By:Loren Anthes, Public Policy Fellow, Medicaid Policy CenterTara Britton, Director of Public Policy and AdvocacyHope Lane, Public Policy & External Affairs AssociateWilliam Tarter, Jr., Associate, Public Policy and External Affairs
Introduction
When the 2020-21 state budget (House Bill 166) was introduced earlier this year, Governor Mike DeWine stated, “for too long, we’ve tinkered at the margins,” he vowed his administration is dedicated to make significant investments in programs and systems where improved outcomes may take years to achieve. Based on the final budget, the Ohio General Assembly largely agreed with the direction of the DeWine administration. The Center for Community Solutions has examined the final state budget for key health and human services agencies including the Ohio Departments of Mental Health and Addiction Services, Developmental Disabilities, Health, Job and Family Services, Aging and Medicaid, which contain many of the key initiatives of the DeWine administration. The analysis of the Department of Medicaid can be found here.
Based on the final budget, the Ohio General Assembly largely agreed with the direction of the DeWine administration.
Ohio Department of Mental Health and Addiction Services
In regards to behavioral health, the Kasich administration elevated and expanded Medicaid, combined the mental health and addiction agencies of the state, carved-in services to managed care and navigated an influx of opioid-related resources from the federal government. However, the DeWine administration not only inherited these policy endeavors, but also one of the most significant behavioral health crises Ohio has known in the form of the opioid-use disorder epidemic.In his first budget, Governor DeWine emphasized children in multiple health and human services efforts and the Department of Mental Health and Addiction Services (MHAS) is no exception.Key takeaways
- Nearly $91 million in additional federal dollars will come to Ohio
- The Ohio Sobriety, Treatment and Reducing Trauma (OhioSTART) program will expand from 34 to 64 counties
- One-time investments are underway in the crisis services infrastructure and a number of other programs through the statewide treatment and prevention line item.
Alcohol, Drug Addiction and Mental Health Services boards (ADAMHS Boards)One of the core responsibilities of MHAS is to oversee the 50 ADAMHS boards that make up the statewide system that uses federal, state and local dollars to finance services for individuals with behavioral health needs. The individual boards typically contract with local providers to furnish services such as therapy, drug and alcohol treatment, assessments, housing and medication assistance. Outside of the money boards receive directly through local sources (such as levies) or the federal government, state funding is provided through general revenue (GRF) dollars via the continuum of care services line item (336421) and dedicated purpose funds (DPF) via the ADAMHS boards line items (336643).
Ohio Sobriety, Treatment and Reducing Trauma (OhioSTART) program provides specialized victim services to children who have parents with a substance abuse issue.
For the continuum of care services line item, ADAMHS boards saw an increase of $14.3 million over the biennium.[1] Much of this is attributable to the expansion of the Ohio Sobriety, Treatment and Reducing Trauma (OhioSTART) program from 34 to 64 counties. OhioSTART provides specialized victim services to children who have parents with a substance abuse issue. There are several new earmarks to continue mental health crisis stabilization in Ohio’s state psychiatric hospitals and more than $2 million will be allocated directly to several provider organizations, but $2 million that had previously been sent directly to ADAMHS boards based on opioid mortality rates will now flow through the ADAMHS board line item. Regarding the ADAMHS board line item, in addition to the reallocation of the $2 million from the continuity of care services line item, there are three new earmarks that deal with crisis services infrastructure, stabilization and prevention. In all, this line item will increase by $22 million over the biennium.
The $2 million that had previously been sent directly to ADAMHS boards based on opioid mortality rates will now flow through the ADAMHS board line item.
Out of all of the line items managed by MHAS, however, the statewide treatment and prevention line item (336623) saw the most significant change with an increase in the first fiscal year of more than $40 million. This money will flow to ADAMHS boards but can also be made available for prescribed special projects or programs, including K-12 prevention education, multi-media campaigns, mental health, first-aid training and recovery.Table 1: ADAMHS* funding[table id=77 /]*Not all dollars will flow to ADAMHS Boards, though their role in each of the line items is meaningful for analysis.Source: Ohio Legislative Service CommissionSignificant federal funding increasesNearly $91 million in additional federal dollars will come to Ohio, with the majority in State Fiscal Year (SFY) 2020 as opposed to SFY 2021. The funds come from a State Targeted Response (STR) grant, which is a part of the 21st Century Cures Act (line item 336503) and the State Opioid Response (SOR) grant (line item 336644), funded by the federal Substance Abuse and Mental Health Services Administration. According to MHAS, this funding will be used to increase access to medication-assisted treatment, expand access to naloxone training and developing employment opportunities for recovering individuals. OMHAS also expects a significant increase in the grants it receives through the demonstration grants line item (336303) from $5.3 million in 2019 to $15 million each fiscal year (an overall increase of $15 million budget to budget).
MHAS’ budget increased by $313.3 million relative to the previous state budget.
Looking at DPF, GRF and federal funding, MHAS’ budget increased by $313.3 million relative to the previous state budget. The majority of these dollars are tied to federal funding, though DPF saw the largest relative increase due to the significant, one-time infusion of resources in SFY20 via the statewide treatment and prevention line item. Importantly, with Ohio’s recently approved 1115 demonstration waiver for inpatient behavioral health services and its reconstitution of the Behavioral Health Redesign in Medicaid, it will be interesting to see how the next budget deals with the potential loss of time-limited resources.[2]Table 2: Ohio Department of Mental Health and Addiction Services Revenue by Funding Source, FY 2019-2021 Source: Legislative Service Commission Appropriation Spreadsheet (with FY 2019 actual expenditures)
Ohio Department of Health
The focus on kids continues into the Ohio Department of Health’s (ODH) budget. The key investments enacted include expanded home visiting, lead abatement activities and increasing the legal age of tobacco purchase from age 18 to 21. ODH is responsible for a wide breadth of issues within its agency including direct service, regulatory duties, programs coordinated through grants and programs coordinated through outside entities. The agency’s overarching goal is “preventing disease, promoting good health and assuring access to quality health care.”Major ODH provisions [3]Home visitingIn the very early days of the governor’s budget, he prioritized upstream investments for Ohio’s youngest residents that would yield results for years to come. The governor’s proposed budget more than doubled the state’s investment in evidence-based home visiting through the state’s Help Me Grow (within ODH) and Early Intervention (within Department of Developmental Disabilities) programs. This proposed increase sought to triple the reach of home visiting, which to date only reaches 6 percent of eligible families (8,915). Expectant mothers, or caregivers with a child age two or under, with incomes at or below 200 percent of the federal poverty level are eligible for home visiting if they fall into one or more of several categories.[4] In the final budget, funding for home visiting was increased, but not to the levels initially proposed by the governor. The Governor’s Advisory Committee on Home Visitation proposed 20 recommendations leading up to the budget’s introduction and it is anticipated that these recommendations will inform the rollout of the expansion of home visiting going forward.
As the state’s public health agency, several elements of ODH’s budget deals with lead.
Lead abatementOhio has work to do to address significant issues relating to lead and lead poisoning. This work includes identifying all lead-poisoned children, treating those impacted and remediating lead in housing where lead has been detected. As the state’s public health agency, several elements of ODH’s budget deals with lead. In addition, federal and local funds will be leveraged to further contribute to these efforts. Within the final state budget, the funds dedicated to lead abatement and the demolition of lead-blighted properties make up a portion of the environmental activities line item (440454) and comprise an entirely new line item dedicated to a lead safe pilot program (440530).Within the environmental activities line item (which funds other programming related to environmental public health) up to $150,000 is earmarked for the City of Toledo to address “lead-based paint abatement, containment and housing rehabilitation projects in the historic south neighborhoods of Toledo.” The city must provide documentation of the amounts of public and private dollars dedicated to these efforts and the state will match this amount up to $150,000.The Lead-Safe Home Fund pilot program will provide grants to property owners who are want to remediate lead. The Lead-Safe Cleveland Coalition will document the amount of local public and private dollars collected to support this work and the pilot program will distribute state funding to match the local amount up to $1 million in each fiscal year.
The budget also requires the ODH director work with the Tax Commissioner to develop a tax-credit program for lead abatement.
The budget also requires the ODH director work with the Tax Commissioner (Ohio Department of Taxation) to develop a tax-credit program for lead abatement. Individuals who have costs associated with lead abatement are for eligible properties can receive a tax credit up to $10,000. The ODH director is authorized to issue a total of $5 million in tax credits per biennium. This program will begin January 1, 2020.A policy change included in the budget requires the ODH director to issue an order that prohibits using a residence, child care or school facility for any purpose where the owner has failed to comply with a lead hazard order or the property has not passed a lead clearance exam.Review committeesWhile no money is attached, language in the budget bill formally establishes the pregnancy-associated mortality review (PAMR) committee. The language in the introduced budget was permissive as to the formal establishment of PAMR, but the final budget codifies PAMR in state law and requires the committee to release data on maternal mortality every two years. It also requires ODH to adopt rules for reviewing maternal deaths.
The final budget codifies pregnancy-associated mortality review (PAMR) in state law and requires the committee to release data on maternal mortality every two years.
Chronic diseaseFunding in the chronic disease, injury prevention and drug overdose line item targets prevention and reduction of obesity, chronic diseases, tobacco use and drug overdoses. This line item was funded at about $3.5 million in FY2019 and increases to $7.7 million in 2020 and $7.9 million in 2021.Tobacco 21The final budget statutorily increased the legal age for purchasing tobacco products, including vapor products, from age 18 to age 21. Legislative language changes the legal age associated with tobacco use from age 18 to 21 throughout the Ohio Revised Code. While this is a key initiative for ODH, there are still insufficient dollars allocated for enforcement of these changes.Other changesFor the first time, there is a dedicated line item for harm reduction services, including syringe service programs. The line item is funded at $50,000 per year and can be used to grant awards of up to $15,000 per local public health departments to operate harm reduction services.This budget saw increased funding and expanded eligibility for the breast and cervical cancer program that offers breast and cervical cancer screenings and diagnostic services to women with low-incomes and limited access to health services. This change increases the income eligibility range from up to 250 percent of the federal poverty level to up to 300 percent of the federal poverty level and expands the age range of women who are eligible from age 25 to 21.
This change increases the income eligibility range from up to 250 percent of the federal poverty level to up to 300 percent of the federal poverty level and expands the age range of women who are eligible from age 25 to 21.
The budget bill includes a revival of the Legislative Committee on Public Health Futures which has made an appearance in a few budget bills over the last eight years. This committee was initially tasked with exploring the local public health system and working toward accreditation of public health departments across the state. This latest iteration will explore the status of recommendations from previous reports and how they’ve been implemented. The committee must issue another report to the General Assembly by December 31, 2020.Table 3: Ohio Department of Health Revenue by Funding Source, FY 2019-2021[table id=79 /]Source: Ohio Legislative Service Commission, ODH Greenbook
Ohio Department of Job and Family Services
The DeWine administration’s commitment to invest in Ohio families and children through the Ohio Department of Jobs and Family Services (ODJFS) was confirmed by the General Assembly, where several provisions even saw increases.Major provisionsTANFThe Temporary Assistance for Needy Families (TANF) program saw no major differences from the executive budget which included a Program Services Framework for fiscal year (FY) 2020-2021. This framework outlined the goal to eliminate TANF’s continued underspending of federal dollars and disproportionate spending in publicly-funded child care by FY 2022. The enacted version of the budget calls for the underspent dollars to be used on 22 different earmarks worth $49 million per FY. These earmarks will be used to fund or boost programs that share in the original purpose of the TANF program - self-sufficiency – and range from the Commission on Fatherhood to YWCA of Greater Cleveland.
The enacted version of the budget calls for the underspent dollars to be used on 22 different earmarks worth $49 million per FY.
Child careFunding for publicly funded child care and child care subsidies comes from a combination of federal and state dollars. While the executive budget proposed no new state GRF dollars dedicated to child care, the budget as-enacted saw minor increases in child care line items with GRF dollars including line item 600555 which supports early care and education and line item 600696 which supports early childhood education. The increased federal funding for child care will go towards implementing the budget’s goal of increasing reimbursements to subsidized providers.
Perhaps the largest budget change to child care deals with the Step Up To Quality system.
Perhaps the largest budget change to child care deals with the Step Up To Quality (SUTQ) system. SUTQ is a five-star quality rating system designed to promote learning and development programs for children, as well as create health regulations for providers. Prior to the budget passing, beginning July 1, 2020, publicly-funded child care could only be provided by a child care provider that was rated through SUTQ. The as-enacted budget adjusted this requirement by exempting certain providers, such as those who only operate during the summer and those located in states bordering Ohio, from being rated through SUTQ.Child welfareThe family and children services line item (600523) is critical for families and children because it supports child welfare agencies in Ohio. After going on a “ride-along” visit with a social worker in his district, Speaker Larry Householder insisted the line item should be more than doubled to support county children’s services, which Governor DeWine already proposed increasing. The as-enacted budget saw a nearly 150 percent increase in the line item from 2019 funding levels.Table 4: Family and Children Services line item (600523) as enacted[table id=80 /]Source: Ohio Legislative Service Commission [table id=81 /]Source: Ohio Legislative Service CommissionLine item 600523 earmarks explained:Multi-system youth: While many line items were altered throughout the budget process, the $25 million dollars per FY for multi-system youth remained intact. This money will be paired with line items in both the Departments of Medicaid and Developmental Disabilities’ budgets to address youth involved with two or more state systems, in an attempt to avoid having to remove children from their families to receive services.Public children services agencies: The bill requires not less than $125 million in each fiscal year to be dedicated to county public children services agencies for staffing, foster parent recruitment and other support services.Kinship Navigator Program: The administration’s budget created a Kinship Navigator Program, housed in ODJFS and allocated $3.5 million per FY to provide information and services to kinship caregivers within established regions. The final version increased this funding to $8.5 million per FY.Cleveland State University: This earmark will be used to support tuition and services of Cleveland State University students who have aged out of the foster care system.Other significant child welfare increases include:
- The adoption services line item (600528) saw an increase of 15.7 percent from $25 million in FY 2019 to nearly $29 million for both FYs 2020 and 2021. This line item will be used to continue to provide state subsidies and maintenance payments for families who adopt children with special needs.
- The children’s crisis care line item (600674) saw an increase of 407.2 percent from $148,000 in FY 2019 to $750,000 in both FYs 2020 and 2021. This line item will be allocated to residential facilities that temporarily provide care for children during an emergency situation.
Adult Protective ServicesWhile Governor DeWine’s initial budget did not increase the adult protective services (APS) line item (600534) for FY 2020 or 2021, the legislature landed on a 59.6 percent increase for FY 2020 and 2021 from FY 2019. This $4.2 million appropriation per FY will provide roughly $48,000 to each county, each year, to help county job and family services investigate and evaluate reports of abuse, misconduct and exploitation of Ohioans age 60 and older. APS staff work closely with state and county jobs and family services agencies, law enforcement and aging advocates to ensure incidences of physical violence, mental abuse or financial exploitation of older adults is addressed in a timely manner. The additional funding will help to bridge the gap between counties with additional resources, like levies, and those that do not have additional funding, so that support for older adults is consistent throughout the state.
This $4.2 million appropriation per FY will provide roughly $48,000 to each county, each year, to help county job and family services investigate and evaluate reports of abuse, misconduct and exploitation of Ohioans age 60 and older.
Table 5: Revenue by Funding Source, FY 2019-2021[table id=82 /]Source: LSC Greenbook Analysis of Enacted Budget, ODJFS
Ohio Department of Developmental Disabilities
The DeWine administration’s key initiatives for the Ohio Department of Developmental Disabilities (ODODD) were mostly maintained throughout the budget process and are included in the final version of the budget. While the ODODD budget will see a nearly 15 percent increase in funding from FY 2019 to FY 2020, this can be largely attributed to the rise in federal Medicaid reimbursement for services provided to individuals with disabilities and their families. These services largely include Medicaid waivers, developmental centers, residential facilities and targeted case management services.Major provisionsEarly interventionThe as-introduced version of the budget provided the Early Intervention (EI) program line item (322421), with a significant increase of $12.3 million in GRF in FY 2020, bringing the total GRF appropriation to $23.2 million in FY 2020 and $23.3 million in FY 2021. This increase in GRF for the program survived the budget process and remains the same in the as-enacted budget, leaving the program with a 112.9 percent appropriation increase from FY 2019 to FY 2020. The EI program provides coordinated services to young children and their families who have, or may experience, developmental delay or disability.
As recommended by the administration, the funding increase will expand program eligibility to include young children with lead exposure and neonatal abstinence syndrome.
Multi-system youthAs discussed in previous posts, multi-system youth (MSY) are adolescents with complex needs who require the care of more than one state department including Medicaid, the Department of Youth Services, the Department of Rehabilitation and Corrections, the Department of Jobs and Family Services and/or the Department of Mental Health and Addiction Services. The budget retained the 2019 appropriation level of $1 million for MSY (line item 322422) in the ODODD budget. This money will complement the $25 million yearly investment from ODJFS, and $18 million from ODM, over the biennium to target services for children with multi-system needs.
This money will complement the $25 million yearly investment from ODJFS, and $18 million from ODM, over the biennium to target services for children with multi-system needs.
TransportationThe legislature and Governor DeWine agreed that more resources needed to be allocated to update community transportation capabilities for the nonmedical transportation of people with disabilities. With the goal of increasing flexibility for people with disabilities to be able to work, go to school and participate in their communities, Governor DeWine proposed to use smaller vehicles for more person-centric transportation as opposed to large vehicles of large groups. The budget maintains the executive proposal to share the cost of the modernization of transportation services with the federal government over the biennium.
Governor DeWine proposed to use smaller vehicles for more person-centric transportation as opposed to large vehicles of large groups.
Vetoed provisionsProvider pay increasesDirect support professionals consist of both homemakers and on-site, on-call caretakers who work with individuals with disabilities daily to ensure their needs are met. The wage of these workers, which largely depends on the Medicaid reimbursement rate, has not been increased in 15 years. The final budget included an 11 percent increase to the average wage of a homemaking professional over the biennium to be conducted in stages of $0.63 per year.Table 6: Executive Budget[table id=83 /]Meanwhile, direct support professionals, providers, county developmental disabilities boards and the individuals they serve continued to lobby the legislature for a more significant increase to bring the average wage to at least $13 an hour. The argument was that anything less would not make a substantial impact on worker shortage and turnover rates.Table 7: As passed by the House[table id=84 /]Source: Ohio Legislative Service CommissionTable 8: As passed by the Senate[table id=85 /]Source: Ohio Legislative Service CommissionAlthough both chambers agreed on a $2.11 hourly wage increase over the biennium, Governor DeWine vetoed the provision, stating he did not want to lock wage increases into state law. DeWine instead issued a state mandate that will go into effect on January 1, 2021 that will increase the base pay for those workers from $11.12/hr to $13.23/hr.Table 9: Ohio Department of Developmental Disabilities by Funding Source, FY 2019-2021[table id=86 /]Source: LSC Greenbook analysis of Enacted Budget, ODODD
Ohio Department of Aging
In 2018, the annual budget for the Ohio Department of Aging (ODA) was $14,684,780 and the estimated budget for 2019 was $14,949,726. The Ohio Department of Aging saw a sizable increase in the introduced biennial budget, which proposed 33 percent GRF budget increase of up to $19,342,491 for FY2020 and $20,816,004 for FY2021.
By 2030, more than 3.3 million Ohioans will be 60 years of age or older.
As we have stated in several publications, Ohio will see an aging trend in coming years. By 2030, more than 3.3 million Ohioans will be 60 years of age or older. In this budget, the Governor proposed increasing funding for several areas under the control of the Department of Aging that would affect support services available for seniors. We will examine a few of the changes below.Ohio Long-Term Care OmbudsmanBy far, the biggest increase in percentage of funding in the ODA GRF budget, was for the Ohio Long-Term Care (LTC) Ombudsman’s office. The Ohio Long-Term Care Ombudsman provides support and advocacy for Ohioans 60 years of age and older that are in nursing homes, assisted living facilities, class 2 residential facilities and unlicensed homes.[5] The ombudsman also voices consumer needs and concerns to policymakers and providers. The office is not a regulatory body, but relies on education, negotiation and mediation to solve problems.[6]The LTC line item (490410) received an increase in funding from $477,193 in FY2019 to $1.84 million in FY2020 and $3.1 million in FY2021, an increase of 292.7% and an additional 68.5% on top of that in FY2021. The funding will be distributed to each of the 12 regional LTC districts across the State of Ohio. The funding will be used to expand the investigation of complaints against providers for long-term care services for the elderly.
The 2019 Senior Farmers' Market Nutrition Program provided $50 worth of coupons to eligible adults 60 years of age or older to purchase locally grown, fresh fruits, vegetables, herbs and honey from local farmers.
Senior community servicesThe senior community services line item (490411) was increased from $6,838,303 in FY2018 to $8,152,696 in FY2020. The senior community services line item currently goes to the 12 regional area agencies on aging, each of which has discretion on how the money is spent to support seniors in their service areas. Currently the State of Ohio receives federal funding to support the Senior Farmers' Market Nutrition Program. The 2019 Senior Farmers' Market Nutrition Program provided $50 worth of coupons to eligible adults 60 years of age or older to purchase locally grown, fresh fruits, vegetables, herbs and honey from local farmers, according to the Area Office on Aging of Northwest Ohio, Inc.[7]The Senior Farmer’s Market program is administered in 45 of Ohio’s 88 counties, through various Area Agencies on Aging across the state. With the increase in state funding of the line item, when combined with the current federal allocation, the farmer’s market program can be expanded statewide.[8]However, the state allocation does not increase funding overall in counties that already receive money.Vetoed provisionsThere were a few items in the budget that were vetoed[9] by Governor DeWine. One was a funding provision which would have increased the rates for assisted-living facilities. Additionally, a funding provision was vetoed which would have increased the rate of pay for home care attendants, personal care and waiver nursing services provided under the Pre-Admission Screening System Providing Options & Resources Today (PASSPORT) program. Finally, the Governor vetoed a provision which would have increased the rate of home-delivered meals during FY2020 and FY2021.In the Governor’s veto message he stated, among other reasons, that he did not want to make the rate of home-delivered meals change by statue. Additionally, regarding the assisted living and some of the PASSPORT services, the Governor’s office has committed to a rate increase, but not to the specific rates that were indicated in the state budget. The Governor’s office continues to work with advocates and provider associations on administrative next steps, even after the budget process is complete.Table 10: Ohio Department on Aging (General Revenue Fund) Source: Ohio Legislative Service Commission
While the frenzy of budget activity has calmed down, the provisions and funding levels enacted in House Bill 166 will serve as the operating budget for the State of Ohio until June 30, 2021.
Conclusion
While the frenzy of budget activity has calmed down, the provisions and funding levels enacted in House Bill 166 will serve as the operating budget for the State of Ohio until June 30, 2021. Community Solutions will continue to examine the implementation of policy and funding changes throughout the course of the biennium.[1] The Ohio Legislative Service Commission, Appropriation Spreadsheet (with FY 2019 actual expenditures). https://www.lsc.ohio.gov/documents/budget/133/mainoperating/EN/appropriationspreadsheet-hb166-en-with-fy2019actuals.pdf[2] Newman, Jeremy. “CMS Approves Ohio’s Substance Use Disorder Demonstration Waiver to Improve Patient Treatment Options.” The Scioto Post, September 24, 2019. http://www.sciotopost.com/cms-approves-ohios-substance-use-disorder-demonstration-waiver-improve-patient-treatment-options/[3] Schroeder, Jacquelyn. Ohio Legislative Service Commission, Ohio Department of Health.[4] Pregnant women under the age of 21; had previous preterm birth; families with a history of child abuse, neglect, or have had interactions with child welfare services; families with a history of substance abuse, or demonstrate a need for substance abuse treatment; families with a child who has a diagnosed developmental delay; families that have users of tobacco products in the home; active military families; families with a history of unstable housing or homelessness; and/or families with a caregiver who has a history of depression or other diagnosed mental health concerns.[5]https://www.lsc.ohio.gov/documents/budget/133/MainOperating/greenbook/AGE.PDF[6]https://www.lsc.ohio.gov/documents/budget/133/MainOperating/greenbook/AGE.PDF[7]https://www.areaofficeonaging.com/programs[8]https://aging.ohio.gov/News/national-farmers-market-week[9] https://content.govdelivery.com/attachments/OHOOD/2019/07/18/file_attachments/1250127/Veto%20Message%20Signed%20%287.18.19%29.pdf
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