Speech-language pathologists and audiologists who work in public schools, deliver health care services under Medicaid, or teach in public universities—and the individuals they serve—will feel the impact of proposed state budget cuts, if current proposals pass state legislatures in the next few months.
The initial state budget proposals of 48 states have been released, and all show steep cutbacks for fiscal year 2012, which begins in most areas on July 1, 2011. Nearly all states are proposing to spend less money (after inflation) than they spent in 2008 when the recession began, although the cost of service provision will be higher and the Medicaid population has grown [Center for Budget and Policy Priorities (CBPP), 2011].
States are facing a combined budget deficit of $125 billion, and the CBPP cites three reasons: 1) revenues remain depressed as the severe recession continues; 2) the cost of services has increased due to demographic changes and a growth in Medicaid expenses as people have lost jobs and wages; and 3) the emergency federal aid that offset about a third of state shortfalls through 2011 is ending.
Most state spending goes toward health care (Medicaid) and education (public schools and universities). At least 21 states have proposed deep cuts in pre-kindergarten and/or K–12 spending, and 25 states have proposed similar of cuts in health care, according to the CPBB report. In higher education, 20 states have proposed significant reductions.
In several midwestern states, including Wisconsin, Ohio, and Indiana, governors have proposed extensive budget cuts to K-12 and higher education, as well as severe restrictions on collective bargaining rights for public employees.
Some particularly severe cuts include:
Pre-K services in Texas, where the proposed budget would eliminate pre-K funding for nearly 100,000 mostly at-risk children—more than 40% of the state's pre-K students.
Health coverage in Arizona, where the governor's budget would cancel health care for 100,000 individuals.
Higher education in Pennsylvania, where funds would be reduced by more than 50% for the state's higher education system, resulting in less state funding than it received in 1983.
Public Schools: K-12
SLPs in K–12 settings are likely to feel the greatest impact of sharp cuts in state spending. According to ASHA's 2010 year-end membership count, more than 52,000 members report working in K–12 settings.
The restriction of collective bargaining rights—which triggered mass protests in Wisconsin—means that public employees no longer can negotiate on issues related to working conditions. At press time, implementation of the state's "budget repair" bill was on hold following a court restraining order.
Some SLPs in Wisconsin, however, see the writing on the wall. "The proposed budget repair bill is going to have a devastating effect on all of us in public education," said Chris Bauman, a school-based SLP in Middleton, Wis. "All SLPs and teachers are looking at a least a 10% pay cut.
"If, as expected, we lose collective bargaining related to working conditions, we will have no input on caseloads, work schedules, amount of preparation time, and the number of evaluations and screenings that will be required," she said. "Also, the Board of Education will have total control in settling disputes on working conditions, and seniority will be meaningless."
Bauman also is concerned that school districts will become less attractive and the shortage of school-based SLPs will increase. "With lower salaries, cuts in benefits, and little to no say in working conditions, public schools will not attract high-quality candidates," she said. "Morale will decline, and studies show that poor working conditions directly relate to student learning conditions."
In Ohio, school-based clinicians are thinking about the impact on caseloads and other working conditions if Gov. Kasich's budget proposal is enacted.
"Our caseloads are at 80—and some SLPs are dealing with 90 kids," said Sandra Combs, an SLP who worked in school settings for more than a decade and now serves as the schools representative for the Ohio Speech-Language-Hearing Association (OSLHA). "And some SLPs have been asked to see children with voice and trach-and-vent problems before physicians have given medical clearance."
At the recent OSLHA conference, Combs led a caucus for school-based members, for whom "the hot-button issue was collective bargaining." Although most SLPs appeared to support full collective bargaining rights, two SLPs said that in their view, collective bargaining was not needed. Combs said that one problem with Ohio education unions is that union representatives often do not understand the specifics of special education law.
In some of the 20 states planning cuts in public university budgets, tuitions are increasing as state support declines. In Pennsylvania, the proposed legislative budget cuts higher education funding in half.
The budget decisions will affect many CSD programs around the country, including the Department of Communicative Disorders at the University of Wisconsin-Madison, which offers undergraduate, graduate, and doctoral programs. According to department chair Jan Edwards, the immediate impact on the department will be about an 8% funding cut for the coming year.
"It's very difficult because 93% of our budget is personnel," she said. "We're trying to figure out how to meet the budget target without compromising our instructional programs."
The budget cuts will necessitate difficult decisions about innovative courses such as the writing-intensive clinical observation course for undergraduates. "It's been a wonderful addition to our program," she said. "Students learn professional writing and fulfill their writing requirements at the same time. But we may have to cut it out, at least for a few years."
There also is a proposal under consideration by the state legislature to split off the flagship University of Wisconsin-Madison from the rest of the UW system. The UW-Madison would receive less state funding, but would have more flexibility with respect to tuition, purchasing, and faculty salaries. It would have its own board of trustees, to which the governor would appoint 11 of 21 members.
In the long run, Edwards believes that the program will weather the budget storm and could eventually prosper, but "it's going to be tough for the next few years." One challenge will be the 5.8% rise in pension contributions that all state workers—including university faculty—will be required to contribute. "This is a pay cut for every public employee in the state, and will be especially difficult for those with lower salaries," she said. "Traditionally, public-sector salaries have been lower than private-sector salaries at every level of education, but public-sector benefits were better. That may no longer be the case."
With colleagues and friends, Edwards joined the huge rallies at the state capitol in Madison to protest proposed cuts in public employee rights and benefits. "We've all been involved in the protests. They have been amazing!" she said. "There were people from all walks of life—professors, electricians, teachers, teenagers, grandparents, toddlers in strollers, teamsters, firefighters, and police. There were up to 80,000 people, and it was completely peaceful."
Edwards said her 17-year-old daughter went with friends to the rallies for five straight days, and then stayed overnight in the capitol. "She testified in the assembly at 2:30 a.m., when they were taking public testimony," she said. "And the kids from all the schools marched together down State Street in support of the public employees." They organized, she added, using Facebook and other social media.
Early Intervention: Pre-K
A number of states plan to reduce funding for pre-K or early intervention (EI) funding. In New York, Gov. Cuomo's proposed budget includes a 10% rate cut for all EI providers (in addition to the 10% rate cut imposed last year by the New York State Department of Health) as well as significant revisions to the program, including billing EI services in 15-minute increments and discontinuing reimbursement to counties for EI coordination.
The proposed budget and program changes have dire implications for SLPs who work in EI programs. Decreasing the rate will reduce access to services for children with disabilities, placing many at risk for life-long disabilities including communication impairments; in addition, providers will be forced to leave the program because they can't cover their costs.
"Imagine being told, ‘You're doing a great job, but we're going to cut 10% and then another 10% because what you do isn't important enough and you make too much money,'" said Theresa Massimi, an SLP from Bloomington, N.Y. "Early intervention SLPs have to cover their own expenses—materials and travel—and eat lunch in their cars, and be available all the time. This last round of cuts will push more people out of this clinical area and will cause agencies to close. It's disheartening."
Medicaid also is going under the knife again—even as the continuing recession translates into more Americans needing assistance to pay for health care services. Another factor is the June 30 end to federal stimulus funds that helped offset state Medicaid costs in 2009 and 2010. Medicaid receives state and federal money, and many states are making deep cuts to their programs.
In January, for example, Indiana's Office of Medicaid Policy and Planning limited nursing and therapy visits, including speech-language pathology services, to 25 per year. Additionally, reimbursement for ambulance transportation services will be reduced by 5% and reimbursement for non-ambulance transportation services will be reduced by 10%.
And Indiana is far from alone—other states such as New York and South Carolina have seen similar changes. New York's proposed budget requires EI providers who receive more than $500,000 in Medicaid revenue to seek reimbursement from Medicaid and private insurers before seeking reimbursement from local public funds. In December 2010, South Carolina's Medicaid service cuts also included combined therapy caps that limit the number of physical and occupational therapy and speech-language services to 75 visits per year; the policy went into effect April 1, but is retroactive to July 1, 2010, the start of the Medicaid fiscal year. More than 12,000 children in South Carolina will have exceeded this cap by April 1 and will have to wait to until July 1 to resume services; the resulting provider pay cuts may force clinicians out of the system.
According to Donna Edwards, an SLP who works with children in an Ohio hospital, "Many children, especially Medicaid children, may have fewer early intervention services and/or private services (hospital/private practice, hearing/speech centers) as these cuts take effect, due to poor reimbursement.
"Children's hospitals are at risk due to minimal reimbursement rates and to the high numbers of children under the Medicaid umbrella being served diligently to optimize functional daily skills for eating, drinking, talking, hearing, thinking, and communicating," said Edwards, who also leads OSHLA's legislative advocacy efforts.
"Our adults on Medicaid already are unable to obtain digital hearing aids" and are approved only for analog hearing aids, "which, I believe, are no longer being produced and made available to them."
Funding for Hearing Devices
Hearing devices have been targeted by budget cuts in some states, particularly on the West Coast. As of Jan. 1, 2011, Medicaid in Washington no longer reimburses providers for the purchase of hearing aids, cochlear implants, and bone-anchored hearing aids, or for repair of the equipment, parts, or batteries. Audiology exams and medical treatment of the ear are still covered by Medicaid.
In California, which faces a projected budget shortfall of some $25 billion through the end of June 2012, Gov. Brown and the state assembly are wrestling with severe cuts to the state's Medi-Cal (Medicaid) program, which covers nearly 8 million people. On March 17, state lawmakers approved the SB69 main budget bill that slashed Medi-Cal by nearly 10%, and limited coverage of hearing devices to $1,510 annually. And even more cuts may be looming, given many lawmakers' deep opposition to the governor's revenue-generating proposal to extend taxes, which is set to expire this year.
ASHA has been tracking state budget developments as they occur, and contacting associations in the affected states, as well as advocating by letter and e-mail to state offices.
States also are getting involved. In Ohio, OSLHA is working closely in a coalition with other speech and hearing specialists to educate and employ an expert lobbyist to assist them with advocacy. "We have seen the benefit of such a relationship over the years, and applaud those legislators who take the issues of our patients and their families to heart," said Edwards, OSLHA's director of legislative advocacy.
"It is imperative for states to remain active in advocacy efforts," she said. "We use advocacy frequently to keep our membership active and informed. I feel strongly that all states should do the same so that collectively we can have a positive impact for those we serve and for our profession."