Claire—not her real name—lived in a small, neat and tidy home. A drafting board caught the eye immediately upon entry, a reminder of her desire to get off welfare and back to work. She was left penniless and pregnant after a series of unhappy events involving her separation and divorce from a drug-addicted husband.
Part of the public assistance she was receiving was prenatal care through Medicaid. When asked why she was getting the care, she said, “Because my doctor told me I needed it.” She didn’t actually know what prenatal care was doing for her.
That was unfortunate, because prenatal care is one of society’s big bargains. Women receive information and resources on diet and vitamin intake and exercise, as well as physical exams, tests and ultrasounds. They may be referred to specialists.
It all helps prevent maternal deaths, miscarriages, difficulties in delivery, low birthweight babies, congenital malformations, birth defects, infant mortality. But those are only the early benefits.
Babies of mothers who do not receive prenatal care often have lives of incredible difficulties, and the cost of those difficulties frequently falls on taxpayers.
As they grow, babies and toddlers can experience respiratory distress syndrome, bleeding in the brain, patent ductus arteriosus (a blood disorder that can cause heart failure), necrotizing enterocolitis (intestinal problems that often require surgery to repair), retinopathy of prematurity (a blood vessel problem that can cause blindness) and breathing problems.
As the child who survives the lack of prenatal care enters school, the lack of prenatal care shows up again. One study reports, “Studies which compare VLBW [very low birthweight] with same age controls consistently show significantly poorer [school] performance, with average scores between 8 and 13 points lower. Even children with no neurological impairments have scores which are significantly lower on cognitive and achievement measures. The extremely low birthweight (ELBW) adolescents fare worse on all measures and perform particularly poorly in mathematics.”
In adolescence, these students can have learning and emotional problems, and developmental impairments.
In adulthood they frequently have high blood pressure, type 2 (adult-onset) diabetes and heart disease.
All through these years, the financial meter is running.
In terms familiar to those who think government should operate like a business, the small amount of money spent on prenatal care is cost effective, preventing hundreds of thousands, probably millions of dollars in later costs.
Little wonder nearly everyone regards prenatal care as a wonderful thing. Even Nevada, which sits out plenty of federal programs because it does not want to pony up the small match in funding, does participate in Medicaid prenatal care.
This is frontloading—putting a little money on the front end of a problem to keep it from becoming a much more serious and hugely expensive problem later on. Nevada uses the technique with prenatal care, but there are plenty of places it does not use it.
“You know, people have heard that ‘Pay now or pay later’ cliché so much that they don’t hear it anymore.”
The speaker is Sen. Sheila Leslie. After 10 years as an assemblymember, all of them on the Assembly’s budget committee, she has moved up to the Senate where, again, she sits on the budget committee. Not many legislators can match her line-by-line knowledge of the state’s budget. One of her particular worries is mental health funding.
Nevada legislators have always had an uncertain relationship with mental health. They have treated it much as they do school funding, as a sort of flexible joint in the budget that can be contracted or expanded, depending on what is happening in the rest of the budget.
During budget crises—Nevada seems to have them about every 10 years—mental health is often the first thing chopped.
To Leslie, this is shortsighted, because letting this kind of care drift is expensive in the long run.
“We’ll be paying much more on the back end—police time, courts, prisons, hospital emergency rooms,” she said. “It just doesn’t make sense to let it get to that point. Most people understand we can’t have severely mentally ill people on the streets. It’s a public safety issue. Without services for the mentally ill, they’re probably going to commit some kind of a crime or have difficulty in other ways.”
To give an idea of why lawmakers like Leslie become exasperated with the reluctance of their colleagues to fund preventive programs, consider that 18 years ago, one of her predecessors was saying the same thing in very similar language.
“When we’re letting out very sick, irrational people … these all present public safety issues that we are not addressing in this budget,” said Washoe County Sen. Diana Glomb on June 2, 1993. That was four governors ago. Glomb’s comment was occasioned by the removal of almost a thousand mental health patients from caseloads as a result of budget reductions following a budget crisis.
In the legislative budget committees, lawmakers go over the state budget page by page with state agency chiefs in front of them to answer questions. Leslie knows of many places where programs are underfunded and will create as many problems as they solve. Put a little more money into them, and they can be preventive. Instead, the legislature squeezes every dime on the front end and leaves the dollar consequences to legislatures of the future.
In fact, because of legislature reluctance to put up early money, Nevada doesn’t even have some programs. In these hard times around the nation, many citizens and legislators are fighting to save programs mostly paid for by the federal government that Nevada does not have in the first place because it is unwilling to pony up the small state matching funds. Medicaid has other programs besides prenatal care.
“There are lots more Medicaid optional programs,” Leslie said. “Other states are cutting things we don’t even have.”
Here’s an example: Nevada has a state agency, the Bureau of Vocational Rehabilitation (BVH). Here is a list of some of the functions it performs for folks with disabilities to help them get jobs and function independently: “Medical treatment and intervention; assistive technology training and purchase of equipment; vocational training; counseling; job development, placement and follow-up services; restoration services related to vocational rehabilitation goals, such as possible corrective surgery or therapeutic treatment; transportation in connection with providing a vocational rehabilitation service; interpreter services; occupational licenses, tools, equipment, and supplies; and transition services for high school students with disabilities interested in entering the workforce upon graduation.”
But BVH’s ability to provide these services is limited. The Nevada Department of Employment, Training and Rehabilitation estimates that BVH could qualify for another $3.3 million in federal funding by providing 21.3 percent of the full amount in matching funds.
Nevada Check Up, the state’s program for children’s health care, could also provide more assistance than it now does. “We’ve had lots of opportunities to expand health coverage to more kids of working families, but we haven’t chosen that option because of the state match,” Leslie said.
From birth control to wildlife, Nevada turns away federal dollars time after time. Republicans who have blamed U.S. Sen. Harry Reid because Nevada gets back fewer federal dollars than it sends to D.C. have not grasped that their state lawmakers don’t ask for those dollars back.
Many of these under-used programs are provided through Medicaid, a U.S. program that aids low-income families and individuals. So there is a fair likelihood that the more expensive consequences years down the road of not participating in some of these programs will fall on taxpayers.
Now or never
More than 30 years ago, renowned children’s advocate Marian Wright Edelman said, “We are willing to spend the least amount of money to keep a kid at home, more to put him in a foster home, and the most to institutionalize him.”
As part of his response to the deep budget shortfall, Gov. Brian Sandoval has recommended that the state cut federal community corrections block grants that provide support to local juvenile justice services. That way, the state will not have to pay the state match.
“This would take away a lot of the judges’ options except to commit the child to a state institution,” said Leslie.
In Washoe County, Judge Francis Doherty presides in family court. She gets deeply involved in the fate of the juvenile offenders who come before her. She follows the studies and research that describe what techniques work best in correcting the behavior of offenders.
One of those techniques is keeping offenders who are sentenced as close to their homes as possible. Generally, Doherty said, full fledged state facilities for young offenders like the Elko and Caliente detention schools are less effective and successful than more local facilities like the China Spring Camp and Aurora Pines Girls Camp, which Washoe and some rural counties use.
It works much like the adult penal system, where work camps and other alternative forms of sentencing are more effective in preventing recidivism than are full fledged prisons—and they are less expensive at the same time. Another similarity in the two systems is that putting inmates where their families can visit helps keep institutions peaceful and aids rehabilitation.
Judge Doherty said, “And all of the state money, including the block grant money, all of it that we receive is used to keep kids regional, close to home, and out of state commitments … and of all the funding cuts, that’s the one that kind of frightens us the most.”
It’s during formative years that kids can be most easily turned away from misbehavior and crime, and dollars spent on things that work are much better spent than rehabilitation dollars on adult offenders.
Sandoval’s recommendation would mean a $25 million cut for juvenile justice statewide over the biennium. In Washoe County, that’s almost a $5 million hit.
That would mean shutting down China Spring and its girls component, Aurora Pines. That would mean sending youth offenders to Elko and Caliente instead, which is called “committing” in bureaucratese.
“So we would lose all those beds,” Doherty said. “And then we would lose, most significantly, our board-and-care money. And that money we use to place kids in non-commitment type facilities. … Our [sentencing] options would shrink to two. We would have no group home board-and-care placement options, which is devastating for our lower-end offending kids with pretty significant therapeutic problems, such as our sex-offending kids. We would have no alternative intervention program that the community development block grant currently supports through two probation officers and a caseload of about 80 kids who would otherwise be committed [sent to Elko or Caliente]. We would likely lose our placement options at China Spring youth camp.”
And she said the state cut will end up costing the state more money, not less. Because the local alternative sentencing options will have to be shut down because of the loss of federal money, the young offenders will have to be sent to the distant, higher-security facilities at Elko or Caliente, where the cost per inmate is much higher and is paid by the state. Those state institutions will be flooded, costing the state millions. And the success rate with the children will likely decline.
“Statewide, we have counted that it would increase our commitments [to Elko and Caliente] by about 500 kids because we have nowhere else to put them,” Judge Doherty said. “The state, under its budget, is going to have enough beds for 230 kids, I think. So what we’re saying to the state is, if you pull all these funds and just keep these [Elko/Caliente] beds, we’ll have no choice but to increase our commitments to a level that won’t be sustainable on the state level.”
To tie everything together neatly, Gov. Sandoval has also recommended shutting down some housing units at the Elko/Caliente level.
Doherty said there is some funding in this category that is particularly urgent. Adult molesters tend not to respond well to treatment. But juveniles who have been molested and have begun moving toward becoming molesters themselves can be treated, Doherty said. “These patterns of behavior are not set” in juveniles, she said, and they can successfully respond to treatment. Waiting until they are older is a no-win strategy—it is truly now or never. A generation of youthful Nevada offenders could be lost.
What is happening in mental health and juvenile justice is happening elsewhere in state government. From agriculture to water planning, legislators know of cost effective or preventive investments they could make but will not do so. Legislators who affect a role as defenders of the taxpayer dollar are often the ones whose “savings” are most expensive to the taxpayer. Some of these legislative behaviors recur time after time.
Sometimes the long term cost to a short term saving is so egregious that even the Nevada Legislature won’t agree. A 1993 proposal during the aftermath of one of Nevada’s budget crises demonstrates this. A proposal on state prisons that year followed the pattern being seen this year in juvenile justice.
Gov. Robert Miller recommended shutting down seven prison honor camps around the state to save money. These are the facilities that cost less to run and have a higher success rate than regular prisons. Miller’s proposal called for setting some inmates free. Others would be returned to regular prisons at a minimum cost of $4,000 a year more (in some prisons the cost would have been higher).
The costs didn’t stop there, though. The inmates in these work camps were an important cog in fighting wildfires in Nevada. They helped make it possible to mount a sort of “instance attack” on a fire. Reduce the work camp crews, and the time it takes to mount an attack on a fire increases, leading to bigger fires, which take longer to fight, cost more, and turn greater swaths of range dark.
Nor did it stop there. The bigger the fire, the more damage to the soil, to the watershed, to the ecology generally. The greater the damage, the greater and costlier the rehabilitation—more replanting and reseeding, more ongoing maintenance. And the meter would run all through the camp shutdown/prison incarceration/firefighting/rehabilitation process.
Lawmakers could not accept such extreme consequences. Miller’s recommendation was rejected, the camps kept open, huge amounts of money saved by a smaller expenditure. The incident provides a striking example of the way a lack of funds can ripple across public needs, creating havoc. And that kind of foresight is not typical of legislative behavior. While lawmakers went in one direction in this 1993 instance, they have gone in the other direction on many smaller, incremental ways many times since then. Every other year, another legislative session provides examples of legislative shortsightedness and leaves an expensive legacy for later Nevadans.
These patterns keep recurring, on large items and small. One recent cut will make it difficult for some people to get to work or look for work and to function in other ways, reducing the productivity of Nevada’s economy.
“In this budget we’re taking away eyeglasses from 7,800 people under Medicaid,” Leslie said last week. “I don’t know about you, but I need my glasses to drive with. Eyeglasses are not a luxury item. They either won’t be able to drive, or they will drive without glasses.”