Good Money After Bad?

In the wake of high-profile abuse in Texas' institutions for the disabled, state health officials want to boost payments to them — to the tune of $25,000 per patient per year. But the proposed Medicaid rate change has drawn the ire of Texas’ disability community, which wants to see the facilities shuttered rather than propped up.

The proposed rate increase could be “devastating” for the majority of disabled people who receive state support outside of the centers, says Amy Mizcles, director of governmental affairs with the Arc of Texas, who believes the increased funding at the centers will come at the expense of programs for people with disabilities living in the community.

Texas’ 13 state-supported living centers have been under intense monitoring since last year, when lawmakers agreed to a five-year, $112 million settlement with the U.S. Justice Department over widespread abuse and neglect at the state-run facilities. The proposed rate hike reflects the irony of that victory: The facilities advocates want closed are now protected from statewide Medicaid rate cuts by the settlement.

Already about a third of state dollars for people with disabilities go to the state centers — which serve just 4,200 residents, or 9 percent of people receiving state services, Mizcles says. With the state facing a budget shortfall estimated at $18 billion, advocates believe the state will be forced to cut community-based programs because they can’t cut financing to the centers. “Public dollars can and must be used more effectively,” Mizcles says.

The abuse at Texas’ state-supported living centers in recent years has run the gamut from physical beatings and restraints to medical neglect; in some cases, advocates say, residents died or were permanently injured from their mistreatment. These types of incidents occur in community-based care, too, where people with disabilities receive services in their individual homes or small group settings for a fraction of the cost. Families of state-supported living center residents say the facilities — often on large campuses — provide safety and around-the-clock stimulation. Advocates for independent living say community care is less restrictive, more economical and far safer, because residents aren’t warehoused in a remote institution.  

As part of the settlement agreement and reforms lawmakers passed last legislative session, the centers have added staff, implemented new security measures and moved residents into community settings — all at a cost. To meet these costs, and to qualify for a hefty federal match, state officials want to raise Medicaid reimbursement rates to the facilities by about 14 percent, from $470 per patient per day to $540. They say the costs, which were anticipated as part of the settlement agreement and would be shared with the federal government, are necessary to ensure “adequate funds will be available to serve individuals residing in those facilities.”

Even as the centers serve fewer people, the state has added staff and spent more money to comply with the Department of Justice agreement to improve state-supported living centers, which now serve mostly high-need residents, says Health and Human Services Commission spokeswoman Stephanie Goodman.

The rate change will be debated at an HHSC public hearing on Friday. Meanwhile, lawmakers on the Senate Finance Committee meet today to ensure all the terms of the Justice Department settlement are being followed, along with the emergency legislation passed last session. Despite many improvements, monitors stationed at state-supported living centers have in recent months found evidence of staffing shortages and “dehumanizing practices” — including giving women the exact same cropped haircut and leaving disabled residents with nothing to do for hours on end.

Cecilia Fedorov, a spokeswoman for the Department of Aging and Disability Services, says the agency has hired more workers, including night-shift supervisors, professional medical staff and facility ombudsmen. Video surveillance systems are being installed at all 13 centers. And the agency has implemented random drug testing and FBI fingerprinting for all state-supported living center employees.

Opponents of the state-supported living centers have worked for years to shutter them, lobbying lawmakers about abusive conditions as a way to move more people with disabilities into community-based services. But with the influx of money to facilities they consider failing, the advocates fear their efforts may have backfired. At this rate, they say, convincing lawmakers that they’re wasting their money is an uphill battle.