Testimony on the Need for Services for Residents with Traumatic Brain Injuries

Chairman 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 nonprofit organization that promotes budget choices to address DC’s economic and racial inequities and to build widespread prosperity in the District of Columbia, through independent research and policy recommendations.

I would like to focus my testimony on the need for services for residents with low incomes who have traumatic brain injuries (TBIs), also known as acquired brain injuries (ABIs), and the need to simplify the DC Healthcare Alliance recertification process.

The fiscal year (FY) 2021 budget included $698,000 to allow some behavioral health outpatient providers to offer enhanced services for TBIs as well as autism spectrum disorders. This is a great new public investment, but the DC Department of Health Care Finance (DHCF) needs 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 also add additional funding to allow Alliance recipients to renew online annually, just like Medicaid recipients do to make the process more equitable and better ensure stable coverage.

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.[1] TBI in adults is associated with an increased risk for substance misuse, major depression, anxiety, and unemployment.[2]

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.[3] The DC rate is elevated as well. In 2010, 199 DC homeless individuals were surveyed and nearly two-thirds had a TBI.[4] TBI may be a risk factor for becoming homeless, research shows.[5] 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.[6]

A 2016 survey of 159 adult DC behavioral health clients found that approximately 50 percent had a history of TBI.[7] 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.” [8] 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.[9]

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.

Ensuring DC Alliance Recertification Is as Easy as Possible Is a Matter of Racial Equity

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 requires 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. The District should be doing all it can to ensure that as many residents as possible have access to insurance and that access is as easy as possible. It is a matter of public health and racial equity.

This policy primarily hurts DC’s Black and brown residents. In FY 2020, 50 percent of Alliance recipients were Hispanic and 20 percent were Black.[10]

DC’s current policy is part of a long, racist history of restrictions on immigrant access to public benefits. Prior to 1965, immigrants to the United States primarily came from Northern and European countries and federal law did not exclude immigrants from public benefit programs.[11] In 1965, the immigration system changed, leading to greater numbers of immigrants coming from Asia and Latin America.[12] Starting in the early 1970s, Congress and some states began restricting immigrants from public benefit programs. Political leaders and the press promoted stereotypes, including that Mexican women immigrated unlawfully to the United States to give children citizenship and public benefits, that Latinx immigrants were lazy and committing fraud when they accessed the benefits for which they were eligible.[13] A 1990 survey of white people found that 46 percent thought Hispanics “generally preferred to live off welfare rather than be self-sufficient.”[14] As a result of these racist stereotypes and a desire to cut spending on programs that benefited people who with low incomes, federal lawmakers excluded many legal immigrants and all undocumented immigrants from Medicaid. Because of this exclusion, DC immigrants have to rely on the Alliance but have stricter recertification requirements then other DC residents who receive Medicaid.

DHS should work with the DHCF to allow Alliance recipients to renew online annually, just like Medicaid recipients do. We should not erect higher barriers just because a resident is an immigrant or has a very low income—DC is a welcoming city, and our policies should reflect that value. The District waived the in-person interview requirement for the Alliance during the public health emergency. DC needs to make this improvement permanent and move to annual, virtual recertification to reflect our DC values.

Shortened Eligibility Period Has Led to Turnover, Poorer Health, and Higher Costs

In 2011, DC implemented restrictive procedures to maintain Alliance eligibility that immediately led to a sharp drop in participation. Thousands of residents who should have health insurance do not have it, and the uninsured rate is much higher among Latinx DC residents than others.[15]

The 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.[16] 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.

We ask that the Department work with DHCF to simplify recertification requirements so that residents can retain their benefits.

Thank you for the opportunity to testify, and I’m happy to answer any questions.

[1]Traumatic Brain Injury & Concussion,” Center for Disease Control and Prevention.

[2] Suzanne Polinder, Juanita A. Haagsma, David van Klaveren, Ewout W. Steyerberg, and Ed F van Beeck, “Health-Related Quality of Life after TBI: A Systematic Review of Study Design, Instruments, Measurement Properties, and Outcome,” Population Health Metrics, February 17, 2015.

[3] Jennifer L. Highley and Brenda J. Proffit, “Traumatic Brain Injury Among Homeless Persons: Etiology, prevalence, and severity, Health Care for the Homeless Clinicians’ Network,” revised June 2008

[4]Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment of Homeless Adult Individuals, Homeless Shelter Providers, TBI Survivors and Family Focus Group, TBI Service Agency/Organizations,” DC Department of Health, revised August 2010.

[5] Jane Topolovec-Vranic, Naomi Ennis, Angela Colantonio, Michael D. Cusimano, Stephen W. Hwang, Pia Kontos, Donna Oucherlony, and Vicky Stergiopoulos, “Traumatic brain injury among people who are homeless: a systematic review,” BMC Public Health, 2012.

[6] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment”

[7] Amy Burkowski, David Freeman, Faiza Majeed, Jennifer “Niki” Novak, Paul Rubenstein, and Celeste Valente, “Traumatic Brain Injury in the District: The Ignored Injury: A Paper Examining the Prevalence of TBI in the District and the Need for Services,” revised July 2018.

[8] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessmen.t”

[9] Ibid.

[10] DC Department of Health Care Finance. “FY 20-21 Oversight Questions Attachments.” Accessed on February 2, 2022.

[11] Elissa Minoff, Isabella Camacho-Craft, Valery Martinez, and Indivar Dutta-Gupta. “The Lasting Legacy of Exclusion: How the Law that Brought Us Temporary Assistance for Needy Families Excluded Immigrant Families & Institutionalized Racism in Our Social Support System.” Center for the Study of Social Policy and the Georgetown Center on Poverty and Inequality. August 2021.

[12] Ibid.

[13] Ibid

[14] Cybelle Fox ‘The Changing Color of Welfare? How Whites’ Attitudes toward Latinos Influence Support for Welfare.” American Journal of Sociology, 110(3): 580–625, 2004.

[15] Jodi Kwarciany, “DC Has Disparities in Health Coverage Despite Its Low Uninsured Rate,” DC Fiscal Policy Institute, revised September 25, 2017.

[16] Ed Lazere, “No Way to Run a Healthcare Program: DC’s Access Barriers for Immigrants Contribute to Poor Outcomes and Higher Costs,” DC Fiscal Policy Institute, revised March 17, 2019.