County Legislative Priorities
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DUBUQUE COUNTY LEGISLATIVE PRIORITIES
2006 SESSION
Presented November 17, 2005
The Dubuque County Board of Supervisors begins this presentation by thanking you for your
assistance in the past. We know that we can continue to work together during the upcoming
session for the well-being of Dubuque County and the State ofIowa.
1. Southwest Arterial
This is a request for your continued leadership and support to keep the IA-32 Southwest
Arterial Project moving forward. As part of the fiscal year 2006-2010 federal budget
Congress appropriated $26.18 million and DMATS has pledged $10 million. The cost of
the initial two-lane project is approximately $64 million. Requests for proposal for the
preliminary highway design were initiated in May 2004 and is expected to take 15 to 18
months. We need your support for an amendment of the 5-year plan to include this
project with a RISE application of$12 million and additional state funding.
2. U.S. 20 Corridor
The completion of the U.S. corridor project continues to take form. The North Cascade
Rd. and Swiss Valley Rd. interchange proj ects are next on the agenda and needed to
alleviate accidents and deaths at theses dangerous intersections.
3. Julien Dubuque Bridge
Final bridge design work is continuing on the companion bridge for the Julien Dubuque
Bridge making the crossing a four-lane facility. The State ofIowa has included this
project in the 2006-2010 5-year plan with a state match ofthe federal earmark of$25
million. The construction schedule for the new bridge crossing is dependent upon
securing further funding. With a bridge construction estimate at $130 million it is
apparent that further federal and state funding will be required. We urge our legislators to
prioritize this project and we thank you for your continuing help with all three of these
transportation projects. We strongly feel that the U.S. 20 Corridor, Southwest Arterial and
4-Lane Julien Dubuque Bridge improvements comprise vital links to our continued
economic growth and development.
4. Iowa Department of Transportation Illumination Specifications and Standards
In the past, the Iowa Department of Transportation has increased the illumination
specifications and standards for lighting on Iowa highways and highway intersections.
We would encourage the legislature to earmark special funding to the Iowa Department
of Transportation to provide more lighting on Iowa's intersections and interchanges
making the roads safe for our citizens.
5. Road Use Tax Fund
Current studies show that all road entities lack sufficient resources to maintain their
existing road and street system. However, neither the Department of Transportation,
cities nor counties should be allocated less than their current share of revenue sources
making up the Road Use Tax Fund. Additional dollars are needed by all to make needed
safety improvements and to respond to economic opportunities. We oppose any diversion
of income to other uses and away from all of the entities.
6. Environmental & Zoning Issue
We continue to ask that the legislature defme the agricultural exemption for zoning
purposes. There are many definitions in the Code for a "farm," but none of them
addresses the zoning issue and under what circumstances corporate commercial animal
confinement facilities fit within the agricultural exemption for zoning purposes.
With definitions that would disqualify these confinement facilities from the agricultural
exemption, counties could gain some control over the siting of these facilities.
7. ARO Audit
Apparently the State ofIowa must pay back $6.2 million due to a federal audit of the
Medicaid Adult Rehabilitation Option (ARO). When ARO was adopted the state reduced
the counties' growth funds in anticipation of the savings they would experience through
implementation of ARO. Therefore, the funds to pay back the federal government should
not come from the counties.
Dubuque County favors the continuation of ARO services and providers in Dubuque
County have participated in ARO for four years. While consumers have enjoyed more
services as a result of the program, the program is not saving Dubuque County sufficient
funding to make up for the loss of state funding. Consumers are receiving more services
at a higher rate, which is a wonderful thing. But it is not a justification for shifting costs
from the state to the counties.
In addition, there appears to be a lack of consistent direction from DHS in providing
technical assistance and oversight of the Medicaid Adult Rehabilitation Option (ARO) to
ensure compliance with federal Medicaid regulations. This is also true for providers of
HCBS programs to ensure the services and that the documentation for the service meets
state and federal requirements.
8. Case Management and the Iowa Plan
Chapter 90 administrative rules provide an authorization process and eligibility criteria
for both the Department of Human Services (DHS) and Magellan to follow in authorizing
targeted case management (TCM) services. Magellan interprets the established criteria
and the role ofthe targeted case manager from a narrow clinical perspective, rather than
recognizing the criteria from Chapter 24. There continues to be TCM de-certifications,
and this is leading to appeals to the state administrative law judge, resulting in additional
costs to both counties and the state. Dubuque County supports the use of the DHS
authorization criteria by Magellan and continued efforts ofDHS in assuring that Magellan
interprets the criteria in the same manner as DHS.
9. Clerk of Court
The Court should continue to find placements for persons committed under Iowa Code
Chapters 125 and 229 rather than shifting this function and cost to counties. Counties
will continue to work with the courts to make this process function smoothly for those
individuals who are funded by a county, but not all persons committed under these two
Chapters are the funding responsibility of the individual counties.
Dubuque County also supports ISAC's stand on the completion of the transition of
funding court-appointed attorneys, advocates, sheriffs fees and court ordered diagnostic
evaluations from the counties to the state. This should include both chemical dependency
under Iowa Code Chapter 125 and mental health under Iowa Code Chapter 229. The state
orders the services, sets allowable fees and then sends the bills to the county often
without the coordination to fulfill the county MH/DD plan requirements.
10. Judicial Advocate Position
The Judicial Advocate position continues to be a problem for counties. These individuals
are appointed and supervised by judges. Counties were mandated to pay IPERS for
advocates appointed under Iowa Code Section 229.19 in December of 2000.
Advocates appointed under 229.19 are not county employees, nor are they state
employees. We object to paying for the advocates; it is philosophically a bad idea
because advocates are paid to represent consumers, while the County pays for Targeted
Case Management to make those determinations. And we also object to paying rates over
which we have no control as they are set by the Chief Judge ofthe Judicial District, who
also supervises their work.
The state should complete the transition of funding and supervision of court-appointed
mental health advocates from counties to the state.
11. Juvenile Services Transition
Planning must occur for all individuals transitioning from youth/juvenile services to adult
services. Collaboration among stakeholders needs to occur at least two years prior to the
individual being eligible for adult MH/DD services. Dubuque County supports legislation
which would ensure that appropriate referrals are made no later than age 16. For example,
legislation could be crafted to require the referring agency to fund appropriate adult
services for the amount of time between the juvenile's 16th birthday and the date the
referral is finally made. This would include targeted case management to assess and
coordinate and facilitate a smooth transition into the adult service system.
Currently there are waiting lists for child waiver programs that can grossly interrupt
funding streams for adult services. Recently in Dubuque County, due to the
inability of a 17 year old to apply for a MR Waiver child slot due to a state wide waiting
list; the County was asked to fund a 24 hour residential service for three months awaiting
a cumbersome application process for an adult MR W slot.
12. Medicaid
The Medicaid program provides necessary medical and medically-related services to
Iowa's most vulnerable residents. It is a safety net that meets needs which otherwise
would go unruet or be absorbed by counties. Dubuque County supports the
continuation of the current Medicaid program, including all optional eligibility groups
and all optional services including dental care.
See "Waiver Services" priority
13. Medicaid Eligibility During Jail and Detention
Loss of Medicaid coverage when adults and children are injail or detention during
the pre-trail phase results in the loss of needed services. Dubuque County supports
the state funded continuation of Medicaid eligibility for those being held injail or
juvenile detention.
14. Mental Health and Substance Abuse/Chemical Dependency Parity
Iowa needs to expand the insurance parity law to cover all mental health diagnosis and
substance abuse/chemical dependency treatment including comprehensive and flexible
insurance coverage and prescription drug coverage equal to that of other medical benefits
in employee health insurance programs.
15. Mental Health Funding to MHIDD Providers
When the State ofIowa Department of Human Services informed counties that their
workers would no longer establish Purchase of Service Rates with providers, counties
banded together to form the County Rate Information System (C.R.I.S.) and retained an
accounting firm to gather necessary information on actual costs of service.
The state should not therefore engage in rate-setting, mandating rates or rate increases
for those providers whose services are paid in whole or in part by the county. Since the
county is a major payer for these services. The state should accept the county negotiated
rate.
16. Mental Health Growth Factor
The mental health growth factor should reflect the state's commitment to property tax
relief made in 1996 by funding all system growth while capping county property tax
funding. This commitment will not be fulfilled until the cuts made in FY02 are fully
restored and future growth truly addresses the three factors in SF 69 (service cost
inflation, increases in number of consumers, and investments for economy & efficiency).
In addition, funding for the risk pool and per capita equalization fund should be treated
separately.
The section of the MH/MR/DD formula enacted in 2002 requiring percentage fund
balances for Counties to be eligible for State funds needs to be repealed. Counties carmot
budget to the exact penny while insuring mental health access to its citizens. If Counties
spend down all resources and new consumers present with mental health needs; their
needs may not be funded or may be funded inadequately.
Proactive and timely access to rapidly changing ARO and Waiver funded services using
federal dollars generally give counties a higher fund balance that was originally budgeted
in a given year.
The best possible solution to the Iowa dilemma for services to the Mentally m, Mentally
Retarded and Developmentally Disabled is for the State to follow almost all other states
and assume responsibility for this entire system. One way to do this would be for the
State to assume the system, in which case the concept of "legal settlement" could be
discontinued and clients could move more freely through the system and be placed in
appropriate settings closer to their homes.
We have suggested in the past that counties could agree initially to pay to the state an
amount based on current tax levies to match federal dollars. Ultimately that amount
would decrease each year until the county property tax responsibility would be gone.
This change could maximize federal money, abolish legal settlement issues and end
fragmentation of services caused by having 99 different management plans in each
county, and would provide equity for "state cases." This would benefit the consum~r and
lower property tax oermanentlv.
17. MH/DD System Redesign
It is our understanding that ISAC will again support the redesign of the Mental Health-
Developmental Disabilities Fund this session of the the legislature. The redesign is based
on the concepts of consumer-driven services, eliminating disparities in services, and
improving outcomes for consumers by providing services in the community rather than
institutional biases. The interdependent components contained in the MHlMR/DDfBI
Commission Report are dependent upon the state to provide adequate funding and be
adopted as a complete packet.
This plan would abolish "legal settlement" and counties would pay for services based on
residency. As a county rich in providers, we oppose this concept until all services are
paid for by the State ofIowa. Providers in Dubuque County furnish services to
consumers from many other counties, and currently the other counties pay for those
services.
In the event that the entire proposal is not adopted, legal settlement must remain in place.
Another consideration is staffing of our Central Point of Coordination, if that office is
expected to manage many more cases and consumers. Please consider the needs of
Dubuque County on this issue.
18. Psychiatrist Shortage
Dubuque County supports a statewide effort for the recruitment of psychiatrists and
psychiatrically trained and certified physicians' assistants and nurse practitioners. The
shortage of trained psychiatric professions is now becoming critical in even urban areas.
19. State Funding for "812" Commitments
Defendants requiring an evaluation to determine competency to stand trial, or restoration
of competence, generally receive services at a state institution. Those institutions, in turn,
look to counties to cover these costs, even though they are a legitimate cost of the
defense. In 2004, the Legislature amended the law to allow 812 evaluations in the
community and restoration of competence in community-based programs under some
circumstances. However, the legislation did not clarify payment responsibility.
Dubuque County supports legislation to revises Iowa Code chapter 812 to clarify that the
cost of evaluation and restoration of competence to stand trial, pursuant to Iowa Code
Chapter 812, is a state funding responsibility in cases where the defendants are unable to
pay.
20. State Case Programs
To allow equal access to services, ISAC supports legislation to require that services for
individuals determined to be state cases will be provided and paid for by the state in
accordance with the county management plan and negotiated provider rates of the county
in which the individual lives.
21. Waiver Services
- MR Waiver
Dubuque County apposes state and federal administrative rule changes and regulations
that shift funding for services from federal and state funds to county funds. There has
been a variety of ongoing changes effecting eligibility. For example, MR waiver funded
pre-vocational services are dependent upon pre-vocational earnings. Currently, those who
eam above 50% of minimum wage do not qualifY for federal Medical dollars and or must
withstand an rigorous evaluation process to maintain eligibility. Although the county
supports this vocational training to attain a job in the community - additional training
often takes years before the goal is accomplished leaving the county to fund the service at
100%.
-BI Waiver
Although the Department of Human Services had made federal application for an
additional BI W slots for this fiscal year, funding of services for a person with a brain
injury is limited and many of these individuals are unable to obtain the services they
deserve through the BI W (for example, compensated vocational training) and results in
Case Managers requesting County funding to supplement the Waiver In addition, there is
a cap on monthly expenditures for necessary services. Consumers needing services
greater than $2650.00 per month again results in case management requesting county
funding.
Counties do not have the resources available to add a new population group or
unexpected service options for those have been determined to be brain injured. Therefore,
it is imperative and equitable that funding comprised of state and/or federal dollars
would provide services for persons with brain injury.
22. Unmet needs in Substance Abuse (SA)
We continue to hear from our constituents about unmet needs for Substance Abuse (SA)
clients. Although the legislature agreed to provide appropriate treatment for these
consumers, Dubuque County has had to budget $75,000 in the general fund to provide
housing services to Substance Abusers at the Julien Care Facility. These consumers are
often awaiting a bed to a state funded SA Residential Treatment Center. Dubuque County
has a halfway house for those who have completed residential SA treatment elsewhere in
Iowa and are in need of ongoing recovery support services in a transitional living
environment in the community. This service is being funded by federal and state funds
and United Way funds in Dubuque.
The original thinking about the transfer of substance abuse services was that the State of
Iowa would fully fund SA services under Iowa Code including commitment costs, which
counties continue to pay. Detoxification services should be included in the definition of
substance abuse services funded by the state. (There is currently no mandate for counties
to pay for detoxification services). The state should also follow the code section mandate
requiring the Department of Inspection and Appeals to pay attorney fees for substance
abuse and committals.
There needs to be more SA dollars allocated to residential treatment in Dubuque County
similar to what is being provided in other metro areas in Iowa. These areas include Fort
Dodge, Mason City, Iowa City, Cedar Rapids, Waterloo, Davenport, Sioux City and
Council Bluffs.
The travel distance to surrounding treatment facilities is a barrier that does not allow the
client and family and other natural supports ready access to the treatment milieu.
The money is managed by Magellan and can't be relocated to different needs in a
community. For example in Dubuque County, outpatient, halfway house services and
assessment services are funded. The State is aware of the needs and new money should
be allocated to under served areas so that all large metro areas have access to SA
residential treatment.
Approximately 70% of persons with chronic mental illness experience a co-occurring
problem with substance abuse/chemical dependency. It is critical that the State of
Iowa and the managed care contractor also approach and fund the treatment needs of this
dually diagnosed population in an integrated community based residential treatment
facility.
23. Additional law enforcement training in areas of Mental Health and Substance
Abuse at the ILEA
The legislature should increase the mandatory training hours of all law enforcement
officers at the Iowa Law Enforcement Academy in areas of Mental Health and Substance
Abuse. This training will benefit our citizens and assist with jail diversion to services
available
We thank you for your leadership for our community and support in the past.
Let's work together to solve the problems and issnes.