As lawmakers on the Social Services and Health Appropriations Committee sit down to pore over the separate budget proposals from the governor and from the legislative analyst, three shadows hover overhead.
Those shadows are major pieces of legislation passed in the last year by Congress.The Omnibus Reconciliation Act of 1987 (called OBRA), the Medicare Catastrophic Coverage Act of 1988 and the Family Support Act of 1988 will all make significant demands on the state's resources by mandating changes in the responsibilities and services provided.
Because the laws are new, department officials and legislative analysts admit that their projections for the fiscal year 1990 budget (which are being discussed at the Legislature) are to some extent guestimates.
Some officials are less than enchanted with the federal mandates. A legislative analyst said it creates a "paperwork nightmare."
During budget discussions, Rod Betit, director of the Division of Health Care Financing (the agency that administers Medicaid and other medical programs for low-income Utahns) referred to his "frustration with a continuing flow of federal mandates."
OBRA, for instance, will require more screening and the expense that goes with it. The divisions of Mental Health and Services to the Handicapped will have to assess whether nursing home residents who are mentally retarded or mentally ill should be there, or if they would do better in other facilities. The act also includes a pre-admission screening and annual review. Then officials have to determine who needs "active treatment." The problem here is the federal government has never really defined active treatment. Feds come in and review facilities and say whether they have it or not - whatever "it" really is.
There's also a provision for quality of life, quality of care and residents rights, but the regulations haven't been written for those, so future impact is unknown.
All three bills are examples of one of Congress' oddities: The law is passed before any real regulations are written up. The regulations for the Family Support Act, for example, aren't expected out until spring, so departments don't know quite what they'll be facing when implementation begins.
The catastrophic coverage legislation is expected to change the financial picture significantly. A number of programs currently considered optional will become mandatory. While the federal government will provide significant funds in most cases, the state still has to come up with its predetermined share - while guessing how many people will be effected and how much money it will cost.
For example, the bill makes the state pay Medicare deductibles and co-insurance for the aged, blind and disabled who live at poverty level or below. Everyone agrees that will benefit a lot of people who need the help. They're just not sure where the money will come from - or what other needy person may have to do without.
The bill does a lot of other things as well, like ending a limitation on the number of days for payment of inpatient hospital service. It increases coverage for poor pregnant women and children, and protects to an extent someone who might have to impoverish himself to "spend-down" so that a spouse going into a nursing home can qualify for Medicaid.
That's a good thing, because the current spend-down standards leave the independent spouse impoverished. But the money has to come from somewhere.
The Family Support Act, generally known as welfare reform, also has lots of provisions, some of them very expensive. Medicaid coverage is extended for welfare recipients who earn enough to leave the program. So is day care, with a sliding-fee scale. During the first six months someone becomes self-sufficient, the state pays medical premiums, deductibles and co-insurance costs, plus provides any benefits they had on Medicaid that are not part of the employer's plan. Again, the state can charge a sliding-fee, based on income. And there's more.
All three bills have fine points and some state officials are looking forward to the challenge. Cindy Haag, Assistance Payments Administration director, was excited when she talked about implementation of the Family Support Act and the money taxpayers would save later when recipients become taxpayers through the programs the act establishes or enhances. It's a challenge, she said, that will improve the quality of life.
I believe that it's important to invest money in the future - and that's what long-term programs like welfare reform do.
But I'm glad I'm not a legislator, trying to decide where the money should come from in order to satisfy federal mandate.