New HampshireNew HampshireDevelopmental Services SystemDevelopmental Services System

Present and Future ChallengesPresent and Future Challenges

Intent Of The ForumIntent Of The Forum

The State is facing a The State is facing a severesevere funding shortage funding shortage Projected to last for awhileProjected to last for awhile

It is likely that our service system will be It is likely that our service system will be affectedaffected Individuals, families, providers, area agencies, Individuals, families, providers, area agencies,

BDS, DDHS and local communitiesBDS, DDHS and local communities BDS and area agencies are soliciting input, BDS and area agencies are soliciting input,

ideas and suggestions regarding how we may ideas and suggestions regarding how we may collectivelycollectively deal with the difficulties we are deal with the difficulties we are facingfacing

Intent Of The ForumIntent Of The Forum

An opportunity to consider creating changes An opportunity to consider creating changes that are more effective with respect tothat are more effective with respect to Desired service outcomes and Desired service outcomes and CostCost

A chance to imagine how:A chance to imagine how: The service system may operate in the futureThe service system may operate in the future It may support individuals and their families It may support individuals and their families Resources can be used in more effective waysResources can be used in more effective ways

Fiscal Conditions And ChallengesFiscal Conditions And Challenges

Fiscal Year 2009Fiscal Year 2009[July 1, 2008 - June 30, 2009] [July 1, 2008 - June 30, 2009]

The State budget hasThe State budget has $5,2 billion$5,2 billion in Total Funds in Total Funds $1,6 billion$1,6 billion in General Funds (GF) in General Funds (GF)

DHHS was assigned the largest share of the DHHS was assigned the largest share of the $1.6B General Funds$1.6B General Funds $713M$713M of the $1.6B of the $1.6B About About 44%44% of the total General Funds of the total General Funds[The next largest GF portion is only 11% of the [The next largest GF portion is only 11% of the

state total] state total]

FY 2009 DHHS General Funds by Program Unit

$0

$50,000

$100,000

$150,000

$200,000

$250,000

Fiscal Year 2009Fiscal Year 2009 Out of the $713M GF within the DHHS Out of the $713M GF within the DHHS

budgetbudget About $103About $103M (14%) GF was assigned to BDSM (14%) GF was assigned to BDS BDS has the second largest share of the GF BDS has the second largest share of the GF

dollars within the DHHS budgetdollars within the DHHS budget Both DHHS and BDS have “high profiles” Both DHHS and BDS have “high profiles”

within the state budgetwithin the state budget

““Cost DriversCost Drivers” According To” According ToNH Center for Public Policy StudiesNH Center for Public Policy Studies

1.1. Medicaid Provider PaymentsMedicaid Provider Payments

2.2. Retirement SystemRetirement System

3.3. Retirement Health Care Retirement Health Care

4.4. CorrectionsCorrections

5.5. BDS Wait ListsBDS Wait Lists

6.6. Catastrophic Aid to SchoolsCatastrophic Aid to Schools

7.7. School Building AidSchool Building Aid

FY 2009 Budget ReductionsFY 2009 Budget Reductions The State has a The State has a $250M$250M (15%) shortage in GF. (15%) shortage in GF. So far DHHS has given up about So far DHHS has given up about $43M$43M in GF in GF The impact on BDS (as of January 2009) The impact on BDS (as of January 2009)

BDS has given up about BDS has given up about $1.2M$1.2M in General in General Funds Funds without interrupting any direct serviceswithout interrupting any direct services• The planned 2% cost-of-living rate increase The planned 2% cost-of-living rate increase

has been eliminatedhas been eliminated• All of the FY ’09 Wait List funds have so All of the FY ’09 Wait List funds have so

far been preservedfar been preserved After two rounds of budget cuts the State is still After two rounds of budget cuts the State is still

facing a facing a $75M$75M deficit deficit

Historical Financial Perspective Historical Financial Perspective On The Current SystemOn The Current System

Area Agency System Total Funding

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09

FISCAL YEARS

Other Direct State Medicaid

Area Agency System Total Funding

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09

FISCAL YEARS

Other Direct State Medicaid

StateSpending Per $1,000 Income

National Ranking

Maine $8.00 1st

Connecticut $7.66 3rd

Rhode Island $7.15 5th

Vermont $5.72 12th

Massachusetts $4.78 20th

New Hampshire $3.72 34th

National Average $4.12

Source: Braddock, 2008

Fiscal Effort Regarding DD Services Spending For Services Per $1,000 Personal

Income

NH’s DD Waiver per person cost compares favorably with the other NH’s DD Waiver per person cost compares favorably with the other New England States’ average costs. New England States’ average costs.

State

Average Per Person Waiver

Expenditures*Variance

to NH

Maine 84,203$ 40,609$ Rhode Island 74,987$ 31,393$ Connecticut 58,139$ 14,545$ Massachusetts 58,045$ 14,451$ Vermont 47,575$ 3,981$ New Hampshire 43,594$ -$ Source: Braddock 2008 *2006 Data

BDS Rate Increase HistoryBDS Rate Increase History

Medical Inflation Inflation

Rate Increase to AAs

1996 3.5% 3.0% 4.9%1997 2.8% 2.3% 0.0%1998 3.2% 1.6% 0.0%1999 3.5% 2.2% 0.0%2000 4.1% 3.4% 0.0%2001 4.6% 2.8% 2.6%2002 4.7% 1.6% 0.0%2003 4.0% 2.3% 0.0%2004 4.4% 2.7% 0.0%2005 4.2% 3.4% 0.0%2006 4.1% 3.8% 2.3%2007 4.4% 2.8% 2.3%2008 4.2% 2.1% 2.0%

Total 51.7% 34.0% 14.1%

Source: US Bureau of Labor Statistics

Future ChallengesFuture Challenges

FY 2010 & 2011 FY 2010 & 2011 Budget ForecastBudget Forecast

NH Center for Public Policy StudiesNH Center for Public Policy Studies The State is likely to have an overall The State is likely to have an overall

shortage of shortage of $500M$500M for the biennium for the biennium Level funding for FY ’10 and 3% growth in Level funding for FY ’10 and 3% growth in

FY ’11 will result in a deficit of FY ’11 will result in a deficit of $403M$403M A 3% cut in 2010 and restoring the 3% in A 3% cut in 2010 and restoring the 3% in

2011 will still lead to a 2011 will still lead to a $230M$230M deficit deficit

BDS Request For FY 2010 & 2011BDS Request For FY 2010 & 2011[ In Comparison To The 2009 Budget ][ In Comparison To The 2009 Budget ] Fiscal Year 2010Fiscal Year 2010

Increase of about Increase of about $25M$25M in General Funds in General Funds $50M in total funds (state and federal)$50M in total funds (state and federal)

Fiscal Year 2011Fiscal Year 2011 Increase of about Increase of about $40M$40M in General Funds in General Funds

$80M in total funds (state and federal)$80M in total funds (state and federal)

2006 - 2007 2008 - 2009 2010 - 2011GF Increase $11M $26M $65M

BDS Request For FY 2010 & 2011BDS Request For FY 2010 & 2011 Enrolment Increases for:Enrolment Increases for:

DD Waiver (648)DD Waiver (648) ABD Waiver (53)ABD Waiver (53) In-Home Support Waiver (80)In-Home Support Waiver (80) Early Intervention (338)Early Intervention (338)

Cost of Living Increase (across the board) Cost of Living Increase (across the board) Direct service staff wage increaseDirect service staff wage increase Health care coverage for home providersHealth care coverage for home providers Family Support (respite, transportation, heating, etc.)Family Support (respite, transportation, heating, etc.) Intensive training for children with Autism (age birth to Intensive training for children with Autism (age birth to

3)3) Core training for direct service staffCore training for direct service staff Fire safety modificationsFire safety modifications

FY 2010 FY 2011

General Fund Requested

$8,600,524 $18,549,405

Individuals To Be Served

476 701

Total GF for the Biennium $27,149,929

BDS General Fund RequestDD and ABD Wait Lists

FY 2008 FY 2009 FY 2010 FY 2011

General Fund Requested $4,410,273 $9,064,722 $8,600,524 $18,549,405

Individuals To Be Served 269 377 476 701

Total GF for the Biennium $13,474,994

Total GF for the Biennium $27,149,929

BDS General Fund RequestsFor DD and ABD Wait Lists

Reasons For Increases In The Reasons For Increases In The Wait List Numbers?Wait List Numbers?

103

122

151 149 149

7079

56 56

71

95

183

270

138 143

164

113

158

181

0

50

100

150

200

250

300

Jun-04

Sep-04

Dec-04

Mar-05

Jun-05

Sep-05

Dec-05

Mar-06

Jun-06

Sep-06

Dec-06

Mar-07

Jun-07

Sep-07

Dec-07

Mar-08

Jun-08

Sep-08

Dec-08

Bureau Of Developmental ServicesDD Wait List

Number Of People

Total Number of Students with Disability[Source: Bureau of Special Education, DOE]

30,077

32,274

27,000

28,000

29,000

30,000

31,000

32,000

33,000

2000 2001 2002 2003 2004 2005 2006 2007

Changes from 2000 to 2007: 2,197 additional students

Increase of 7%

Total Number of Students In NH Schools [Source: DOE]

232,906

221,614

208,000

216,000

224,000

232,000

240,000

2000 2001 2002 2003 2004 2005 2006 2007

Changes from 2000 to 2007: 11,292 fewer students

Decrease of 4.8%

Number of Students with Autism, Intellectual Disability, or Traumatic Brain Injury [Source: Bureau of Special Education, DOE]

1,4691,524

1,590

1,709

1,814

1,903

2,008

2,309

1,000

1,200

1,400

1,600

1,800

2,000

2,200

2,400

2000 2001 2002 2003 2004 2005 2006 2007

Changes from 2000 to 2007: 840 additional students

Increase of 57%

Number of Students (ages 3-21) Diagnosed with Autism (Source: Bureau of Special Education, DOE)

397

474

568

667

799

905

1,060

1,320

100

300

500

700

900

1,100

1,300

1,500

2000 2001 2002 2003 2004 2005 2006 2007

Changes from 2000 to 2007:Additional 923 students

Increase of 232%

Number of Graduating (turning 21) Students Who Have Autism, Intellectual Disability or Traumatic Brain Injury

[Source: Bureau of Special Education, DOE]

4956

44

6979

115

87

161

62 60

194

202

162

166

152

164169

0

50

100

150

200

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

The projections for years 2008 through 2017 are based on the December 2007

numbers for different age groups

Cumulative Numbers

Age 65 or older 71

Age 65 or older 71

Age 60- 64 52Age 60 or older 123

Age 55-59 48Age 55 or older 171

Age 50-54 102Age 50 or older 273

Age 45-49 102Age 45 or older 375

Age 40-44 120Age 40 or older 495

Age 35-39 106Age 35 or older 601

Number of people living with their families or independently [ NOT receiving residential services currently; supported by elderly parents or other family members]

Bureau of Developmental ServicesAging Consumer Base

Future Wait List Enrollees For Residential Services

Cumulative Numbers

Age 65 or older 193

Age 65 or older 193

Age 60-64 102Age 60 or older 295

Age 55-59 126Age 55 or older 421

Age 50-54 184Age 50 or older 605

Bureau of Developmental Services

[Future Wait List Enrollees For Additional Services] Number of people receiving residential services [Aging and medical issues mean greater need for supports from others]

Aging Consumer Base

FY 2009 FY 2010 FY 2011(Backlog)

DD Wait List 257 181 210

ABD Wait List 23 15 15

Totals 280

701

421

Total Number Of To Be Served

Bureau Of Developmental ServicesDD & ABD Wait List Projections

FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 Totals(Backlog)

DD Wait List 257 181 210 215 178 1,041

ABD Wait List 23 15 15 15 15 83

Totals 280 1,124

BUREAU OF DEVELOPMENTAL SERVICESDD and ABD Wait List Projections for FYs '09, '10, '11, '12, '13

421 423

Senate Bill 138Senate Bill 138RSA-171-A:1(a)(II)RSA-171-A:1(a)(II)

““Beginning with the fiscal year ending June Beginning with the fiscal year ending June 30, 2010, and thereafter, the department of 30, 2010, and thereafter, the department of health and human services shall incorporate health and human services shall incorporate the cost of fully funding services to eligible the cost of fully funding services to eligible persons … and the legislature shall persons … and the legislature shall appropriate sufficient funds to meet such appropriate sufficient funds to meet such costs and requirements.”costs and requirements.”

Aging Careg

ivers

More

Students

Aging Out A

ging Individuals

Financial Challenges

$126,885,412

$99,813,337

$120,231,000

$197,464,766

$-

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

2001 2002 2003 2004 2005 2006 2007 2008

Waiver Institution

What NH would have paid for combined residential and day (24/7) services under institutional (ICF/MR) rates vs.what it actually paid under the Medicaid Waiver