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Nearly 22,000 Pennsylvanians who participate in the state’s consumer-directed care program — and the workers who care for them — face an uncertain future if a plan promoted by state government officials comes to fruition.

Currently, Pennsylvanians who are elderly and/or have a disability can choose to hire home care aides. The workers’ wages are paid for by Medicaid waivers, and the clients who hire them are considered their employers.

Intermediary entities known as financial management services (FMS) providers, meanwhile, issue the aides’ paychecks, purchase workers compensation insurance, and handle other accounting tasks.

In January, however, state Department of Public Welfare (DPW) secretary Gary Alexander announced a plan to drastically consolidate these providers, reducing their total from 37 to no more than three, and perhaps just one.

Last year, the passage of the controversial Act 22 gave DPW the authority to make sweeping changes to the FMS system without the usual regulatory oversight by the state legislature.

Alexander’s move is part of a broader campaign by the administration of Governor Tom Corbett (R) to curtail state spending by cutting funding for many programs that benefit low-income Pennsylvanians. More than 80,000 children have been cut from Medicaid rolls since last August, and a Corbett-endorsed plan to subject food stamp recipients to an asset test was scaled back only after widespread public outcry.

“Centralizing the FMS system is counterproductive to the ideal of consumer-directed care,” said Joe Angelelli, director of the Health Services Administration program at Robert Morris University and a former PHI Pennsylvania Policy Director. “A more networked and localized approach is more person-centered and effective.”

– by Matthew Ozga

As many as 4,000 people in North Carolina could be forced from their adult care homes when the state finally begins to comply with federal Medicaid eligibility requirements for personal care services at the end of April.

Under the new state rules, residents who need assistance to perform at least two activities of daily living (ADLs) will qualify for Medicaid. Previously, residents had to need assistance with just one ADL.

About one-third of funding for adult care home residents comes from Medicaid. These public dollars are used to hire direct-care workers who provide care for the residents.

Tara Larson, the chief clinical operating officer at the state Division of Medical Assistance — the agency that manages Medicaid — told a state legislative committee last week that the state “[does] not have a place identified for every individual living in an adult care home for an alternative placement.”

Al Delia, acting secretary of the state Department of Health and Human Services, told the Associated Press that some of the 4,000 people who stand to lose their services in adult care homes may qualify for the Community Alternatives Program for Persons with Mental Retardation or Developmental Disabilities (CAP-MR/DD), a different Medicaid program for people with developmental disabilities.

– by Matthew Ozga

“State Advocate Experiences and Engagement in Duals Integration” is the subject of the Friday Morning Collaborative‘s next webinar.

The webinar will take place March 9 from 2:00-3:30 p.m. EST.

It will highlight the experiences of Massachusetts and California advocates in their efforts to coordinate care and lower costs for people with both Medicare and Medicaid. The webinar is part of the Collaborative’s ongoing series on Medicaid home and community-based services.

Space is limited. Register and learn more online.

– by Deane Beebe

A recent report by PHI Michigan for the Michigan Department of Community Health (DCH) provides the first demographic profile and other data on direct-care workers employed by by self-directed (SD) consumers through the Michigan (MI) Choice Medicaid Waiver Program.

The report, Self-Determination and the MI Choice Medicaid Waiver Program (pdf), is based on a survey of 624 direct-care workers in the MI Choice Program. It offers recommendations and strategies to strengthen the SD program for workers and participants.

“The survey findings should stoke what should be a growing discussion of the intersection of the paid direct-care workforce and family caregivers,” said PHI Director of Midwest Policy Hollis Turnham.

“Self-direction models across the country rely on family caregivers as well as friends and neighbors to become paid direct-care workers,” Turnham said. “As self-direction grows as a delivery option, we need to acknowledge and learn more about that intersection of individual roles and public funding — both about the challenges and the opportunities.”

The survey of workers in the SD program was designed to:

• Collect baseline demographic information;
• Understand the workers’ motivations, job satisfaction, and training needs; and
• Identify strategies to strengthen and support recruitment and retention.

The report compares the findings from three types of SD workers — family, friends, and strangers — and explains that while they are “indistinguishable” in many aspects, “there are some remarkable differences among the groups.” For example, more friends and neighbors were found to be working with an individual with a disability rather than elders.

The Findings

The survey findings are summarized as follows:

Satisfaction: While SD workers are, overall, satisfied with their jobs and find the work rewarding, they indicated low satisfaction with their wages and the number of hours they work. SD workers earn wages that are among the lowest of all direct-care workers in the state, and have higher rates of uninsurance.

The SD workers — especially the SD workers who are family and friends — reported that they provided services for which they were not paid, which is an indication that the SD model is built on the informal unpaid support that these caregivers provide.

Relationships between Workers and Participants: Common assumptions about family members and friends working in the SD MI Choice Option are not reflected in the findings. In fact:

• A significant number of paid family members do want training. Almost half of the workers expressed an interest in training in specific clinical topics and communications skills.
• A majority of the family members (57 percent) do not live with the participant they support.

Recruiting and Retaining SD Workers: The MI Choice program — like every long-term care services and supports program — is challenged to find and retain qualified, competent workers. Only half of the workers indicated they intend to continue working for the participants for whom they currently provide support, which points to a “potentially high level” of turnover among these workers.

Recommendations

Based on the findings, PHI has made the following recommendations for the MI Choice program:

• Develop mechanisms to ensure that workers have the opportunity to receive training on topics that are relevant and of interest to them.
• Provide training opportunities and resources for participants to be effective employers in the MI Choice SD Option.
• Offer more and continuing work to current workers to build and sustain a workforce willing to serve SD participants.
• Explore opportunities to maximize outreach and enrollment in Medicaid and subsidized health plans under the Affordable Care Act (ACA) to secure health care for uninsured and underinsured workers.
• Identify mechanisms and opportunities for SD workers to recognize and address workload imbalances and concerns.

The project was made possible through a technical assistance award from the National Direct Service Workforce Resource Center to the Michigan Department of Community Health and, with additional funding from the Centers for Medicare and Medicaid Services State Profile Tool Grant to the Michigan Office on Services to the Aging.

– 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

The Joint Committee on Deficit Reduction — better known as the “Super Committee” — has only until November 23 to report out a deal to find $1.2 trillion in savings over the next ten years or face a “trigger” that would result in automatic cuts.

It is looking less and less likely that a deal can be struck, according to news reports.

If a deal can be reached, this would be the second installment of deficit reduction measures, following the cuts made by Congress earlier this year.

Areas that the committee is likely considering include:

• revenue increases, including raising taxes and reforming the tax code to eliminate tax breaks and loopholes;
• military spending cuts; and
• measures to reform and slow the growth of entitlement programs, including Medicare, Medicaid, and Social Security.

Divided Over Cuts to Safety-Net Programs or Raising Taxes for the Wealthy

The Committee, made up of six Democrats and six Republicans, is divided over the balance between cuts to core safety-net programs for low- and middle-income Americans and tax increases for the very wealthy.

On November 15, Representative Jeb Hensarling, the Republican committee co-chair, said he and his colleagues had “gone as far as we feel we can go” on taxes, and that “any penny of increased static revenue is a step in the wrong direction.”

If the super committee fails, Hensarling said that Republicans will look to undo the compromises they have already made.

Automatic Trigger Would Devastate Key Government Programs

Should the automatic “trigger” go into effect, half of these cuts are scheduled to come from domestic spending (excluding Social Security, Medicaid, and a few other programs that help the poor). The other half is scheduled to come from the Pentagon. Neither party wants to see defense budget cuts of that scale, which is intended to be an incentive to reach a deal.

Though discussed less often, the 7.8 percent across-the-board cuts to domestic spending would be devastating to key government programs, such as homeland security, law enforcement, environmental protection, food safety, and transportation infrastructure.

The committee is considering various proposals, from a $4 trillion “grand bargain” that would match significant tax increases on the wealthy with significant cuts to programs such as Medicare and Medicaid, to smaller packages that would not require new revenues. Given the looming deadline, more proposals are expected over the next few days.

Advocates Turn Up the Heat

Advocates are turning up the heat to push the super committee to not agree to any cuts in Medicare, Medicaid, and Social Security.

For example, the American Health Care Association and the Alliance for Quality Nursing Home Care have launched a Care Not Cuts effort to fight cuts in programs. A wide range of labor and consumer organizations, including Caring Across Generations, are holding rallies in Washington, DC and across the country on November 17 to support jobs, not cuts.

For more information on how Medicaid cuts would affect beneficiaries and threaten millions of health care jobs, read PHI’s Medicaid Matters…in Super Committee Deficit Reduction Deliberations (pdf).

– by Carol Regan, PHI Government Affairs Director