Lanier Cansler stepped down Tuesday as secretary of the North Carolina Department of Health and Human Services, saying that he expects the frustration of running the state's largest agency to increase in an election year.
Cansler, who has headed DHHS since the beginning of Gov. Beverly Perdue's administration three years ago, announced Jan. 13 that he would leave at the end of the month to start a consulting business focusing on finding better ways for health care to work in North Carolina.
He said he's used to challenges – he was a four-term Republican lawmaker who has served for a Democratic governor. Still, reconciling the differences between the executive and legislative branches of government became tougher than ever in recent months.
"It does get frustrating whenever you're working on the issues and you get caught in the political contest," he said. "In each of their minds, I think what they're thinking is the best thing for the state, but there's great philosophical differences."
Republican legislative leaders and Perdue have been at odds in recent weeks, for example, over how to handle a growing budget hole at DHHS.
The agency's budget was cut by more than $350 million last summer, but difficulties in making those cuts – the federal government didn't approve of many moves – has left DHHS with a $150 million deficit. It's projected to grow to more than $240 million by fiscal 2012-13, which starts in July.
"I realize politics are always going to be there, but to the extent you can let the right decision rule the day rather than let politics rule the day, that's the goal, because that's when you can achieve the most for the state," Cansler said.
Throughout his tenure, Cansler also dealt with allegations of neglect and abuse at the state's psychiatric hospitals. Months before he took over, a patient at Cherry Hospital in Goldsboro fell and was left in a chair, neglected for nearly 24 hours before he died.
One of his first actions in 2009 was to establish a zero-tolerance policy for patient abuse, yet a May 2010 incident at Cherry Hospital prompted him to order intensive retraining for all employees of the facility.
Cansler said he's proud of the strides made to change the culture inside DHHS, such as better training, to fight Medicaid fraud and to stabilize the state's mental health system. He said, however, that the state needs to invest more in mental health.
Perdue has named senior policy advisor Al Delia acting secretary of DHHS. Cansler has agreed to be chairman of Perdue's new Commission on Affordable and Sustainable Healthcare, and he said he would be available to help Delia as needed.
"I'll still be in the mix. I just don't have to worry about the crisis of the day," he said.
No one has more control over deciding how babies died in North Carolina than Dr. John Butts.
As N.C. state's chief medical examiner, he has the final say on thousands of autopsies each year. He doesn't hesitate to change findings that don't fit his standards.
But when it comes to healthy N.C. babies who die unexpectedly in their sleep, Butts' approach has troubled law enforcement officials, prosecutors and even members of his own staff.
"We're frustrated," wrote the head of a Gaston County child protection panel, protesting a SIDS ruling from Butts' office. "We realize that there is controversy around this topic and understand hesitancy in broaching and yet we see children dying..."
Butts believes unexplained baby deaths should be ruled sudden infant death syndrome, or SIDS, barring concrete evidence of suffocation, such as a witness or a confession. He attributes deaths to SIDS even when faced with factors that suggest other causes.
Butts' bias toward the SIDS label - which is supposed to indicate a natural and unpreventable death - runs counter to a national trend. Other states and jurisdictions are finding new ways to classify those deaths if circumstances suggest babies may have suffocated while sleeping with adults or in unsafe bedding.
Supporters of the trend hope to prevent infant deaths by educating parents about the dangers of unsafe sleep and to help researchers focus on finding the cause of truly unpreventable deaths. Law enforcement authorities say different classifications would also leave open the possibility of criminal charges in instances of neglect or abuse. Charges now are difficult to pursue when the cause of death is listed as SIDS.
Butts, who is 64 and near retirement, resists the trend. He argues it wrongly assumes foul play, does not save lives and worsens innocent families' grief.
He's proud that his philosophy has remained consistent since he joined the chief medical examiner's office in 1975.
"I impose my will on how we do things," Butts told the Observer.
That will is based on his training as a forensic pathologist and his compassion for parents.
"When we assign a cause of death, it's not just a purely intellectual activity," Butts said. "It has consequences for people, particularly if we said something that you did killed your child - that you rolled over on it, slept on it, that you were in bed with it."
'We're frustrated'
In Gaston County, officials believe some infant deaths that have been labeled SIDS were clearly asphyxiation. Members of a child protection team complained in 2008 about the case of a 5-week-old found dead sleeping between her parents.
The medical examiner's investigative report says the girl flipped from her back and onto her side, where her nose and mouth pressed against her father's body. The local pathologist ruled the 2006 death "positional asphyxia."
Butts' office disagreed.
A medical examiner changed the cause of death to sudden infant death syndrome.
Aware of the dangers of adults sleeping with infants, the child protection team questioned in a letter why the cause of death changed.
Cathy Kenzig, chairwoman of the group, said the panel did not suspect malice by the parents. But she said only through "honest findings of asphyxiations" could child protection officials save more lives.
Butts said he reviewed all the original investigative and medical records and concluded there wasn't enough evidence to call the death asphyxia.
In a response to the team, he wrote that while an infant's sleeping with other people is considered a risk factor, it cannot be regarded as the cause when a child is found facedown and dead.
"There was nothing to say that it was more likely that the child died as a result of being asphyxiated by a parent than sudden infant death syndrome," he told the Observer.
Dispute led to Law
One of the most public disputes between Butts and local authorities erupted in 2001 when Alamance County investigators asked Butts to change a SIDS ruling. He refused.
Investigators learned 5-month-old Kaitlyn Marie Shevlin died napping in a bouncy seat in an unlicensed day care center. Her blood contained an antihistamine, which the owner used to make babies sleepy.
A state pathologist, Dr. Thomas Clark, called it SIDS. Then-District Attorney Rob Johnson asked Butts to change the cause of death to poisoning.
Butts recalled the case in a recent interview with the Observer.
"He wanted us very badly to change it to something that would allow him to prosecute," said Butts, who still believes there wasn't enough evidence to show drugs caused the death.
Butts said he doesn't often hear complaints from investigators about his rulings, but he says a SIDS diagnosis should not stop a prosecutor from proceeding with a case.
Johnson, in fact, did go forward. Instead of pursuing a homicide charge, he successfully prosecuted the day care owner for misdemeanor child abuse and neglect.
He also worked with state legislators to secure passage of "Kaitlyn's Law," which toughened penalties for day care workers who drug babies to quiet them.
To this day, the autopsy reads SIDS.
Johnson, now a Superior Court judge, is still "uncomfortable" with the SIDS ruling, but respects the longtime medical examiner.
"Dr. Butts is not one who overstretches," Johnson said. "He doesn't go out on a limb to espouse a theory that is questionable... It's not his job to roll over and play dead for the DA."
Compassion for parents
When it comes to infant deaths, Butts sees parents as his patients.
Their feelings are on his mind as he recites the doctors' creed, "First, do no harm."
Butts said the vast majority of parents whose babies die unexpectedly have had nothing to do with the death. A ruling of "undetermined," instead of SIDS, would unjustly burden parents with feelings they may have done something wrong, he says.
Over the years, his office has organized SIDS support groups to help parents. He speaks on SIDS education at least once a year.
He remembers an acquaintance, a doctor, who lost a baby to sudden infant death syndrome. "It scarred her for life," he said. "A nightmare."
Asked about his compassion for parents, Butts said: "Well, aren't most people compassionate? I was trained as a physician... That's part of my role.
"As a physician, I'm supposed to help people."
A new approach
Dr. Henry Krous, a nationally known SIDS researcher and professor of pathology at the University of California at San Diego, says there's confusion among medical examiners across the country about the SIDS diagnosis and high numbers of cases that involve sleep risks.
An Observer review of 554 SIDS deaths in North Carolina over five years found that 69 percent involved risks for suffocation, such as unsafe bedding and bed-sharing.
Krous believes medical examiners should use the SIDS diagnosis if they're not certain about a cause, but should also counsel parents against unsafe sleeping conditions found at a death scene.
He chaired an international panel in 2004 that recommended separating SIDS cases into categories for research purposes, depending on sleep position and other risks.
Others argue compassion should not get in the way of science.
"The worst truth is better than the sweetest lie," said Dr. Ljubisa Dragovic, chief medical examiner in Oakland County, Mich.
"We have an obligation to the public to serve them with truth. It's the crux of public service. It's important to start with the facts."
SIDS is a diagnosis of exclusion, meaning all other causes of death have been eliminated after an autopsy, a thorough death scene investigation and a review of the baby's medical history.
Classifying deaths as SIDS if there's a possibility of suffocation or another cause does not conform to the accepted definition, says Dr. Gregory Schmunk, a board member of the National Association of Medical Examiners.
"SIDS means there is nothing else leading you in another direction," Schmunk said.
Dr. Clifford Nelson, Oregon's deputy state medical examiner, says he stopped using the SIDS label about five years ago. He now lists many infant sleep deaths under a broader category, sudden unexpected infant death, or SUID. He lists the manner of death as "undetermined," instead of natural.
Nelson says other medical examiners in his office who have more seniority still use SIDS and list the manner of death as natural. "It's a generational thing," Nelson said. "It's about where they were trained and what was the philosophy" they were taught.
The latest trend holds little attraction for Butts.
Medical examiners are undoubtedly going to have different philosophies, Butts says. Some may disagree with his use of the SIDS category, but he says his standards have remained consistent.
Statisticians, he says, can use his data more confidently to study trends because they know what goes into each category. Other examiners change classifications every several years, he says.
'Inconsistent' rulings
In Butts' Chapel Hill office, some staff members disagree with his philosophy about SIDS.
They have found subtle ways to alert the public a SIDS ruling may not be correct.
Associate Chief Medical Examiner Dr. Deborah Radisch, who will take over for Butts when he retires July 1, follows his guidelines. But if she believes unsafe sleeping might have been a factor in the death, she adds a note saying the possibility of suffocation couldn't be ruled out.
"I know it sounds inconsistent and maybe it is," she said. "My main concern is that parents get the information that this is a preventable death."
Butts, she said, "doesn't want to make families feel bad." But she said deaths need to be diagnosed properly to prevent future deaths.
She doesn't think most SIDS cases are asphyxiation. "I don't think you can just make that jump. I just wish we knew what caused it and we wouldn't have to call it SIDS any more."
Her colleague, Lisa Mayhew, lead child death investigator and trainer, acknowledges that many sudden infant death cases involve bed-sharing and are still called SIDS, even when medical examiners say they couldn't rule out suffocation.
"It's the bane of my existence," said Mayhew, who has worked in the N.C. medical examiner's office for 10 years. "I could take one case and pitch it to six doctors and I bet you that I would get three different decisions - undetermined, SIDS and overlay."
But Mayhew said she has "come to a meeting of the minds" with Butts. "I respect the way that he sees it. SIDS is kind of an 'undetermined,' really.... I see his viewpoint in terms of what you're giving to a family."
Butts doesn't deny that some of the deaths he called SIDS could have been suffocation. But it's not many, he says, and he doesn't worry about missing a few.
"Don't we have a principle in this country, something to the effect that 'A thousand guilty should be let loose rather than convict someone who's innocent?'"
Thousands and thousands of children sleep with their parents each night, he said.
Too often in North Carolina Baby deaths, SIDS hides the truth.
The public knows sudden infant death syndrome as a mysterious, unpreventable death that strikes otherwise healthy babies in their sleep.
Medical examiners are supposed to classify deaths as SIDS only after a thorough scene investigation, autopsy and review of a baby’s medical history have ruled out all other causes.
But in this state, newborns and infants have died face down in pillows and soft couches. They have died on adult beds and alongside one or more people, or with their heads covered in blankets. In some cases, police have suspected foul play, even homicide.
The N.C. chief medical examiner often calls those deaths SIDS.
That’s different from what a growing number of national experts say may be the real killer:
Suffocation
“SIDS has been used as an easy option,” says Dr. Ljubisa Dragovic, chief medical examiner in Michigan’s Oakland County, who rarely uses the SIDS diagnosis. “It has had a catastrophic effect. Every year babies die of preventable causes.”
An Observer investigation has found that in North Carolina, two-thirds of SIDS autopsies list risks that raise the possibility babies suffocated because of unsafe bedding or sleeping with another person.
North Carolina’s bias toward SIDS masks the danger of suffocation when parents lay their babies to sleep in unsafe surroundings, the Observer found.
The wide use of SIDS also frustrates law enforcement agents, who say the diagnosis – considered a natural death in North Carolina – prevents them from prosecuting neglect or other crimes.
Investigators in Alamance and Gaston counties dropped efforts to file criminal charges in two cases after medical examiners linked the babies’ deaths to SIDS, the Observer found. In both families, more than one baby had died unexpectedly during sleep.
The Alamance investigation was recently reopened following questions by the newspaper, but no one knows how many cases remain stalled or were never pursued.
Medical examiners in states and counties across the country say suffocation – usually unintentional – is more common than previously believed.
Instead of using the label SIDS so often, they list deaths in categories they say are more accurate and specify unsafe sleep conditions that may have played a role.
In Virginia, the medical examiner has even launched a review of 20 years of SIDS cases to raise awareness that unsafe sleeping practices may have contributed to infant deaths.
N.C. Chief Medical Examiner Dr. John Butts refuses to adopt such changes, even though experts say they represent current research-based recommendations and practices.
Butts defends his approach and the work of his office. Without strong evidence of another cause, he labels cases SIDS. His sympathies are with parents.
“One of the principles of medicine is first do no harm,” Butts says. “When we assign a death to asphyxiation, we’re saying that the family’s action killed that child. … That’s a terrible burden to put on a family when you have no degree of certainty that that happened.”
Observer findings
The cause of SIDS, also called “crib death,” remains unknown. Scientists suspect problems with babies’ breathing, and where and how they sleep.
In 1992, the American Academy of Pediatrics first recommended against placing babies to sleep on their stomachs, citing studies that showed the practice was a risk for SIDS. A nationwide “Back to Sleep” campaign in 1994 urged parents to put babies to sleep on their backs.
Cases called SIDS declined about 50 percent in the next few years, according to Carrie Shapiro-Mendoza, a SIDS researcher with the Centers for Disease Control and Prevention in Atlanta.
She says in 1999 medical examiners began moving away from calling babies’ unexplained deaths SIDS and toward classifying them as accidental suffocation or undetermined.
After conducting thorough death scene investigations, states and smaller jurisdictions that follow those rules find relatively few cases of “classic SIDS” – a baby sleeping alone, on his or her back in a crib and without fluffy bedding or stuffed animals.
North Carolina recently reported a dramatic jump in SIDS, from 98 in 2007 to 136 in 2008, a 39 percent increase. The spike came in the same year that total N.C. child deaths dropped by 5 percent.
The Observer’s study of 554 N.C. SIDS autopsies from 2004 to 2008, the most recent years available, found:
Only about 25 babies, or five percent of those thought to have died of SIDS, were apparently sleeping safely, on their backs in their own cribs without dangerous bedding.
Some 69 percent of SIDS autopsies, about 383 deaths, listed risk factors such as unsafe bedding or babies sleeping with other people.
Among them, about 237 babies died while sleeping with at least one adult or child. At least four infants were found in bed with four other people.
Twenty-five percent of the autopsy reports, or about 136, did not include enough information to determine whether unsafe sleep conditions existed.
In about 50 SIDS autopsies, medical examiners actually wrote that they could not rule out accidental suffocation by adults. In several, they wrote that any time an adult sleeps with an infant it is impossible to rule out accidental suffocation.
“When an infant sleeps with one or more adults, asphyxia due to overlying cannot be entirely excluded as the cause of death,” Dr. Deborah Radisch, N.C. associate chief medical examiner, wrote in one autopsy.
Movement away from SIDS
In recent years, jurisdictions outside North Carolina – including Georgia, New Mexico, Michigan, St. Louis and Charleston – are working harder to investigate and clearly classify unexplained baby deaths.
“You can’t prevent deaths if you don’t know why they died,” says Dr. Mary Case, chief medical examiner for St. Louis County, Mo.
But there’s no national standard. Medical examiners use their own guidelines for diagnosing SIDS from state to state, county to county.
New Mexico is part of a federal pilot project involving five states that are trying to more carefully and consistently label unexplained infant deaths.
“It’s reinforced the need for very thorough scene investigations,” says Dr. Sarah Lathrop, an epidemiologist with the New Mexico medical examiner’s office. That office collects some of the same information North Carolina seeks: the child’s sleep position, where it slept, a description of the bedding and other risks.
Results in her state, Lathrop says, “follow the national trend. Fewer deaths are being called SIDS, and more are ruled undetermined or accidental strangulation.”
Virginia recently started categorizing babies’ deaths that involve unsafe sleep separately from SIDS.
Medical examiners there in 2007 started using “sudden unexpected infant death,” or SUID, to raise awareness that unsafe sleep may have played a part. Dr. Anna Noller, a forensic epidemiologist for the state’s chief medical examiner’s office, says she hopes the findings will eventually save lives by educating parents.
In North Carolina and across the country, public health agencies and nonprofits give away cribs or playpens, conduct public information campaigns and work with hospitals to alert new parents about the dangers of unsafe sleep.
Confusion arises when deaths are called SIDS even though unsafe bedding or other risk factors may have been present and could have caused suffocation, says Janice Williams, director of the Center for Injury Prevention at Carolinas Medical Center.
Williams says in some cases the label SIDS is used to protect families from guilt. “But what really concerns me is that while we save these parents that grief, we can’t help the other parents unless we clarify that message.”
It’s not just parents who don’t get the message. Pediatricians and family doctors who warn families about SIDS don’t always understand the risk of accidental suffocation.
“If we could get all the professionals to be more aware,” Williams says, “they could all start adjusting the message they give to parents about how to protect their infant in a sleep environment.”
Inconsistent investigations
States and counties that thoroughly investigate child deaths report fewer SIDS cases.
In Charleston County, S.C., Deputy Coroner Bobbi Jo O’Neal says, two investigators look into each unexplained infant death. Authorities visit the death scene and use a doll to perform a re-enactment with the person who discovered the body.
O’Neal says officials have found bed sharing, soft bedding or other risks in virtually every case. Deaths that were once considered SIDS, she says, are now ruled undetermined or sudden unexpected infant death (SUID). The death certificate lists any unsafe sleep risks.
“You miss those scenes, you miss a lot,” O’Neal says. “There’s got to be consistency in that investigation before you call it SIDS or anything else for that matter.”
North Carolina doesn’t have full-time trained investigators to send to most infant deaths. Law enforcement sometimes isn’t called. Local medical examiners, paid $100 per case by the state, often don’t go to the scene, either. Police are asked, but not required, to fill out a checklist for the state medical examiner’s office.
Lisa Mayhew, the state’s top child death investigator, says the medical examiner’s office where she works has made strides in the past 10 years. Among them was creation of the child death investigation checklist distributed to most law enforcement agencies and local medical examiners.
Mayhew said use of the checklist is improving. Those forms are now filled in and returned for more than half of child death cases.
But when medical examiners receive a baby’s body and perform the autopsy, they may have one document that tells little more than name, time, address or similar information surrounding the death.
And then the autopsy may reveal – nothing.
An autopsy alone usually can’t distinguish between SIDS and suffocation. That’s why it’s important to get evidence from the scene.
“We don’t really know why these babies are dying,” says Dr. Patrick Lantz, a medical examiner in Winston-Salem who does autopsies for the state.
Lantz agrees with much of Butts’ philosophy about SIDS. Both say it is a real condition that scientists don’t yet understand. SIDS has struck infants, especially those between ages 2 months and 4 months, for thousands of years. They point to how millions of babies have slept with their parents since biblical times and how most adults today slept facedown when they were infants. The vast majority survived.
Even so, Lantz says he understands why medical examiners nationally are going through a “diagnostic shift,” with many refusing to label cases SIDS if there are risk factors such as infants sleeping with adults.
“That’s for research into why these babies are dying,” he says. If all the risk factors are mixed up under one name, “you’ll never figure it out.”
Butts acknowledges that some deaths the state called SIDS could have been suffocation. But he says the number is probably very small.
He says you don’t need to change SIDS diagnoses to advocate for safe sleep. “I can’t tell you how often that we’ve pushed for safe sleeping practices,” he says. And his office does collect information about sleep risks for research, though that database is not accessible to the public.
Butts does not agree with the new scrutiny other states and counties are applying to sleep-related baby deaths. He says the movement unfairly casts suspicion on parents.
Reclassifying sleep deaths, Butts says, has failed to save lives. He says the child death rate in those jurisdictions remained unchanged even though medical examiners reported fewer SIDS cases.
“They just call it something else,” Butts says. “It’s great fashion to fix things by changing the name. So call it something else. Does it fix anything?”
Compassion vs. Science
Medical examiners who advocate for new classifications hope the answer is yes.
They say the purpose is to prevent infant deaths by alerting parents to the dangers of unsafe sleep.
Law enforcement authorities also say different classifications could have made criminal prosecution more likely for parents they believe were negligent in baby deaths.
Most infant deaths, including SIDS deaths, are sleep related, says Dr. Scott Krugman, who heads the pediatrics department at Franklin Square Hospital in Baltimore County, Md. Krugman says that SIDS does exist, but better investigations have shown it’s not the great baby killer experts once believed.
“The bucket that we call SIDS is getting smaller and smaller and smaller,” he says.
Maryland Chief Medical Examiner Dr. David Fowler says his office was among those who moved to new classifications about 10 years ago.
He considers Butts a traditionalist in his view of SIDS.
Like Butts, Fowler does not want to worsen parents’ grief with a ruling that might cause them to worry they did something wrong.
“But unfortunately, if we don’t look at these in detail over the years at some point, we’re never going to understand it. We’re just going to repeat the same thing day in and day out,” Fowler says.
Laura Reno, a SIDS parent and staff member with First Candle, a national group that tries to reduce infant mortality, says 99 percent of calls to her group about sleep-related deaths involve bed sharing.
“We don’t need compassion in order to figure out why babies are dying,” Reno says. “We need facts, and we need consistent diagnosis. … Being compassionate is not helping us find the answers.”
No single youngster can be the poster child for America's foster care system, with its mix of happy endings and heartache. Yet Tatiana Fowler's smile, as she embraces the woman who adopted her, gives a hint at the groundswell of change that is altering that mix for the better.
Tatiana, 16, and her 15-year-old sister Brittany were adopted earlier this year by a cousin of their mother after four years in foster care.
They became part of a dramatic trend in New York City, which has reduced its foster care population from nearly 28,000 in 2002 to under 16,000 this spring.
Thanks to sizable reductions in several other states, it's a coast-to-coast phenomenon — the latest federal data, from 2008, recorded 463,000 children in foster care nationally, down more than 11 percent from 523,000 in 2002.
Each jurisdiction is different, but by reducing stays in Foster Care, speeding up adoptions and — perhaps most crucially — expanding preventive support for troubled families so more children avoid being removed in the first place, the numbers are coming down.
Encouragement
Many states still are experiencing stable or rising foster care populations. And child-welfare advocates worry that budget cuts may undermine some of the promising new policies.
Overall, however, there's encouragement that New York City and a few other places — notably California, Florida, Georgia, Illinois, New Jersey and Ohio — have been able to sharply reduce the number of children in foster care.
"We're going to continue to see practices get better," said Anita Light, director of the National Association of Public Child Welfare Administrators. "In many cases, a child can remain at home and be safe with the proper amount of support."
When removal is deemed necessary, and parental rights are terminated, agencies have been working harder to arrange timely adoptions.
That was the case for Tatiana and Brittany Fowler — whose mother, a repeat drug abuser, proved incapable of keeping the family together.
The sisters initially were placed in foster care with another relative, but conflicts arose. Last year, Karen Simmons, a cousin of the mother, said she and her auto-mechanic husband, Dwayne, would be willing to adopt the girls, adding to a household already abuzz with the Simmons' three teenagers.
The Simmonses — devout Jehovah's Witnesses who'd known Tatiana and Brittany since they were little — live in a modest, three-bedroom apartment in the Bronx, on a monthly income of roughly $2,000, including food stamps.
Elation
Tatiana is finishing 10th grade at West Bronx Academy for the Future and aspires to be a child-welfare advocate after college so she can help the next generation of foster children. Her foster care experience helped hone a high degree of self-reliance, but she's elated to be adopted.
"I was fortunate somebody stepped up to the plate," she said. "To be a successful person, you need strong support. Now if I have an issue, a problem, I have someone to talk to."
John Mattingly, commissioner of New York City's Administration for Children's Services, noted that the city's foster care population has been declining gradually since a peak of nearly 50,000 in the early 1990s following the crack cocaine epidemic.
One stubborn problem, in New York City and some other places, is a slow-moving family court system that sometimes prolongs children's stays in foster care. Mattingly is working with judges to impose a timetable that would cut some nine-month delays to 90 days or less.
But even if the court issues are resolved, proposed budget cuts that could cost New York City 3,000 slots in its preventive-services program are a concern. Mattingly hopes the consequences won't include a new surge of foster care entries.
"All of these models that we've seen as successful are in danger — there's a great risk of going back to the old days," said Jane Golden of the Children's Aid Society, which arranged Tatiana's adoption.
Remarkable turnaround
To many experts, Florida's turnaround has been the most remarkable. Its foster care population soared after the high-profile 1998 beating death of a 6-year-old girl by her father, and stayed high through 2006.
Since then, Florida has implemented a wave of policy changes that have reduced its foster care population from about 29,300 in 2006 to 18,700 this year.
The key for Florida, alone among the 50 states, was obtaining a statewide waiver from federal funding rules.
This allows federal foster care money to be used for a variety of child welfare initiatives rather than being limited to out-of-home care — enabling the state to support troubled families with economic aid, parenting classes and substance abuse treatment so a child doesn't need to be removed.
George Sheldon, who heads Florida's Department of Children and Families, said a group of youths who'd spent years in foster care had urged him to pursue the changes.
"Almost to a child, they said, 'I would have rather stayed at home and dealt with issues than go into foster care and get passed from home to home and school to school," Sheldon said. "Even if it's a quality foster home, they feel they don't belong there."
Florida also sped up the average time for foster children to be reunified with their families. And in the remaining cases where parental rights are terminated, Florida has intensified efforts to get the children adopted or placed permanently with other relatives.
Though adoptions from foster care in the state reached all-time highs — more than 7,400 in 2008-09 — Sheldon hopes Floridians can do more.
"After the earthquake in Haiti, everybody wanted to adopt a Haitian child," he said. "We're trying to take that passion to help and say there are children in this country, in Florida, who are in need of adoption."
One leader on the front lines is Jim Adams, CEO of Family Support Services of North Florida. The private nonprofit helped cut the number of children in foster care in Jacksonville by 62 percent between 2006 and the end of 2009 — while spending far less money and achieving better outcomes.
"The way the system had been built, you had to isolate the child from the family," said Adams, a 33-year veteran of the field. "Now we try to have family engagement — working with the moms and dads and relatives.
"A lot of kids got put into foster care not because of physical abuse, but because of poverty — no food on the table, utilities cut off," he said. "With the waiver, we've been able to redirect the dollars that went to warehousing kids into funding families and the long-term challenges they've got."
'We're just kids'
Among the youths aided by Family Support Services is Lauren Lindgren, 18, who's now working for the agency as she prepares for college next fall. She was in foster care from age 2 to 7, when she was adopted, then returned to foster care at 14 after her adoptive parents divorced.
She hopes agencies working with foster children look "to see what's best for the kids, not what's best for everyone else."
"In foster care, it used to be you couldn't even spend the night at your friend's house — they had to get a background check," Lindgren said. "They changed that, so now you can. They're trying to make it seem like we're just kids, rather than foster kids."
In raw numbers, the biggest drop has occurred in California — where the foster care population fell from 90,692 in 2002 to under 65,000 last year, and the average stay in foster care was sharply reduced. Los Angeles County, where a Florida-style funding waiver is in effect, accounts for much of the decrease.
Karen Gunderson, chief of the Child and Youth Permanency Branch at California's Department of Social Services, said the changes reflect a push to get more foster children adopted or placed in the guardianship of relatives.
More recently, there's been an emphasis on so-called "wraparound" services — which develop individualized plans to help families deal with behaviorally troubled children so they don't have to be removed from home.
Abuse and Neglect
Georgia, another success story, had about 14,500 children in foster care in 2004, the result of a surge in investigations of suspected abuse. Now the figure is under 8,000.
B.J. Walker, commissioner of Georgia's Department of Human Services, said the key change was a more thorough, flexible approach at the front end, finding ways to support high-risk families without removing the children.
"We had to get our workers to believe this was safe," Walker said. "If you come into the system now, you're truly a child who's experienced abuse and neglect."
Her department, which had been taken to court by a New York-based advocacy group in 2002, says the recurrence of child maltreatment has dropped well below the national average and its average caseload per caseworker has decreased markedly.
Not all states joined the trend — those with rising foster care numbers in 2002-08 include Arizona, Texas, Indiana and Nevada. Steve Meissner, a spokesman for Arizona's Department of Economic Security, noted that his state's population grew during that period, with the influx including many potentially vulnerable children.
"The sad fact is that though there has been real improvement in some states, in much of the country things are as bad as ever," said Richard Wexler of the National Coalition for Child Protection Reform, which seeks to reduce the number of children unnecessarily placed in foster care.
"To the extent that there has been a real improvement," Wexler added, "it begs the question: What took so long?"
A fundamental problem, in the view of many child-welfare advocates, is the federal funding system — which in effect is a disincentive for states to reduce their foster care populations.
According to the Pew Charitable Trusts, 90 percent of federal child-welfare funds are reserved for supporting children in foster care, with only 10 percent available for front-end prevention and reunification services that can help keep families together.
Negative trend
The child welfare administrators' association, under Anita Light's direction, is proposing to change the law so all states would have more flexibility in how they spend child-welfare funds. Light believes there's bipartisan support for the change, and hopes for congressional approval sometime this year.
Even among those heartened by the drop in foster care populations, there's concern about one negative trend — the number of foster youths aging out of the system without a permanent family has risen from 19,000 in 1999 to a record high of nearly 30,000 in 2008.
Without the safety net of a family, these young adults often face immense challenges in securing decent jobs and housing.
Tatiana Fowler was relatively lucky in getting adopted at 16 — most foster children that old age out of the system without a permanent family.
Among them is Derrick Riggins, now 25, who had five different foster care placements growing up in Orlando, Fla. He now has a master's degree and is eying law school, aspiring to be a children's rights advocate.
Riggins was among the young people sought out by Florida officials to provide firsthand input on child-welfare reforms — and he stressed the importance of keeping more children of out foster care to begin with.
"The first couple of nights you stayed away from your own family is the toughest time," he said. "These are complete strangers you have to stay with. You ask, 'How did I get here? How long do I have to be here?' Questions you don't get answers to."
The NC State Secretary for Health and Human Services has continued to receive checks of about $3,000 a month from his former lobbying firm even as the firm helped land $30 million in No-Bid contracts from the agency.
Lanier Cansler, a former Republican legislator from Asheville, says he stepped away from any role in awarding the contracts to avoid a conflict of interest.
He said that before he returned to government service, he sold his stake in Cansler Fuquay Solutions, the lobbying firm he helped found in 2005. Cansler said the monthly checks are payments and interest for his share of the company, which he sold to his partner.
In a complaint filed with the NC State Ethics Commission this week, Richard Morgan, the former co-speaker of the state House, said that the continued payments violate a state law that forbids government officials from enriching themselves through their duties.
"The money travels in a circle," said Morgan, a Moore County Republican now campaigning for the state Senate. "Delegating to someone you hire and control isn't a recusal - it's a dodge. It's like Mike Easley appointing the trustees of N.C. State University, telling them to hire his wife, then saying they made the decision."
Cansler said that he has done nothing wrong and that Morgan has a beef against him going back more than a decade, when the two served together in the state House.
"I've been completely open about all of this," Cansler said Thursday. "I've complied with every ethical requirement under state law. I'm confident there are no ethical violations."
The issue revolves around two no-bid contracts awarded to the Carolinas Center for Medical Excellence, a firm the state hired to help determine whether Medicaid recipients are qualified to receive in-home nursing care or specialized outpatient therapy.
The programs are expensive, and Cansler has made it a priority to save the state money by making sure services go only to those entitled to them.
Cansler Fuquay Solutions is the lobbyist for CCME.
On state ethics forms filed in February 2009, Cansler disclosed that Cansler Fuquay owes him money from the sale of his share of the business and that the debt would be paid over time. He did not disclose on the form the amount of his regular payments from Cansler Fuquay. He said Thursday that amount totals about $36,000 a year.
A certified public accountant, Cansler said he was not required to disclose the repayment arrangement at all, but did so only out of an "abundance of caution."
The ethics form requires officials to disclose income. The repayment of principal from a debt is not income, Cansler said, only the interest earned on the note is. He said his former firm pays him 6 percent interest on the debt.
Governor Bev Perdue was aware
Chrissy Pearson, a spokeswoman for Gov. Beverly Perdue, said the governor knew about Cansler's arrangement with his former lobbying firm before appointing him.
"The governor was aware of the secretary's prior business arrangement, as was everyone else because he disclosed them freely from day one," Pearson said. "A plan was in place before he even began work to recuse himself as was appropriate. As far as the governor knows, he has done just that."
Cansler's lobbying ties were raised as a potential ethical issue almost from the moment Perdue, a Democrat, announced his appointment in January 2009.
In addition to his relationship with CCME, Cansler also worked for Value Options and Computer Services Corp. , companies that have DHHS contracts valued in the hundreds of millions.
Stacey A. Phipps, an attorney for the Ethics Commission, wrote to Cansler in a Dec. 30, 2009, letter that the payment of the debt presents "the potential for a conflict of interest."
As long as Cansler recused himself from decisions involving current and past clients of his former firm, Phipps advised, he would not violate ethics rules.
Cansler says he did right
Cansler said Thursday that he has recused himself in every case, including the no-bid contracts to CCME. A deputy secretary handled the negotiations, and they were given final approval by the state Department of Administration.
"I had nothing to do with any part of the process," Cansler said. "I didn't even know they had done them until they were pretty much done."
Morgan said that argument doesn't hold up. He is making the issue a focus of his campaign for the state Senate.
Morgan is running for the Moore and Harnett county state Senate seat held by GOP Sen. Harris Blake. Morgan has created a television ad that accuses Cansler of participating in a "pay to play" scheme.
"You are supposed to divest yourself of those types of potential conflicts," Morgan said. "It's an embarrassment to Bev. The timing on it is right in the middle of when she's talking about more transparency and cleaning up government and stopping corruption, and Bev, now's the time to do something about it, with all due respect, governor."
NC State officials say the motivation behind a no-bid contract to provide diabetes supplies for people on Medicaid was the need to cut costs in difficult budget times.
But critics - from Government watchdogs to health educators - say North Carolina may have been too quick to embrace such contracts after awarding the diabetes contract to a company whose owners have a troubled business history.
They also question whether the use of such contracts provides the sort of Transparency in government that Gov. Bev Perdue promised.
The NC State Medicaid office has signed Charlotte-based Prodigy Diabetes Care to a two-year contract to provide supplies for about 50,000 people on Medicaid who have diabetes.
Prodigy is run by two brothers, Ramzi Abulhaj and Rick Admani, who have been involved in a string of legal battles involving companies they started in Florida, including a Bankruptcy and Lawsuits Alleging Patent Piracy.
The state signed a contract with the little-known company in October, two months after Prodigy was founded. Until word leaked about the no-bid contract, competitors, retailers and diabetes educators were unaware that state officials had been talking to Prodigy's parent company for months. People with diabetes on the government health insurance program did not know they would need to get new meters to monitor their blood glucose levels.
"We weren't given all the information up front," said Andy Ingram, owner of Home Assist Medical Equipment in Laurinburg.
"We were given information in bits and pieces," said Ingram, a retailer who will distribute the Prodigy equipment to patients. "We're finding things out after they actually occurred."
The Prodigy contract is one of several no-bid deals the state Department of Health and Human Services has signed in the last few months, using special powers granted last summer by the state legislature. Legislators hoped the state agency would save money by eliminating time needed to request and evaluate bids.
Bob Phillips, Executive Director of Common Cause North Carolina, said no-bid contracting practices should be reviewed and made consistent, and the reasons for eliminating competition made narrower and more clearly defined.
"I think it sends a bad signal to the public at a time when there is already a lot of suspicion about how open things are in state government," Phillips said. "I think the governor has made great strides. There still remain questions, and this just adds to that."
DHHS Secretary Lanier Cansler has said the department is pushed to squeeze savings out of the fast-growing Medicaid program. The contract with Prodigy is estimated to save the state $4.4million over two years.
"This contract is short term and allows savings of millions of dollars," Chrissy Pearson, a spokeswoman for Perdue, said in a written statement. "The secretary has confirmed with the governor that his department is monitoring closely the quality and accessibility of this product while protecting the quality of patient care."
Senate Minority Leader Phil Berger, an Eden Republican, said no-bid contracts should be exceptions and that agencies have an obligation in those cases to make sure the state is getting quality services at competitive prices.
In circumstances where agencies want to move quickly, it may be a good idea to seek informal bids from several companies to find the best deal, Berger said.
"We're talking about taxpayers' dollars," he said. "The obligation is to be very careful with that money."
Sen. William Purcell, a Laurinburg Democrat who helps write the budget for DHHS, has fielded complaints about Prodigy and has heard that the state might face a lawsuit from those who don't like the no-bid contract.
Legislators told DHHS to wring out savings in a time when more people are signing up for Medicaid but the state budget is shrinking.
"It's hard to tell them to save money, then say we don't like what you're doing," Purcell said.
NC Health Care Advocates are questioning contracts the NC State Department of Health and Human Services awarded in recent months without competitive bidding.
Lawmakers allowed the no-bid contracts so DHHS could save time and money during a difficult budget year. Department officials maintain that the contracts are with companies with proven track records and can provide better value.
Still, some people question the fairness of the deals and the potential for conflicts of interest.
"No-bid contracts are bad government," said Adam Searing, director of the North Carolina Health Access Coalition, a group that advocates health care reform to benefit uninsured people.
Searing notes that DHHS Secretary Lanier Cansler was a lobbyist before Gov. Beverly Perdue picked him in January to run the state's largest agency. Three of the five no-bid contracts awarded in recent months have gone to clients of his former lobbying firm: two to the Carolinas Center for Medical Excellence and one to SAS Institute.
CCME's contracts, valued at $29 million total, are to review personal care services and outpatient therapies for determination of clinical necessity. DHHS officials estimate they will save the state at least $24 million.
SAS has an $800,000 subcontract on a $229 million Medicaid information systems contract that was awarded through a competitive bidding process in 2008.
DHHS spokesman Brad Deen said Cansler "has taken deliberate actions to abstain himself from dealings and negotiations involving former clients." He cited a June 9 memo Cansler issued to Deputy Secretary Allen Feezor in which Feezor and other officials were instructed to handle any contract decisions involving Cansler's former clients.
"I don't think, from what I've seen, anything untoward is going on from (Cansler's) perspective, but it gives the appearance of favoritism. That's the problem with these no-bid contracts," Searing said.
Another of the no-bid contracts went to Charlotte-based Prodigy Diabetes Care LLC, which makes diabetes testing equipment. Officials estimate the two-year, $27 million contract will save taxpayers $4.5 million.
Raleigh pharmacist Mike James said he never heard of Prodigy before its blood glucose meters started showing up on his shelves in recent months. Now, the company's monitoring products are the only ones that his customers on Medicaid can buy.
"It is concerning to me. We haven't seen any history on this product," James said.
Federal records show the owners of Prodigy previously ran a company called Vitalcare that filed for bankruptcy after getting sued for patent infringement. The FDA also issued safety warnings for Vitalcare's manufacturing plant in China.
Charlotte used incentives to convince Prodigy's parent company, Diagnostic Devices Inc., to move its headquarters and manufacturing to the Queen City. With the new state contract and tax incentives, the company has promised to add space and jobs.
James said the lack of a track history for Prodigy raises questions for him.
"Is the product going to be in the pharmacies as people need them because of the toughness in supply?" he said. "Is the product going to work efficiently?"
The fifth no-bid contract went to MedSolutions to reduce redundancies and inefficiencies in radiological imaging. The two-year, $230 million deal is expected to save the state $77 million, DHHS officials said.
Imagine this: A state agency is looking to buy ovens for a cafeteria, and an N.C. company in your hometown is competing for the contract.
But an out-of-state company comes in with the lowest bid at $100,000. Even if the N.C. company's bid is just a few dollars more, the out-of-state company wins the contract because state government chooses the low bid.
That means $100,000 in taxpayer money will go to a company outside North Carolina, money we could be investing to create jobs and grow businesses here at home.
I don't believe that makes sense for North Carolina. And when something in state government doesn't make sense for our people and our businesses, we must set government straight.
Last week, I took action to set government straight and help create jobs, jobs and more jobs in our state.
I signed an executive order to give preference to N.C. companies who compete to sell goods to state government - everything from binders to Bio-diesel fuel.
Remember that $100,000 contract that would have gone to an out-of-state company? Now, the N.C. company will have the opportunity to match the low bid and win the contract.
That means we're investing our tax dollars in North Carolina, and we're giving an N.C. company a better chance to grow and create jobs here at home.
Here's another example of how I set government straight to help create jobs.
State government offers many services to help small businesses thrive in North Carolina. But those services are spread out in different areas of state government.
A small business owner might get a headache just trying to figure out who to talk to for help on applying for a loan or developing a business plan. Those decisions could make the difference between staying in business or closing up shop, so it's good for North Carolina if our small businesses have an easy time finding help.
New N.C. Small Business Chief
So last week I announced I'm streamlining our many resources to help small business, and I'm putting them under the leadership of North Carolina's first Small Business Commissioner.
The Small Business Commissioner will take stock of all small business services in state government, he will look for ways to make them more efficient and he will reach out to small businesses to let them know where to go when they need help.
More than two-thirds of all new jobs come from small businesses, so it's critical that we do all we can to support them.
In these tough times, North Carolina can't afford to leave small businesses without the help they need to stay in business and grow. North Carolina can't afford to send taxpayer dollars to out-of-state companies when those dollars could be invested to create jobs here at home.
Setting government straight fixed that. And in the next several weeks I will continue righting the wrongs in state government to help create jobs, jobs and more jobs in North Carolina.
While saving money on the state's over-budget Medicaid program for the poor is laudable, trying to reach that goal by pushing no-bid service contracts can be a risky proposition.
With the General Assembly's blessing, the Department of Health and Human Services can circumvent, for six months, the competitive bid process. The rationale is that quickly finalizing contracts will help generate substantial savings during the recession.
However, that gives DHHS way too much discretion without sufficient oversight. Unless the agency's clients are properly served, any money saved will be a hollow accomplishment.
And questions are being asked about the $33 million Medicaid diabetes supplies pact with a company that relocated to Charlotte from Florida, where it left a trail of questionable business practices, lawsuits and bankruptcy.
Equally troubling are complaints from health professionals that Prodigy Diabetes Care's glucose testing meters may be confusing and less accurate than some other models. They fear that unless people enrolled in the program receive proper training, some may put off testing, which could lead to serious, costly health issues.
Letting contracts under a veil of secrecy inevitably leads to questions. Did the state get the best deal possible? What went into the decision-making process? Could another vendor have provided a superior product or service for less, had it also been notified? There's no way of knowing.
According to The News & Observer of Raleigh, a protesting competitor contends that the no-bid procedure clearly violates federal Medicaid rules. That ought to be easy enough for the state to determine - and promptly.
Ideally, heightened transparency should compensate when competition lags. But despite rumblings that this deal included a Prodigy promise to move production from China to Charlotte and create 150 jobs, the contract lacks specific incentives.
Even if company officials can adequately explain past problems, enough red flags are waving to justify closer DHHS scrutiny and proceeding cautiously. To protect taxpayers, checks and balances need to be in place.
State contracts first must assure clients that they're getting the highest level of service from reliable providers. Opening the process to all qualified bidders is the best way of doing it. To do otherwise understandably raises fears of favoritism and abuse.
NC State officials say the motivation behind a no-bid contract to provide diabetes supplies for people on Medicaid was the need to cut costs in difficult budget times.
But critics - from government watchdogs to health educators - say North Carolina may have been too quick to embrace such contracts after awarding the diabetes contract to a company whose owners have a troubled business history.
They also question whether the use of such contracts provides the sort of Transparency in government that Gov. Bev Perdue promised.
The NC State Medicaid office has signed Charlotte-based Prodigy Diabetes Care to a two-year contract to provide supplies for about 50,000 people on Medicaid who have diabetes.
Prodigy is run by two brothers, Ramzi Abulhaj and Rick Admani, who have been involved in a string of legal battles involving companies they started in Florida, including a Bankruptcy and Lawsuits Alleging Patent Piracy.
The state signed a contract with the little-known company in October, two months after Prodigy was founded. Until word leaked about the no-bid contract, competitors, retailers and diabetes educators were unaware that state officials had been talking to Prodigy's parent company for months. People with diabetes on the government health insurance program did not know they would need to get new meters to monitor their blood glucose levels.
"We weren't given all the information up front," said Andy Ingram, owner of Home Assist Medical Equipment in Laurinburg.
"We were given information in bits and pieces," said Ingram, a retailer who will distribute the Prodigy equipment to patients. "We're finding things out after they actually occurred."
The Prodigy contract is one of several no-bid deals the state Department of Health and Human Services has signed in the last few months, using special powers granted last summer by the state legislature. Legislators hoped the state agency would save money by eliminating time needed to request and evaluate bids.
Bob Phillips, Executive Director of Common Cause North Carolina, said no-bid contracting practices should be reviewed and made consistent, and the reasons for eliminating competition made narrower and more clearly defined.
"I think it sends a bad signal to the public at a time when there is already a lot of suspicion about how open things are in state government," Phillips said. "I think the governor has made great strides. There still remain questions, and this just adds to that."
DHHS Secretary Lanier Cansler has said the department is pushed to squeeze savings out of the fast-growing Medicaid program. The contract with Prodigy is estimated to save the state $4.4million over two years.
"This contract is short term and allows savings of millions of dollars," Chrissy Pearson, a spokeswoman for Perdue, said in a written statement. "The secretary has confirmed with the governor that his department is monitoring closely the quality and accessibility of this product while protecting the quality of patient care."
Senate Minority Leader Phil Berger, an Eden Republican, said no-bid contracts should be exceptions and that agencies have an obligation in those cases to make sure the state is getting quality services at competitive prices.
In circumstances where agencies want to move quickly, it may be a good idea to seek informal bids from several companies to find the best deal, Berger said.
"We're talking about taxpayers' dollars," he said. "The obligation is to be very careful with that money."
Sen. William Purcell, a Laurinburg Democrat who helps write the budget for DHHS, has fielded complaints about Prodigy and has heard that the state might face a lawsuit from those who don't like the no-bid contract.
Legislators told DHHS to wring out savings in a time when more people are signing up for Medicaid but the state budget is shrinking.
"It's hard to tell them to save money, then say we don't like what you're doing," Purcell said.
NC Health Care Advocates are questioning contracts the NC State Department of Health and Human Services awarded in recent months without competitive bidding.
Lawmakers allowed the no-bid contracts so DHHS could save time and money during a difficult budget year. Department officials maintain that the contracts are with companies with proven track records and can provide better value.
Still, some people question the fairness of the deals and the potential for conflicts of interest.
"No-bid contracts are bad government," said Adam Searing, director of the North Carolina Health Access Coalition, a group that advocates health care reform to benefit uninsured people.
Searing notes that DHHS Secretary Lanier Cansler was a lobbyist before Gov. Beverly Perdue picked him in January to run the state's largest agency. Three of the five no-bid contracts awarded in recent months have gone to clients of his former lobbying firm: two to the Carolinas Center for Medical Excellence and one to SAS Institute.
CCME's contracts, valued at $29 million total, are to review personal care services and outpatient therapies for determination of clinical necessity. DHHS officials estimate they will save the state at least $24 million.
SAS has an $800,000 subcontract on a $229 million Medicaid information systems contract that was awarded through a competitive bidding process in 2008.
DHHS spokesman Brad Deen said Cansler "has taken deliberate actions to abstain himself from dealings and negotiations involving former clients." He cited a June 9 memo Cansler issued to Deputy Secretary Allen Feezor in which Feezor and other officials were instructed to handle any contract decisions involving Cansler's former clients.
"I don't think, from what I've seen, anything untoward is going on from (Cansler's) perspective, but it gives the appearance of favoritism. That's the problem with these no-bid contracts," Searing said.
Another of the no-bid contracts went to Charlotte-based Prodigy Diabetes Care LLC, which makes diabetes testing equipment. Officials estimate the two-year, $27 million contract will save taxpayers $4.5 million.
Raleigh pharmacist Mike James said he never heard of Prodigy before its blood glucose meters started showing up on his shelves in recent months. Now, the company's monitoring products are the only ones that his customers on Medicaid can buy.
"It is concerning to me. We haven't seen any history on this product," James said.
Federal records show the owners of Prodigy previously ran a company called Vitalcare that filed for bankruptcy after getting sued for patent infringement. The FDA also issued safety warnings for Vitalcare's manufacturing plant in China.
Charlotte used incentives to convince Prodigy's parent company, Diagnostic Devices Inc., to move its headquarters and manufacturing to the Queen City. With the new state contract and tax incentives, the company has promised to add space and jobs.
James said the lack of a track history for Prodigy raises questions for him.
"Is the product going to be in the pharmacies as people need them because of the toughness in supply?" he said. "Is the product going to work efficiently?"
The fifth no-bid contract went to MedSolutions to reduce redundancies and inefficiencies in radiological imaging. The two-year, $230 million deal is expected to save the state $77 million, DHHS officials said.
By the end of June 2010, NC Officials will no longer use Medicaid a Federal government Health Care Insurance program to help poor residents, to pay for a major service for Disabled Infants and Toddlers in North Carolina who have fallen behind in walking, talking or speaking.
State officials must figure out a way to replace the service despite the elimination of federal money, because federal education laws require states to help disabled children. So any future program would likely be trimmed to narrow the kinds of help provided and serve fewer families.
Parents and therapists are pushing back in an effort to preserve the service.
The program provides therapists who go to homes and day care centers to show parents or teachers the best way to interact with young children to improve their physical and emotional development. It is aimed at children younger than 3.
The program, along with other early intervention services, is considered essential to help disabled children prepare for school.
"Our service is there to teach the caregiver," said Briana Kelly, a therapist from Pender County. She started an online petition that had 399 signatures as of Wednesday afternoon.
The program is meant to help disabled children catch up in skills with those of most children their age, Kelly said. If the severity of the disabilities won't allow that, the goal is to "get them to the best they can be," she said.
"If they saw those kids and those families, they won't cut the service," Kelly said of state officials.
In recent years, the federal government has told states to stop using Medicaid money to pay for services that are not considered rehabilitative, said Brad Deen, a spokesman for the state Department of Health and Human Services. The services cost Medicaid an average of $1 million a month over the 12-month budget cycle that ended last June, Deen said.
As the state looks to narrow the kinds of service offered, it will consider how to limit use and keep out some children who state officials don't believe need the help, he said.
"Medicaid would like there to be a little more selectiveness," Deen said.
In August, 4,766 children were eligible for the service, and about 65 percent of them were thought to be on Medicaid, according to Deborah Carroll, head of the early intervention office in the DHHS.
As the state struggles financially, the department is trying to figure out what comes next for the services and the children who get them.
How other states cope
In a Dec. 11 memo, Carroll listed some states that had devised ways to have Medicaid pay for community-based infant and toddler services similar to what North Carolina offers, but she said in an interview this week that she did not know whether the DHHS would pursue that course.
Private insurance, state money and federal grants are also used to pay for the service.
Jennifer Pfaltzgraff of Raleigh, whose 6-year-old son, Ethan, received community-based services when he was younger, said the program is essential for all disabled children and their families.
"It's a great tool in that it's not only the professional working with the child, but the family's involved," she said. "It's the best way to pull the services together and make it understandable for the parent."
Potential impact
Private insurance paid for the services for Ethan, who has cerebral palsy. But Pfaltzgraff said Medicaid cuts can hurt middle-class families, too.
Some private providers could go out of business without the Medicaid income, which would mean fewer therapists available to work with children, said Pfaltzgraff, who is president of the ARC of Wake County, an advocacy group.
A Federal District Court Judge today stopped a Government Mental Health Management Agency from enacting cuts that would lead to two disabled people losing their apartments.
The Beacon Center, the local mental health agency that covers Wilson, Greene, Edgecombe, and Nash counties planned to cut the state money that helps two mentally ill and developmentally disabled residents live in their own apartments.
The two Wilson-area residents, Marlo M., 39, and Durwood W., 49, sued with the help of Disability Rights North Carolina, which argued that the move violated the federal Americans with Disabilities Act and a U.S. Supreme Court decision that gives disabled people the right to live in the least restrictive settings possible.
The U.S. Department of Justice supported their argument. The federal government has participated in cases in several other states where the civil rights law for the disabled was at issue, said Justice Department trial attorney David W. Knight. In other cases, the Justice Department was trying to help residents move to community living, he said. This is the first case the federal government was arguing for people already living in the community fighting imminent institutionalization, Knight said.
U.S District Judge Terrence W. Boyle stopped The Beacon Center's cut, at least until a ruling on the merits of the suit, saying Marlo M. and Durwood W. would suffer irreparable harm, and that it was in the public interest to have state programs and funding adhere to the Americans with Disabilities Act.
The Beacon Center's lawyer, Christopher P. Brewer, said he did not know whether they would appeal.
Vicki Smith, executive director for Disability Rights North Carolina, called Boyle's decision "a victory for people with disabilities in North Carolina."
-It took the state months to notice that one of its Medicaid funds was flush with money, but employees couldn't figure out why.
Now, because of a huge accounting error, North Carolina must repay the federal government about $300 million for taking too much for public hospital services.
The state will pay back $200 million by the end of this month, and will repay the rest during the next 11 months, according to the state Department of Health and Human Services.
Medicaid is the federal government's health insurance program for the poor and disabled. The state received about $7.5 billion in federal Medicaid money last year. Though the federal government pays most of the costs, the state picks up about one-third of the expenses.
The mistake was triggered in November, when a state worker sent the department's controller's office incorrect information on how much money hospitals should take from the federal government and how much they should take from the state account, said Lanier Cansler, DHHS secretary.
State workers noticed the Medicaid account was out of whack about March, but couldn't find the source of the problem, Cansler said. The state discovered the mistake at the end of June as it prepared to make more changes to Medicaid billing formulas, and told the federal government about it.
The $200 million can be repaid almost immediately because the state has unspent money in the account hospitals were supposed to be tapping, Cansler said.
The $300 million mistake comes at a sensitive time for Gov. Beverly Perdue, as she pushes for tax increases to cover a budget that is nearly a month overdue. Earlier this week, the governor upended budget negotiations, saying she could not support a budget with an income tax surcharge and a drop in per pupil education spending.
In a statement, Perdue said she told Cansler and the state's new Medicaid director, Craigan L. Gray, to make correcting the problem a top priority. She said she wants a report on disciplinary actions.
"While this problem may have originated prior to my term as Governor, the circumstances under which it was made and perpetuated are simply unacceptable," she said.
Perdue said Friday she ordered DHHS to tell the state budget office if its Medicaid accounts are more than 2 percent off projections and submit a report explaining the cause.
This isn't the first time the state has lost the handle on Medicaid payments. DHHS was criticized in a recent legislative report for losing track of how much Medicaid money it was spending on a community mental health program that peaked at more than $100 million a month soon after it started.
New computers coming
A key to better monitoring Medicaid money, Cansler said, is a computer system that will be installed in four months that will let users know quickly how much money is being withdrawn from accounts and where it's going. It will replace a system that Cansler called "old and outdated."
The computer system will cost about $500,000, and the federal government will pay about 90 percent, he said.
After discovering the mistake, DHHS and the state budget office checked all of the department's federal accounts and will examine them each month for problems, Cansler said.
"It raises confidence issues in my mind about everything," he said. "We didn't find anything else. We will continue to look at everything like that and how we can strengthen controls."
Not being run very well
Senate Minority Leader Phil Berger, an Eden Republican, said the state should have been taking such care with its accounts all along.
"You would think there would be internal audit procedures and internal review procedures," he said. "This is just one more indication that our state is not being run very well."
In the past, the state has been asked to repay Medicaid because of incorrect payments to hospitals.
In 2006, the state and 51 hospitals had to repay the federal government $151.5 million in excess Medicaid payments made over six years. The hospitals paid $91.5 million and the state was responsible for the rest.
A two-year investigation found that the state mistakenly claimed too much money through a federal program designed to subsidize hospitals for their care of poor patients.
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No Intentionally Malicious Slander, Libel or Defamation of Character content will be published and I will always Credit all Sources.
NOTE TO ALL ELECTED OFFICIALS, APPOINTED OFFICIALS & PUBLIC FIGURES:
Per the Landmark U.S. Supreme Court Case: 1964 case of New York Times v. Sullivan………
The Public has a Right to Criticize the People who Govern them, so the least Protection from Defamation is given to Public Officials. When officials are accused of something that involves their behavior in office, they have to prove all of the above elements of defamation and they must also prove that the defendant acted with “actual malice.” (For a definition of actual malice, see the “History of Defamation and the First Amendment, below.”)
People who aren’t Elected but who are Still Public Figures because they are influential or famous — like Actors, Actresses, Movie Stars, Singers & Entertainers, Journalists, TV Hosts, Bloggers, etc., — also have to Prove that Defamatory statements were made with Actual Malice, in most cases.
To the Associated Press and other Media Organizations:
When I use your Content Links., I’m also citing the Fair Use Doctrine (Title 17 U.S.C. Section 107) for further Copyright permission.
Posts and Links published on Black Political Buzz are not endorsed by Black Political Buzz Blog Author Laurel’s Employer, nor the Employers of other Black Political Buzz employees.
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Comments, Links and Opinions of site visitors are Independently-Owned and not endorsed by Black Political Buzz employees, Blog Author Laurel or Laurel’s Employer.)
(No Personal Offense intended) Please know that Black Political Buzz is not responsible for nor do I endorse Requests for Donations from Third Parties on this Blog.
I will Only Endorse Requests for Donations made on behalf of BLACK POLITICAL BUZZ Blog for Business Purposes & Operating Expenses.
I will also Only Endorse Requests for Donations on behalf of Legitimate Politicians and Legitimate Political Candidates. PERIOD!!
If anyone else or another Organization wishes to post a link to Request Donations, I am NOT endorsing ANY of those Requests!
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God Bless
Laurel @BLACK POLITICAL BUZZ
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