Mind and Body

To tell the truth about the budget

Poor reimbursement rates for Medicaid turn out to be a killer, when it comes to the mental health, behavioral health and substance use crises

Image courtesy of YouTube version of "The Dance of the Hours."

The annual release of the state budget in Rhode Island, with its choreographed stagecraft, often brings to mind "The Dance of the Hours," the Disney cartoon from "Fantasia" with the ballet between the crocs and hippos, a dance of predators.

By Richard Asinof
Posted 6/17/19
In a moment of truth-telling, Linda Hurley, president and CEO of CODAC, named the biggest problem, what she called the elephant in the room: how low reimbursement rates paid by Medicaid for behavioral health and mental health services are crippling the ability of the state’s health care delivery system to respond to the crisis. But the new state budget contains more cuts to Medicaid, not a boost in rates.
Which reporter will be the first to ask House Speaker Mattiello about the cuts to Medicaid? How is the crisis in mental health, behavioral health and substance use disorders in Rhode Island exacerbating the problems at DCYF? When will access to safe, affordable, healthy housing become part of the equation in looking at how to improve education outcomes in the Rhode Island? Without new sources of revenue, where will the funds come from to support educational initiatives? When will the deaths from the diseases of despair – alcohol, suicide and drug overdoses – be treated in a larger, holistic fashion, rather than as silos? Will Janssen, a division of Johnson & Johnson, now on trial in Oklahoma over the manufacture of opioids, have any legal liability in Rhode Island under the new opioid tax proposed in the state budget?
On Friday, June 21, from 6-9 p.m., the Rhode Island Communities for Addiction Recovery Efforts, or RICARES, will be celebrating its 20th birthday at the Hope Artiste Village in Pawtucket. The group, which calls itself “the historians of Rhode Island’s recovery culture,” as well as the recovery brokers and ambassadors, has produced an impressive group of leaders in the recovery community, including Tom Coderre, Holly Cekala, Michelle McKenzie, and Ian Knowles, among others, who have helped to champion the recovery community’s voice into a constituency of consequence.

PROVIDENCE – The budget dropped on Friday night, June 14, at the R.I. State House, in a staged event as heavily choreographed as the release of the new Taylor Swift single.

The ritualistic release of the state budget has often reminded ConvergenceRI of the “Dance of the Hours” from the animated Disney film, “Fantasia,” with its comic rendition of a ballet between hippos and crocodiles, a cartoon of courtship and love between predators. [See link below to the YouTube video.]

In the Rhode Island version, it is a pas de deux between the House Speaker and the Governor, with the Senate President kibitzing, offering advice from the sidelines.

Which be the croc, and which be the hippo? Which be the judge, and which be the thief? It is anyone’s guess in the handy-dandy world of politics in which we live. Backstage, the lobbyists chortle.

Much of the sausage making contained in the art of the deal which makes up the ingredients of the nearly $10 billion Rhode Island state budget for the next fiscal year occurred behind closed doors, without any real public transparency.

The news media [though they would never see themselves as such] serve as the enablers of the process, glorifying the moment, with all of their breathless frenzy, to report on the late-night shenanigans when the budget document is actually dropped, much like reporting on the glittering ball descending in Times Square in New York City on New Year’s Eve. Ten, night, eight…

A brief flash of blunt clarity
But the real, truer story often happens far away from the maddening crowds of reporters, cameras and microphones.

Like a fleeting glimpse of a scarlet tanager visiting in Rhode Island in late spring on its migratory path to northern forests, honest, blunt talk in response to failing budgetary policies is always a bit surprising if not startling.

When it occurs, it often takes place at events that require shoe-leather reporting and a tolerance for bureaucratic drudgery, outside the lens of most news coverage, such as attending the monthly meeting of the Governor’s Task Force on Overdose Prevention and Intervention.

Such a flash of brilliant clarity and bluntness occurred at the June 12 Task Force meeting, breaking through the clutter of some 85 minutes of presentations and reports, in the brief five minutes afforded to public comment.

The elephant in the room

Linda Hurley, president and CEO of CODAC, sitting next to Sen. Josh Miller, chair of the R.I. Senate Health and Human Services Committee, both members of the more than 40-person Task Force, began her comments by saying she was reluctant to say what she needed to say.

Hurley, like the other members of the Task Force and another 100 or so people in the audience on the second floor of the R.I. Department of Administration building, had patiently listened to two detailed reports that attempted to peel back the onion on data regarding co-occurring diagnoses of mental health and substance use disorders in Rhode Island.

In the first analysis, Dr. Brian Daley, chief medical officer at the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals [BHDDH], had presented what he considered to be a rather shocking datapoint: only 6.9 percent of all patients in Rhode Island who were diagnosed with either a substance use disorder or a mental health disorder were treated for both, despite the fact that the co-occurring conditions overlap. Can you spell silo?

But, for Hurley and for many other Task Force members representing the recovery community, the gaps in services were not that revealing, they were a daily reality at her agency serving on the front lines of delivering care. And, Hurley then pinpointed a major reason why such gaps existed.

Hurley told the assembled crowd that she had recently met with top officials at Coastal Medical Group, one of the state’s largest physician group practices. The folks at Coastal Medical, Hurley continued, were stymied, not only by the high demand for services in the mental health and substance use disorder continuum, but because there were no providers to which they could refer patients. The major reason: the rates from Medicaid reimbursement were too low. Coastal Medical had come to Hurley to ask for her help.

“The low Medicaid rates are the elephant in the room,” Hurley said. Because of the low rates, Hurley continued, “Coastal Medical told me, ‘We can’t refer [patients] to anyone.’”

There it was, in plain English, with no translation needed. All the data and all the analysis and all the platitudes and all the executive orders don’t mean a thing if the state is unwilling to invest in meeting the needs in the mental health, behavioral health, and substance use crises afflicting Rhode Islanders.

Money talks, patients walk
Hurley had spoken the cold, sober truth, based upon the reality beyond the data: The state needs to invest more money to boost Medicaid reimbursement rates in order to address the ongoing crisis in mental health, behavioral health and substance use disorders in Rhode Island. [There is also the unresolved issue about providers in the behavioral health and mental health care sectors getting paid on time by the state, which is now using a third-party private contractor.]

But, apparently, no such increases are contained in the new state budget; instead, there are cuts.

The exact extent of the cuts to Medicaid are still unknown, according to state Sen. Sam Bell, who wrote in a Facebook post following the release of the state budget: “Very little was done about the brutal round of Medicaid cuts the Governor proposed. It looks like the hospital cuts may have been pared back a bit, but the bulk of the cuts seem to remain in place. Still waiting for final numbers on this, but it looks really bad.”

Bell continued: “I know many other more liberal Rhode Island legislators don’t prioritize this issue as much as I do, but I think it really matters. We have eviscerated the Medicaid budget, and the results have devastated our health care system for low-income people. How much more pain can we take?”

In briefing reporters on what was in the budget, R.I. House Speaker Nicholas Mattiello told a much different story. “Our principles in this budget were to make sure the budget was business-friendly, did not impose any new taxes that we felt were onerous to our economy, and we wanted to continue to provide an environment for economic growth,” as reported by WPRI’s Ted Nesi.

Further, according to Nesi, Mattiello said there was limited scope to fund new initiatives because of the state’s ongoing struggle with annual deficits. “We have to be very careful and good stewards moving forward, and we have to look at the out-years,” he said. “That’s one of the reasons that we tried to be very judicious in any new programming that we created.”

In a state of denial
ConvergenceRI may have missed it, but none of the flurry of stories reported out by the news media following the release of the state budget provided any details on the planned cuts to Medicaid. Why was that?

And, of course, because there were no other reporters present at the June 12 meeting of the Governor’s Task Force, Hurley’s blunt truth telling was the proverbial tree [or should that be bodies] falling in the forest.

Mental health, behavioral health and substance use disorders do not discriminate, touching almost every Rhode Island family, whether you are a top CEO, a media personality, or a state senator. For the last three years in a row, despite Herculean efforts on prevention and intervention, the annual death toll from overdoses in Rhode Island continues to be more than 300 people a year.

Where the discrimination occurs, it seems, is in the state budget. The phrases used by the House Speaker to describe the budget – business-friendly, no new taxes onerous to the economy, an environment for economic growth, and good stewards moving forward – will not cover up the body count.

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