Monday, October 04, 2010

'Legislative Research Commission' to Study 'cost-effectiveness' of Supportive Housing : Rep Insko Outlines Possible State Supportive Living Measures

When you're 'urban hiking' in Asheville, NC, its not uncommon to come across someone's sleeping bag---indicating that fairly recently that person has been sleeping within the city's limits, but under a bridge or just off a path where you might hike w/ your dog. There are lots of homeless looking young people in downtown Asheville, walking w/ a leashed dog as if he was their last friend

Accordingly.....from Representative Wray's website/ blog re: NC Legislative activities (this being said, it's Verla Insko, D-Orange County, as in, is the woman going to run for governor someday, who created the details to be studied regarding 'supportive housing' (see below). First, Rep Wray provides a helpful overview of the issues around mental health vis a vis the state legislature first.......

In a nutshell, Verla, if all the pieces of 'supportive living' could be organized and were administratively overseen by one clearly demarcated entity, it might be speculated that the costs would go down and that citizens' rights would be better protected. Addtionally, we would not have (public & therefore pertinent to the NC State Legislature) embarassing events like the former Administrative Director of Smoky Mountain Center being charged with creating real estate endeavors so as to funnel available monies for the establishment of housing for people having mental health issues------towards himself and his real estate agent wife.

Hidden costs that need to be taken into account regarding 'supportive living' include the following (and there are a lot of 'quality of life' issues/ costs here). :

1. State costs which are not federally picked up as re: Section 8 housing; in particular, and as related to the more rural areas of the state, 'supportive living' in the forms of trailers and poorly insulanted houses create housing that has to be attended to by the local county DSS e.g., heating bills, emergency phone bills, other utilities that free-standing 'supportive housing' crank.

2. Splintered agencies across the state all think they see the elephant when in fact they are simply a mole on its haunch: there are city housing authorities (see below) and DSS staff dedicated to family care homes, etc.

3. If one was to consider 'cost-effectiveness' it might be useful to include the interdictory activites of the management/ police/ DSS/ mental & physical health practitioners vis a vis those who live under the umbrella of 'supportive housing'.

Here is Rep Wray's overview of matters pertaining to MH as per what is up and coming in the NC State Legislature:


"......Mental Health

While we had to balance our budget and trim spending in many areas, we believed it was important to continue trying to improve our mental health services by providing more local options. For that reason, we increased funding for local inpatient beds for mental health patients by $9 million to $29 million and directed that the money be spent equitably throughout the state. (SB 897)

We extended the First Commitment Pilot Program until October 2012 and authorized the expansion of the program to up to 20 local mental heath management groups. The program allows properly trained licensed clinical social workers, master’s level psychiatric nurses, or master’s level certified clinical addictions specialists to conduct first-level examinations in the involuntary commitment process. Since local community hospitals have greater access to these professionals, the pilot reduces unnecessary time delays while maintaining essential safe guards of the process. State law generally allows only physicians to conduct such exams. The act also directs the Division of Mental Health/Developmental Disabilities/Substance Abuse Services to expand its training requirements to include refresher training and to evaluate the participation rate of eligible examiners. (SB 1309)

The North Carolina Institute of Medicine has been asked to put together a task force that will study the needs of children aged birth to five with mental health problems, as well as the needs of their families. The task force’s report is due to the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services by January 15, 2012. (SB 900, Part XVI)

The Legislative Research Commission has authority to establish a task force to study the cost‑effectiveness of supportive housing as an alternative to institutionalization of people with mental health, developmental or substance abuse problems. The study would examine whether such housing would help reduce the number of emergency room visits and hospital admissions, improve treatments and decrease homelessness, among other outcomes. (SB 900, Part XVIII)...."
Defarge comment re: 'cost effectiveness of supportive housing': (see this URL for that bill:

In surveying the bill, everything from ownerless dogs & cats to beauty pageants to changing demographics of community colleges is about to be 'studied.'

Insko, whom works with Martin Nesbitt (D-Buncombe County), is the co-chair of the Joint Legislative Oversight Committee for Mental Health Reform. From the just above URL, she has outlined the particulars of what needs to be studied as regards 'supportive living':

"The Commission should address all of the following in its findings and

(1) A recommendation as to whether and how a statewide supportive housing
initiative could achieve each of the goals referenced in subdivisions (1)
through (9) above.

(2) The number of supportive housing units that would be necessary for
successful implementation of a statewide supportive housing initiative in
North Carolina.

(3) The amount of capital investment that would be necessary for initiating and
maintaining a statewide supportive housing initiative.

(4) Different funding resources that could be used to pay for ongoing
operational costs of a statewide supportive housing initiative.

(5) The potential cost-savings to be achieved by the State through
implementation of a statewide supportive housing initiative.

I would like to outline the current 'supportive living' measures that are in place.

Currently, there are four ways that people w/ mental & physical health issues can live, to a varying degree, independently in 'supportive housing'. 'Supportive housing' means,however, that the residents have to pay attention to the tidyness of their apartments and there can be no unseemly activity (see below).

These citizens do not have the rights that people living in non-supportive housing have. If one was to consider 'cost-effectiveness' it might be useful to include the interdictory activites of the management/ police/ DSS/ mental & physical health practitioners vis a vis those who live under the umbrella of 'supportive housing'.

Additionally, cost saving measures that everyday people employ, particularly when it gets cold, cannot be used by people living in Section 8 housing. They cannot have wood stoves or free-standing propane heaters (I reckon due to their potentially incendiary nature). Their heating bills are commonly addressed, in some good measure, by the county DSS. Thus, that is another expense that needs to be taken into account re: 'supportive living.'

Citizens living in the most restrictive environment, specifically family care homes, must have moved through the Social Security Disability process and have a disability check that comes to them on a monthly basis. Therefore, another cost associated w/'supportive living' would be all those legal machinations around the obtaining of a disability check. I know of only two individuals who obtained Social Security Disability within a year; both were heavily vested in the Social Security System and one of them was an attorney with a head injury. Mostly, people wait for years. Who can calculate the monies lost/ put at risk related to waiting for a clogged-up system to open the sluice so your family can eat?

I believe you would obtain an innacurate picture of the overall cost of 'supportive housing' unless you included those components, as well as others I have not even considered below:

1. Free-standing Section 8 housing (if there is even a hint of any illegal drug use or inability to care for oneself e.g., keep a tidy apartment, as a surprise inspection is always possible----the person is removed from the housing and there is a three year moratorium w/o any ability to intercede utilizing local legal aide services, to intervene and resume Section 8 Housing. Thus, the burden of proof of difficulties like the above rests on the tenant whom is disabled and commonly not completely functional). Section 8 Housing lists are long for Buncombe county and assumably the more populated counties, in general. By free-standing, I mean apartments, trailers, or houses that can be rented utilizing a Section 8 Housing voucher. In most of Western NC, the entity that concerns itself w/ that is Mountain Projects, administratively housed in Waynesville, NC, in Haywood County. Poor people live in crummy environments and landlords are not inclined to pay much attention to the housing.

2. Local Housing Authorities e.g., Waynesville Housing Authority, etc., create housing in the form of multi-story buildings w/ free standing apartments within. For instance, Waynesville Housing Authority has two very good multi-story apartment buldings for people having disabilities located in Waynesville, NC. Asheville also has some good multi-story buildings right downtown. One of them, across from Lake Junaluska, would satisfy me : its beautiful, has wonderfully designed apartments, a library downstairs, and a view that only the very wealthy can command.

3. Local Section 8 Housing in the form of 'the projects.' Asheville,for instance,has some very conveniently and centrally located 'projects' and indeed,the current mayor of Asheville, Terry Bellamy is rumored to have 'come out of' one of 'the projects.' This being said, when I was doing voter registration at many of these projects in Asheville several years ago, it was the norm for the crack dealers---in broad daylight--- to run towards my car as fast as possible, assuming that this odd white lady was there for that reason. So, imagine raising your children in that environment. It is weird to me that a resident may not smoke a joint in their Section 8 housing apartment without risking losing their housing,whileas crack dealers roam the streets in broad daylight, with the entire community standing around. Yes, I have a client whom was arrested and escorted from his muti-story Section 8 housing in Asheville by a handful of Asheville Police Department policemen whom stormed in and said, 'show us your marijuana' upon which he very willingly emptied his pockets. He had no Miranda Rights for he was in public housing.

4. Family Care Homes: I have written a lot about these homes over the past couple of years as associated with my clients who live there. These are mid to large size houses, owned by private individuals, with probably six to ten people living in private bedrooms in one house, with a living room, with multiple houses on the property. There is a person who passes out medication; most residents take meds. Commonly, bedrooms are shared with another person; you guessed it: just like you and me, we don't want to share our bedroom with a stranger.

These family care homes address the issue of homelessness moreso than the other housing and are funded by the county Medicaid offices as well as the entire disability checks (for the most part) of the residents. If someone has worked for a number of years,their disability checks are usually $850-900/ month. If they had a parent who placed them under their social security number prior to they turning 21, they receive the full benefits of said parent. Contrarily, people who have never worked have disability checks of around $600/ month. These citizens have Medicaid only whileas those who have vested in the Social Security System receive Medicare as primary and Medicaid as secondary. This is important because there are a lot more physicians who will take Medicare but not Medicaid. As for this psychologist, NC Medicaid pays me pretty well. Go figure.

Funding to pay for the housing, utilities, food and 24/7 attending Supervisor-in-Charge (SIC) and roving medication tech, derives from scooping all of the residents' disability check (of whatever amount) minus $66; the county Medicaid office pays the rest and the overall cost of staying in such a family care home/ month is about $1300. For that, residents receive meals three times/ day; they usually have TV's in their rooms; and, they receive some transportation to important medical appointments. 'Social activities' are posted e.g., playing bingo, etc., but are poorly attended. There is a great deal of cigarette smoking on the porches and inactivity and boredom are rampant. People get overweight and then Type II Diabetes sets in.

To my mind, these are the descendents of the large state mental health hospitals which were very significantly downsized as associated w/ a lawsuit back in the late 1970's which created the community mental health treatment centers due to the change in the law which demanded that the large hospital facility could not keep people without 'giving them treatment.' (warehousing them was considered to be non-treatment).

The NC Department of Health Service Regulation (under NC DHHS) oversees these family care homes and there are representatives in each county as well as someone(s) at the local Department of Social Service whom interfaces w/ the family care home and provides for inspections and complaints. The residents are loathe to complain as they know who butters their bread. There is a telephone number for an ombudsperson posted on the living room walls of these homes; supposedly this is a helpful person when one has a complaint but again, you don't want someone to withdraw their helpful attentions if you begin to complain.

The homes are run by some well meaning people but there is also a hidden massive scramble to drag off the residents to 'my' family care home and I have been threatened with arrest by the Buncombe County Sheriff's Office when one particularly obnoxious manager of a family care home in Leicester, NC, told me I was not welcome to render therapy to my client 'after hours' (with they being able to determine what 'after hours' means, regardless of the client's desires.

Thus, of all the 'supportive living' alternatives, the family care homes are the least desirable place to end up but certainly can address the issue of homelessness but FIRST----for the most part----the citizen has to have a disability check which pays for a good measure of staying there.

Sunday, October 03, 2010

Medicaid or Medicare for ALL?

This was posted on the Division 42 (Independent Practice) of the American Psychological Association, as associated (first part) Kaiser (insurance) and secondly, by the identified psychologist----below:


"....Under health reform, Medicaid will be expanded to cover nearly all individuals with incomes below 133 percent of poverty resulting in a large adult expansion in most states, particularly adults without dependent children who had historically been barred from coverage under the program. This expansion provides the foundation for new coverage under health reform.

Not surprisingly, Medicaid officials are playing a lead role in preparing for health reform implementation, in many cases alongside insurance commissioners. Some of the key challenges that states will face in implementing reform include implementing the Medicaid expansion, transitioning to a new income eligibility methodology for Medicaid, setting up Health Insurance Exchanges and re-designing eligibility systems to coordinate with the Exchanges.

These challenges are magnified by recent administrative cuts and state workforce reductions limiting states’ capacity to focus on new responsibilities. Many states said that they need
timely regulations and guidance as well as financial support to help them move forward and meet tight implementation timelines.

"Comment: In spite of the infusion of funds from the American Recovery and Reinvestment Act of 2009 (ARRA), states are implementing Medicaid provider rate cuts and implementing Medicaid benefit restrictions. Yet with the enactment of the Patient Protection and Affordable Care Act (ACA), the Medicaid program will be greatly expanded to include almost everyone with incomes below 133 percent of poverty.

Medicaid always has been and always will be a welfare program for low-income individuals. Serving a population that lacks an adequate political voice, it also has been and always will be a chronically underfunded program.

Most physicians who do accept Medicaid patients do so, in spite of inadequate reimbursement, because they believe that everyone should have health care. With a much greater volume of Medicaid patients some physicians will certainly face the dilemma of crowd-out of privately insured patients because of the Medicaid overload in their appointment schedules.

Imagine a physician facing Medicaid overload, declining net revenues, and frustrations of trying to help patients negotiate a system with diminishing benefits and with impaired access to specialized services because of a lack of willing providers.

Certainly some physicians will feel that they have no other choice than to close their practices to Medicaid patients. What will that do to other physician practices that are already overloaded with Medicaid patients?

Adverse selection can sink insurers, but it would be much more tragic to see adverse selection sink the practices of those physicians who are trying their hardest to do the right thing.

If everyone were in the same health care program, say an improved Medicare for all, an underfunded, segregated sector of stigmatized and humiliated welfare patients wouldn't even exist. They would have access to the same care the rest of us have. Wouldn't that be nice for a change.

Don McCanne, M.D. Physicians for a National Health Plan, Senior Health Policy Fellow, writes daily on health care financing, reform, etc. at:

David Byrom, Ph.D.
Co-Director, Family Therapy Institute of Suffolk
39 Landing Avenue
Smithtown, New York
(O)631-361-3662 (Fax)631-361-8750
Secretary, National Board, Universal Health Care Action Network"