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An analysis of 6 million caregivers in California who provide services and supports to family members or friends found that those who are paid by Medi-Cal to assist low-income elders and people with disabilities were the most likely to be “economically insecure.”

In Hidden in Plain Sight: California’s Paid Medi-Cal Caregivers Are Vulnerable (pdf), researchers at the UCLA Center for Health Policy Research report that of the 290,000 Medi-Cal paid caregivers assisting family or friends — most of whom are likely to be employees of the In-Home Supportive Services (IHSS) program — more than half (57 percent) had incomes below or near the federal poverty level (average monthly income of $1,970).

The analysis also found that of these paid caregivers for Medi-Cal recipients:

• Nearly a third (31 percent) were uninsured;
• Nearly a third (31 percent) had food insecurity (reduced meal size or skipped meals due to lack of sufficient resources); and
• 16 percent were likely to stay in the job for less than a year, “suggesting a high client turnover.”

The researchers compared Medi-Cal paid caregivers to all paid caregivers, unpaid caregivers, and non-caregivers, finding that Medi-Cal paid caregivers fared the worst on the economic indicators.

Nearly half (49 percent) of all paid caregivers (450,000, which includes the Medi-Cal paid caregivers) in the study had poverty or near poverty incomes.

Little Pay for Hard Work

“Paid caregivers do a lot but get paid very little,” said Geoffrey Hoffman, the study’s lead author. “They play a critical and complex role caring for our aging or disabled parents, grandparents, friends, and neighbors yet can earn only a little more than minimum wage.

“When we talk about caregiving, we should be thinking not only of the supportive services we provide to older adults but also the vulnerable people providing those services,” said Hoffman, who added that proposed cuts to the IHSS program and the downsizing of the state’s Adult Day Health Care program will not only hurt consumers but “will also harm paid caregivers.”

“Of course, all of us promote the value of family members caring for one another through thick and thin,” said San Francisco IHSS Public Authority Executive Director Donna Calame, who is also a PHI board member. “What the larger public — and unfortunately many policymakers — do not understand is that paying family members the relatively low wages we do in IHSS keeps families together.

“Family members are not paid for things like cooking or cleaning the house,” Calame continued. “They are paid for doing things like bathing, dressing, or helping their loved one use the toilet. The average IHSS consumer uses about $1,500 per month. Parents caring for severely disabled children especially save the taxpayer from annual institutional costs of about $250,000-$300,000 per year. That IHSS pays family members is a humane and cost-effective use of public dollars.”

– by Deane Beebe

Separate court proceedings in California and Louisiana last week upheld the right of elders and people with disabilities to receive care in their homes under the Americans with Disabilities Act (ADA).

In California, federal judge Claudia Wilken issued a preliminary injunction on Jan. 19 blocking the state from enacting a 20 percent cut to the In-Home Supportive Services (IHSS) program, which provides care to nearly 450,000 elders and people with disabilities who have Medicaid.

The cuts were initially scheduled to take place on Jan. 1, but were temporarily halted by Wilken last December due to concerns that they violated the ADA. Wilken reiterated those concerns in her latest injunction.

If ever enacted, the IHSS budget cut would cause 372,000 IHSS consumers to see reductions in home care services, possibly forcing them into nursing homes or other institutions — a violation of the ADA. In 1999, the Supreme Court ruled that the ADA gives seniors and people with disabilities the right to live at home if their care needs can be reasonably met there.

“Judge Wilken has consistently recognized how crucial IHSS is for people with disabilities in California,” said Donna Calame, the executive director of the San Francisco IHSS Public Authority and a PHI board member.

“Her ruling was terrific for both technical legal reasons and because it continues, for the time being, the current level of service hours to people who live in borderline poverty situations — both consumers and the workers who assist them,” Calame added.

The state plans to appeal Wilken’s decision to the Ninth Circuit Court of Appeals. Last month the Ninth Circuit ruled that Washington State had violated the ADA by cutting its Medicaid in-home care program by 10 percent.

Louisiana Lawsuit Settled

Meanwhile, in Louisiana, advocates for elders and people with disabilities reached a settlement with the state over a reduction in-home care services there.

Advocacy Center and AARP Foundation Litigation advocates had filed a class action lawsuit in September 2010, arguing that the state was violating the ADA by imposing a 32-hour weekly cap on consumers enrolled in the state’s Medicaid in-home services program.

As part of the settlement (pdf), state officials will request 200 waivers from the federal government allowing Louisiana residents who receive Medicaid to qualify for long-term personal care services.

The waivers will be awarded to consumers who can demonstrate that the 32-hour cap would force them to transfer into a nursing home.

Ken Zeller, a senior AARP attorney, told the Associated Press that the settlement is “win-win” because it “allows people to age in the place they know and love and at the same time saves the state money in more costly nursing home placements.”

– by Matthew Ozga

Gov. Jerry Brown

To help fill the $9.2 billion gap in California’s 2012-2013 budget, Governor Jerry Brown’s (D) budget proposal includes cuts of $163.8 million to the In-Home Supportive Services (IHSS) Program by eliminating domestic assistance — such as meal preparation, food shopping, laundry, and housework — for clients who reside in the same home as their caregivers.

The IHSS program provides personal care — including help with bathing, dressing, toileting, and feeding — and domestic services to about 435,000 low-income elders, the blind, and people with disabilities who live in their own homes but are at risk for nursing home placement without the services and supports that the program provides.

About 60 percent of IHSS clients would be affected should the proposed cuts take effect at the start of the new fiscal year on July 1, according to an article in the Sacramento Bee.

The caregivers, many of whom are family members, receive hourly wages and benefits between $8 and $14.78, reports the publication.

Cuts Deemed “Unwise”

Calling the proposed cuts to the IHSS “unwise,” a Los Angeles Times editorial says that “Slashing or ending that care means people in need will have to go to nursing homes, which can also be on the state tab but are more expensive.”

“The general public does not understand how easy it is to end up in a nursing home because it is the only place where care will be provided,” explained San Francisco IHSS Public Authority Executive Director Donna Calame, who is also a PHI board member.

“Sometimes, the simple acts of assisting someone with food shopping and preparation are all that keep a person well nourished and out of a hospital or nursing home. For a very few number of hours per IHSS consumer per month, California will not be saving very much money with these cuts and is risking much higher public expenditures for care in an institution.”

The state’s share of the IHSS Program costs is projected to be about $1.4 billion for 2012-13; the remaining costs are covered by state and county funds, reports the Sacramento Bee.

“There is an institutional bias in public funding of long-term services and supports,” Calame said. “IHSS advocates certainly hope the legislature will reject this proposal from Governor Brown.”

Brown has also proposed closing the budget gap by increasing revenues through a temporary half-cent sales tax increase and imposing higher taxes on the rich. A ballot measure which will be voted on in next November’s election will determine whether these proposals will become effective.

California had planned to cut the IHSS Program services by 20 percent beginning on January 1, as part of automatic, midyear across-the-board cuts enacted to offset tax revenue shortfalls. Disability Rights California filed a suit contending that these cuts violated the Americans with Disabilities Act, and a U.S. District Court judge ruled to temporarily halt them.

– by Deane Beebe

A December ruling by the Ninth U.S. Circuit Court of Appeals could prevent massive cuts to California’s In-Home Supportive Services (IHSS) program.

The Dec. 16 decision (pdf) by the San Francisco-based U.S. Court of Appeals did not directly address California. Rather, it centered on 12 Washington State Medicaid consumers who sued the state for its decision last February to reduce in-home care hours by 10 percent.

The Ninth Circuit found that the dozen plaintiffs would likely be forced to live in nursing homes as a result of the 10 percent cut — a violation of the federal Americans with Disabilities Act (ADA). The court therefore restored in-home services for the plaintiffs.

The court did not overturn the 10 percent cut, however, since the lawsuit was not presented as a class action on behalf of all 45,000 Washington State in-home care recipients.

Implications for California

The Ninth Circuit’s decision has clear implications for another case involving cuts to the California IHSS program.

On Jan. 19, U.S. District Court Judge Claudia Wilken will preside over a hearing to determine whether the state of California can legally proceed with a proposed 20 percent cut to IHSS, which provides care to 440,000 low-income elders and people with disabilities.

In December, Wilken halted the proposed cuts — which had been scheduled to take effect Jan. 1 — because they potentially violated the ADA and the Social Security Act, among other federal laws.

Wilken will have to take the Ninth Circuit’s recent decision into account during the upcoming hearing.

“The Ninth Circuit’s conclusion that loss of hours of home care services exacerbates people’s risk of involuntary institutionalization is very relevant to the case in California,” attorney Stacey Leyton told the San Francisco Chronicle in December.

– by Matthew Ozga

A federal judge ordered a temporary halt to potentially disastrous cuts to California’s In-Home Supportive Services program last week.

The cuts — totaling $100 million, or 20 percent of IHSS’s overall budget — were scheduled to begin Jan. 1, triggered by the state’s failure to take in an additional $4 billion in revenue in 2011.

However, Judge Claudia Wilken handed down a temporary restraining order (pdf) on Dec. 1, suspending the state from enacting the cuts until a hearing is held on their legality.

In the restraining order, Wilken said there are “serious questions” as to whether the cuts violate several federal laws, including the Social Security Act and the Americans with Disabilities Act.

The judge’s ruling allows those who rely on IHSS to live in their homes and communities “to get through the holidays without fear of losing their in-home care and being forced into institutions,” said Laphonza Butler, president of SEIU United Long Term Care Workers, in a statement. SEIU had filed the request that led to the restraining order.

The California IHSS program provides care to 440,000 low-income elders and people with disabilities. An estimated 372,000 of those consumers would see service reductions if the proposed 20 percent cuts are ever enacted.

Last year’s state budget reduced IHSS funding by 3.6 percent.

– by Matthew Ozga

By the end of August, 35,000 low-income elders and people with disabilities will have received notification that Medi-Cal, California’s Medicaid program, will no longer cover adult day health care (ADHC) beginning December 1.

Adult day health programs provide health, therapeutic, and social services to those at risk of being placed in a nursing home, the California Department of Aging explains.

In California, there are 300 ADHC programs. According to the California Disability Action Network, they employ 7,000 people.

Eliminating the Medi-Cal benefit for ADHC was proposed by Governor Jerry Brown last January to help close the state’s budget gap.

Class Action Suit Filed

Advocates, including the AARP California Foundation, Disability Rights California, National Senior Citizens Law Center, and National Health Law Program, filed a federal class action suit on behalf of the ADHC consumers.

The organizations charge that the elimination of the Medi-Cal ADHC benefit violates federal disability law, and are trying to stop it, “unless the state can provide adequate and appropriate replacement services.”

“Adult day health care has been a cost-effective means to keep thousands of people out of nursing homes and other institutionalized care,” said Barbara Jones, senior attorney, with the AARP Foundation.

“Estimates of the increased annual cost of premature institutionalization to California, if adult day health care is eliminated by year’s end, have topped $50 million. California still has not found alternate services for the thousands of low-income and elderly people dependent on this program,” Jones said.

Managed Care Plans to Coordinate Services

The state’s plan — just released on August 5 — is to mandatorily enroll the ADHC clients in Medi-Cal managed care plans, with an “opt-out option.”

The managed care plans will be responsible for coordinating services for the ADHC clients, including additional in-home supportive services, physical and occupational therapy, and social services, a Los Angeles Times article explains.

“State health care officials know they have 35,000 medically needy elderly and disabled patients whose lives clearly depend on what they do in finding coordinated care for these patients’ complex medical needs in a matter of weeks or face disastrous legal consequences in court,” said California Association for Adult Day Services Executive Director Lydia Missaelides, in a media statement (pdf).

“Pressed for time, they had to produce something, and the result is now a plan and strategy that is nothing more than a list of existing health care services for ADHC patients to be plugged into like widgets or lumped together in managed care plans that the patient may not accept or that may not be able to provide for the patient’s specific needs because the services simply don’t exist,” Missaelides said.

Strong Attachments

California’s required ratio of direct-care workers to clients in ADHC programs is 1:16, but many programs have higher worker staffing, Missaelides told PHI.

“Despite their strong attachments to clients, some of the ADHC staff is starting to look elsewhere for employment because of the uncertainty of the program’s future. It’s a very emotional time: the workers are attached to clients but they have their own families to feed,” Missaelides added.

A hearing is scheduled for November 1 to determine if California’s scheduled elimination of ADHC is in compliance with federal disability law.

– by Deane Beebe