West Virginia's behavioral health care providers may suffer "a domino effect" of losses and closures if the state doesn't resolve its budget shortfall in time to fund them, and stakeholders are pushing both an increase in the tobacco tax and changes in policy to address the problem.
Members of the West Virginia Behavioral Healthcare Providers Association met with Gazette-Mail editors on Tuesday to talk about how the state's continued budget impasse, and the threat of more budget cuts, could hurt behavioral health providers in the state.
Legislators began a special session Monday to decide how to address a $270 million shortfall in the 2016-2017 budget, with the governor and the Legislature at odds. Gov. Earl Ray Tomblin's proposed 45-cent tobacco tax increase would generate roughly $79 million, and he has proposed a sales tax increase of up to 1 percent, as well as a repeal of the sales tax exemption for telecommunications services.
Republicans in both the House and Senate are overwhelmingly against tax increases of any kind, and Senate President and gubernatorial candidate Bill Cole, R-Mercer, said the gap could be closed through a combination of cuts, money from the state's Rainy Day Fund and sweeping accounts of reappropriated funds.
Tim Morris, the regional director for REM, a home and community-based health services provider, said that although he understands the position the state is in financially, the reality for health providers is also dire - many have also suffered from year-over-year budget cuts, and several smaller providers have been forced to close their doors in the last few months.
"You can't throw in two minimum wage increases, Obamacare, increased regulations and cut rates and think that anybody is going to be left standing," Morris said. "It gets done to this population a lot because they're not the teachers' union and they're not AARP; it happens because it can happen, and the sad part is that if we got the right people in the room and said 'We're going to lock ourselves in here until we figure this out,' we could figure this out."
WVBHPA represents 26 of the more than 100 behavioral health care providers statewide that are already running on razor-thin margins - providers like Highland Hospital, who are treating people with increasingly serious mental illness who, if left alone, are far more likely to end up homeless or unemployed, according to Cynthia Persily, president and CEO of Highland Hospital Association.
"What I hear my staff saying every day is, 'We can't go any further and continue to provide high-quality care to patients who desperately need us,'" Persily said. "It's perpetuating that cycle of not having care services, which fuels all these other problems. Go into the justice system, go into the juvenile justice systems, problems in schools - all of those things are treatable, and we're treating them every day."
Since the state's Medicaid expansion under the Affordable Care Act, the question of how the state will absorb the cost of more than 170,000 new Medicaid patients has become another pressing issue, but one that both Persily and Morris said could be better addressed. Currently, the federal government matches state Medicaid dollars nearly 3 to 1, so that any cuts to the state's Medicaid budget means a three-fold loss in Medicaid dollars. Mark Drennan, executive director of the WVBHPA, noted that while community-based providers receive the Medicaid match, those who are institutionalized are paid for entirely by state dollars.
"We understand that when you don't have money, you don't have money," Morris said. "The problem is, from my viewpoint, that if you get to the point where you're willing to cut from this population - from the most vulnerable population that needs it as much as anybody - and you're willing to do that to the point that you'll give up three times as much as you pay, that sends a message that we're doomed."
Drennan said even a $1 tobacco tax increase, which would generate an estimated $115 million in additional revenue, wouldn't be enough to entirely bridge the budget gap, but other regulatory measures that affect behavioral health providers could be streamlined to help. The state's recent move to unbundle child residential services - forcing providers to bill separately for services that were once bundled together - replaces Medicaid dollars with state dollars and contributes to the state's fiscal issues, Drennan said.
Other changes only require DHHR approval - the Centers for Medicare and Medicaid Services recently changed a rule that will allow freestanding psychiatric facilities with more than 16 beds, like Highland Hospital, to treat Medicaid recipients between the ages of 21 and 64, something the facility is currently barred from doing, Persily said.
"When the ACA was passed, there was a demonstration project that allowed freestanding psychiatric hospitals to be reimbursed for Medicaid; it lasted for three years and ended last May with no changes in policy, so for three years we could take care of Medicaid patients, and now we cannot," she said. "What you have then is beds that are sitting empty and people who need services, and what you also have is people backed up in emergency rooms waiting for a placement, because we can't use the 40 beds we have at Highland, or at River Park [in Huntington] for adults with Medicaid."
According to Morris, another blow to funding for behavioral health could prove disastrous, and has the potential to create a cascade of closures as smaller agencies fold and increase the burden for larger ones like REM.
"We take care of people 24 hours a day - when I first got into this business, for the first six months, every night I went to bed it occurred to me that I had 200 employees making a low wage, and all they'd have to do is get mad and walk out in the middle of the night, leaving a vulnerable person alone, and we could be put out of business," Morris said. "I don't have the money to pay the wages I feel comfortable with, and if we keep taking these hits ... you're seeing it with the smaller providers already, who have folded up, and it's working its way up."
Reach Lydia Nuzum at lydia.nuzum@wvgazettemail.com, 304-348-5189 or follow @lydianuzum on Twitter.