Magazine article Policy & Practice

Texas Independence: Money Follows the Person in the Lone Star State

Magazine article Policy & Practice

Texas Independence: Money Follows the Person in the Lone Star State

Article excerpt

Wilma* is 94 years old, has no children, and her husband died more than 20 years ago. She was living with her niece's family when a heart attack briefly put her in a nursing facility. She had only been home a couple of weeks when a second heart attack--this one much more severe--sent her back to the nursing facility and put her future in question. Four years passed. It seemed likely she would be institutionalized for the rest of her life.

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Mike* was only 27 years old, but had been in and out of nursing facilities for most of his adult life. Diagnosed with schizo-affective disorder, insulin-dependent diabetes, and a substance abuse problem, he had lived on the street since his mid-teens and was in precipitous physical condition. Upon his last nursing facility admission, Mike, who is 5'9" tall, weighed a mere 80 pounds. The nursing facility restored him to a healthy 140 lbs, but he remained unprepared to make his own way in the community. While he is friendly and engaging, Mike was considered a behavior problem in the facility because he did not understand how to respect people's personal space.

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The Texas Story

Everything is bigger in Texas. Since its inception, more than 35,000 Texans have returned to life in the community from nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) using the services and supports provided under MFP. Texas is one of the originators of the MFP financing policy and served as a model for the national MFP Rebalancing Demonstration.

Currently, Texas accounts for 27 percent of total community relocations under the MFP national demonstration. The success of MFP in Texas is the result of a number of factors, including a history of innovation in community-based services and a tradition of intense collaboration between advocates, state executives and legislative leadership.

Texas is fiscally conservative, with stringent eligibility criteria for Medicaid. Consequently, the state must be creative in leveraging Medicaid to fuel innovation. Beginning in the early 80s, for example, Texas used a Medicaid waiver and, subsequently, a state plan amendment to provide personal assistance services to individuals with income above the Supplemental Security Income (SSI) level who qualified financially for Medicaid in an institution. This approach enabled the state to delay or divert these individuals from nursing facilities without making them eligible for full Medicaid benefits.

As a result of access to personal assistance services, nursing facility admission rates have remained relatively stable for 30 years despite an explosive population growth rate of more than twice the national average for all age groups.

Collaboration between advocates and state leadership has contributed to a number of large scale initiatives. These initiatives progressively broadened the array of community-based programs and made services available to many more people. Beginning in 1985, Texas implemented a series of HCBS programs for various populations. In 1998, Texas implemented STAR+PLUS, one of the nation's first managed care programs, which included both acute medical care and HCBS services under combined federal Medicaid waivers. The STAR+PLUS program provided greater flexibility in financing services, enabling Texas to eliminate the HCBS waiting list for STAR+PLUS members on SSI.

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Promoting independence

Not surprisingly, Texas was one of the first states to have a comprehensive working plan in response to the U.S. Supreme Court's Olmstead decision, which affirmed the fundamental right of people with disabilities to live in the community. In 1999, Governor George W. Bush issued an executive order which began Texas' Promoting Independence Initiative. This directive was reinforced by a second executive order from Governor Rick Perry. …

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