The increased population from immigration, documented (legal) and undocumented (illegal), has strained the budgets of state and local governments without adequate federal government help. "Drama" (conflict) has disrupted activist movements that build communities of people to advocate the interest of constituencies within the communities.
In Montgomery County, Maryland in the recession of 2000 to 2003 population increases due to immigration led to a division between advocates of 'safety net' services for people with mental illness who were uninsured or underinsured citizens and documented and undocumented immigrants.
Short term grants were given here and described in this article
Council OKs $695,000 for mental health clinics
By Karl Hille
Montgomery Journal staff writer
Wednesday, October 17, 2001
The Montgomery County Council Tuesday granted $695,000 to bail out nine mental health clinics that are experiencing difficulties under increasingly complex federal Medicaid and Medicare payment provisions and shrinking state funding.
The grant raises to $870,000 this year the county's stake in a mental health care system council members insist is not a local government responsibility.
``In this area, it is clear to me the federal government ignores its responsibility, the state takes piecemeal responsibility and the county is left to make Band-Aid solutions," said Council President Blair G. Ewing, D-at-large.
The grant includes a $20,000 base allotment to each clinic to cover administrative costs. The rest of the money will be distributed based on the number of patients relying on public insurance coverage who come for treatment.
To receive the support, the clinics agreed to a management audit by the county Department of Health and Human Services, to work with the agency to determine how to measure its performance and to continue appropriate treatment for patients who enter county jails or homeless shelters.
Clinic operators said the grant would allow them to continue serving patients already in their care, but almost none of the clinics operating in the county will take on new patients either dependent on Medicare or uninsured.
``We have been forced to choose between survival and complete dedication to our mission ... to serve the people who need us the most," said Jeff Carzwell, vice president of marketing for Affiliated Sante Group, one of the nine clinics.
Federal Medicare coverage for seniors covers only 50 percent of psychiatric services, and providers say many who depend on the federal system cannot afford to make up the difference.
Pam Cudahy, director of St. Luke's House in Bethesda, said this one-time grant will help the clinics survive this year only.
``Unless there is change at the state and federal level, we believe the [reimbursement] rates will continue to be inadequate over a period of time," she said.
Evelyn Burton, spokeswoman for the Montgomery chapter of the National Association for the Mentally Ill, said the alternative would be to deny treatment to many county residents.
``These funds are needed today to prevent clinic closure," she said. ``There is currently no public clinic to serve as a safety net for the long term needs of English-speaking adult consumers who may be denied treatment by private clinics because they are uninsured or underinsured."
Burton also said requiring clinics to extend their services to jailed patients could have ``dire financial and organizational consequences" if the clinics do not receive an additional grant.
``These are services that are not reimbursable by Medicaid," she said, ``and were not contemplated in the calculation of the grant requested by the clinics."
Randall Bosin, a mental health advocate, supported the grant, though he said the grant agreement did not guarantee strong enough protections for existing patients.
``It would be good if the subsidy is tied to certain trackable, concrete commitments the providers are required to make," he said.
He said the county ``poured out" money last year for a similar grant to keep the Chestnut Lodge clinic in Rockville open for a few extra days. The clinic, which offered care to the mentally ill, eventually closed.
Bosin also said the need for these services could increase.
``There's evidence already that we are going to have increased requirements of these services since Sept. 11," he said.
The crisis continued into 2002 a state and local election year as well as a 'midterm' federal election 2 years after a presidential general election.
https://health.maryland.gov/newsclippings/archives/2002/apr02/041902.htm#General%20Assembly%20failed%20many%20ailing%20Marylanders
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`Dire shortage' strikes mental health clinics
By Whitney L. Jackson and Karl Hille
Montgomery Journal staff writers
Friday, April 19, 2002
Two privately run mental health clinics will no longer take new patients, despite efforts by Montgomery County to keep clinics operating.
Washington Assessment and Therapy Services in Silver Spring and Affiliated Sante Group in Wheaton announced they do not have the resources to treat a growing number of patients coming to their doors for help.
``Since December we have just been overrun with people who need treatment because we were the only place where they could find that," said Jeff Carswell, vice president of corporate development for Affiliated Sante Group.
The clinic, which is located in the Mid-County Service Center on Reedie Drive, currently serves about 1,151 patients. Since December, the clinic has been accepting 75 to 100 new patients a month, Carswell said.
The clinic also absorbed many of the patients from the closing of CPC's Chestnut Lodge in Rockville last April, Carswell said.
Susan Wynne, site manager of Washington Assessment and Therapy Services, told the County Council that they too have a ``dire shortage of psychiatric coverage" at a public hearing Tuesday night.
Council member Blair Ewing, D-at-large, proposed adding $645,000 to the county budget to assist mental health clinics.
The $645,000 allocation includes $100,000 for Medicare, underinsured and uninsured clients, $100,000 to pay for care management at the clinics, and a $75,000 independent assessment of the clinics.
Many clinic representatives have said they need a lot more money to stay in operation. They have said the state privatized its mental health-care system in 1996, but private providers have had difficulties getting payment for older patients under Medicare, and handling the large amount of paperwork they say is needed to get payment from the state.
The Montgomery County Council allocated $870,000 in emergency funds in October 2001 to help the county's nine clinics keep their doors open, and the county executive and state health department announced an additional $1 million in reallocated funds in January tied to reform
measures.
Many clinic operators, however, said while the emergency appropriations from the County Council helped, government processing has kept most of the funds from reaching their target.
Carswell said Affiliated Sante Group only received $90,000 of the $140,000 they billed the county, and Threshhold Services in Silver Spring said they would close their doors permanently in March and Montgomery General Hospital closed their Colesville clinic in February.
``The County Council has been really supportive, but it takes so long for the money to get to the providers," Carswell said.
Affiliated Sante Group, which is the largest mental health provider in the county, employs about 13 therapists and four physicians.
Ewing blamed the county's Department of Health and Human Services for stonewalling and opposing the current proposed allocation.
``The Department of Health and Human Services didn't send comments or show up" to the public hearing, Ewing said. ``They said the funds are unnecessary and current funding is adequate."
David Weaver, spokesman for County Executive Douglas M. Duncan, said the appropriations already passed should be adequate to keep clinics open temporarily, but the rest of the burden should not fall on the county.
``We do not believe Montgomery County taxpayers should be the funders of first resort for mental health," Weaver said. ``It's very clear in this current environment that the state needs to do even more. ... This is a state responsibility and the state needs to meet its obligation."
Ewing said the shortage of clinics taking new patients could discourage mentally ill individuals from seeking treatment.
``People with serious mental illnesses won't be able to get treatment anywhere," he said. ``If it's made harder to get into a clinic, their willingness to pursue treatment could go down."
Journal staff writer Kelly Smith contributed to this article.
Ultimately Montgomery County could only afford to support primary health clinics for non-English speaking people (immigrants both documented and undocumented) in need.
[no link available Montgomery Gazette closed in 2015 and took their links down as well]
County looks at money to aid upcounty clinics
By Sean R. Sedam
Montgomery Gazette Staff Writer
Wednesday, July 2, 2003
The executive director of the Spanish Catholic Center says the nonprofit needs county money in order to continue providing medical care to uninsured residents when the center's Gaithersburg clinic closes next week.
That money would be used to bolster medical services at the center's Langley Park clinic, which could take on more patients when the Gaithersburg clinic closes July 10.
"There is absolutely no consideration or plan to close or curb services in the Langley Park clinic, either in the adult clinic or in the pediatric clinic," said the Rev. Donald F. Lippert, who directs the Spanish Catholic Centers in Gaithersburg, Langley Park and Washington, D.C. "But we need continued support of the county in order to do it."
The County Council's Health and Human Services committee, in a closed session Monday, discussed giving money that would have gone to the Gaithersburg clinic solely to Langley Park, said George L. Leventhal (D-At large) of Takoma Park, who chairs the panel.
"At this point we're going to agree to award funds to Langley Park because the closure of Langley Park would be so devastating that we cannot afford the impact," he said.
Last month the Spanish Catholic Center's board of directors decided to close the Gaithersburg clinic, citing its rent and salary costs. The center's 13 employees were notified June 11 that they were to begin preparing to close the clinic. As many as nine employees, including the manager of the Gaithersburg and Langley Park centers, were told they would be laid off.
The Langley Park clinic, which serves 1,200 patients, is one of eight clinics to which Gaithersburg's 850 patients are being routed through letters, phone calls and announcements on Spanish-language television and radio.
But during the public portion of Monday's hearing, Leventhal voiced reservations about giving the Spanish Catholic Center any more taxpayer money, saying representatives of the center, which is affiliated with the Archdiocese of Washington, D.C., had not been candid with the County Council.
The council increased support to the clinic in this year's budget, earmarking up to $160,000 all told for the Langley Park and Gaithersburg clinics. The clinics provide routine examinations, preventive care, diagnosis and early treatment for low-income, uninsured residents.
"Had we known that such a closing was imminent, we would not have committed so much county funding to the Spanish Catholic Center," Leventhal said.
It is up to the county's public health chief, Lynn Frank, to decide whether the Spanish Catholic Center will keep all of that money now that Langley Park will be its sole medical clinic in the county. She is expected to make a recommendation to the council within the next two weeks.
The county had considered redistributing the money from the Gaithersburg clinic to others in the upcounty, including Mercy Health Clinic in Germantown, Proyecto Salud in Wheaton, Community Clinic in Gaithersburg and Mobile Medical Care.
But representatives of those clinics said they did not need the extra money to care for 25 Gaithersburg patients the county projects that each could see, Frank said.
The county pays about one-third of the operating costs of the clinics. The county will review how Gaithersburg's patients are distributed among the remaining clinics to determine how much each will receive in taxpayer money.
"It's hard to predict exactly what those clients are going to do," Frank said.
People will go where they are comfortable, she said, "whether that is the faith-based Mercy clinic or the strong Latino culture of Proyecto Salud."
The Department of Health and Human Services will provide Spanish interpreters to clinics that see an increase in Spanish-speaking patients, she said.
The Gaithersburg clinic will remain open through July 25 for patients to pick up their records. Any unclaimed records will be saved at the center's Washington headquarters.
Mobile Medical has offered to bring its van for six months to the center's Gaithersburg site on 117 N. Frederick Ave. for walk-in patients, Frank said.
The center's social service referral program will be discontinued along with the clinic, but officials are looking to reopen elsewhere in Gaithersburg with its employment, immigration and English classes.
Council members on Monday asked whether the clinic's closing could have been avoided.
Lippert sent two letters to Leventhal in April informing him of the center's financial difficulties and indicating that the center may be forced to close.
The Gaithersburg and Langley Park clinics faced a combined $155,000 deficit when Lippert took over in April. He is the center's fourth director in four years. Gaithersburg's share of that deficit was about $80,000, Lippert said.
The center expects to save about $350,000 by closing the Gaithersburg clinic, finding another site for the center's classes and legal clinic and reducing staff at its Washington headquarters, he said.
The organization spent $3.5 million to operate centers in Gaithersburg, Langley Park and Washington in fiscal 2003, he said. A Wheaton center that included a medical clinic closed in 2002.
Last year the county gave the center $120,500 to operate between the Gaithersburg and Langley Park clinics and earmarked an additional $40,000 for the centers in fiscal 2004, which began Tuesday.
But more was needed.
"Our Board of Directors, executive director and medical director are looking very seriously at closing down some of our medical clinics and/or services due to severe funding shortages," Lippert said in an April 23 letter to Leventhal.
But Leventhal said he did not know how grave the situation facing the Gaithersburg clinic was until last month.
"This whole notion that this was a complete surprise was something that completely threw me off," Lippert said Tuesday.
Leventhal, who called the clinic's closing "the most serious matter I've had to take up as chairman of this committee," said Tuesday that he responded with a letter informing the center of the additional $40,000 the county was giving the clinics.
In a tight budget year when many nonprofits are asking for additional county help, he said, the center's voice may not have been loud enough.
"I don't think that we considered his letter to be a sign that they were about to shut down," Leventhal said.
At Monday's hearing, Leventhal told Lippert that the way the center handled the clinic's closing undercut his confidence in the center.
"It is the obligation of a public agency to be very transparent, not to surprise us," he said. "And that obligation has been very much violated, I think, in this case."
The state of Maryland failed to help the largest county in Maryland pay to keep its safety net mental health and primary care clinics open for services.
https://health.maryland.gov/newsclippings/archives/2002/apr02/040302.htm#Plan%20to%20Boost%20Psychiatric%20Clinics%20Dies
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Plan to Boost Psychiatric Clinics Dies
Md. Bailout Would Have Raised Taxes, Lawmakers Say
By Matthew Mosk
Washington Post Staff Writer
Wednesday, April 3, 2002; Page B02
Maryland lawmakers said yesterday that they have rejected plans to give a financial boost to the state's strapped psychiatric clinics and hospitals, because doing so would have required raising taxes.
The decision means lawmakers will emerge from the 2002 General Assembly session next week with no firm resolution to Maryland's mental health crisis, advocates for the mentally ill said yesterday.
"Unfortunately, it's going to keep getting worse, and there's no relief in sight," said Herbert Cromwell, executive director of Community Behavioral Health Association of Maryland Inc. "I think you can expect to see more of a meltdown."
Thirteen outpatient mental health clinics and private psychiatric hospitals have closed in the past four years, forcing patients out on their own, sometimes with dire consequences. In particular, emergency rooms have had an influx of urgent psychiatric cases in every corner of the state, state health officials say.
When legislative leaders convened in Annapolis in January, they vowed to solve what they agreed was a health crisis. Midway through their 90-day session, they found untapped federal funding that would immediately direct $40 million to shore up a $70 million deficit in the mental health budget.
But yesterday, with a week left before they break for the year, lawmakers said they will opt against a measure that advocates say is far more important -- one that channels more money to the financially troubled clinics. The roughly $45 million needed to pay for that effort was to come from a 2 percent tax on the income health maintenance organizations raise through premiums.
"Someone has decided they don't want it," said Sen. Edward J. Kasemeyer (D-Baltimore), who sponsored a bill creating the tax and directing it to mental health. "I think it's a dumb political move, but there's not much I can do about it."
The Senate approved the tax, but House leaders have balked. With lawmakers poised to raise the state cigarette tax, several said yesterday that they feared the political consequences of voting for an additional levy.
"I don't think anyone wanted to move toward another new tax this session," said Del. Sheila Ellis Hixson (D-Montgomery), who chairs the House Ways and Means Committee. "I'm not sure the bang is worth the buck."
Strong opposition to the tax came from lobbyists for HMOs and small businesses, which had no interest in swallowing the added cost of the tax.
Lobbyist Ellen Valentino, an aggressive opponent of the tax, said the independent businesses she represents in no way objected to the goal of more funding for mental health. They just did not believe the responsibility for those costs should fall to them.
"There have been decisions not to properly fund mental health, not just this year but over a number of years," Valentino said. "The question is: Who should pay for that?"
Indeed, money problems have plagued Maryland's mental health program since 1997, when the state changed the way it reimburses clinics and hospitals for the care they give uninsured and Medicaid patients. Budget analysts estimate that the system faces a $20 million deficit this year; next year, that could grow to $70 million.
Maryland's crisis mirrors troubles in dozens of states that have experimented with managed care to pay mental health costs.
Maryland Health Secretary Georges C. Benjamin said yesterday that lawmakers and the governor have made improvements to the mental health system and that additional federal funding will help reduce the department's budget shortfall.
"But I think we all recognize that there's a lot of work yet to be done," Benjamin said. "The problem is, in this time of sacrifice, we couldn't afford to do all that we would have liked."
A prior Montgomery County policy to privatize its public mental health system to nonprofits (NGOs) that subsidize public money with individual donations incentivized by tax deductibility was undermined when even the individual donors became 'fiscally challenged.' The generous individual donors had to reduce or cut their donations as individual incomes, even high incomes, dropped in 'bad business cycles/economies/recessions.'
https://health.maryland.gov/newsclippings/html/newsarchives061401.html#Another%20disaster%20looming%20for%20mental%20health%20care
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Another disaster looming for mental health care?
Montgomery Journal Commentary
Thursday, June 14, 2001
Once again Montgomery county officials, with some exceptions, are fiddling around while vitally needed mental health services for thousands of county residents with serious mental illnesses are in flames. The refusal of the County Council (save Isiah Leggett, Derick Berlage and Phil Andrews) to support council President Ewing's plan to save Chestnut Lodge Hospital is the latest instance of this county government failing to respond to a crisis arising largely from its own misguided policies and negligence.
Starting in the early 1990s, the County Council began moving the county toward the privatization of mental health services - something County Executive Doug Duncan also supported - [a]nd making this the county's policy in 1994. Reductions in county funding for mental health during this period, especially dramatic in 1994, signaled this intent.
This policy began to be implemented in 1997, with the hasty recruitment of CPC Health, the county's largest private mental health provider and owner of Chestnut Lodge, with incentives of temporary subsidies and free rent, to take over the county's Wheaton clinic.
County officials tried to allay concerns about this transition, raised at the time by me and many others, including Gov. Parris Glendening, by assuring that CPC was a stable, longstanding provider that would offer the same level and continuity of care as the county clinics. These concerns were dismissed notwithstanding an awareness that private providers were struggling with drastically reduced payment rates under a new state funding system.
Moreover, by 1997 CPC was already beset with financial and organizational problems, according to Paul Williams, president of the medical staff, writing on behalf of 30 staff members in a local newspaper. CPC was $4 million in debt from its purchase of Chestnut Lodge the previous year, according to former CEO, Steven Goldstein, who cited this debt as the chief reason for the company's bankruptcy.
The county either failed to properly vet CPC or it knowingly handed over this - and subsequently, another - clinic to a troubled organization while making assurances to the contrary.
Elected and appointed county officials disingenuously claimed (and still do) that the likely loss of approximately $1 million in revenue under the new state system forced them to divest the county's clinics. They argued that under the new system the county could not ``afford to stay in
the mental health business.''
However, the county will spend less on mental health for the upcoming fiscal year than it did in 1994 or 1997, despite an increase in the operating budget of approximately $900 million, or 50 percent, and a doubling of the Health and Human Services budget, under which mental health falls, since 1994. Clearly, other priorities, both within and without HHS, were affordable. The state's changeover to a managed-care system became the convenient excuse for politicians to do what they had been intending for years.
The county washed its hands of its clinics and didn't look back. It failed to monitor, as mandated by the state, or address CPC's deteriorating financial situation and consequent disruptive impact on treatment over the past three-plus years. Even with subsidies and free rent, CPC's clinics were ``barely breaking even,'' according to their former clinical director. Once the subsidies ended, the clinics began running deficits, exacerbating the company's financial woes.
When CPC declared bankruptcy last fall, county officials merely offered assurances of a ``contingency plan'' in the event CPC went under. Had they exercised adequate and timely oversight, CPC's difficulties could have been addressed long ago, and Chestnut Lodge's demise
averted. Their failure to do so compounded the initial, inadequate vetting of CPC, thereby contributing to its downfall.
County officials evade responsibility by blaming CPC's demise, with some justification, on the company's mismanagement and a flawed state funding system, while excusing the privatization, even though all of the county clinics transferred to other private providers are also losing money, as are most outpatient clinics in the county.
Furthermore, they claim they couldn't have known about the internal problems of private providers like CPC, despite meeting monthly with representatives from these organizations since the privatization began for just this purpose.
Representatives, CPC's included, say they repeatedly told county officials of their organizations' plights. However, if county officials couldn't properly monitor CPC, why then, at times of great uncertainty, did they turn county clinics over to such a troubled provider? Moreover, if their assertions are correct, then it was necessarily unwise and irresponsible to privatize the clinics while promising to oversee the process.
In the current, hasty transition of CPC's clients to other struggling providers, the same officials are offering the same, meaningless reassurances about ``a smooth transition'' and ``minimal disruption of services'' as they did in 1997. Yet many unanswered questions remain about this transition, which is already proving to be problematic.
Responsible officials must acknowledge and learn from the mistakes that led to the CPC fiasco to avoid repeating it, including an understanding of the privatization's role and its inherent dangers. Only such an honest appraisal, coupled with pro-active vigilance will prevent similar catastrophes in the future.
Randy Bosin, of Chevy Chase, is an advocate for the mentally ill and a member of the National Alliance for the Mentally Ill. [later renamed National Alliance on Mental Illness]
