House Budget: Elders Up, Funds Down

On April 13th, the House Ways and Means (HWMs) Committee, chaired by Rep. Brian Dempsey (D-Haverhill), released its FY 2017 state budget, the next step in the legislative process after the release of the Governor’s budget, House 2, in late February.

HWMs provides around $209.626 million combined for home care, care management and Enhanced Home Care programs. This is the same total provided the consolidated line items in House 2. The HMWs committee chose not to consolidate the ECOP program (9110-1500) into the home care line items, but keeps the 3 programs separate, as they were in FY 16.

State House

Compared to FY 16 appropriation levels, the basic home care and care management accounts have lost $4,861,112 (1630 lost $3,109,894 and 1633 lost $1,751,218). But, the ECOP program gained $4,089,795, so the net loss is around $771,317.

The Administration’s language in 1630 account that would “transfer” funds whenever a home care client joined a Senior Care Organization, was deleted. Outside section 39 in the Governor’s budget, which gave the Executive Branch unilateral power to “restructure” $15.4 billion in MassHealth programs, also was rejected by HWMs. The Administration was planning on “passively enrolling” elders into the SCO plan, but without the “restructuring” language, the SCO law in force says the program must be voluntary.

The HWMs budget also cut nutrition funds by $746,941, which would cause a loss of roughly 100,000 meals on wheels. The Naturally Occurring Retirement Community (NORC) program lost its $642,000 in the FY 16 budget, and EOEA’s Explorer Lab data project was not funded.

Mass Home Care’s request for an income eligibility increase to 300% of the federal poverty level was not funded, and a request to increase the rate for the Enhanced Community Options Program was also not funded.

In response to these cuts, Mass Home Care lined up behind a series of amendments designed to help older people live at home:

  • Representative Chris Walsh of Framingham filed an amendment raising the rate for the enhanced community options program. Walsh’s amendment would equalize the rates for two separate home care management rates (ECOP and Choices) that essentially have the same scope of care management services. The projected cost of this rate equalization for FY 17 is $5.01 million based on projected caseload.
  • Representative Paul Brodeur of Melrose: filed an amendment identical to language that House Ways & Means inserted into the most recent supplemental budget. It calls for EOEA to conduct a study the caseload and costs of expanding home care income eligibility to 275% and 300% of the federal poverty level. It also permits the Administration to file for a 1915i state plan amendment that would bring in roughly $19 million in new federal revenues to the Commonwealth to help pay for any future home care expansion.
  • Representative Tom Sannicandro of Ashland filed an amendment that requires Accountable Care Organizations (ACOs) who provide long term services and supports (LTSS) to give their members a benefit called “conflict free care coordination (CFCC).” This is currently a benefit found in the Senior Care Options (SCO) program, the One Care program, and the Home Care program.  The CFCC helps assess what a member needs for care—but does not provide that care, and thus has no ‘conflict’ to over-assess what people need, or to refer to their owned services. This is an important consumer protection, because the CFCC is not owned by the ACO, but is described by CMS as an “independent agent” for the consumer. The CFCC’s goal is to help the member live in the least restrictive setting. The conflict free assessment is part of the federal CMS final rule for home and community based services. It is also a benefit that the state promised CMS it would implement as part of the Balancing Incentive Payment (BIP) program, which brought in more than $230 million in federal matching funds.
  • Representative Chris Markey of Dartmouth filed an amendment that restores funding back to the FY 16 appropriation level for the line item which  pays for the operations and staffing at the 26 Aging Services Access Points (ASAPs). These staff are mostly frontline care managers and RNs. A 2015 independent salary study of 1,305 ASAP care managers and RNs concluded that workers in the home care system are being paid “below market rate salaries.” The care management turnover rate is 20% per year. This account stood at $39.87 million in FY 2008, and has been frozen at $35.5 million for 7 years. This amendment restores the ASAP funding to where it was in FY 16, which is the same level it was funded at in FY 2011. This funded is needed to mitigate the “low salary/high turnover” syndrome that causes employees to leave the elder services field.
  • Representative Paul Donato of Medford filed an amendment to add $871,886 to the state elderly nutrition program. Elder meals are provided at more than 400 congregate meal sites in Massachusetts and through home-delivered meals to senior citizens (age 60 or older) and people with a disability under age 60 who live in housing where congregate meals for elders are served. Home delivered meals are provided to older individuals who are homebound due to illness, disability, or geographic isolation. Services are targeted to those in greatest social and economic need with particular attention to low income individuals, minority individuals, those in rural communities, those with limited English proficiency and those at risk of institutional care. Nutrition programs for the elderly are recognized as having a significant impact on health and well-being. The malnourished generate bills $2,000 to $10,000 higher per hospital stay than others do. The journal Clinical Nutrition found a threefold increase in medical costs among the malnourished. Based on the current average meals cost of $7.43 per meal, this amendment would restore 117,347 meals in FY 17.
  • Representative Jennifer Benson of Lunenberg filed an amendment, which has twice made it to a conference committee, that would add spouses to the list of family members who can be paid as a caregiver at home. 17 other states and the Veterans Administration allow spouses to be paid as caregivers, to help the elderly and disabled live independently at home. The Adult Foster Care program, and the Personal Care Attendant program allow family members to be caregivers.  But these same programs do not allow “spouses” to count as caregivers. As a result, many disabled individuals are denied care from the person closest to them, whom they trust the most. Many consumers do not want to turn to children—or strangers—to provide their care. According to the most thorough study of spouses as caregivers in the nation, researchers in California reported that using spouses as caregivers is cheaper than using strangers or other relatives, because a spouse does not have to be paid for existing home maintenance chores, like cooking and cleaning, which they perform already. The remaining personal care costs of bathing, dressing, and toileting are cheaper to provide with spouses. Veterans in Massachusetts can already get spousal care. Programs like PCA further reduce MassHealth costs by preventing costlier nursing facility patient days.

Source: Al Norman, Executive Director of Mass. Home Care, a non-profit that represents a statewide network of agencies that offer community-based supports for older adults, caregivers, and younger people living with disabilities.