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County Legislative Priorities j 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.