Shutterstock.
By DCist contributor Jonathan Neeley
Many of D.C.’s most vulnerable residents— like low-income or homeless people with schizophrenia or bipolar diagnoses and ongoing battles with addiction and health problems — could lose access to mental health care if the government shutdown lasts much longer.
Late Wednesday night, the Department of Health Care Finance informed the Department of Behavioral Health that it cannot make Medicaid payments until the shutdown ends or Congress approves D.C.’s budget for the 2014 fiscal year.
According to Shannon Hall, executive director of the D.C. Behavioral Health Association, of which two-thirds of the city’s mental health care providers are members, about 28,000 of the District’s residents are beneficiaries of Medicaid-funded mental health services at a collective cost of $285,000 per day. The DHCF will reimburse providers once the shutdown ends, but in the meantime they’ll have to cover services on their own.
“My biggest concern is that an already-strained system will get more sluggish,” said Richard Bebout, chief of business development and strategic planning at Community Connections, D.C.’s biggest mental health care provider, as well as president-elect of the DCBHA. “When somebody who’s in trouble asks for help and doesn’t get it, it’s easy to imagine scenarios in which additional delays and lengthier waiting periods to get seen could result in consequences that could be very real.”
Mental health issues have lately been relevant to the greater D.C. population. Aaron Alexis, the Navy Yard shooter, reportedly heard voices in his head and believed that people were keeping him awake with low-frequency microwaves; Miriam Carey, the woman who police killed Thursday after chasing her car from the White House to the Capitol building, reportedly thought that Barack Obama was stalking her, although her sisters deny this; on Friday, a man set himself on fire on the National Mall.
“Those are higher profile events, but what our members do everyday is intervene with people in crisis to avoid them getting to that point,” Hall said. Medicaid funds providers that offer a range of services from psychiatric counseling, substance abuse rehab, and medication management to housing support and job placement. On top of mental health diagnoses, their consumers usually live below the poverty line and also grapple with physical afflictions and addiction.
“I think you’re going to see an increase in emergency room use [if providers can’t stay afloat],” Karin Ostlie, Behavioral Health Services director for Catholic Charities, said. “If people can’t see a psychiatrist at their regular health provider, you run the risk of having them out there on the street lost.”
“Larger agencies will manage cash flow problems,” Bebout said. “But there are a number of smaller agencies that can’t withstand any kind of protracted interruption.”
“Smaller providers have fewer resources to draw on,” Hall added. “One of our members has only seven days of cash on hand, and organizations like those will be most challenged to meet payroll.”
Aside from the matter of providers paying for care, a number of officials raised concerns over consumer access to pharmaceuticals. “These patients need antidepressants, antipsychotics, and mood stabilizers,” a head psychiatrist at George Washington University Hospital, who was not authorized to speak on the record, said. “If you don’t have funding for community mental health services, you have nothing to offer patients who are chronically psychotic or depressed or substance abusing”
“If people can’t get their medication,” Ostlie said, “it’s extremely detrimental for psychiatric and physical health.”
D.C.’s mental health sector already runs on thin financial margins. Many providers have been operating at a loss since the January 2011 budget crisis. At a Thursday meeting to discuss reimbursing health care providers in the wake of last spring’s collapse of Medicaid claims processor D.C. Chartered Health, DHCF said that it would begin processing mental health payments once hospitals and primary care providers were covered.
“When you go to a primary health center, the doctor that sees you gets paid $154,” Hall explained. “When you make an initial visit to a psychiatrist, they get paid $45 or less.”
The Medicaid freeze comes as a result of D.C.’s inability to spend its own locally raised revenue without Congressional approval. Under Medicaid, states and territories cover all of the upfront costs and then the fed reimburses them a percentage of those expenditures, called the Federal Medicaid Assistance Percentage (FMAP). D.C.’s FMAP is 70 percent, but without authorization to spend the money upfront, reimbursement is a moot point.
According to DHCF director Wayne Turnage, the only other option for continuing Medicaid payments would be to dip into the department’s $140 million contingency fund. But with total Medicaid costs during the first week of the shutdown totaling $90 million – they are highest at the first of the month because that’s when DHCF pays its four health plan providers – and an inability to replenish the fund, doing so would mean gutting the DHCF’s resources.
Turnage empathized with the city’s Medicaid-dependent service providers. “I think it’s a bit much to ask a health care provider to figure out what Congress is going to do,” he said. “They have their hands full putting together the appropriate systems to provide critical services to patients. And even if they did see it coming, what can you do about it?”
“Anyone with a sense of governance should understand how difficult it is for a jurisdiction as sophisticated as D.C. is to manage a city without the authority to spend its money.”
