State of Washington
For months Washington lawmakers have been struggling to reconcile the state’s largest budget deficit in history ($9 billion) and not make total waste of the important programs and services that the budget funds. The magnitude of the deficit is daunting and it forces all of us to consider what matters most in public investments and which decisions, at the end of the day, we can live with.
On the chopping block is the state’s General Assistance Unemployable (GAU) program. GAU provides much-needed economic security to the people it serves. The program offers modest cash assistance and medical benefits to low income adults who are temporarily unable to work because of physical or mental disability. This could be a veteran who becomes injured in a car accident and needs time and medical care to recover from his injuries, or a woman who suffers from severe anxiety and depression and needs assistance.
Without the program, people on GAU are at risk of hunger, homelessness, and deterioration of their health problems. With GAU, Washingtonians are assured that a modest level of support will be there in the event of an unexpected illness or injury. Moreover, maintaining and improving GAU will save the state money from escalating health care and other public expenses.
Washington has long been a leader in progressive social policies. In 1988, we expanded access to health care for lower income workers through the state’s Basic Health Plan, the first program of its kind in the nation. Soon after, in 1993 Washington began providing health care coverage to children from lower income families, five years ahead of the federal government’s creation of the State Children’s Health Insurance Program. And two years after national welfare reform, in 1998 our state’s General Assistance program covered not only those who were temporarily disabled, but also pregnant women, immigrants who no longer could receive federal benefits, and certain families with children.
These days, General Assistance is limited to very low income adults who are unable to work due to physical or mental disability. There are 21,000 people enrolled in any given month in the GAU program; recipients can be found in every county in the state. Back in December, faced with a growing state budget deficit and the task of writing a balanced budget, Gov. Gregoire proposed eliminating GAU entirely, including the $339 monthly cash grants for basic needs and medical benefits.
On paper, it looks like the state would spend $400 million less. But in reality, we will still end up paying to support the health and basic needs of GAU recipients. GAU clients have complex, ongoing health problems. If they can’t go see a doctor, they will likely go to public hospital emergency rooms and community health clinics, which are required to provide care regardless of a patient’s ability to pay. This is not cost efficient. An ER visit can cost up to four times as much as the average doctor’s office visit. In addition, health outcomes are better for people who have health insurance and can address concerns before they become serious medical conditions.
Even with GAU medical benefits, clients still utilize hospital ERs to manage their health problems. Part of this is the result of the seriousness of their health concerns, and partly it is due to the fragmented health care system in which they try to get served. Many doctors do not accept the medical coupons offered by GAU patients, and there are few support services to help them find providers who do.
Instead of gutting the program, lawmakers should make improvements to GAU that will lead to better outcomes for patients and cost savings for the state. For starters, GAU clients should receive coordinated care, sometimes called a “medical home,” which allows the patient and provider to develop an ongoing health care relationship.
In 2004, a pilot program in King and Pierce counties (the two with the highest number of GAU clients) set out to examine the health and cost-saving benefits of a managed care model. Contracted through the Community Health Plan, the pilot program sets GAU clients up with a single primary care provider. The provider offers health care directly or refers the client to specialists. Currently over 5,600 people are enrolled in the pilot study. Results find that for the same price of coverage, clients have increased access to medical services and a reduction in spending on pharmaceutical drugs and inappropriate use of emergency rooms.
Despite the fact that disabling mental illness is one of the criteria for inclusion in GAU, the program currently does not cover comprehensive treatment of mental health disorders. This means that GAU clients who are experiencing acute and possibly catastrophic mental illness cannot always readily access the appropriate care. In 2007, the GAU managed care pilot program expanded to include coordinated mental health services. Although results from the pilot are not yet in, research on this approach is promising.
One recent study from the University of Washington of older adults with depression found long term health care costs were significantly reduced for patients who received mental health treatment as part of their health care plan. The study showed that initial costs were higher for the group that received the mental health services, but those costs went down over time and the net effect was significant cost savings.
In addition, substance abuse treatment can be accessed through the GAU medical plan, but available programs are often elusive. And yet, for one-third of GAU clients, substance abuse is a co-existing condition that drives up costs to the state. Emergency room use is higher among GAU clients that have a substance abuse problem than it is among those who do not. Likewise, arrest rates are higher among GAU clients who have a substance abuse problem than those who don’t. Treatment for alcohol and drug addiction can reverse these trends. A recent study from UW found that GAU clients who received substance abuse treatment had significantly reduced criminal activity compared to those with untreated substance abuse problems.
Finally, the state can lower costs by more accurately identifying clients in the GAU program who could qualify for federal benefits. This will happen more accurately and efficiently if clients are enrolled in a medical home model of care where their primary provider can properly diagnose their health status.
But it is not enough for the state to rely solely on federal programs to ensure the economic security and health of lower income adults with disabilities. For those who do not qualify for federal disability benefits, the threat of hunger and homelessness will be very real.
GAU is a vital part of our state’s economic security and health care infrastructure. Without it — or if deep cuts are made, as proposed by the state Senate — costs in other areas of the budget will undoubtedly rise including use of emergency rooms for health care, programs that assist the homeless, and public safety resources. Conversely, by making smart investments, the state can save money and improve outcomes for recipients.
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