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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

Kansas State Building in Topeka

Advocates say that Kansas’s ability to care for people with disabilities in home- and community-based settings will be further hampered by proposed cuts to state Medicaid costs.

One proposal, advanced by Lieutenant Governor Jeff Colyer (R), would lower Kansas’s Medicaid spending to $400 million, from $600 million.

“Deep cuts to services, an increase in the eligibility threshold, or other negative changes to home- and community-based services are some of the feared consequences of a large Medicaid budget reduction,” said Mike Oxford, executive director of the Topeka Independent Living and Resource Center.

“These consequences could cause the nursing-facility census — already approaching record levels — to really go up,” he continued.

A Violation of Olmstead

The loss of this choice could also put Kansas in violation of a 1999 Supreme Court ruling in the case Olmstead v. L.C.

The Olmstead decision says that states are responsible for ensuring that people with disabilities can choose the most integrated care settings possible in order to meet their needs.

Since the proposed Medicaid cuts would reduce home- and community-based options for many Kansans with disabilities, the federal government could find that the state has violated Olmstead.

Already Poised

Indeed, the Department of Health and Human Services already appears poised to do just that.

Although an announcement won’t be made until mid-August, reports suggest that Kansas will be among the states identified as being in violation of Olmstead. Federal officials have met with disability advocates there several times in recent months.

They have paid special attention to the length of waiting lists for people who want to transition from nursing homes into home- and community-based care.

According to Nick Wood of the Disability Rights Center of Kansas, it is “not unusual at all” for people with disabilities who are seeking community-based services in Kansas to be placed on waiting lists of up to two years.

In certain cases, those waits can be even longer, Wood said. People with developmental disabilities, for example, can face wait times of up to five years for community-based services, Wood told the Kansas Health Institute News Service.

Renee Wohlenhaus, a deputy chief in the Disability Rights Section of the Department of Justice, said that the federal government views wait times of longer than six months as violations of the Olmstead decision.

– by Matthew Ozga

As President Obama and Congress continue to wrestle over a budget plan to reduce the federal deficit, a small group of bipartisan senators known as the “Gang of Six” put forth a proposal which, if enacted, would cut Medicare, Medicaid, and Social Security, and repeal the Community Living Assistance Services and Supports (CLASS) Act.

The CLASS Act, a provision in the health care reform law passed in March 2010, establishes a voluntary, federal insurance plan designed to help people purchase long-term services and supports.

Details of the CLASS Act — including the monthly premiums and the cash benefit to purchase these services and supports — have yet to be worked out. However, according to the law, the Secretary of the Department of Health and Human Services (HHS) has until October 2012 to do so.

HHS Secretary Kathleen Sebelius has said that she is developing a plan that would make the voluntary, long-term insurance plan solvent, as required by the health reform law.

The sustainability of the CLASS Act has been called into question by some Republican lawmakers, prompting a March 11 hearing. Assistant Secretary for Aging Kathy Greenlee, who is the administrator of the CLASS Office, testified that the program would remain fiscally sound even when elders and people living with disabilities begin to make claims.

The CLASS Act would lower the cost of Medicaid, which pays for 62 percent of the nation’s long-term services and supports costs (pdf), say supporters of the program.

“What’s strange to me is that this started out as a cost-saver, and now it’s being targeted in the name of cost savings,” Judy Feder, a professor at the Georgetown Public Policy Institute and fellow at the Urban Institute, told Politco. “The people who are saying it will cost us money say that that’s a challenge that cannot be met, but I believe it can.”

Personal Care Attendants Workforce Advisory Panel

Less well-known is that the CLASS Office is also charged with managing a Personal Care Attendant (PCA) Workforce Advisory Panel.

While HHS has accepted nominations to the panel, which were to be announced last fall, to date there has been no such announcement.

The panel is responsible for examining the adequacy of the number of personal care aides, their wages and benefits, and access to their services, as well as advising Congress.

Personal Care Aides are projected to be the fourth fastest-growing occupation in the country between 2008 and 2018, increasing by 46 percent, according to a PHI analysis available in PHI FACTS 3: Who Are Direct Care Workers? (pdf).

– by Deane Beebe

Valerie Jarrett, a senior advisor to President Obama, wrote about why Medicaid matters on the White House blog.

In her entry, Jarrett — who spoke at the inaugural National Care Congress on July 12 — tells the stories of Linda Guzman and Shannon Saunders, two ordinary Americans who have benefited from Medicad.

Linda’s son, who has autism and a connective tissue disorder, relies on Medicaid for medication, surgeries, and therapy. Medicaid also pays for his personal care services, allowing Linda to work full-time.

Shannon, meanwhile, was diagnosed with cerebral palsy at age two and told she would never walk or talk. Thanks to Medicaid, Shannon was able to receive crucial medical treatments, and today, at age 13, says she wants to be a teacher when she grows up.

Because of such stories, Obama strongly opposes Republican proposals to slash Medicaid funding, Jarrett says.

“Are there any Americans who really believe that we should ask Linda to quit her job when we need everyone contributing to our economy, or that we should ask Shannon to sacrifice her future just so that a millionaire can receive another tax cut?” Jarrett writes.

Like Jarrett, PHI opposes cuts to Medicaid, as detailed in the ongoing PHI fact-sheet series Medicaid Matters.

– by Matthew Ozga

On August 1, Montana will institute across-the-board cuts to Medicaid reimbursement rates, jeopardizing the care of thousands of seniors and people with disabilities.

Home care agencies, hospitals, mental health centers, group homes for people with disabilities and other health care providers face cuts of 2 percent — rolling back the increase they received in 2009.

Assisted-living facilities, however, will have their reimbursement rates slashed by 10 percent, reversing a 10 percent increase the state enacted two years ago as an incentive for these facilities to accept people with Medicaid coverage, reports the Billings Gazette.

The Medicaid-rate cuts will be enacted as part of legislation setting Montana’s budget for the 2012 and 2013 fiscal years, which was signed by Gov. Brian Schweitzer (D) in May.

Thousands Affected

Overall, more than 2,300 Montanans use the Medicaid waiver program to receive long-term services and supports in the “least restrictive setting” possible.

Rose Hughes, executive director of the Montana Health Care Association, which represents assisted living facilities and nursing homes in Montana, said that her organization is “very concerned that the assisted living cuts will affect access to these services for elderly Medicaid waiver clients.”

An estimated 800 Montanans covered by Medicaid live in assisted-living facilities.

Evictions Likely

Operators of assisted-living facilities say the 10 percent cut is unacceptable.

They are already losing money on Medicaid residents, they say. The cut will likely force them to evict Medicaid residents in favor of private-pay clients.

Mike White, who operates several assisted-living facilities in Montana, told NBC Montana that it is “completely unreasonable to expect facilities to stay in business when their costs are increasing and you’re cutting their revenue by 10 percent.

“How many businesses can deal with that?” White added.

Damage to Transition Program

Hughes notes that the cuts will do great damage to Montana’s “very successful” nursing home transition program, in which the state works with nursing homes to identify individuals who can successfully transition to assisted-living facilities and other home- and community-based services.

“These transitions won’t happen if assisted-living facilities are financially unable to accept these residents,” Hughes said.

Since Medicaid rates are higher for nursing homes than for assisted-living facilities, Montana will incur greater costs if the transition program is weakened.

Amendment Affects Direct-Care Workers

Meanwhile, the budget legislation included an amendment appropriating funding for pay increases and bonuses for direct-care workers employed by Medicaid-funded nursing homes and community-based services.

The appropriation, however, will be $500,000 less than in the previous biennium.

“We are obviously pleased that the Montana Legislature chose to renew the appropriation for direct care wages that was set to expire,” even at a lower rate than in previous years, said Mike Hanshew, director of policy for Consumer Direct Personal Care, a for-profit home care company with locations in Montana and seven other states.

However, because of the cuts to Medicaid reimbursement rates, direct-care workers will likely see no direct benefit from that appropriation, he added.

Medicaid-funded in-home service agencies such as Consumer Direct Personal Care will have difficulty doing “anything more than maintain our current levels of services and direct-care worker compensation,” Hanshew said.

– by Matthew Ozga

More than 175 organizations, including PHI, have signed onto an advertisement (pdf) placed in today’s Roll Call which speaks out against proposed cuts to Medicaid.

The proposed cuts would jeopardize long-term services and supports, the ad states.

The cuts would also “cost thousands of direct-care jobs, putting a greater burden on individuals and families,” the ad continues.

The ad was the result of a collaboration between national aging and disability advocacy groups, long-term care providers, health care advocates, labor unions, women’s groups, and other organizations.

Other groups that signed onto the ad include AARP, the National Council on Aging (NCOA), LeadingAge, the Arc of the United States, the National Partnership for Women and Families, and the Consumer Voice.

More information about the importance of Medicaid to long-term care and low-wage direct-care workers is available in Medicaid Matters, a series of fact sheets by PHI.

Additionally, PHI’s Health Care for Health Care Workers campaign is asking advocates to call their congressional representatives to urge them to reject any cuts to Medicaid.

– by Matthew Ozga