Lawmakers have given providers an impossible task: deliver the same level of services to more kids, with far less money.
There was a moment Charlcie Flinn considered giving up. It was July 2016, and the child therapy services program in Wichita Falls that Flinn had run for more than 20 years announced it was shutting down due to state budget cuts. The closure wasn’t exactly a surprise. Drastic funding cuts combined with an increased demand for speech, mobility and other therapies for kids with severe developmental disabilities had left Flinn and her staff of about 30 in a bind. The widening gap between kids needing care and funds available was unsustainable, and the program had reached its breaking point.
In the months before Flinn’s program officially closed, she and the state scrambled to find a replacement contractor. Half the staff quit. It wasn’t until the day before the program closed at the end of October that a new contractor, Helen Farabee Center, signed on. It took several months for the new program to get up and running, to hire new staff, buy equipment, set up the office and start nearly from scratch. Families and kids disappeared from contact without staff to reach them, and many went months without necessary services.
Flinn calls that period “heart-wrenching” and “gut-wrenching.” Parents of kids with conditions like Down syndrome and cerebral palsy were “so upset their lifesaver had been taken away from them,” she said. “We’re often the best hope families have for what happens to their child.” So Flinn stayed on at the new center to continue “fighting the fight.” But the new program is already running out of money for the year despite scrimping on services, and Flinn doesn’t know how long they’ll last.
What happened in Wichita Falls isn’t unique. It’s a pattern across Texas and the direct result of state lawmakers slashing budgets while expecting the same level of required services. Under federal law, Early Childhood Intervention (ECI) must be available to every eligible child from birth to age 3. But state budget cuts have dramatically dropped the number of ECI providers from 58 in 2010 to 44 today, as the number of kids needing services has increased. In 2015, state lawmakers slashed $350 million from the program, cutting Medicaid reimbursement rates for providers.
Last session, lawmakers agreed to restore 25 percent of the rate reductions, but it wasn’t enough. On top of that, providers say a new Texas Health and Human Services Commission (HHSC) change to how services are billed shifts more costs to staff in rural areas, for whom the long distances they may drive to see patients is no longer considered in their reimbursement. Two more providers have announced they’ll stop ECI services at the end of May, dropping the total to 42.
The cuts have put ECI providers in an impossible situation. They must deliver services to all eligible kids, even beyond the number specified and funded in their contracts with the state. If Medicaid doesn’t cover the full cost, if a kid is uninsured or if the private insurance company doesn’t cover these services, the provider is on the hook.
“We’re constantly juggling demands,” Flinn said. “Our focus has been on juggling rather than on families and how we’re serving them.”
With far less money, providers have had to make significant cuts. They’ve delayed hiring and downsized staff, reduced employee benefits, cut back on training, reduced efforts to find new eligible kids, put off new equipment purchases and pulled money from other programs. Eligibility cuts in 2011 dropped the number of kids served significantly, and providers worry this tactic will be used again. And if none of these are enough, the programs close and the cycle begins again.
HHSC does not yet have a replacement for the two programs closing in May, deputy associate commissioner Lindsay Rodgers said in an appropriations hearing late last month, and more closures are expected. “These are only those who submitted their official termination notices,” she said. “We hear consistently that others are on the fence about continuing with our program.”
Even if replacement contractors are ultimately found, it’s difficult to get programs running again.
For several months during the transition period for the Wichita Falls program, Jaime Stirewalt’s daughter, Maevelyn, went without the therapy she had come to rely on. Now almost 3, she has a rare genetic disorder that causes extreme muscle weakness and congestive heart failure. ECI taught Maevelyn, who is “so busy trying to survive that her language is lacking,” how to communicate and move around in a limited way, Stirewalt said. When she lost the services for a few months, Maevelyn regressed and the whole family, which lives 45 minutes from Wichita Falls, was overwhelmed. “We don’t have many lifelines,” said Stirewalt. “On days when I’m crushed or worried about the future with her, [the therapist] comes in and lifts me up.”
When Flinn’s team left the rehab center, they were actively serving about 250 kids, about 135 of whom, including Maevelyn, continued services with the new contractor. Now, a little more than a year later, they’re serving about 208 kids — still fewer than before, but also 30 percent more than their contract says they should serve. The program is still understaffed, because it’s time-consuming to find and train new therapists. And the contractor is hesitant to hire when its future is so uncertain. Therapists have to rush through sessions to fit in as many clients as they can, and they’ve cut back on training opportunities because staff don’t have a few days to spare. Even Flinn’s travel to Austin for a legislative hearing or an ECI meeting is a strain, because she’s pulled away from extra administrative responsibilities she’s recently taken on.
It’s a bad equation. If everyone does more with fewer resources in the same amount of time, something’s got to give. The services suffer, the providers suffer and the kids suffer. For now, Flinn is operating one month at a time. She estimates the program will have a shortfall of $60,000 to $120,000 by the end of the year; how that will be paid, she doesn’t know.