The Citizens Action Coalition (CAC) is working as a member of the Indiana Home Care Task Force to stop once and for all the practice of forcing people into nursing homes who should not be placed in those facilities. To achieve this goal CAC and the Task Force are seeking an end to the near absolute control exercised by nursing homes over the tax dollars that are allocated for long term care services.

The specific actions from the state that are being sought by CAC and the Task Force include:

• A supplemental appropriation from the General Assembly for the CHOICE home health care program of $26.7 million.

• Expansion of Medicaid waivers for home and
  community based care for persons with disabilities of all ages.

• The establishment of new Medicaid waivers for assisted living and adult foster care.

• Petitioning the federal government for a new Medicaid waiver to allow all funds currently used by Medicaid for nursing home care to also be used for home and community based long term care.

• The dedication by the General Assembly of a significant portion of Indiana’s share of the national tobacco settlement dollars for new home and community based services for the elderly and disabled, who have often been victimized by tobacco-related
  illnesses.

CHOICE HOME CARE FUNDING

In the 1999 General Assembly the Task Force and CAC fought hard for a biennial increase in CHOICE funding of $45 million. That did not happen. Instead, the General Assembly only increased the two year home health care budget from $75 million to $85 million — some $35 million short of the level recommended by the state’s CHOICE Advisory Board.

Since the end of the session the Task Force has determined it shall seek a supplemental appropriation for CHOICE in the 2000 General Assembly. Because of the lost time during the current biennial budget period the Task Force will seek a prorated increase of nearly $26.7 million.

According to John Cardwell, CAC Legislative Director and Task Force chair, the pro rated $26.7 million supplemental appropriation will allow consumers served by CHOICE to increase by 1,146 to a total of 12,842 in FY 2000, and to jump by 6,192 to a total of 17,887 in FY 2001. "Even though the General Assembly only increased CHOICE by slightly more than ten million dollars in the 1999 legislature we can still make impressive gains in the number of people served if this proposed supplemental budget is passed and immediately implemented during the short 2000 legislative session. In fact, the supplemental appropriation would take CHOICE funding by the biennium’s end to the level proposed by the Task Force during this past session,".

The "savings" associated with home care, however, are dramatically illustrated when average costs for nursing home costs residents are compared with those of consumers in the CHOICE program. The average cost for all CHOICE clients is $7,268 per year. The average annual cost for a resident in an intermediate care nursing home paid through the Medicaid program is $27,760, and the number jumps to a shocking annual average of $37,753 in a skilled nursing facility.

Presently, the state provides Medicaid waivers for medically fragile children, for the autistic, for persons with developmental disabilities leaving ICF/MR institutions to live in a community setting, for persons with traumatic brain injuries, and for the aged and disabled. 

These waivers are statutory exceptions to the federal Medicaid law. Each waiver is a contract between the state and the federal government to allow a specified sum of Medicaid dollars to be spent on services for a fixed number of people with defined impairments.

Since federal tax dollars are combined with a smaller level of state funding to underwrite the cost of Medicaid waivers they are a good financial bargain for the state, and a means for Hoosiers to see their federal taxes at work in Indiana. Medicaid waivers are also a way to get policy makers in Indiana to swallow the financial pill of providing long term care services that people could not afforded by other means.

The Home Care Task Force and CAC have been negotiating with the O’Bannon administration for an expansion of current Medicaid waivers, for new waivers, and for additional waiver funding as indicated above.

According to Nancy Griffin, CAC board vice president and executive director of the Indianapolis Resource Center for Independent Living (IRCIL), Indiana should be moving aggressively in this direction.

"The Clinton administration has shown a willingness to let states experiment with waivers. Indiana shouldn’t let that opportunity slip by. Our state already has permission to fund waiver slots to divert an additional 5,000 people from nursing homes, and to transition another 5,000 out of nursing homes under its Aged and Disabled waiver. Those slots need to be funded and utilized," Griffin said.

"Indiana must also act to amend current waiver language so adult day care can be readily available to more Hoosier families, and we must apply soon for new waivers for adult foster care and assisted living. We have been discussing these issues for over two years with the O’Bannon administration, and during that time too many people have needlessly suffered for the lack of long term care. It is time to see some real results from these negotiations," said Griffin.

Medicaid Dollars

The negotiations with the O’Bannon administration regarding new ways to fund and to operate long term care service programs in Indiana originated in discussions between Governor O’Bannon, the Task Force and CAC in 1997. That led to the Governor establishing the Long Term Care Dialogue Group in 1998. The Dialogue Group consisted of negotiators from the state’s Family and Social Services Administration (FSSA) and from the Indiana Home Care Task Force. CAC staff and board members were members of the negotiating team.

The Dialogue Group identified problems and opportunities to be addressed in publicly funded long term care programs, and issued a report in December 1998. After a lull in the process through much of 1999 the Governor established the Long Term Care Work Group in September that has the assignment of recommending specific steps for gubernatorial and legislative action.

The Work Group consists of representatives from FSSA, the CHOICE Advisory Board, and the Task Force. Once again, CAC board and staff members are a part of this group.

The Work Group has acted quickly. In October it asked the Governor to seek new Medicaid waivers for assisted living and adult foster care before the end of 1999, and to amend the aged and disabled waiver so more people can utilized adult day care.

The Task Force members of the Work Group are challenging the O’Bannon administration to approach the Health Care Financing Administration (HCFA), the federal agency that acts on state Medicaid waiver applications, with an innovative and far reaching proposal. The Task Force believes Indiana should pursue the ability to let Medicaid funding that can presently be used for nursing home care only to be used for any type of long term care services needed by qualified consumers.

If approved by HCFA, and implemented in Indiana, this change would break the nursing home industry’s monopoly control over Medicaid long term care funding. The change would mean the legal entitlement status granted to Medicaid funded nursing home care could no longer be used to deny Medicaid funding for other types of long term care services, including home care. The change would also force nursing homes to compete on a level playing field with other forms of long term care that are preferred by consumers and their families.

TOBACCO DOLLARS

When states attorneys general across the nation initiated law suits against the tobacco industry years ago to recover health costs incurred by the public from the use of tobacco related products few people foresaw the results of that litigation. The settlement requires the industry to pay hundreds of billions of dollars to state governments over the next 25 years and beyond.

In Indiana, the tobacco settlement is scheduled to bring into the state’s treasury four billion dollars by 2025. Already, the state is receiving a first year payment of nearly $49 million dollars, and second and third year payments of nearly $131 million and $141 million.

According to Paul Severance, CAC board member and executive director of United Senior Action of Indiana (USA), people cannot assume that the state will spend the tobacco money on the people who have suffered and are suffering from tobacco related diseases. Severance states, "The Governor will recommend uses for the tobacco settlement monies, but it is the General Assembly that will make those decisions. We believe a substantial portion of the settlement dollars should be spent on the people with chronic and threatening diseases and disabilities, many of which are directly related to tobacco.

"A substantial portion of the Indiana’s tobacco settlement dollars should be used for long term care home and community based services that are not funded or grossly under funded. These services include assisted living, adult foster care, hospice care, and the CHOICE program.

"The money should also be used for prescription drug services for the elderly and non-elderly disabled with long term care needs." 

On November 10th the Indiana Home Care Task Force hosted the Indiana Legislative Summit on Long Term Care Solutions in Indianapolis. Many members of the General Assembly attended this summit during which a panel of LTC experts discussed with the lawmakers the ideas outlined in this article.

Additionally, over the last several years and in detail over the past few months all Indiana legislators have had communications and discussions with citizens on these critical long term care issues, including the need to increase CHOICE funding, to expand Medicaid waivers, and to break the nursing home industry’s monopoly control over Medicaid dollars.

As indicated above, Governor O’Bannon has personally pushed the search for long term care policy solutions within his administration, and called for a greater investment in LTC alternatives when he spoke to a statewide audience at the Governor’s Conference on Aging on October 7th.

However, none of the above guarantees anything.

The substantial successes of the CHOICE program, beginning with its enactment in 1987, have only come after intense public pressure has been asserted on the legislature and past governors. Success in the year 2000 will be no different.

Indiana’s nursing home industry is still extremely powerful. Nursing home owners successfully lobbied behind the scenes in 1999 to hold down the level of new funding for the CHOICE program while getting the General Assembly and the administration to approve of a new biennial budget with over eight hundred million a year in Medicaid funds just for nursing homes. Furthermore, that industry is already working hard to keep tobacco settlement monies from funding alternatives to nursing home care.

To truly guarantee a substantial increase in Indiana’s investment in alternatives to nursing homes CAC members must act. CAC members must contact their state legislators and Gov. O’Bannon, and encourage other citizens to do the same. CAC and its allied organizations within the Indiana Home Care Task Force can only succeed if their members succeed in being ‘active citizens.’ 

As Charlie Fields, a volunteer member of the AARP State Legislative Committee, states: "People in Indiana will not have better home care and more affordable long term care based on what I say at the Statehouse. The fate of people needing CHOICE and Medicaid waivers will be determined by citizens who call, write and speak to their legislators and the Governor. How well we use our democracy will determine our level of success. So make those calls and write those letters!"

AVERAGE COST PER MONTH PER MEDICAID WAIVER

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