Governor Terry Branstad made a remarkable claim at his latest press conference: because "the people of Iowa elected me to reduce the size and cost of government," he has the authority to "make tough decisions" on closing state-run mental health facilities and reorganizing Medicaid services for more than half a million Iowans.
To justify his position, Branstad channeled President Harry Truman: "The buck stops with me." But his view of governance reminds me more of Mel Brooks in the movie "History of the World, Part 1": "It's good to be the king."
O.Kay Henderson covered Branstad's April 6 press conference for Radio Iowa, and Rod Boshart covered it for the Sioux City Journal. Asked about his plan to close two of Iowa's four state-run mental health institutes, Branstad claimed a mandate for his actions.
"I'm the chief executive," Branstad told reporters this morning. "I was elected by the people of the Iowa to reduce the size and cost of government and to make it more efficient and to modernize it and to provide better services for the people of Iowa and we have been moving in that direction from the day that I took office."
Last year Branstad ordered the Iowa Juvenile Home be closed and while legislators complained, they were unable to stop the process. This year the Senate has passed a bill that called on Branstad to keep the Clarinda and Mount Pleasant Mental Health Institutes open and accept patients through June 30. Another senate bill that passed on a bipartisan vote called for keeping the MHIs open until a plan was in place to ensure there's care somewhere for the most severely mentally ill Iowans.
Similar legislation is pending in the House, but Branstad isn't interested in a delay. "I understand there's always going to be resistance whenever you look at making a major change like this, but this is long overdue," Branstad says.
Reasonable minds can differ on whether the Clarinda and Mount Pleasant facilities should remain open, but Branstad should have worked with state legislators and mental health experts in carrying out the plan. He may have spoken broadly about the need to shrink state government, but at no point during last year's election campaign did he call for closing two of Iowa's four mental health institutes. He didn't discuss plans to close the facilities to lawmakers before this year's legislative session, nor did he mention it during his annual Condition of the State address. Instead, lawmakers found out while reading the fine print of the governor's draft budget for the 2016 fiscal year.
By mid-February, new patients were no longer being accepted for various Clarinda and Mount Pleasant-based programs, a development that worried some mental health professionals:
"It's a very dangerous proposition to go about this in a hasty way," said Ron Honberg, national policy director for the National Alliance on Mental Illness. [...] "If there's not a good plan in place, it's frankly a prescription for disaster," said Honberg.
Even many leaders of community mental health agencies, which could stand to benefit financially from the shift, are nervous.
Mary Anne Gibson, who runs southwest Iowa's Waubonsie Mental Health Center, is enthusiastic about offering more mental health services outside of big institutions.
"It's just that we're not there yet," she said of preparations. [...]
Suzanne Watson, chief executive officer of the new, nine-county Southwest Iowa Mental Health and Disabilities Region, said her agency is accelerating plans to open a small crisis center by the time the Clarinda mental hospital closes. She said she would prefer a less abrupt change.
"These are great programs," she said of the new alternatives. "We're just jumping the gun a little bit. It would be great to have about a year to plan."
Meanwhile, Tony Leys reported for the Des Moines Register on March 25, "Administrators at the state Mental Health Institute at Clarinda have started transferring mentally ill senior citizens from the institution to private nursing homes." That set off alarm bells at the advocacy group Disability Rights Iowa, whose executive director Jane Hudson wrote a March 26 guest editorial for the Register:
DRI has serious concerns about the process and timeline for transitioning the 17 patients in the long-term care psychiatric nursing facility at Clarinda. Most are medically fragile and need a high level of both psychiatric and medical care. Patients in the long-term psychiatric nursing facility told DRI staff that they had heard about the closing on the news, but none had received official notice from DHS. We also learned that social workers were not supposed to start planning the transition or finding other placements. Planning for their transition and services needs to start immediately.
To date, DHS has been the only entity involved in this planning. Disability Rights Iowa has repeatedly asked DHS to officially notify the Iowa Department of Inspections and Appeals of the planned closing so it can activate the Iowa Long-Term Care Facility Closure/Crisis Team. The team, which includes DRI and the state's long-term care ombudsman, provides a consumer voice for the individuals being moved and makes sure that they receive the care they need both during and after a closing. The Register reported that the state has begun moving patients out of Clarinda. Until appropriate transition and long-term care services are in place, DHS should not move these vulnerable individuals, regardless of the arbitrary June 30 deadline.
Leaving aside the wisdom of the governor's plan from a public health perspective, Branstad's unilateral action raises constitutional questions. His determination to close Iowa Workforce Development offices, against the express intent of the Iowa House and Senate, landed the governor on the wrong side of a unanimous Iowa Supreme Court ruling in 2012.
Last year, a Polk County District Court judge ruled that the governor acted unlawfully when he closed the Iowa Juvenile Home. The governor's appeal of that case is pending before the Iowa Supreme Court. The justices may not rule on whether the governor had the authority to close the home for troubled youth. Branstad has defended his decision in light of alleged abuses by Iowa Juvenile Home staff, but he had other options: namely, to implement the recommendations of a task force he had appointed to study operations at the home.
Notably, Branstad is not shutting down the mental health institutes in the middle of a fiscal year, as he did with the Iowa Juvenile Home. Rather, his administration is proceeding on the assumption of the governor's budget: zero dollars will be spent on the Clarinda and Mount Pleasant facilities after June 30. Some of those actions may still contradict provisions of the DHS appropriations bill for the current fiscal year, which Branstad signed into law.
Branstad's unilateral action on Medicaid will have more far-reaching effects than what happens to the mental health institutes. Medicaid covers health care for more than one in six Iowans, about 564,000 people, at an annual cost of some $4.2 billion (including federal as well as state funding). In mid-February, the Department of Human Services sought bids from vendors to transform Medicaid into a managed-care program. The official announcement was full of happy talk about saving $51 million in 2016, "improving quality and access, promoting accountability in outcomes, and creating a more predictable and sustainable Medicaid budget."
But even the American Journal of Managed Care acknowledged in this report by Mary Caffrey,
In other states, transitions to Medicaid managed care that were driven primarily by the need for budget savings have been rocky, with service disruptions and complaints about bureaucracy. Last year in Ohio, for example, news accounts chronicled tales of home health aides who left long-term clients for other jobs, after working for weeks without pay. New Hampshire's move to Medicaid managed care is not yet complete, but already some families say they lack access to longtime providers.
Democratic State Senator Joe Bolkcom warned in an Iowa Senate floor speech last month,
"If you look at the fine print...those managed care companies will extract about $800 million a year that's currently being spent on services to our constituents for the pleasure of operating the program," Bolkcom said.
And Bolkcom argued it's likely health care services to poor and disabled Iowans will be cut to cover the cost of the contracts.
Branstad may have the legal authority to transform Medicaid without approval by the Iowa House or Senate, but that doesn't mean it's wise to pursue such a big policy change with no legislative input. All 50 state senators approved a bill to provide some oversight for the shift to managed care for most Medicaid recipients. In theory, that bill died in the legislature's second "funnel" after not advancing in the Iowa House, but speaking to Rod Boshart, Senate President Pam Jochum "said she expected the issue to resurface during budget negotiations." Addressing her Senate colleagues on April 2, Jochum said,
Here's a very important issue House Republicans and Governor Branstad appear to be overlooking.
The issue is oversight of the privatization of almost all of Iowa's Medicaid system.
Medicaid is one 6th of the state budget.
It provides health care to a half million Iowans.
70% goes to help seniors and people living with disabilities.
Governor Branstad appears to want to privatize Iowa's Medicaid system in the worst way possible: doing too much at once, doing it too fast, and making all the decisions himself.
During yesterday's news conference, Branstad indulged in some Orwellian doublespeak when asked about the new Medicaid policy and the mental health closures.
On Monday, Branstad told reporters he "clearly has the authority" to proceed with actions his administration has undertaken. At the same time, he said he respects that the Legislature has oversight and budgeting authority and executive branch officials "always try to be open and responsive to any questions or concerns" that legislators have.
"I mean we bend over backwards to give them all kinds of information and we will always continue to do that because I do respect the legislative responsibility for oversight," Branstad said.
"But, I am the chief executive. The buck stops with me. I have to make tough decisions and I'm willing to do that because the people of Iowa elected me to reduce the size and cost of government and to make it more accountable and more responsive and more transparent and we're going to continue to do that."
Branstad respects legislative oversight so much that he repeatedly closes state-run institutions for which the legislature has appropriated funds.
He "bend[s] over backwards" to give lawmakers "all kinds of information," but key legislators had no heads-up about the plans to close the mental health institutes and were not consulted about the Medicaid changes before the DHS put out the request for proposals from managed-care providers.
The same voters who elected Branstad to a sixth term elected the members of the Iowa House and Senate. The governor doesn't have a blanket mandate for every cutback that may appeal to him, especially since his last re-election campaign was short on policy specifics. Instead of bragging about alleged transparency and his ability to make decisions alone, Branstad should work collaboratively with legislators on policies that affect the most vulnerable Iowans.
UPDATE: As usual, the Cedar Rapids Gazette's Todd Dorman hits the nail on the head. No excerpts, just click through and read the whole piece.