The 4th meeting of the Poverty Task Force was held on Wednesday, December 2, 2009, at 10:30 AM, in Room 154 of the Capitol Annex. Senator Brandon Smith, Co-Chair, called the meeting to order at 10:53 AM, and the secretary called the roll.
Present were:
Members: Senator Brandon Smith, Co-Chair; Representative Greg Stumbo, Co-Chair; Senators Dan "Malano" Seum, Robert Stivers II, and Johnny Ray Turner; Representatives Linda Belcher, Dwight D. Butler, Leslie Combs, C. B. Embry Jr., Kelly Flood, Keith Hall, Richard Henderson, Martha Jane King, Mary Lou Marzian, Reginald Meeks, Fred Nesler, Kevin Sinnette, Kent Stevens, Ken Upchurch, and Addia Wuchner.
Guest Legislator: Representative Dennis Horlander.
Guests: D. W. Bouchard, Executive Director, and Jennifer Weeber, Hazard/Perry County Community Ministries; Patrick McKiernan, CADC, Homeless Veterans Outreach Coordinator, Kentucky Department of Veterans Affairs; Nina Walfoort, Director of Marketing, Transit Authority of River City (TARC); Tawny Acker-Hogg, Program Development Director, Leslie, Knott, Letcher, Perry (LKLP) Community Action Council, Inc.; Melissa Benton, Kentucky Interagency Council on Homelessness, Executive Director, Kentucky Housing Corporation; and Marlene Gordon, Coalition for the Homeless.
LRC Staff: DeeAnn Mansfield, Lou DiBiase, Amanda Dunn, Mustapha Jammeh, Carlos Lopes, John Scott, and Gina Rigsby.
A motion to approve the minutes of the November 16, 2009 meeting was made by Representative Stevens, seconded by Representative Stumbo, and approved by voice vote.
Douglas W. Bouchard, Hazard/Perry County Ministries, and Patrick McKiernan, CADC, Homeless Veterans Regional Administrator, Kentucky Department of Veterans Affairs (KDVA) provided testimony on initiatives to serve the homeless.
Mr. Bouchard gave an overview of poverty, homelessness, and mental health in Eastern Kentucky. He stated that some Appalachian communities have successfully diversified their economies; some are still adjusting to structural changes in declining sectors; and some severely distressed areas still require basic infrastructure, such as water and sewer systems. In 1965, one in three Appalachians lived in poverty. By 1990, the poverty rate had been cut in half, but not in Eastern Kentucky. The Kentucky Interagency Council on Homelessness results of the January 24, 2009 Point-in-Time Count of Homeless Persons show there were 2,825 homeless persons in Louisville and Lexington, 3,174 in rural Kentucky for a total of 5,999. The Third Annual Homeless Assessment Report to Congress (AHAR) reports, in Kentucky, that there are three Continuum of Cares or jurisdictions designated by HUD, comprised of homeless service providers: the Balance of State, Lexington/Fayette County, and Louisville/Jefferson County. In some states, Continuum of Cares that represent more rural portions of a state may also account for a large share of a state’s homeless population. In 2007, the majority of homeless persons in Kentucky were located in the Balance of State Continuum of Care.
For many decades, social science researchers have known that poverty and mental illness are strongly related. The poorer the person, the stronger likelihood his or her chances are of having some sort of mental disorder. A report by Mental Health America, Ranking America’s Mental Health: An Analysis of Depression Across the States indicated several statistically significant predictors of depression and suicide rates: Mental health resources - the higher the number of psychiatrists, psychologists, and social workers per capita in a state, the lower the suicide rate; barriers to treatment - the lower the percentage of the population reporting that they could not obtain healthcare because of costs, the lower the suicide rate and the better the state’s depression status. The lower the percentage of the population that reported unmet healthcare needs, the better the state’s depression status. Mental health treatment utilization - holding the baseline level of depression in the state constant, the higher the number of antidepressant prescriptions per capita in the state, the lower the suicide rate. Socioeconomic characteristics - the more educated the population and the greater the percentage with health insurance, the lower the suicide rate. The more educated the population, the better the state’s depression status. Mental Health America suggests the following five public policy solutions: (1) improve the availability of mental health professionals; (2) reduce cost and other barriers to mental health treatment; (3) encourage appropriate utilization of mental health therapies; (4) provide a richer socioeconomic environment by improving education levels, economic status, and health insurance coverage; and (5) legislate mental health benefits that are equivalent to that for physical health. In the mental Health America report Kentucky ranked 49th. The American Foundation for Suicide Prevention ranks Kentucky 13th in the United States for rate of suicides. Kentucky earned an “F” on the National Alliance on Mental Illness 2009 Report Card.
According to the Centers for Medicare and Medicaid Services, 42 CFR § 431.51, Free choice of providers, Section 1902(a)(23) provides that recipients may obtain services from any qualified Medicaid provider that undertakes to provide the services to them. A recipient may obtain Medicaid services from any institution, agency, pharmacy, person, or organization that is qualified to furnish the services and willing to furnish them to that particular recipient. 907 KAR 1:515, Section 4, Provider Qualifications, states that provider participation shall be limited to the fourteen regional mental health mental retardation centers, licensed in accordance with 902 KAR 20:091.
Mr. Bouchard recommends creating legislation that would enable a wide array of community mental health service providers to provide services. The legislation would (1) provide impoverished people a choice of mental health providers; (2) provide services outside of and in addition to the community mental health centers; (3) create a link between new service providers and a funding source – Medicaid; (4) allow for free market forces to play a role in the mental health resources of Kentucky; (5) allow for entrepreneurial opportunities for potential service providers; (6) provide a wider array of mental health services; and (7) impact mental health issues of impoverished people earlier and more effectively, thereby helping to bring them out of poverty.
Senator Smith asked what it was like before 907 KAR 1:515 went into effect. Mr. Bouchard stated that the regulation is approximately 30 to 40 years old, and he could not find anyone who knew what it was like before the change. Senator Smith said approximately ten percent of the individuals in homeless shelters are veterans, and he asked if the change desired in the regulation would affect the funds that go to the homeless shelters. Mr. Bouchard stated that if the regulation is changed, it would allow access to Medicaid dollars and that would allow someone onsite to assess people’s needs and make referrals, possibly to the regional mental health centers.
Representative Meeks asked about the function of the 14 regional mental health centers and coordinating services of providers. Mr. Bouchard stated that allowing other providers to have case management for services would allow a broader array of choices and would not cut the regional mental health centers out of services but allow them to be a part of the continuum of care for individuals.
Marlene Gordon, Executive Director for the Coalition for Homeless in Louisville, stated that the 14 regional mental health centers were formed prior to the explosion to homelessness.
Representative Hall said that a federal Senate health care bill is trying to address mental health needs, and asked if the legislation would allow the money to go to other service providers other than the regional mental health centers. Mr. Bouchard stated that the regulation does not allow for money to go anywhere else but to the 14 regional mental health centers. Mr. Bouchard stated that the proposed federal legislation would offer a wide array of mental health services with more choice for individuals.
Senator Smith asked if the choice would be modeled on self determination. Mr. Bouchard stated that self determination is very important within the mental health field.
Representative Wuchner stated that she volunteers in a homeless shelter and approximately 80 percent of the individuals do not qualify for Medicaid. She asked if they do not qualify for services, how individuals can get access to treatment. Mr. Bouchard stated that there is a project in Kentucky called SOAR that tries to make sure as many people are qualified for services as possible. He stated he would like to see more than one place or option for mental health services. Ms. Gordon stated that one issue is access, not just transportation, and she stated that the Medicaid service delivery needs to be examined by the General Assembly. One huge problem is that mental health services cannot be provided for an individual during the two-year gap after foster care ends at age 19 and eligibility for services at age 21. During this timeframe, some become homeless, addicted to drugs, or have their mental illness worsen, which costs the state more money to treat than if treatment could be provided immediately. There is a need to look at the structure of Medicaid to see how it addresses homelessness and the poor. Senator Smith asked if Ms. Gordon would send a copy of her testimony and concerns to the task force.
Representative Stumbo asked if the 14 regional mental health centers were different from community action agencies, and Mr. Bouchard said they were different.
Steve Shannon, Executive Director, Kentucky Association of Regional Mental Health and Mental Retardation Programs, stated that there is a network of providers that has access to community mental health centers in all 120 counties. He said that it is a great model, but not well implemented. He stated that they would like to embed staff at homeless shelters, provided there was a way to pay for it. He said that they provide services to one in 25 Kentuckians. He said that there is an inability to access enough resources to support enough individuals without a payor source. He stated that Medicaid system can meet the demand to provide services. He said that the community mental health centers have spread themselves as thin as possible.
Representative Marzian stated the Kentucky Commission on Services and Supports for Individuals with Mental Illness, Alcohol and Other Drug Abuse Disorders, and Dual Diagnoses started meeting in 2000 to come up with a long-term strategy for mental health issues. Mr. Shannon stated that the Medicaid cost-based rates have not increased since 2001 based on fiscal year 1999 dollars. He said that the mechanism is there to provide access to services, but the problem is the unavailability of funds.
Representative Stumbo asked if there is any evidence from other states that shows a more competitive system provides a more cost-efficient way to provide adequate services with the dollars available. He asked that the information be provided to the task force.
Representative Flood asked if more federal dollars are available to Kentucky if we diversify access beyond the 14 regional mental health centers. Mr. Bouchard stated that if there were a wider array of services and qualified providers willing to provide services, additional state funds would be needed to draw down more federal funds. Mr. Shannon stated the number of providers does not matter if state funds are not available for the federal match. Ms. Gordon stated that the way Medicaid dollars are or are not being used leads to barriers. The system was implemented in 1966 but it has not been evaluated or restricted along the way. The population and the need have grown exponentially. Ms. Gordon said that people have to be met where they are and be connected with needed services. When looking at poverty, individuals need someone to help them through the difficult systems to get access to services.
Representative King asked if medical records for homeless people who migrate from one shelter to another were available to make sure Medicaid is not doubled charged. Jennifer Weeber from Hazard/Perry County Ministries stated that someone would have to give permission in order to access their medical records.
Representative King asked about access to medical records. Ms. Weeber said that the individual would have to give permission to access medical records. Ms. Gordon stated that medical records are harder to access if someone is coming out of foster care or has just been released from prison. Representative King stated that if an individual’s medications cannot be monitored, they could end up back in the judicial system.
Representative Horlander asked if providers had access to the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system to prevent double coverage for medications. Ms. Weeber stated that the KASPER system only covers narcotic medications, and Medicaid will not allow refills on medications until it is due.
Representative Henderson asked that a list of the 14 regional mental health centers be provided to the task force. Representative Henderson asked how the centers are funded. Mr. Shannon stated that there are two pots of money. There is a Medicaid dollar which CMHC provides to cover the bills and is not distributed but paid on how services are provided to Medicaid recipients. There is $25 million state general fund dollars for community care and support flexible dollars and the board of directors decide how the money is spent. The division of funds is specified in regulation.
Dr. McKiernan gave an overview of the Homeless Veterans Outreach Program of the Kentucky Department of Veterans Affairs (KDVA). Margaret Plattner, Deputy Commissioner, KDVA, was available for questions. He stated KDVA’s mission is to ensure Kentucky’s 345,000 veterans and their families receive all the benefits and services they have earned. KDVA provides counseling, skilled nursing care at state veterans’ centers, dignified interment at state veterans’ cemeteries, and special programs for women veterans, homeless veterans and others. Approximately 637,000 adults in the United States are homeless in a given week and 2.1 million adults experience homelessness over the course of a year. The Veterans Administration (VA) estimates that nearly 130,000 veterans are homeless on any given night, and 800 to 1,200 of them are in Kentucky and that there are 3,500 homeless veterans annually in Kentucky. The VA estimates there are 200,000 incarcerated veterans in the United States; which means for the first time there are more incarcerated veterans than homeless veterans. The following are veteran statistics: (1) 26 percent of homeless population are veterans; (2) 33 percent of male homeless population are veterans; (3) 15 percent served before the Vietnam Era; (4) 47 percent served during the Vietnam Era; (5) 17 percent served after the Vietnam Era; (6) 67 percent served three or more years; (7) 33 percent were stationed in a war zone; (8) 25 percent have used VA homeless services; (9) 89 percent received an honorable discharge; (10) 85 percent completed high school or GED compared to 56 percent of non-veterans; (11) 79 percent reside in central cities; (12) 70 percent suffer from substance abuse problems; (13) 45 percent suffer from mental illness; (14) 46 percent are age 45 or older compared to 20 percent of non-veteran homeless citizens.
On July 14, 2000, the Kentucky Homeless Veterans Program (KHVP) was created to develop a statewide network of services that provide treatment for addictions, including, but not limited to alcohol, drug use, and gambling; services that lead to permanent housing; services that lead to employment; and concerned citizens and nonprofit agencies that provide shelter. KRS 40.340 established the KHVP with a mission to work toward the elimination of homelessness and the prevention of the threat of homelessness and its causes in the veteran population of the Commonwealth. Under the directive, the KHVP will request funds to obtain, retain, or secure housing/lodging and/or other related support needed for homeless or potentially homeless veterans and their dependent family members. The Homeless Veterans Trust Fund provides prevention and intervention funds. In 2008, the total HVTF expenditures were $35,349.49 and provided assistance to 139 veterans and 70 family members. In 2009, the total HVTF expenditures were $48,203.79 and provided assistance for 166 veterans and 75 family members.
State and federal strategies to assist homeless veterans include maximizing federal resources such as the Grant and Per Diem Program for transitional housing, HUD Veterans Affairs Supported Housing (VASH), Homeless Veterans Reintegration Project (HVRP), Incarcerated Veterans Transition Program (IVTP), VA Benefits-disability and pension claims, and Housing and Emergency Assistance Reaching the Homeless KY HEARTH). Barriers to assist the homeless veterans include the 12-month rate claim turnaround, federal guidelines for eligibility, VA provides very few services to dependent family members, employment opportunities, limited housing subsidies, and substance abuse. Societal and community benefits of substance abuse treatment for veterans outweigh costs by four to one, reduces burdens to the government, reduce criminal activity by up to 77 percent, increase employment, improve physical and mental health, reduce medical costs, provide significant immediate and long-term savings, and provide countless gains to the individual and his/her family, such as improved relationships, increased wellbeing, and keeping families together.
Senator Smith asked about recommendations to help veterans know about available services and benefits. Mr. McKiernan stated that a public service announcement telling veterans to obtain their DD Form 214, Certificate of Release or Discharge from Active Duty, and call to see if they are eligible for services and benefits. Senator Smith asked if someone could go online and find information to see if a soldier meets the eligibility criteria to be considered a veteran and is eligible for benefits. Mr. McKiernan stated that the DD214 is available online, but the homeless population does not generally have access to or knowledge of a computer. Shelters should be more diligent to find out if individuals are veterans or widows of veterans to make sure they access all available services. A great number of Kentucky veterans do not even realize they are eligible for benefits.
Representative Belcher said that she was impressed and said to keep up the good work.
Nina Walfoort, Director of Marketing, Transit Authority of River City (TARC), and Tawny Acker-Hogg, Director, Program Development Director, Leslie, Knott, Letcher, Perry (LKLP) Community Action Council, Inc., gave presentations on transportation issues for the low-income population.
Ms. Walfoort stated the Transit Authority of River City’s (TARC) mission is to explore and implement transportation opportunities that enhance the social, economic, and environmental well-being of the Greater Louisville community. In 2009, there were 15.1 million TARC customers. The TARC has 65 routes in five counties with 255 buses and trolleys and 89 paratransit vehicles. Title VI, 49 CFR § 21, is a section of the Civil Rights Act of 1964 requiring that no person in the United States shall on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. The TARC grants provide for equal access to its programs and services for all citizens, ensure that the community understands civil rights laws that protect their receipt and benefit of such services as defined by Title VI, explain and provide a process for making a Title VI complaint, and report and ensure compliance every three years. The main reasons someone uses the TARC are to go to work, go to school, go to the doctor, or go to the store. Individuals who ride transit can save on average $9,190 annually based on the November 9, 2009 national average gas price and the national unreserved monthly parking rate. Public transportation provides much needed access to jobs, health care, and education, increases mobility for people with disabilities and older adults, reduces energy consumption, improves air quality, provides an alternative to driving, and offers relief from high fuel cost. TARC programs include job hunting trips, ticket assistance for the Coalition for the Homeless, Bikes on Board work trips, assistance at job fairs, and travel for training to the Kentucky Refugee Ministries and Catholic Charities.
Senator Smith asked the number of transitional riders, and Ms. Walfoort stated 15 percent of riders use the transit to go to school and 56 percent to jobs.
Representative Wuchner said that there are identifications that veterans and seniors can use to help get them to medical appointments. She asked if there is a voucher or fair rate that someone impoverished or on Medicaid can get to have medical access. Ms. Walfoort stated that there is a half-fair for all Medicaid trips, but there is no program that picks up people on an emergency basis. Representative Wuchner asked how half-fair rates are supplemented. Ms. Walfoort stated that is an unmandated requirement in Title VI.
Representative Stumbo asked for information about public transportation provided for the distressed or impoverished counties listed on page three of Mr. Bouchard’s handout.
Ms. Acker-Hogg stated that the LKLP Community Action Council, Inc. is designed to be a community action service and planning agency, to develop to the fullest potential of the human and natural resources in the four-county area. Although the council’s primary focus is the poor, it seeks to actively and substantially involve all segments of the community in an effort to alleviate the distress of poverty. The council began in 1966 with transportation and nutrition programs in Leslie, Knott, Letcher, and Perry (LKLP) counties. Currently, the council has 23 on-going programs in 56 counties across the Commonwealth and provides low-income youth with camp opportunities in the summer. LKLP is one of the only regional agencies providing services to the most vulnerable populations from infancy through aging, and providing public and human services transportation delivery (HSTD). Public trips must originate or end in the LKLP service area. Anyone who does not have a Medicaid card or has a Medicaid card, but does not meet other eligibility requirements for transportation through the HSTD brokerage, can call to schedule public transportation. Public trips need to be scheduled 24 hours in advance and no later than 3:00 p.m. the day prior to the trip. Drivers make the appointed pick-up and take passengers to the scheduled destination and then return to take them to their next destination. All rates are calculated from the origin of the pickup to the drop off destination. In 2008, there were 706,763 HSTD trips.
The Elderly and Persons with Disabilities Formula Program is authorized by 49 U.S.C. § 5310. The program makes funding available to private, nonprofit organizations and associations and designated public entities for the purchase of capital equipment for use in transporting the elderly and persons with disabilities, where existing services are unavailable, insufficient, or inappropriate. This program is designed to supplement other capital assistance programs by funding transportation projects for the elderly and persons with disabilities in all areas – urbanized, small urban, and rural. The goals of the Section 5311, Rural and Non-urbanized Rural Public Transportation Program, are to enhance the access of people in non-urbanized areas, especially elderly persons, persons with disabilities, and economically disadvantaged persons, to health care, shopping, education, employment, public services and recreation, assist in the maintenance, development, improvement, and use of public transportation systems in rural and small urban areas. The Section 5316, Job Access Reverse Commute (JARC) program is under the Federal Transit Administration of the United States Department of Transportation. The purpose of the JARC grant program is to assist states and localities in developing new or expanded transportation services that connect welfare recipients and other low-income persons to jobs and other employment related services. JARC projects are targeted at developing new or expanded transportation services such as shuttles, vanpools, new bus routes, connector services to mass transit, and guaranteed ride home programs for welfare recipients and low-income persons. Reverse Commute projects provide transportation services to suburban employment centers from urban, rural, and other suburban locations for all populations. In 2008, there were 3,367 JARC trips in a four county service area. The purpose of the New Freedom grant under Section 5317 is to encourage services and facility improvements to address the transportation needs of persons with disabilities that go beyond those required by the Americans with Disabilities Act (ADA). In 2008, there were 3,615 trips in a four county service area.
SoGo is a demonstration grant the council received in 2008 from the National Center for Senior Transportation, a partnership of Easter Seals and the National Association of Area Agencies on Aging, supported with funding from the United States Department of Transportation, Federal Transit Administration and guidance from the United States Administration on Aging. The council was one of eight grantees chosen to be funded from across the United States to create an innovative program to better serve senior citizens.
Some transportation barriers are mountainous terrain, lack of adequate infrastructure, lack of adequate area services, population in outlying areas, and lack of resources, both agency and client. More than 1.6 million rural households do not have cars, with the proportion of carless households highest in the South, Appalachia, the Southwest, and Alaska. High carless rural communities are characterized by persistent poverty. Transportation needs to be integrated as a holistic component of all poverty initiatives and services designed to assist families and individuals in their transition to self-sufficiency. All newly funded or refunded poverty initiatives should include funding for a transportation delivery system in the program design before it is enacted as legislation or is approved in individual governmental departments.
Representative Stumbo asked that a list of states that have addressed the public transportation issue be provided to the task force.
Senator Smith asked that Ms. Walfoort and Ms. Tawny-Hogg get together and come up with recommendations for a public transportation system that could be used statewide.
A motion to recognize the accomplishments of Mudd Creek Clinic and the work of its founders was made by Representative Wuchner, seconded by Representative Hall, and approved by voice vote.
Representative Henderson stated that it has been an honor to be able to be a part of the task force, and he looks forward to continuing the work.
Representative King stated that the Pikeville Medical Center has been named the national hospital of the year by the American Alliance of Healthcare Providers.
Representative Stumbo thanked the members for all their hard work. He said that the task force has a better understanding about poverty issues and programs that impact the poor. He said he hopes that the task force is able to continue the work and that as we gain more information on the subject there will be opportunities at the state level to focus some monies into meaningful programs in the future when the economy improves. There is interest in producing a long-term strategy from the state level that would be more productive.
A motion to accept the revised draft recommendations and incorporate them into the final report was made by Representative Henderson, seconded by Representative Stumbo, and accepted by voice vote. A motion to amend the recommendations to reauthorize the Poverty Task Force to meet in the 2010 Interim was made by Representative Hall, seconded by Representative Belcher, and approved by voice vote.
There being no further business, the meeting was adjourned at 1:22 p.m.