Law and People with Disabilities

7 November

• Most support programs are funded by Medicaid, and administered at the county level. The organizations have a section in them for determining eligibility (income maintenance, etc.). There's also a development disabilities section, an aging unit, a mental health unit, and so on.

  So things are divided up by diagnosis (and physically disabled people go with frail elderly, for whatever reason).

  Waiver programs were for people who could have been institutionalized (i.e., their disability was severe enough that this would be an option).

  So you have the COP programs for physically disabled people. For mental illness, there's far less support. It's really for people with severe bipolar/schizophrenia, etc. Comprehensive community services are there (at least in some counties) for people with less severe issues.

• In the old days, if you had a child with a developmental disability that you didn't feel you could handle at home, you could drop them off (permanently) at one of the various regional centers. These were colonies, with a couple thousand people in them each. Some of them with only very mild cognitive disabilities.

  These are pretty spendy for the state to operate. And in the 1980s, people started having more humane thoughts. So they've been working on downsizing and closing them. The northern center is closed now, and only 410 people remain between southern and central.

  There were also county-based nursing homes for people with developmental disabilities. ICFMRs. The majority have closed over the last 10 years.

  So the institutional population of people with developmental disabilities has plummeted over the last few years. Most services are provided in community settings. And actually similar things can be said about aging and physical disabilities as well.

• In 2000, the state determined that the existing system wasn't working. Basically this was because of the way services were funded. There were huge waiting lists, etc.

  So, Family Care was invented. And the big difference was a managed care model. Care organizations would get paid a lump sum for every member, and they'd be responsible for managing the risk of providing services to the members.

  There were so many programs delivering services to different niche groups, it would be more effective to work like an HMO and pool things together.

  People thought this would be a replacement of the county-by- county system. And we'd be combining all those separate units in the counties.

• So one-stop shopping might be a nice thing. But the trade-off is the lack of specialized expertise. And the drive to provide the services as cost-effectively (i.e., cheaply) as possible. So we got rid of waiting lists, which is nice.
• Sum-sufficient vs. sum-certain. We used to have waiting lists because once the money appropriated was committed, it was done with and there wasn't room for anyone else (sum certain). Other things are "sum sufficient:" once you're eligible, you get what the benefit offers. So they said basically: if y'all can agree to a managed care model (which we all know is imperfect), we'll make it an entitlement. And of course, this is why we always have a medicaid deficit, by the way.
• But all the promised benefits have been eroded over the years, because of budget cuts.
• WI is a very "county-based" state-- they're all really different. So it pays to have representatives locally.
• Community-based long term care outline
  This mostly talks about the old progams. Until 1981, there weren't really any non-institutional programs for people with long-term care needs. It was either the state centers or a private institution for you.

  When medicaid started funding long-term care, there was a sudden over-building of nursing home beads. And they weren't very nice. So WI developed the Community Options Program. And this was before it could be funded by medicaid-- it was all state in those days. Then the Home and Community-Based Waiver got set up by the feds, basically following WI's lead.

  The things that normally get waived: comparability, and state-wideness.

  So WI started creating waiver programs for specific segments of the otherwise medicare-eligible population.

  Medicaid is a federal law that will give states money to match what states will do, subject to some federal requirements. States can opt out, but none have as of now.

  CIP-1A and CIP-1B are targeted at developmentally disabled people. ICFMR: Intermediate Care Facility for the Mentally Retarded.

  If the cost of the placement exceeds the rate that is provided, the county pays enough of the difference to bring in the federal match (40.07%).

• Back with Judy K
  This was a CIP-1A case.

  The court's holding is an effort to avoid absurd results (i.e., institutionalizing people in a more restrictive environment, and with more total cost just because it would save the county money).

  But this case only covers Chapter 55 people (i.e., people under guardianship). So the waiting lists remain...

• Waivers can expand the list of services available.
• So those waivers were around until 2000. And there were these big waiting lists.
• Family Care (including Wisconsin Partnership, PACE-- now pretty much gone, and IRIS).
  So, functionally, except for IRIS, this is sort of a managed care thing. It's a replacement for CIP/COP; the services are more or less the same, but the provider model is different.

  It looks great on paper, but doesn't work for everyone. So there's IRIS, if you want that. It's basically to address the fact that Medicaid won'e allow the states to funnel all people into the same managed care organization. It has been wildly more popular than people anticipated.