State has bad habits in dealing with long-term care needs

Guest Opinion: A new study could chart better ways to dealing with the needs of the aging and the disabled. But our record isn't promising.
Care for Alzheimer's and dementia patients in a Midwest facility.

Care for Alzheimer's and dementia patients in a Midwest facility. Kansas Poetry (Patrick)/Flickr

Is our state's policy on long-term care policy at the tipping point?

This year's state budget established a joint legislative executive committee on aging and disabilities. The committee is tasked with studying our state’s long-term care needs and issuing an initial report this month, with a final report due in December 2014. Some compassionate legislators of both parties serve on this committee, as does the secretary of the Department of Social and Health Services. But the future of long-term care in an aging state — where more and more of us can be expected to need help for an extended period of time — has been studied innumerable times before with no results.

For years, long-term care policy has been as much directed by sanctions as it has been by affirmative policy decisions by the state.

Since Initiative 775 passed in 2001, compensation for the state’s in-home caregivers has been determined not through good-faith bargaining on the state’s part, but rather through a series of arbitration awards. In fact, then-Gov. Gary Locke welcomed, so to speak, the passage of I-775 by vetoing a 25-cent-an-hour wage increase for caregivers in 2002.

A 2007 Washington Supreme Court decision required additional Medicaid funding for in-home care hours for laundry, meal preparation, shopping and other services that the state was refusing to cover. The state had callously slashed compensation for care needs by 15 percent in cases where the low-wage workers lived with their impoverished clients; clients would have been better off with homeless caregivers. The court found that even “before any reduction, the hours required to provide for the needs of the individual plaintiffs greatly exceeded the hours actually reimbursed.” The state’s defeat required an additional $15 million appropriation in 2008. 

The implications of the 2007 opinion still resonate today: A follow-up 2010 Thurston County court decision found that the state owed $95 million to 22,000 caregivers who had continued to provide lifesaving care despite the state’s penny-pinching. The case is now before the Washington state Supreme Court. With studied callousness, the state has argued that “people received the care provided for under Medicaid, and their caregivers were paid for the number of service hours awarded.” In other words, the hours actually worked were quite irrelevant. There are less polite terms for such servitude.    

In 2009 the Legislature was required to come up with $23 million in Medicaid reimbursement for nursing homes after a Thurston County judge’s decision found the state had miscalculated a previous reimbursement increase, forcing it to make retroactive payments. The state accommodated this by ceasing to pay more current costs.

In 2011, the state started to consolidate its Residential Habilitation Centers (RHCs) for those with severe disabilities, facilities that fulfill a duty of long-term care as old as statehood: The 1889 language in the Washington Constitution required the state to foster and support institutions “for the benefit of blind, deaf, dumb, or otherwise defective youth; for the insane or idiotic.” 

From the beginning the RHC downsizing has been an exercise in social Darwinism. In October 2011 a 30-year-old former resident of the Frances Haddon Morgan Center in Bremerton drank laundry detergent and died following placement in a less-supervised environment.  Now the federal government has concluded that, in attempting to save $1 million in caring for 27 residents at a state-run nursing home in Spokane County’s Lakeland Village, the state broke the law at least 41,231 times. The state may now be on the hook for a penalty of as much as $16 million, quite apart from the irreparable harm to very vulnerable citizens.

Put another way, by trying to save $1 million on the care of 27 people, the state may now be penalized as much money ($16 million) as it saves each year by ignoring the costs of nursing home care for 10,000 Medicaid patients throughout the state and keeping their reimbursement fixed to 2007 costs, through 2015. Does this seem like a wise way of saving money, quite apart from any consideration of principled long-term care policy?

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Posted Mon, Dec 9, 8:07 p.m. Inappropriate

Despite being Secretary of DSHS I enjoyed reading this article. It pointed to the choices that have been made in past years that have been contrary to good care or a careful reading of our legal obligations (not all, but too many). In the most recent item referenced, the 2010 decision to care for some groups of our citizens with developmental disabilities in nursing home settings I looked back amd found that when this cut was imposed the Department advised that this reduction could lead to lawsuit by the Department of Justice or the Federal Center for Medicare and Medicaid or to a disallowance. The latter disallowance is exactly what happened. Inside the Department there were many thinking "I told you so" just as news outlets were hyping their standard narrative that bureaucrats had lost $16 million trying to save $1 million. None of those numbers are correct.

I am also frankly glad that the article pointed out that the same situation, serving clients with developmental disabilities in nursing facilities rather than residential habilitation centers (RHC), exists not just for the 27 people identified at Lakeland Village RHC, but for many more at Lakeland Village, and for many many at Fircrest RHC and Yakima Valley School, and many in the community. Within DSHS we're engaged in an extensive corrective action to provide the additional special services these citizens require and can benefit from.

So why does this condition persist? Frankly its a legacy of past reductions made to social services where DSHS was simply told to do with less, and to do so without eliminating any programs. Cuts to administration meant cuts to IT, QA, training and HR that both exacerbated, and hid, some of these issues.

These issues are important to governor Jay Inslee, my boss. This is the very sort of thing he was fighting for when he said he would protect human services funding. These are the issues he is implicitly raising when he fights, as he did last year, to protest cuts to human services as the means to balance the budget, when he leads on closing tax loopholes in lieu of cuts to humans, or when he says he won't pit education against the desperate social needs of children and families.

Back to my clients with developmental disabilities being undeserved in Lakeland Village, why didn't we address this sooner? Frankly, because similar underfunding exists across DSHS and because, although we are not providing the quality of enrichment that we should be (and thankfully that we will be soon), I did not fear for their safety. (When the issue was raised, however, by an outside interest group we immediately raised it with the Feds, which is what triggered the disallowance.) By contrast, in the area of Child Protective Services and Adult Protective Services caseloads and inadequate referral processes have been such that life threatening mistakes were possible. Despite the CPS and APS teams doing a great job, I'm concerned with the cases that we lack investigators to properly refer or staff. These were social services priorities I brought to the Governor, along with needs in our state mental hospitals, and he not only lead on these concerns, he encouraged me to move as quickly as possible. The Governor has clearly been the high water mark that we have seen in many many years for protecting the vulnerable. The Governor is well in front of the band, as the band catches up we'll be able to take more corrective action.

We have work to do.


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