiums.  It would be the only state to charge a premium to enrollees below 100% of the poverty line and disenroll them if they are unable to pay.

The proposal would impose a 48 month time limit on benefits if the individual is working less than 80 hours a month and is not participating in job training.  Full-time students and people who have been determined to have a disability or a mental illness would be exempt.

Bare questions the use of “job training” and “employment training” interchangeably and  points out that neither term is defined.   He argues that the exemptions from the work requirement should be expanded to include individuals with two or more chronic conditions and those who are homeless.  Bare also makes the point that access to health care enhances the capability of an individual to find work and  poor health impedes that effort.

The most notorious aspect of the waiver is the request that applicants be screened by questions about illegal drug use and tested if deemed necessary.  Refusing or failing the test and then rejecting treatment would mean the applicants go at least six months without Medicaid coverage.

That request has been challenged on many grounds.  It would unfairly target minorities, identify few people with drug abuse problems, and cause further and unnecessary stress to people who are struggling  to get by, according to a story in the Boston Globe.   Click here to read the full article.

Wisconsin Assembly member Jimmy Anderson pointed out that states that had tested recipients of other welfare benefits programs found only 200 positives out of the thousands of people who received benefits.  He wrote that the effort likely would be challenged as unconstitutional because people have a “right to be secure in their persons against unnecessary searches and seizures.”   Click here to read his op ed.

For a more academic analysis of these problems, read Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin by Kaiser Health Network.  KHN cites Wisconsin’s own figures that project a decline in the number of those covered.   “Wisconsin projects that enrollment will decrease from 150,050 beneficiaries in CY 2016 to 146,407 in CY 2018, while costs will increase from $825 million in CY 2016 to over $1 billion in CY 2018.”

UPDATE:  Click here to read an article on 6/8 about Walker’s submission of the waiver.  Drug testing requirements were modified slightly.

UPDATE:  Click here to read a more comprehensive analysis of changes Walker made as a result of submitted comments.

UPDATE:  Click here to read the summary of comments and responses DHS posted on its website.  As of receipt of the application, the federal government has 15 days to determine if it is complete and to notify the state government if it is not.  A 30-day comment period begins upon a ruling that the application is complete.

UPDATE:  Click here to read an AP story reporting that less than 10 of the comments submitted supported the waiver.

Trump’s Budget Cuts Funding for Mental Health and Substance Abuse Programs

Much attention has been paid to the effect of Trump’s proposed cuts to Medicaid.  Numerous editorials, articles, advocacy statements, and personal testimony have described the damage they would cause to mental health and substance abuse services.

Now, Trump has added new targets to his hit list.  Here is the list of cuts in his federal budget proposal.

Substance Abuse and Mental Health Services Administration  (Decrease of $400 million)
Mental Health Block Grant (Decrease of $116 million or approximately 20%)
Substance Abuse Prevention and Treatment Block Grant  (Level funding)
Primary and Behavioral Health Care Integration and Technical Assistance and Training Center (Program eliminated)
Mental Health First Aid (Program eliminated)
National Institutes of Health (Decrease of $5,673 million or approximately 25%)
White House Office of National Drug Control Policy (Decrease of $2 million)
Click here to read the full story from the National Council on Behavioral Health.

Another Red State Moves toward Medicaid Expansion

A happy byproduct of the tortured debate about the Affordable Health Care Act is recognition of the benefits of Medicaid expansion.

Republican Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska wrote in a letter to Majority Leader Mitch McConnell. “We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,”

Less than a week after the demise of the Trump/Ryan bill, the Kansas legislature voted to accept Medicaid expansion funds.  Here is an excerpt from the Washington Post story on March 29 covering the event.  

TOPEKA, Kan. — “State lawmakers in this deep-red state on Tuesday did what a year ago would have been unthinkable: They voted to expand Medicaid under the health-care law that Republicans here have railed against for years.

Among them was Sen. Barbara Bollier (R), whose support last year for extending the government health program to more poor Kansans was considered so rogue that her colleagues tossed her off a health committee. This month, so many Kansas lawmakers voted for the expansion that they nearly mustered the two-thirds majority needed to block the Republican governor’s expected veto.

The abrupt reversal in Kansas could be the front edge of a larger shift nationally, as state lawmakers absorb the repercussions of congressional Republicans’ failed attempt to repeal and replace elements of the Affordable Care Act.  (My bolding)

In Virginia, Gov. Terry Mc­Auliffe (D) on Monday pledged to revive efforts in his state’s Republican-led legislature to pass Medicaid expansion. Georgia’s Republican governor, Nathan Deal, also announced plans to change his state’s Medicaid program. Medicaid advocates in North Carolina see hope for renewed momentum as Gov. Roy Cooper (D) has sought to expand the program there through executive action.”

JAMA, journal of the American Medical Association, reported that 67% of Republicans, 79% of Independents, and 90% of Democrats supported the statement that “States may chose to expand Medicaid.”

If Kansas can do it, why not Wisconsin?  Some Republican governors and legislatures gradually moved to accept Medicaid expansion money after passage of the AHCA.  More are headed in that direction.  The evidence is clear that the federal funds save state dollars and help people who need it.

NOTE:  Maine voters will be able to support Medicaid expansion at the ballot box next November.  A petition drive to put the issue on the ballot succeeded in February.   Maine has a Republican governor who refused expansion funds.

UPDATE:  Click here for “The States where Obama’s Footprint Might Get Even Bigger.”

UPDATE: Click here to read a less hopeful report on prospects for change.  It is “No Obama Ceasefire in Red States.”

UPDATE:  Click here for a detailed report by NPR of what’s happening with Medicaid expansion in Kansas, Virginia, and Maine.

UPDATE:  Kansas legislature failed to override the governor’s veto.  A majority of the Republican-controlled legislature voted for expansion, but the measure failed by 3 votes because a 2/3 vote was required to override.



“You’ve Got to Have a Moral Compass Inside You”

There are lots of reports today that show the Republicans’ health care plan would help the rich and hurt the poor.  But, Sen. Joe Manchin,  (D-WVa) put it best.

“I got an older population, I got a poorer population, and I got an opiate issue we need to clean up,” Manchin said. “And now, talk about insult to injury. You’ve got to have a moral compass inside of you. You can’t do that. Look at the elderly, look at the poor, look at the sick. How can you look at yourself and say, ‘Okay, I’ll help the person who needs help the least, the wealthiest people, with more tax cuts, because I’m going to be taking away from the elderly population?”  (Reported in the Washington Post on 3/14)

For a more reasoned analysis, click on the NY Times article “Republican Obamacare Repeal Would Benefit Wealthiest.”

For an analysis of the effects in Wisconsin, read this report by Jon Peacock of the Wisconsin Council on Children and Families.  Click here.


Repealing ACA Would Help the Rich and Hurt the Poor

Sometimes a headline captures the full meaning of a story.  That is the case with two reports published by the Center on Budget and Policy Priorities.

Here they are.  Click on the links if you need details.

Eliminating Two ACA Medicare Taxes Means Very Large Tax Cuts for Higher Earners and the Wealthy and ACA Repeal Would Lavish Medicare Tax Cuts on 400 Highest-Income Households.

Repealing ACA Would Be Catastrophic for Mental Health and Substance Abuse Treatment

Here is an excerpt from a report in USA Today that describes what would happen to people with mental health and substance abuse problems.

“In New Hampshire, which has the highest synthetic opioid death rate in the country, Democratic Sen. Jeanne Shaheen is reminding Trump about some of his campaign promises in her state.

“He pledged to take on this crisis, not immediately make matters much worse,” Shaheen said in an email Friday. “Repealing the Affordable Care Act without a replacement is highly reckless and will come at a high cost for people struggling with substance use disorders.”

Almost any route taken on Capitol Hill leads to an unraveling of addiction and mental health.coverage for these people. Even the partial ACA repeal Congress is considering would eliminate the tax credits that reduce the premiums for about 85% of those who buy insurance on the federal and state exchanges. Most of those who get tax credits pay less than $100 a month for insurance and have very low out-of-pocket costs that make it possible for them to afford coverage.”

Repeal would also destroy the progress under ACA for people with mental illness and substance abuse problems in jails and prison.  Here is an excerpt about Chicago.

” The Cook County jail here is often referred to as the largest mental health facility in the country. Up to 30% of the 9,000 or more inmates in the jail have a diagnosed mental illness, according to jail data. “The ACA has been a game changer for those who are in and out of Cook County Jail,” says Mark Ishaug, CEO of Thresholds, a community-based mental health and addiction services provider in Chicago. He says poor people of color, especially single men, were finally able to keep health coverage once they left the jail. It costs less than $20,000 a year for Threshold’s highest level of community-based mental healthcare with a housing voucher, compared to nearly $70,000 a year to keep the patients in jail. About a third of Threshold’s 15,000 clients became eligible for coverage through the ACA.”

Read the full story here.