Many people probably read the title of this diary and skipped it right over. Those who recognize Olmstead are my target audience though, and I hope to hear comments from as many as possible.
The nuts and bolts are this: How do we ensure that the employer shared responsibility section of the Affordable Care Act accommodates employers who provide services to those at risk for institutionalization due to mental illness or mental disability.
Everyone is familiar with the employer shared responsibility (aka employer mandate) portion of the ACA. While I think the mandate could use some tweaks I am not opposed to it in general. However I think something that hits close to home for me has been overlooked.
My company and others in the filed provide home and community-based services to individuals with intellectual and developmental disabilities. These services are funded by Medicaid via the NC Innovations Waiver as an alternative to institutionalization.
Without going into great detail, the rates for these services are set by Managed Care Organizations under the Medicaid umbrella. They are not what I would consider high to begin with and have not been adjusted for inflation in over a decade.
Basically, a provider agency hires and trains employees. Out of the hourly rate they pay the employees, pay overhead, pay Qualified Professionals to oversee the employees and track the progress of the individuals receiving services, and take a modest profit.
So keep in mind that the provider agencies cannot raise prices, nor can they reduce wages without sending these workers to other fields. For a service that reimburses at $13.00 per hour, the employee will get at least $8.00 an hour of that. Throw in overhead, administrative staff, and clinical staff, and there's just not a lot of meat left on the bone, so to speak.
Currently my agency and several others in the area are utilizing transitional relief from the ACA employer mandate for 2015. That ends in January. None of these agencies can bear the cost of offering compliant insurance. Most can withstand paying the penalty for a year, maybe two at the most.
This brings me to Olmstead. The Supreme Court ruled that any public policy, procedure, or regulation that puts individuals with mental illness at risk of institutionalization violates the Americans with Disabilities Act. If a reasonable accommodation exists that would not disrupt the fundamental purpose of the regulation, the government is required under Olmstead to allow it.
Multiple provider agencies closing or cutting employee hours to mitigate the penalty would put such a risk in place.
Many experts and administration officials have said that eliminating the employer mandate altogether would not disrupt the fundamental purpose of the ACA. But we are not proposing that. What we would like to see is an accommodation that exempts employers who provide services exclusively to those with mental illness or disability from the employer shared responsibility.
At last count there are 12,000 individuals in North Carolina receiving these services, with 9,000 on the waiting list. Without these services, a good number of these individuals would be institutionalized. The moral and financial cost of this would be immense, and, in my opinion, run afoul of Olmstead.