Shrinking Services

Allocating Medicaid funds to Georgia's poor and disabled proves to be a lopsided balancing act

It was the Barbie doll in Big Lots that ignited Brittany Jefferson's outburst. Brittany spotted the doll and asked her mother to return the new jeans and T-shirts she'd just bought so she could purchase it instead. Daphnie Jefferson told her daughter they couldn't buy the doll right now. Brittany needed the clothes, not the doll.

That didn't sit well.

Within seconds the girl's eyes narrowed and she stomped the floor. Her mother was able to drag her out of Big Lots, but only in time for Brittany to grab her mother's arm and vigorously shake it while she tried to drive. The girl wailed. Saliva spewed from her mouth. People stared.

Daphnie Jefferson tried to remain calm. These outbursts were typical when her daughter was allowed out of the hospital.

"You actually are scared," Jefferson says. "But it happens so much now I'm more calm about it."

Brittany, a plump 15-year-old with soft eyes and freckles, suffers from adjustment disorder (extreme distress in normal social settings), attention deficit disorder, and moderate mental retardation. She's received special education since kindergarten and currently lives at Georgia Regional Hospital Atlanta in Decatur, a psychiatric facility. In 18 months, she's been admitted to a psychiatric ward five times because of her outbursts. Each time Brittany explodes, her mother brings her to a hospital because she has nowhere else to take her, and the staff doses her with anti-psychotics to quiet her fit.

Usually, Brittany is released after six weeks. This time, however, she's been confined in the child and adolescent unit for seven months.

But under the Americans with Disabilities Act, she shouldn't have to stay in the hospital at all. That's because she legally qualifies for mental health Medicaid services that would allow her to live in the community - at a cheaper cost to the state.

But the state of Georgia, which administers those services, seems to have failed Brittany. Despite being obligated to grant her access to more therapeutic community-based care, the state done no such thing, according to a lawsuit filed last month in U.S. District Court in Atlanta.

Brittany's attorney, Andrea Jolliffe of Atlanta Legal Aid, claims the state's withholding of such services is a violation of Brittany's due process rights. The lawsuit alleges the state has disregarded basic guidelines in administering Medicaid, the combined state and federal health plan serving 1.5 million poor and disabled Georgians.

Jolliffe is hoping that if a judge sides with her, Brittany's case could set a precedent - and every one of the 5,593 eligible people on waiting lists for Medicaid services would benefit.

If Brittany is granted the Medicaid services promised by the Americans with Disabilities Act, Jolliffe's logic goes, so should everyone who's eligible.

And while Brittany is a classic example of being denied the health care opportunities offered by federal law, her case also characterizes a larger issue plaguing the state. Drastic federal Medicaid cuts have forced Georgia and other states to reallocate Medicaid funds, says Linda Lowe, a consumer health advocate who lobbies for the state's Medicaid programs. The result is that access to certain Medicaid services is getting swept under the rug, Lowe claims. And those services are often the ones that work best.

Lowe says the state's $600 million-plus budget deficit doesn't help. In the current GOP-run state government, the first Republican-controlled Legislature since Reconstruction, the outlook for mental health and other, less mainstream treatment is even more grim.

What's more, Georgia is one of the nation's fastest growing states, which is part of the reason why Georgia's Medicaid costs have skyrocketed. Lowe points out that as a result, lawmakers often overlook that Georgia's Medicaid coverage per person is far less than such costs in the private sector.

"Sometimes, policymakers are pressed into having to know the price of everything and the value of nothing," Lowe says. "So really shortsighted decisions are made.

But these are very efficient programs, and the private sector can't match them in any way."

Still, Gov. Sonny Perdue has indicated that he wants to lessen the Medicaid burden by relying more heavily on private insurers to pick up where Medicaid leaves off.

A spokeswoman for the division of the state Department of Human Resources that oversees mental health services and funding did not respond to requests for comment.

Lowe says federal Medicaid cuts will hurt every person in the state, even those not on Medicaid. That's because the feds match the states' contributions, and if both are reduced then not only mental health services, but all state hospitals will be further drained by the Medicaid crunch.

"When we go into the hospital emergency room, the quality of our care is impacted by whether or not health care facilities are receiving adequate reimbursement from Medicaid," Lowe says. "If people don't have insurance [and Medicaid funds are exhausted], that has an impact on every one of us."

Under federal Medicaid provisions, Brittany is entitled to screenings to monitor her mental health and is eligible to receive community-based, Medicaid-funded treatment that would allow her to live at home, the lawsuit alleges.

What's more, community-based care would not only offer a better chance at rehabilitation. It would cost the state a lot less than her extended hospital stays.

Instead of waking up at 4 a.m. in a hospital bed and being told what to wear, Brittany would wake in her own bedroom, pick out her own outfit for the day and eat breakfast with her mother before school. Instead of being escorted in a hospital car to a visiting facility just to sit with her sister and nephew in a stark conference room, she could sit with them at their kitchen table.

When Brittany gets to spend the weekends at home in Decatur, she usually lounges on the couch and watches You Got Served, her favorite movie. She'll listen to Tupac and Usher, two of her favorite artists.

But when she's in the hospital, relaxing on a Saturday afternoon seems like a distant memory.

"I want to go home - it's not fair," Brittany says in the visiting room at Georgia Regional. "That would be super duper, super duper."

Says Jolliffe: "[Brittany's] got a functional level that we've never seen. If she got special services, she could very well amaze us all."