Health-Aide Shortage Stirs Worry as Medicaid Budget Gap Looms

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While some seniors have a network of friends and family to train or hire for these “consumer” based programs, others must rely on professional homecare workers.

A shortage of home health aides across New York state raised concerns at an Assembly hearing on services provided for aging New Yorkers last week.

The hearing arrived as a $15 million budget increase for aging services began reaching counties, though advocates testified some counties received no additional funding from that amount. It also came amid a ballooning statewide Medicaid deficit and the possibility of cuts to programs in the next budget.

The $15 million investment was part of the state’s 2020 budget which targeted counties with waitlists for services, focusing on programs for home-based care. The money was directed to home-delivered meals, case management, home modifications and programs for Medicaid ineligible families in need of long-term care.

Gail Myers, deputy director of the New York Statewide Senior Action Council, testified that there were severe gaps in capacity for New York’s Expanded In-Home Care for the Elderly Program, or EISEP, the state’s long-term care program for families who don’t qualify for Medicaid. She said this was a result of insufficient resources and a shortage of homecare workers.

“You can’t address strategies for aging-in-place without addressing the homecare work shortage,” she said.

EISEP was started in 1987 to provide in-home care, transportation and other services for seniors whose incomes disqualify them from Medicaid. Medicaid has become the default for seniors who need long term care services, which are not provided through Medicare.

Changes made to EISEP in 2011 allow for seniors to train and hire friends or family members to provide care while being paid by the state. A similar model was also implemented under Medicaid, called CDPAP, or Consumer Directed Personal Assistance Program. (Medicaid pays for 87 percent of New York’s homecare workforce.)

While some seniors have a network of friends and family to train or hire for these “consumer” based programs, others must rely on professional homecare workers recruited by Certified Home Health Agencies (CHHA’s) and Licensed Home Care Service Agencies (LHCSA’s).

Because of low wages and competition from other sectors, 17 percent of home health aide jobs across the state are unfilled, according to a Home Care Association of New York report released earlier this year.

The result is that, according to HCA’s report, 24 percent of people in need of home health aides across the state can’t access them, and another 14.8 percent experience delays in service.

In addition to pay, which Myers referred to as the “elephant in the room,” the home health care worker shortage can be attributed to a lack of transportation and the difficulty of the job, advocates testified.

Myers testified that New York needed to prepare for the increasing need for aging services, a result of both demographic aging of NY’s population and the state’s increased outreach and public education on caregiving.

“As they identify themselves (as caregivers)…the number and need is going to explode for services,” Myers said. “There’s this hidden waiting list.”

She said that 10 counties across the state received no funding from the $15 million despite a need, and suggested a more pro-active approach had to be taken to gauge the needs of those counties. The counties self-report unmet need to the state, but may not be keeping track in a consistent way, she suggested.

This was in contrast to earlier testimony by Greg Olsen, director of the New York State Office for the Aging, who testified that counties reporting no unmet need should be viewed as a positive. “To me, that’s a success story,” Olsen said.

A bill passed by the assembly, but not the Senate, this year, would require every county agency on aging in the state to report on unmet needs for aging services, which Myers said she supported.

Many of those who testified called for the passage of the Caregiver Tax Credit, which is intended to support family members and friends who are performing uncompensated caregiver duties for a loved one. The bill is still in committee and has not been up for vote in either house.

The $15 million in new funding distributed across the state went to, among other services, forming a state run “private pay market” for seniors who need care and who are middle- or higher-income. Olsen said each county would have to opt-in to the program and it is planned for those at 400 percent of poverty or above.

EISEP, by contrast, is free for those below 150 percent of the federal poverty level, and for those making more there’s a sliding scale fee. For those at 250 percent or more, EISEP is full cost.

The new “private pay” system, which has not yet been rolled out, is for higher earners and would compete with private care companies, which Olsen suggested were not doing thorough enough assessments of seniors before placement.

The hearing was held against the backdrop of a widening gap in the state’s Medicaid budget. Attendees at Friday morning’s hearing were already aware that Medicaid spending had gone $3 billion over the state’s self-imposed “global cap,” a mandatory spending limit implemented in 2011 as part of Governor Cuomo’s Medicaid redesign. The governor’s office had rolled over Medicaid payments in the 2018-2019 fiscal year to avoid exceeding the gap, in order to avoid cuts to spending required by law.

But the picture became more stark later Friday afternoon, when a mid year update revealed that the budget gap had grown to $4 billion over the state’s cap.

The increase was attributed to a higher minimum wage for healthcare workers and higher enrollment in managed long-term care plans, among other factors. According to the Empire Center for Public Policy, the state’s cap is flawed, as it is strained whenever enrollment goes up.

“A significant shortcoming of the cap is its lack of an adjustment for enrollment,” according to a report from the Center.

In a statement to City Limits, Freeman Klopott, a spokesperson for the New York State Division of the Budget, said a plan to scale back Medicaid spending would be introduced in January’s Executive budget. The report released Friday states that a savings plan could consist of delayed payments or “across the board reductions in rates paid to providers and health plans.”

The governor is still embroiled in a fight over changes proposed in last year’s budget that advocates said would shut out many home health aides. Those changes were shut down by a judge last month.

The state and counties have been investing in managed long-term care as a way to reduce emergency-room visits, hospital admissions and nursing home stays, which are all more expensive than home care in the current model.

To boost awareness of caregiver issues, the city’s Department for the Aging published three PSA’s on its website last week. The videos, a combination of simple animations and long interviews with caregivers and service providers, are meant to help caregivers identify their work for loved ones as caregiving and introduce them to statewide and citywide programs like the New York State Paid Family Leave Act, the CARE Act and respite care services around the city.

The videos follow up on a 2017 survey of caregivers that DFTA conducted and a 2018 set of recommendations based on that survey. The survey was mandated by a law that passed the City Council in August 2016. That law also requires DFTA to report on its progress toward its own recommendations in 2020, and once every five years thereafter.

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