Gov. Paul LePage and Department of Health and Human Services Commissioner Mary Mayhew have described the drastic cuts that are part of their proposed supplemental 2011-2013 budget as necessary to fill a projected $220 million gap in the department’s budget over the next two years and preserve the essential parts of the state’s safety net, which has been growing to make a larger proportion of the population eligible for a wider array of benefits.

From conversations with local youth services providers that would be affected by the cuts, including the Game Loft (see related story), three themes emerged: being a large organization or affiliated with one is not the measure of protection it may have once been; not only the elderly would be affected by the cuts; and prevention is cheaper than treatment, or at least a cheaper form of treatment.

Being a big fish is not what it used to be

The last time the Game Loft suffered a major blow to its funding was in 2008 when the program lost out in its bid for a Department of Health and Human Services grant that accounted for 40 percent of the program’s annual budget at the time.

Though the circumstances were somewhat bizarre — the Game Loft had received the grant for many years and was the only program from Waldo County to apply — the fallout from the much publicized denial was enough that when DHHS responded with a special supplemental grant, the Game Loft reapplied under the larger Broadreach Family & Community Services.

According to Game Loft co-founder Ray Estabrook, this was done to keep the Game Loft name out of the mix, but it also presaged the sheltering merger with Spurwink Services in 2009.

By that time the program was getting only around 10 percent of its operating budget from the state. The merger with Spurwink offered the little program a chance to expand, but in a roundabout way it meant once again relying on government disbursements, through which Spurwink was able to boost the Game Loft’s budget by around 30 percent.

Teaming up with a big fish also seemed to offer some security to the smaller program. Like a remora and a whale, the two organizations have, by all accounts, enjoyed a mutually beneficial relationship. With the proposed cuts to the DHHS budget, however, even the largest organizations have suffered and Spurwink is not unique in this regard.

When the funding is available, larger organizations have the administrative resources to handle the reams of paperwork that must be completed for some grants. During the struggles with DHHS Ray Estabrook occasionally produced the oversized binder he kept with documentation relating to the grant as a kind of self-explanatory exhibit of bureaucracy. After the merger with Spurwink, he spoke of being relieved that burden and free to focus on programming.

A somewhat larger local organization that offers youth program, the Waldo County YMCA has been able to make do almost entirely without government funding, relying primarily on contributions from individuals, businesses and municipalities.

This has been somewhat out of necessity. The Y has received grants but has no full-time grant writer. Executive Director Dale Cross noted that in one case in which the Y did receive government grant money for a smoking prevention program, it was only through a collaboration with Waldo County General Hospital.

“The hospital was a big enough agency to be the custodian of those funds,” he said.

Proposed cuts at DHHS would affect youth, too

Reports on the governor’s supplemental budget have tended to focus on the impact to senior citizens residing in private, non-medical institutions or PNMIs. The image of elderly residents in peril has been potent enough that some legislators in the governor’s own political party, according to the Bangor Daily News, have expressed opposition to that part of the administration’s proposal.

Cuts to funding for PNMIs account for a large portion of those proposed at the Department of Health and Human Services, and while the category includes nursing homes, it also covers residential treatment facilities for young people, like those operated by Spurwink Services in other parts of the state, and several organizations with facilities in the Midcoast, including Harbor Family Services and Sweetser. PNMIs serving children are not included in the current budget proposal, according to John A. Martins, director of communications for DHHS.

Martins said a second supplemental budget will be drafted at some point, but has yet to be submitted. Carl Pendleton, CEO of Sweetser, said he has been told by DHHS officials that a second supplemental budget would include cuts to children’s PNMI services, and he worries such cuts could force the company to close its Belfast campus.

[Editor’s note: This updated version of the article clarifies that PNMIs serving children are exempt from the current supplemental budget proposal, and also clarifies that Pendleton’s comments were made in the context of a potential second supplemental budget (which, to date, has not been submitted).]

“We’re trying to figure out a way to salvage what we have,” he said. “We’re hoping that we can get the legislature to see that it would be a fool’s game because these children who are with us in Belfast, if they don’t have that resource they’ll wind up in jails or emergency rooms of hospitals, which is high-end care. Not that Sweetser’s cheap by any means. Services are expensive,” because of state and federal requirements that those in treatment receive certain professional services.

Sweetser gets its funding from a wide range of sources including private insurance reimbursements, grants, private fundraising and Medicaid. The problem with cutting government funding, Pendleton said, is that in recent years the state has directed nonprofits like Sweetser toward grants where the federal government kicks in a sometimes sizeable match.

“And so if the governor says he’s going to cut a dollar out of the state’s budget, and save the taxpayer, it’s questionable what he’s really going to save the taxpayer, because when he cuts the one, he loses the two from the fed,” he said.

The proposed budget would also take more than half of the budget from the Fund for Healthy Maine, which was created in 1999 as a way to channel receipts from a national settlement with tobacco companies into substance abuse prevention and treatment, smoking prevention and cessation, childcare, dental and school nutrition programs.

The local affiliate, Healthy Waldo County, is run out of offices at Waldo County General Hospital and offers prevention-based youth health programs almost as an extension of the hospital’s services.

“Ten years ago, there was no public health infrastructure in Maine,” said Project Administrator Vyvyenne Ritchie. “It was very loose and not organized. So, Healthy Maine Partnerships were developed to do all the public health. From that work we’ve been able to leverage millions of prevention dollars from the federal government that we could never get before because we didn’t have an infrastructure in place and now the governor wants to dismantle that.”

Prevention vs. treatment

Historically prevention has been harder to quantify than treatment, and as a consequence prevention programs are quick to be scrapped in a crisis.

The lament of the primary care physician who can’t get paid for keeping people healthy appears also to be true in social services where prevention programs are ineligible for direct reimbursements through MaineCare and so rely on speculative investments in the form of grants.

Patrick Walsh of Broadreach described a more blurred boundary between treatment and prevention, in which a spectrum of treatments ranges from “primary” (prevention) through “tertiary” (intervention and treatment).

“That’s sort of across the board, from alcohol abuse to cancer,” he said.

Programs on the primary end, however, face different challenges when trying to justify their existence.

Coincidentally, Broadreach is entering the active stages of administering the local portion of a five-year study funded by the RAND Corporation that may go some way toward quantifying what services exist and how much good they do. The study aims to combine two model approaches to social services called “Asset Development” and “Getting to Outcomes,” widely used in other states, Canada and Europe.

The local region was a control group for the first two years, but Walsh said Broadreach recently began doing an “asset inventory,” surveying organizations and institutions falling somewhere on the spectrum of prevention and treatment.

The list, which includes the Belfast Free Library, Restorative Justice Project of the Midcoast, Waterfall Arts, Waldo County Cooperative Extension 4H Program, Family Planning and the Universalist Unitarian Church, goes some way toward showing the range of organizations that have some version of “positive youth development” (the term of art, according to Walsh), in mind.

For the time being, some programs that fall cleanly on the side of prevention are on the chopping block, notably the Fund for Healthy Maine, which would lose more than half of it’s $54 million allocation in 2013.

“We realize cuts have to be made, we can’t keep having the debts that we’re having, that it doesn’t make sense. But I’ve worked prevention and have for many years and prevention activities work,” said Vyvyenne Ritchie.

She cited a widely statistic widely circulated by advocates for the program that a $1 investment in prevention has saved $7.50 in Maine. In a simple version of this equation, a young person either chooses not to smoke or quits because of a prevention program or smokes for 50 years and requires costly cancer treatments later in life.

“Some states fixed roads with their money. It wasn’t earmarked for prevention. It could be used for anything,” she said. “But Maine, 11 years ago, decided to develop strategies around developing a whole prevention model.”

“All of that will go away if they eliminate funds and put it into the Medicaid deficit,” she said. “So, hopefully the legislators will be wise in their decision making.”