Chairman Gray and members of the Committee, thank you for the opportunity to testify today. My name is Kate Coventry, and I am a senior policy analyst at the DC Fiscal Policy Institute (DCFPI). DCFPI is a non-profit organization that shapes racially-just tax, budget, and policy decisions by centering Black and brown communities in our research and analysis, community partnerships, and advocacy efforts to advance an antiracist, equitable future.
I would like to focus my testimony on the proposed, simplified DC Healthcare Alliance recertification process and the need for services for residents with low incomes who have traumatic brain injuries (TBIs), also known as acquired brain injuries (ABIs). I ask the Council to support the proposed Alliance recertification process, and I ask the Department of Health Care Finance (HCF) to use the fiscal year (FY) 2022 funds dedicated to TBIs to create a path forward for Department of Behavioral Health (DBH) certified-provider organizations to be among those allowed to offer these services. We also encourage DHCF to consult with stakeholders about proposed rules and move forward expeditiously with issuing formal rules to allow these services to become available.
The Council Should Support Proposed, Simplified DC Alliance Recertification Process
DCFPI thanks the Bowser administration for including funding in the proposed FY 2023 budget to simplify the DC Alliance recertification process. The DC Healthcare Alliance program provides critical health care coverage to residents with low incomes who do not qualify for Medicaid, most of whom are immigrants. Given their shared purpose, the DC Healthcare Alliance and Medicaid program should have identical, low-barrier application and recertification requirements. But the DC Healthcare Alliance has required participants to recertify every six months and normally does not allow participants to do this online, while Medicaid only requires annual recertification and allows participants to do so online. These restrictive rules also contribute to a high rate of turnover in the Alliance, as residents join the program but then drop off due to the time-intensive requirements. Prior to the pandemic, only 55 percent of Alliance participants renewed their eligibility when it comes up, data from the District’s DHCF show. Given that many Alliance members are working at jobs without paid leave and that visiting a DHS center can take an entire day or longer, it is not surprising that many are not able to renew their benefits.
The FY 2023 proposed budget includes $4.2 million in recurring funding so that the Alliance recertification process matches the Medicaid process, meaning that Alliance recipients would be able to more easily access and maintain health insurance. The Council should support this change.
The Department of Health Care Finance Should Offer Enhanced Services for Residents with TBIs
The FY 2022 budget included $698,000 to allow some behavioral health outpatient providers to offer enhanced services for TBIs as well as autism spectrum disorders. This was a great investment, but HCF needs to create a path forward for DBH certified-provider organizations to be among those allowed to offer these services. We also encourage DHCF to consult with stakeholders about proposed rules and move forward expeditiously with issuing formal rules to allow these services to become available.
TBIs Have Significant Negative Effects
TBIs are injuries resulting from a blow or jolt to the head, or a penetrating injury to the head, that disrupts the function of the brain. TBI in adults is associated with an increased risk for substance misuse, major depression, anxiety, and unemployment.
TBIs can negatively affect self-regulation and executive functioning. Self-regulation refers to a person’s ability to manage behavior associated with stress and anxiety. For a person with TBI, this might entail difficulty waiting or taking turns; difficulty calming down; or feeling overwhelmed in new places. Executive functioning refers to higher-order brain functions associated with setting goals, organizing, remembering, following directions, and focusing attention. People with TBIs can become easily confused or forgetful; have difficulty learning new information; filling out forms; and using public transportation. Some have difficulty problem-solving, and others have problems with judgment and decision-making. After experiencing a TBI, people may have trouble keeping track of time, making plans, making sure to complete plans or assignments, applying previously learned information to solve problems, analyzing ideas, and looking for help or more information when needed.
Vulnerable Populations Are Particularly at Risk
People who are homeless are at high risk of acquiring a TBI: 50 to 80 percent of them have sustained at least one brain injury prior to homelessness, national statistics show. The DC rate is elevated as well. In 2010, 199 DC homeless individuals were surveyed and nearly two-thirds had a TBI. TBI may be a risk factor for becoming homeless, research shows. Homeless individuals are also at a higher risk of acquiring a TBI because they are more likely to be victimized by assault, experience trauma, and have substance use disorders that can cause falls.
A 2016 survey of 159 adult DC behavioral health clients found that approximately 50 percent had a history of TBI. Additionally, active-duty military personnel are at very high risk. Domestic violence survivors are also at high risk because “the head and face are among the most common targets of intimate assaults.” And finally, TBI is a common co-occurring disorder among people who are diagnosed with a major mental illness and who have a history of substance misuse and criminal justice involvement.
DC Residents with TBIs Are Not Getting the Services They Need, with Devastating Implications
Right now, DC behavioral health providers generally do not screen, identify, or treat the symptoms of TBI because TBI is not an official billable diagnosis in DC’s behavioral health system, and there is no system to train mental health providers. Community-based providers cannot receive payment for services provided to treat TBI, whether it is a standalone diagnosis or co-occurring disorder. This results in DC residents with TBIs not getting the care that they need. The new investment of $698,000 to allow some outpatient providers to offer enhanced services for both TBIs as well as autism spectrum disorders is a great first step, but more funding is needed to reach all residents in need.
The lack of services has terrible implications for individuals with TBI. Research has found that people with cognitive impairments like TBI may be falsely considered non-compliant and then get expelled from programs because these impairments prevent them from fully participating in the services. Or sometimes they are banned from sites because of “disruptive behavior or failure to comply with prescribed treatments.”8 To the untrained eye, problems with executive functioning can look like lack of motivation, laziness, disregard for others, and a reluctance to engage in social activities. Given that a 2010 survey of 12 DC homeless service providers found that only one provider had received any training on TBIs, it is likely that many homeless individuals with TBI are being excluded from mainstream homeless services.
DHCF needs to create a path forward for DBH-certified provider organizations to be among the providers allowed to offer these services. We also encourage DHCF to consult with stakeholders about proposed rules and move forward expeditiously with issuing formal rules to allow these services to become available.