Clawback looms over mental health redesign
|By Mike Anderson, Waterloo-Cedar Falls Courier, Iowa|
|McClatchy-Tribune Information Services|
Also referred to as "
"The clawback is all about taking money out of the system," said Democratic Sen.
Though it has yet to be fully activated, the clawback will funnel millions of dollars from a mental health system that has been historically underfunded back into the state's coffers. Experts believe the clawback will result in significant cuts to mental health services and a regression to the stagnant system in place before the redesign.
All the clamor revolves around a single, central question: What is the future of mental health services in
Neither the governor nor state lawmakers can begin to answer that question until they start talking about the mental health redesign law as a whole. So far this year those conversations haven't happened, not in the
"The silence on this issue in
Both Johnson and Bolkcom serve on the
According to Johnson, the fiscal viability committee hasn't met since the legislative session began
With only weeks left until the session adjourns in April, Johnson is worried the mental health redesign has fallen to the wayside.
"It leaves me at a loss for what's going on," Johnson said. "I would call it poor management of the issue. And it's an important issue."
To understand what the clawback is and why it's important requires a crash-course on the history of the mental health redesign law.
The redesign is
State mental health experts say it was an inherently flawed concept marred by inequality; depending on population and finances, some counties were unable to provide any mental health services.
The old system's death rattle was sounded in the spring of 2012 when the state passed the mental health redesign law. It was meant to lift much of the financial burden from individual counties and create a standardized level of mental health services across the state.
The redesign reorganized the state's 99 counties into 14 regions. The law requires each of these regions to provide a standardized package of core mental health services. The goal is for each region to someday be financially sound enough to expand services.
But providing even the core services has proven financially difficult for some regions, prompting
The clawback looms large over those funding strategies, and in the eyes of some Democratic lawmakers, threatens to derail them.
"Basic core services are in danger," Bolkcom said. "The clawback is going to prevent us from putting that system together."
Lincoln is the administrator for the
"In some ways it's more important to know what funding we will receive," Lincoln said. "We came out of a system that was very hard from year to year to predict what funding was available. ... It's hard to start programs even when you have money if you don't know if you're going have the money next year."
Counties collecting more than
But the already tenuous confidence instilled in mental health experts by this new funding structure is being shaken by two things: an expiration date and the clawback.
The equalization funds associated with the
Furthermore, if the counties save any money between now and then as a result of the
If there's a rabbit hole somewhere in the tangled galaxy of mental health redesign, it's at the crux of property taxes and health insurance reform.
At the bottom of the rabbit hole is the clawback.
"First of all, I don't know where the term 'clawback' came from," said
This is where the clawing back begins.
If counties save money because of health insurance reform, the state will get 80 percent of it.
The clawback, or
If a county had to lower its property tax levy to meet the new
The clawback is actually a compromise, according to
DHS must decide how much money each county will have to pay back
"The trouble is, how do you accurately figure that out?" Hoffman said. "I haven't seen a clear description for how that's going to be measured."
Hoffman hasn't seen a clear description because none exists. The state is already two months into DHS six-month "offset" calculation period, and still no methodology has been laid out.
Data for health insurance related savings remains incomplete, and estimates of how many counties still need state assistance are contradictory. ISAC says there are 11, DHS says there are only five.
The result is confusion. How much is the state going to claw back? Will there be annual adjustments based on inflation? How can the regions expand beyond the core services if they're bleeding dollars?
According to Hoffman, it's too soon to know.
"We're counting savings before the savings have arrived," Bolkcom said. "We're in danger of this whole system unraveling."
"We are not as a society paying attention to the seriousness of mental health. Period," said Democratic Rep.
Lawmakers like Kressig have joined their voices with mental health experts and county officials across
The ISAC is against the clawback.
"If that money goes back to the state, I can tell you there's no money coming back to the service providers to take care of people," Eachus said.
"Every (mental health) redesign I have seen in my time that involved state funding has failed because the state didn't live up to its commitments," he said.
Despite the opposition, Branstad continues to see the clawback as a positive thing.
"At least 80 percent of (the money) would go directly to property tax relief for the citizens," Branstad said. "And we think this is the fair thing to do. We're relieving this burden from the county, and we think it should be passed on to the property tax payers."
According to DHS, any equalization dollars taken back by the state will be placed in the
"The way it's presented as property tax relief, it's hard not to be in favor of the clawback," Hatch said. "But it could do just the opposite. Counties could raise property taxes to meet services."
The mental health redesign law requires that counties pay for core services "regardless of funding source." It's unclear whether counties would be allowed to raise taxes for mental health services under the law, but Hatch isn't alone in thinking it's a possibility.
Lincoln, the administrator of
"It's just introducing more complexity into an already complex funding formula," Lincoln said. "It going to unravel one of the best things of the redesign, which is to come to an equitable formula for mental health funding across the state."
Counties in regions like Lincoln's have already started to pool their funds for mental health services. The clawback, in Lincoln's eyes, will require the regions to "unravel" themselves one county at a time for the purpose of identifying funds to send back to the state.
The result, Lincoln fears, would be something that mirrors the old system, where every county fends for itself, property tax levies are all over the board and funding is inconsistent from year to year.
"Even without the clawback it's hard to predict what out our funding is going to be for next year," he said. "So when you don't have confidence in the system, there's a tendency to not invest in that system."
Eachus thinks many counties are already having a hard time paying for just core services. Mental health administrators all over
"Our region is trying to improve what we have, but without funding it's hard to say how it's going to impact us," Petlon said.
"The problem with mental health for years has been funding," Hyndman said. "And now they want to take back 80 percent of what they see as savings. ... It's just setting us up to fail in the new regions."
"We've got a golden opportunity to improve services, and the next thing we're going to do is take away a pot of money that could have been used for that," Farrell said. "It's money that's already in the system. To take it out only to have to fight for it again makes no sense."
What happens next?
Before it adjourned last year, the fiscal viability committee released a list of 26 recommendations related to the mental health redesign.
Included on that list were recommendations to switch to a regional funding formula and delay the activation of the clawback by at least one year.
"Let's leave the money in the system," said Peterson of the ISAC, "until we have a better understanding of what the significant changes to the system will be for people in need of services for mental health."
Peterson and state lawmakers like Hatch think delaying the clawback would at least allow the counties time get on their feet in the new regional system while DHS figures out how to calculate clawback amounts.
Some people, like Hoffman with Pathways, would like to see the clawback eliminated entirely.
In the mean time, various Democratic state lawmakers continue to insist they will vote against any mental health measure with the word clawback attached to it.
Until a decision is made, mental health providers like Lincoln and Eachus will simply have to wait and see what happens.
"Let's see if we can actually get something done with mental health redesign," Eachus urged lawmakers at a recent legislative forum in
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