By Bruce Chernof, M.D.
Gov. Arnold Schwarzenegger’s proposed budget for the coming year has serious implications for California’s low-income seniors.
According to a recent analysis by the UCLA Center for Health Policy, the proposal would dismantle California’s home- and community-based long-term care system.
Full implementation of the proposed cuts would likely leave frail, low-income seniors – among the state’s most vulnerable residents – without needed support. Many could face a total loss of daily assistance, including those with serious functional limitations (e.g., inability to bathe themselves) and cognitive impairments such as Alzheimer’s disease. Left with few alternatives, many would be forced to turn to nursing homes for care. However, the state has neither enough open licensed beds nor the funds to pay for the increased demand on institutional services.
In California and throughout the country, efforts at long-term care policy reform have for years focused on helping people with disabilities remain in their homes and communities. To support the highest level of autonomy possible, the Americans with Disabilities Act of 1990, backed by findings of the U.S. Supreme Court in Olmstead v. L.C. (1999), holds the state accountable for providing care and support in the community where possible as an alternative to institutionalization. As a result, California’s community-based long-term care services have kept thousands of older adults and adults with disabilities out of institutional care. The UCLA Health Policy Center’s analysis of U.S. Census data found that nursing home rates have dropped from 5.1 percent of the population in 1980 to 2.8 percent in 2008. This time frame corresponds with increased access to publicly supported home-and community-based services.
These programs, designed to allow individuals to stay in their own homes rather than placing them in more expensive nursing homes, are subject to substantial cuts. For example, the In Home Supportive Services (IHSS) program provides personal care assistance to nearly half a million low income people who are over the age of 65, blind or disabled. Proposed cuts, according to data from the nine counties analyzed in the UCLA study, would eliminate services for 87 percent of all current recipients. More than two-thirds of elders with cognitive impairment would have their services totally cut, as well as 94 percent of those who live alone. But even the few who will retain services are at risk. If the state does not receive all $6.9 billion of federal assistance it requested, then “trigger cuts” would eliminate the entire program.
Seniors in jeopardy of losing IHSS also stand to lose Adult Day Health Care (ADHC), a community-based day care program that provides health, therapeutic and social services to 37,000 persons at-risk for nursing home placement. Cuts propose to eliminate this program all together.
Other cuts to programs that help seniors are up for discussion as well, forcing them and their families to scramble for long-term care alternatives should services disappear. Among the most unpopular of alternatives is going to a nursing home. Yet even this option presents challenges. The California Legislative Analyst’s Office estimates that up to 50 percent or 213,500 of those losing IHSS services could seek nursing home placement as a result of cuts, yet the state has only around 20,000 licensed nursing home beds available at any moment. The UCLA analysis suggests that – at most – 5 percent of those needing placement could be accommodated. Where will the rest go?
Left to fend for themselves, low income older and disabled adults with substantial impairments could likely turn to the more expensive acute care system – emergency room visits and hospital admissions – for help.
Compared to the rest of the country, California has the largest number of older adults in the nation and as baby boomers retire, that number will only grow larger. While the proposed reductions might save money in the near term, it could likely result in increased acute care costs and long-term care costs down the road.
Dismantling these programs would also have a negative effect on an already precarious California job market. If the cuts go into effect, unemployment will almost certainly rise. As many as 7,600 employees would lose their ADHC jobs and up to 370,000 paid caregivers would lose some or all of their IHSS work. Many would lose health insurance benefits provided by these jobs. Also, family caregivers who rely on these services to help care for loved ones so they can maintain employment outside of the home would be forced to find with alternative care or face jeopardizing their own jobs.
The current collection of home- and community-based services in California is not perfect. With little cohesion, this patchwork of programs often operates in silos and could benefit from a more comprehensive and effective coordination process. However, its overall contribution has been positive for seniors and family caregivers alike.
The State of California faces an overwhelming financial crisis that threatens to unravel the safety net for seniors. There are no simple answers to this painful crisis. Yet it presents an opportunity to create a more integrated, efficient and person-centered approach to care rather than leaving our poorest and most vulnerable Californians with no place to go.
Bruce Chernof, MD, is the president and CEO of The SCAN Foundation in Long Beach, California. The SCAN Foundation supported the UCLA Center for Health Policy analysis of the governor’s proposed budget.