Health and human services has become an important government responsibility, second only to education in terms of budget authorization. The disability services system, which serves North Carolina’s mentally and physically disabled, receives approximately 17 percent of the funds of the Department of Health and Human Services (DHHS), for a total of $1.25 billion in fiscal 1996.
Problems in the Current System
There are a number of problems associated with the ability of DHHS to effectively serve and efficiently manage the disability service delivery system in North Carolina. The most pressing issues are the following:
- Program and service duplication. Other non-disability agencies of DHHS provide many services to the disabled. Organizing around programs and categories of disability populations fosters unchecked bureaucratic growth and less effectiveness. Millions of taxpayer dollars are wasted through these inefficiencies.
- Lack of consistent and reliable statistical information on disabled citizens. Because the state has not defined the “disabled” for policy and statutory purposes, the system is vulnerable to manipulative decision-makers and program managers.
- Few incentives to improve client service outcomes. The result is that while millions of dollars continue to be spent on administration, the quality and quantity of client service outcomes continue to erode. The cost per rehabilitation has been increasing, while the number of rehabilitations per personnel has been decreasing.
- Job placement rhetoric. Because there is no state policy on disability services in North Carolina, there is significant evidence of fragmentation in existing agencies. The state pursues a rhetoric of job placement, while the reality is that it must pursue a disability service mission of economic independence consistent with the state’s non-disability, general society goal. Labor force participation for disabled citizens has actually decreased since the ADA changes in 1990.
- Lack of a sovereign state disability policy. The current system serves to monitor compliance with federal legal policies and program mandates. There are no established disability priorities within the state budget; nor is there a process to establish priorities relating to disability services.
Conclusions and Recommendations
North Carolina is generally responsive and sensitive to its disability population under the federal purview. However, in order to take advantage of federal resources, the state has given up its responsibility to be both efficient and effective in providing for its disabled citizens.
While the primary emphasis of this report is the state of North Carolina, the information regarding service delivery systems, people with disabilities, privatizing disability service provision, economic independence of the disabled, and comprehensive state disability policy development is applicable to other states as well. To address the problems presented above, we have proposed the following five specific policy recommendations:
Problem: Program and service duplication.
Solution: Creation of a Division of Disability Services at the DHHS Assistant Secretary level that will 1) consolidate existing disability agencies throughout state government, and 2) be organized around the major life activity groups of work, school, play, and self-care.
Problem: Lack of consistent and reliable statistical information on disabled citizens.
Solution: A disability should be defined as “the existence of a physical, mental, or emotional condition, disorder, or pathology that causes an impairment or inability to perform in any major life activity, and the effects cannot be removed or reduced through the application of medical, technological, therapeutic, or clinical assistance.”
Problem: Few incentives to improve client service outcomes.
Solution: The position of casework manager will coordinate purchase-of-service and caseload service delivery. Vouchers covering services necessary to achieving consumer service outcomes should be assigned to individual consumers. Employee bonus incentives based on hands-on achievement of qualitative and quantitative annual goals should be instituted to reward such casework performance. Finally, contracting-out should be applied widely.
Problem: Job placement rhetoric.
Solution: Economic independence should be the first focus of all state disability programs and services through the intake and evaluation process. Subsistence and cash benefits for the disabled poor will become a part of the general social services delivery system when applicants do not meet the “economic independence” test at intake. State and federal funds should be consolidated, at the market-work placement service, to finance market-preparation, market-ready, and market-work placement consistent with the social integration model.
Problem: Lack of a sovereign state disability policy.
Solution: A state disability commission should be established to plan, develop, and oversee the execution of all state and federal legislative enactments, policies, and programs concerning disability issues and the disabled. The commission should develop uniform definitional data sets and use all information and operational data at its disposal to create and disseminate reports, research, and policy analyses.
The bottom line of the research in this report is that we should reassess the traditional methods of public sector service acquisition of disability services and use more modern methods of acquiring private sector service. Such an approach will empower clients to pursue their own independent living at far less cost to taxpayers and at far greater success for disabled North Carolinians.