Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4510-0600	Environmental Health Services	3,947,284	4,030,022	2,702,345	2,709,962	3,146,865	3,187,661
4512-0103	AIDS Prevention, Treatmt. & Svcs.	49,569,025	40,561,545	34,972,875	32,056,975	33,344,099	34,697,303
4512-0106	HIV Rebates (Ret. Rev.)	1,200,000	1,200,000	1,200,000	1,200,000	1,900,000	1,900,000
4512-0500	Dental Health Services	1,305,021	1,429,675	1,397,396	1,399,150	1,556,150	1,556,150
4512-0501	Tufts Dental Prog. Equip.	--	518,920	0	0	0	--
4512-1300	Family Planning Services	977,344	988,961	0	0	0	--
4513-1000	Family Health Services	12,775,715	11,485,421	10,344,077	4,840,000	7,010,000	8,332,196
4513-1002	WIC Nutrition Services	13,927,265	13,663,615	13,142,281	12,571,048	12,571,048	12,859,601
4513-1010	Early Intervention (Ret. Rev.)	2,414,628	2,556,679	2,538,952	2,700,050	2,700,050	2,700,050
4513-1020	Early Intervention	29,663,816	29,716,956	28,562,518	29,188,130	29,270,778	29,840,024
4513-1021	Early Intervention Respite Services	414,663	390,754	0	0	0	--
4513-1023	Newborn Hearing Screening	83,085	66,628	0	83,060	83,060	83,060

*     Final FY05 Budget includes Prior Appropriations Continued for FY04 in the supplemental budget passed in September 2004.

The Massachusetts Department of Public Health (MDPH) is part of the Office of Health under the umbrella of the Executive Office of Health and Human Services (EOHHS). MDPH operates scores of programs charged with carrying out preventive, educational, public relations, research, direct therapeutic and health, laboratory research, data collection, and numerous other services on behalf of public health in the Commonwealth.

These programs include: smoking cessation and treatment for gambling addiction and substance abuse; services for survivors of sexual assault; education on and testing for many forms of cancer and other diseases; services for people with HIV and AIDS; tuberculosis testing; a system of state hospitals; the maintenance of health statistics and vital records; family programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Early Intervention for young children at risk of developmental delays; management of state accreditation systems for nurses and other health professionals; and various health-system and patient-protection quality oversight.

Even more than most agencies, the work of MDPH is considered by public health proponents to reduce future and emergency costs to tax payers.

FY05 OVERVIEW

MDPH Attempts to Cope with a Budget Slashed 29% Between FY01-FY04

The FY05 story at MDPH only comes into clear focus with an understanding of the agency's recent history. Between FY01-FY04, MDPH's budget was cut 29%, unadjusted for inflation. For just non-hospital programs, the FY01-FY04 cut was 37%. These were the deepest cuts to any agency within the Executive Office of Health and Human Services (EOHHS). April 2004 data shows that MDPH has cut 363 full-time equivalent staff (FTEs) since FY01, a total staff loss of nearly 18%. Compounding these problems, cuts in local aid to cities and towns have been deep and public health services are being slashed at the municipal level.

Researchers [1] have examined the effects of recent MDPH budget cuts on the Commonwealth and concluded, in part, the following:

·       Cuts fall disproportionately on the poor, communities of color, women, and children. Cuts to school health, prostate and breast cancer awareness, diabetes, teen pregnancy prevention, WIC, prenatal care, AIDS, etc. all disproportionately impact communities of color, women, and in some cases children.

·       Cuts to public health infrastructure make health disparities and other vital health impact data difficult to track. Cuts in the public health infrastructure have reduced capability at state and local levels to maintain information systems that track diseases, health problems, and how services are being used.

·       The service-delivery system is now in jeopardy. In Massachusetts, local services are provided by an infrastructure of private, community-based provider agencies. Replacing large state institutions, they have demonstrated their ability to reach populations often ignored by larger, more centralized agencies. Cuts have eliminated some of the most successful and innovative programs and vulnerable people have been cut from care with nowhere to go.

·       MDPH cuts increase stress on the Uncompensated Care Pool and MassHealth. Elimination of preventive health protection programs funded by the state will increase the need for primary care, particularly for the poor and uninsured, thereby increasing the strain on MassHealth and the Uncompensated Care Pool.

Between 1990-2003, Massachusetts fell from 1^st to 22^nd in a nationwide ranking of state support for public health. While more federal funding has been provided to the states for public health infrastructure, these funds do not begin to compensate for state cuts in Massachusetts. Over $28 million in new money has come from federal sources, including the Center for Disease Control (CDC) and the Prevention and Health Resources and Services Administration, compared with nearly $160 million cut from state funding for MDPH and local health agencies.

FY05 Sees 9% Improvement over FY04-But Still 23% below FY01

In FY05, including a September 2004 supplemental budget that was applied to FY05, the legislature restored $32.8 million of the MDPH cuts that had been sustained since FY01. Yet for non-hospital programs, the MDPH budget is still 31.5% below the FY01 level, unadjusted for inflation; with hospital programs included, the funding loss since FY01 is 23%.

Partial restorations include the following: $14.7 million more for the Bureau of Substance Abuse Services (44% above FY04); $700,000 more for the HIV Drug Assistance Program (58% above FY04); $1.28 million more to AIDS Services (4% above FY04); $2.17 million more to Family Health Services (45% above FY04); and $125,000 more for Suicide Prevention (100% above FY04).

H1 for FY06 OVERVIEW

Near Level Funding Means More Program Erosion

H1 proposes a 1% increase to MDPH, from $409.5 million in FY05 to $416.1 million in FY06, according to the Mass. Public Health Association (MPHA). Most programs receive level or near level-not maintenance-funding. The lack of inflationary increases will translate into continued program erosion.

H1 would cut substance abuse services 5% (by $2.6 million) as compared with FY05 funding, however he filed a supplemental budget for $9.2 million on the same day as he released H1. Substance abuse advocates say the supplemental was for more than originally anticipated because of new information on the state's maintenance of effort matching requirements needed to preserve federal dollars for substance abuse. In addition, this budget badly under funds the beleaguered public health hospitals, and cuts the State Laboratory Institute by 1%.

Line Item Analysis[2]

Account:      Environmental Health

Line Item:   4510-0600

The Environmental Health account funds:

·       The Division of Food and Drugs

·       The Radiation Control Program

·       The Bureau of Environmental Health Assessment

·       The Community Sanitation Program

·       The Renal Disease Program

The Bureau of Environmental Health Assessment's services include the tracking or surveillance of important diseases such as childhood asthma, childhood and other cancers, and lead poisoning. It is the expertise within this bureau that designs community-based studies and conducts investigation to clarify whether an environmental agent is causing illness.

Line Item	Description	FY01 Final	FY02 Final	FY03 Final	FY04 Final	FY05 Final Budget	H1 for FY06	% Change H1 vs. FY05
4510-0600	Environmental Health Services	3,947,284	4,030,022	2,702,345	2,709,962	3,146,865	3,187,661	1%

 

FY01-FY05 Impact

Funding to this line item was cut 37% between FY01-FY04, with 33% of all funded positions eliminated-a loss of both infrastructure and expertise.

Funding to the Bureau alone for its community studies has fallen by 39%. Meanwhile, the number of calls received by the Bureau's Community Assessment program has increased by 22% over the same period. Many ongoing investigations have been discontinued mid-stream and other studies have gone into a longer waiting time for execution. MDPH reports that the cut in staff impacts regulatory services required by statute and provided by the Division of Food and Drugs, Bureau of Environmental Health Assessments, Radiation Control, and the Community Sanitation Program.

FY05 restored $436,903 to this account, a 16% improvement over FY04. However, it added $545,000 in new ear marking not included in FY04 and therefore core bureau functions were cut again. Overall, the account is still 24% below FY01, unadjusted for inflation.

Governor's H1 for FY06 Recommendations

H1 recommends 1.3% more than FY05 to this account. The funding is for the POS Salary Reserve initiative and for collective bargaining contracts with unionized workers.

Account:      HIV/AIDS Bureau

Line Items:  4512-0103 and 4512-0106

The HIV/AIDS Bureau is funded through 2 separate accounts.

Line 4512-0103 funds:

·       HIV/AIDS Counseling and Testing Services-according to the Project ABLE coalition, in FY03 over 54,000 HIV tests were performed at these programs targeting difficult-to-reach individuals, such as the homeless and injection drug users;

·       HIV/AIDS Specialty Care Services-for non-reimbursable services including home care and primary health care visits, mental health services, and medication adherence support programs; currently serving 8,000-10,000 people;

·       HIV/AIDS Client Support Services-including nutrition, transportation, housing support, emergency assistance, respite care, and child care; currently serving 8,000-10,000 people.

·       Prevention and Education Services-located in drop-in centers, substance abuse treatment programs, family planning programs, and community health centers; currently reaching tens of thousands of Massachusetts residents; and

·       Substance Abuse Services-for individuals with or at risk of HIV seeking outpatient treatment for heroin use and inpatient detoxification treatment; thousands are served.

Line 4512-0106 funds:

·       HIV Drug Assistance Program (HDAP)-to pay for life-saving AIDS medications for income-eligible people who are under- or uninsured. This is a retained revenue account collecting federal financial participation (ffp)-over 3,200 people are served through this combination of state and federal funds. (HDAP also receives funds through line item 4512-0103.)

Advocates with Project ABLE warn that the level of drug-resistant HIV virus in Massachusetts is increasing. An estimated 10% of new infections are caused by drug-resistant viruses. Interruptions in medical care due to budget cuts contribute to the development of these strains. More costly medical services are necessary due to cuts to programs which keep people healthier longer and living independently in their own communities. Out of the nearly 23,000 people infected in Massachusetts, several thousand do not know they are infected with HIV and may be putting others at risk of infection.

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4512-0103	AIDS Prevention, Treatmt. & Svcs.	49,569,025	40,561,545	34,972,875	32,056,975	33,344,099	34,697,303
4512-0106	HIV Rebates (Ret. Rev.)	1,200,000	1,200,000	1,200,000	1,200,000	1,900,000	1,900,000
Totals:		50,769,025	41,761,545	36,172,875	33,256,975	35,244,099	36,597,303

FY01-FY05 Impact

FY02-FY04 budget cuts resulted in many program cuts for which restorations are still needed:

·       Elimination of 25,000 HIV tests-representing about a third of the testing/counseling program-meaning that thousands of high-risk residents did not find out their HIV status, potentially putting others at risk;

·       No provision of treatment and support services, including transportation, nutrition, and emergency assistance-essential for keeping people living in the community and able to follow complex treatment plans-to 2,500 people between FY01-FY04;

·       Reduction or elimination of health center, home health care, and county jail-based programs;

·       Cuts to prevention and education services of 38%-consequently 350,000 contacts with high-risk individuals were lost;

·       A loss of Specialty Care Services-including home care, medication adherence help, and mental health services-for 1,000 individuals;

·       Thousands of persons cut from narcotic treatment and several hundred were cut from detoxification treatment-at the same time that substance abuse treatment for more than 250 clients at the Department of Corrections (DOC) was cut.

In FY05, these HIV/AIDS accounts are funded at nearly 33% below their FY01 funding level, unadjusted for inflation and including the September 2004 supplemental budget for FY05 of $2.4 million. The supplemental, combined with restoration of eligibility for the HIV MassHealth program from 133% to 200% of poverty, narrowly averted the creation of waiting lists at HDAP for life-saving drugs.

Still needed in FY05 is an additional $2.2 million supplemental budget to cover the cost of serving individuals who should be covered by MassHealth. The state is waiting for the approval of an HIV Medicaid waiver, and the approval delay has resulted in $2.2 million in unanticipated HDAP costs. MDPH anticipates the federal waiver will be approved and the clients moved to MassHealth before FY06.

FY06 Needs

Project ABLE is advocating for an additional $7 million to 4512-0103 in FY06 to fund $5.1 million beyond FY05 funding for HDAP to cover the rise in HIV infections (with 1,000 new infections per year) and $1.9 million for Education and Prevention, Treatment, and Support Services.

H1 for FY06 Recommendations

H1 recommends $1,353,204 (4%) for these services above the FY05 allocation. It maintains the ceiling on the HDAP retained revenue account (line item 4512-0106) at $1.9 million. MDPH reports that $1.086 million of the increase is maintenance funding for HDAP to continue supporting the 4,000 HDAP clients projected by the end of FY05. At this funding level, new enrollees in FY06 will have to be placed on a waiting list for life-sustaining drugs.

Account:      Dental Health

Line Item:   4512-0500

The Dental Health account funds the Office of Oral Health, which provides public education and dental care for people who are court-mandated and people with developmental disabilities. Programs include:

·       The Tufts Dental Program, that serves persons with disabilities with oral health education, screenings, and case management at 8 sites around the state and provides operating room facilities for extensive care and behavioral management at 2 Boston-area facilities;

·       A community fluoridation program in 22 communities, serving 58% of the state's population;

·       A statewide school fluoride mouth-rinse program for children, serving 59,000 children in non-fluoridated communities; and

·       A Head Start fluoride tablet program in non-fluoridated communities, serving 2,000 children.

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4512-0500	Dental Health Services	1,305,021	1,429,675	1,397,396	1,399,150	1,556,150	1,556,150
4512-0501	Tufts Dental Prog. Equip.	--	518,920	0	0	0	--
Totals:		1,305,021	1,948,595	1,397,396	1,399,150	1,556,150	1,556,150

FY01-FY05 Impact

In FY03, the account was cut by $44,560, eliminating technical and financial assistance to new communities requesting support for starting a community water fluoridation system. Most programs have received level-funding for years.

In FY05, the account's funding grows by $157,000 (11%). The increase is improving funding for the Tufts contract in order to expand services to developmentally disabled children and adults. New earmarking also designates a minimum of $122,000 for a dental clinic in Taunton to serve moderate- to low-income residents. Last year's $200,000 earmark to a different Taunton dental clinic is gone.

FY06 Needs

Health Care for All's (HCFA) Oral Health Advocacy Taskforce is working to bring statewide community water fluoridation to all communities in Massachusetts with public water supplies serving more than 5,000 residents. HCFA reports that the initiative would have an average statewide cost of 50 cents per person per year and would save millions of dollars annually on dental care. Massachusetts ranks 35^th in the nation for fluoridation status.

H1 for FY06 Recommendations

H1 recommends level funding with the FY05 allocation.

Account:      Family Health Services

Line Items:  4512-1300 and 4513-1000

The Family Health Services account funds Primary Care Programs for Pregnant Women, Children, and Adolescents (and a number of other programs, not discussed here). These programs provide primary care to more than 130,000 pregnant women, children, and adolescents in 40 health centers and primary care sites serving low income and/or medically underserved communities across the state. These programs offer clinical care, psychosocial services, nutrition, outreach and case finding, case management and care coordination, and health promotion and disease prevention activities. Federal Maternal and Child Health funds also support these primary care programs.

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4512-1300	Family Planning Services	977,344	988,961	0	0	0	--
4513-1000	Family Health Services	12,775,715	11,485,421	10,344,077	4,840,000	7,010,000	8,332,196
Totals:		13,753,059	12,474,382	10,344,077	4,840,000	7,010,000	8,332,196

FY01-FY05 Impact

Each of these critically important programs suffered severe cuts during the recent fiscal crisis.

Between FY02-FY03, Primary Care Programs for Pregnant Women, Children, and Adolescents were cut 36%, from $1,702,414 in FY01 to $451,000 in FY03. According to MDPH, cuts to primary care increase the use of emergency rooms and urgent care services, and diminish the ability to diagnose communicable diseases early. Cuts also cause a decrease in early prenatal care, and increase untreated mental illness, substance abuse, household violence, and other conditions for which primary care screens.

In March of FY03, FIRSTSteps, a maternal child health home visiting program that had served 20 sites in high-risk communities throughout the state, was eliminated. The program served 1,560 persons in FY02 and 952 persons in FY03. MDPH now channels the federal funding they receive into Early Intervention Partnerships-a revised model of what had been FIRSTSteps. Fewer individuals are served through this model.

In FY04, $2.38 million of the reduction to this line represented funding transferred to other accounts. In addition, $470,776 was cut from an Interagency Service Agreement (ISA) to the Department of Mental Retardation (DMR) that paid for 11 adult residential placements in staffed apartments and community-based residences, along with the support and rehab services these clients need. DMR has had to cover these clients from their own limited budget.

FY06 Needs

Advocates are seeking a $1.8 million increase to 4513-1000 in order to earmark $6 million for family planning. They would like to see $400,000 of this money earmarked for HIV counseling and testing services for at-risk family planning program participants.

H1 for FY06 Recommendations

H1 recommends $8,332,196 for this account, a 15.86% ($1,322,196) increase over FY05 funding. Of this money, $72,832 is for annualization of the FY05 POS salary reserve initiative to increase the salaries of the Department's contracted direct care employees.

Account:      Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Line Items:  4513-1002 and 4513-1012

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program accounts fund this joint state-funded and federally-funded program. Line item 4513-1012 is a retained revenue account, holding federal matching funds the program generates.

WIC serves low- and moderate-income pregnant, breastfeeding and postpartum women; infants; and children up to age five who are certified as medically or nutritionally at-risk. The program provides nutrition education and counseling, health care and social service referrals, and checks to buy protein rich food-such as eggs, milk, and cheese-at stores approved by the program. WIC participants also receive coupons redeemable at community farmers' markets for fresh produce. 

WIC became an entitlement program in Massachusetts in the early 1990s. Outreach is conducted to reach the homeless, nutritionally deficient, and poor in places like health care centers, churches, food pantries, shelters and soup kitchens. The average monthly caseload was 118,248 in FY03. It is projected to be 119,842 in FY04.

The Nutrition account also funds a statewide network of 6 growth and nutrition programs, established in 1984 to evaluate and treat children with growth deficiencies-children commonly known as having a "failure to thrive"-through a multidisciplinary approach. Services are provided by a physician, nutritionist, nurse practitioner, social worker, case manager and/or a specially trained psychologist. Thousands of children have been served since the network's inception.

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4513-1002	WIC Nutrition Services	13,927,265	13,663,615	13,142,281	12,571,048	12,571,048	12,859,601
4513-1012	WIC (Ret. Rev.)	22,513,925	21,865,750	21,254,273	23,230,000	23,230,000	24,076,000
Totals:		36,441,190	35,529,365	34,396,554	35,801,048	35,801,048	36,935,601

FY01- FY05 Impact

Since FY01, WIC has been cut nearly 2%, unadjusted for inflation (and including consideration of the retained revenue account). The Department has worked to maintain its caseload during the economic downturn-when demand only rises-by reducing education and outreach materials. MDPH notes that less access to WIC by women who need it will mean lower birth weight newborns, more premature births, and an increase in infant mortality.

FY06 Needs

MDPH has established the need for $1.1 million in additional funding to the 4513-1002 account in FY06 to support an anticipated 5% inflationary rise in food expenses, particularly the price of milk. An additional $846,000 is requested for line item 4513-1012 for a 5% increase in the cost of infant formula. Project Bread is advocating to maintain level funding for 4513-1002 in FY06.

H1 for FY06 Recommendations

H1 recommends $12,859,601 for 4513-1002, a 2.3% ($288,533) increase over FY05. It is essentially level funding, because the new money is for continuing the POS Salary Reserve initiative first funded through a separate account in FY05. H1 for FY06 does, however, increase the ceiling on the WIC retained revenue account (4513-1012) by $846,000. The combined funding would cover an average monthly caseload of 120,555.

Account:      Early Intervention

Line Items:  4513-1010, 4513-1020, 4513-1021

The Early Intervention (EI) accounts fund a statewide, comprehensive, developmental service available to families of children from birth to age 3 who have or are at risk for developmental delays. Family-centered diagnostic and treatment services are provided by nurses, social workers, speech, occupational, and physical therapists. Attention is focused as well on empowering families and providing family supports and networking. MDPH estimates the FY05 caseload will reach 30,294 persons (6.5% more than in FY04).

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4513-1010	Early Intervention (Ret. Rev.)	2,414,628	2,556,679	2,538,952	2,700,050	2,700,050	2,700,050
4513-1020	Early Intervention	29,663,816	29,716,956	28,562,518	29,188,130	29,270,778	29,840,024
4513-1021	Early Intervention Respite Services	414,663	390,754	0	0	0	--
Totals:		32,493,107	32,664,389	31,101,470	31,888,180	31,970,828	32,540,074

FY01-FY05 Impact

Since FY01, the combined EI accounts have been cut 1.6% ($522,279), unadjusted for inflation. At the same time, caseload has increased between 5-6.5% annually. In FY03, a former separate respite account was de-funded by consolidating it into the main EI account (line item 4513-1010) without corresponding funding.

The agency has kept up with demand in two ways.

·       First, beginning in FY02, MDPH became the payer of last resort for these services-the law was changed so that third party payers (public and private insurers) are required to pay for services rendered by EI specialists up to a specified benefit cap. In FY05, this cap was increased from $3,200 to $5,200-the change is expected to keep up with the caseload increase, but reduced service hours are now the norm.

·       Second, in FY03, MDPH cut services-group service hours and parent group service hours were cut back and transition services for special education eligible children along with some other provider reimbursements were eliminated.

The Early Intervention Consortium reports that in addition to service cuts, the program is also suffering due to stagnating provider rates. EI has a very high turnover for physical therapists, occupational therapists, speech pathologists, and other specialists. The last rate increase was for 1.21% in April 2002. The program used to employ nurses, but cannot anymore. High turnover negatively impacts families-when service coordinators change frequently, relationships with trusted practitioners are severed.

FY06 Needs

Advocates are requesting a $2 million increase to line item 4513-1020 in FY06, earmarked for program enhancement (not caseload growth). The funds are needed for services-such as translator services and parent/family liaisons-that have been cut in recent years. In total advocates seek $31,188,130 for line item 4513-1020 in FY06.

Advocates also call for the program to remain at MDPH and not to be moved into the new Department of Early Education and Care (DEE&C). They want to ensure that insurance providers continue to be able reimburse for medically necessary services, which could look suspect under an education and care department. The state is currently paying for just one-third of the cost of these services.

MDPH has established the need for an additional $558,000 for line item 4513-1020 in FY06-$384,994 is for an anticipated FY06 increase in autism costs and $173,006 is for FY06 caseload growth.

H1 for FY06 Recommendations

H1 recommends $569,246 (1.9%) above FY05. The funds would remain at MDPH and not be consolidated into the new DEE&C. MDPH reports that expansion funding of $558,000 would allow the program to deliver services to 31,764 children-a 5% increase over the projected caseload of 30,251-during FY06. Approximately 70% of the additional funding will support specialty services for children with autism, and 30% will cover the general EI direct services caseload increase. The remaining new $11,246 is to annualize the FY05 POS salary reserve initiative to increase the salaries of the lowest paid contracted direct care workers.

Account:      Universal Newborn Hearing Screening

Line Item:   4513-1023

The Universal Newborn Hearing Screening account funds the tracking, notification, and follow-through of newborns with potential hearing disorders to families, primary care providers, and early intervention programs. Since passage of a 1998 statute, hearing screenings are required prior to a newborn's discharge from a hospital or birthing center-4 babies in every 1,000 have a permanent hearing loss detectable by newborn hearing screening. MDPH reports that detecting hearing loss at birth and having habilitation well under way by six months of age has been shown to result in higher cognitive, language, and social outcomes than later diagnosis.

The program is also supported by federal funds through two sources: the Centers for Disease Control's (CDC) Childhood Hearing Data System Project, for a computerized infrastructure; and the Maternal and Child Health Bureau's Massachusetts Infant Hearing Linkage Project, to help connect families to a continuum of services.

Line Item	Description	FY01	FY02	FY03	FY04	FY05	H1 for FY06
4513-1023	Newborn Hearing Screening	83,085	66,628	0	83,060	83,060	83,060

FY01-FY05 Impact

Since FY01, this line item has been cut by 17%, from $100,000 to $83,060. Under-funding at the Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH) has also meant poor follow through for families referred to that agency.

H1 for FY06 Recommendations

H1 for FY06 recommends level funding.