Tuesday, October 30, 2012

Michigan Self-Determination Guidelines Revised

Self-Determination is a method of delivering services to people with developmental disabilities that allows individuals to have more control over the services they receive, the people who provide the services, and the expenditure of public funds to pay for the services. This is an option that must be made available by Community Mental Health agencies for anyone who desires it, including people with the most severe disabilities who have guardians who speak on their behalf. People who want and need a more traditional program of services may choose not to use Self-Determination.

Last March, 2012, the Michigan Department of Community Health  (MDCH) issued proposed revisions to the Self-Determination Policy and Practice Guidelines. The proposal appeared to be designed as a blunt instrument to bash guardians and to remove them from the planning process for self-determination as much as possible. The vast majority of guardians for people with developmental disabilities are parents, other family members, or close friends of the person with a developmental disability.

Ignoring the jurisdiction of the Probate Court to appoint or remove guardians and to establish the legal disabilities of the person with a developmental disability that lead to the need for guardianship, the MDCH encouraged Community Mental Health agencies to police guardians and circumvent their authority to make decisions on behalf of their wards. The MDCH said that CMH must  "…support  individuals who have guardians … to identify an independent advocate," (emphasis added), presumably to protect individuals from their court-appointed guardians. To add insult to injury, the guidelines would have allowed CMH to terminate self-determination arrangements when an agency determined that the guardians "restrict the individual's rights."

Thanks to the efforts of ddAdvocates of Michigan and families and other individuals who commented on the proposed Guidelines, most of the guardian-bashing wording was removed. The new guidelines are a great improvement over the initial proposal.

I still believe, however, that the claim by people who promote Self-Determination, that it gives people with disabilities more freedom to choose the services they want and more authority over available resources compared to other arrangements through CMH, is exaggerated. All agreements as to how Self-Determination arrangements will be handled, how much money will be available to pay for services, and how the finances will be managed is subject to the guidance, approval, and continual oversight of the CMH agency. This is to be expected with an agency that has the responsibility for overseeing the expenditure of public funds, primarily Medicaid funds.

It is important to keep other options available when Self-Determination is impractical or is not suitable to the needs of the individual. Self-Determination can place extra burdens on disabled individuals and families to administer the provision of services and funds normally handled by CMH, while the public agency still has control and must approve the expenditure of the funds provided. At best, these arrangements can open up new possibilities for providing and paying for desired services that are beneficial to many recipients of CMH services.

Election 2012: More on Michigan's Prop 4

The Detroit Free Press held an on-line Web Chat on Proposal 4, Michigan's ballot initiative  on collective bargaining rights for Home Help workers and continuation of an entity called the Michigan Quality Home Care Council to replace the Michigan Quality Community Care Council (MQC3) as the employer of Home Help workers for the purposes of collective bargaining with the union, SEIU Healthcare of Michigan. See an analysis of Prop 4 here and here .

The moderator for the chat was Jewel Gopwani from the Detroit Free Press. She was joined by Dohn Hoyle, Executive Director of the ARC Michigan, and Derk Wilcox from the Mackinac Center. They debated the issues involved in Prop 4 and answered questions from the public. The full transcript for the Chat is here . There were some details left out of the discussion and some statements that need further clarification.

Home Help workers are employed by seniors and people with disabilities and are paid with Medicaid funds to help their "employers" stay in their own homes. They provide help with personal care and household chores. Providers are often family members and friends of the senior or person with a disability and this was mentioned several times. The fact that they make up 75% of home help providers was left out. 80% of providers have only one client.

Parents, other family members, and friends usually view their participation in the Medicaid-funded Home Help Program as a way of subsidizing  the care their loved-ones need at home, rather than as as a career choice or a way to make a living. They are often surprised that they are part of a unionized workforce. It is understandable that people who are trying to make a living taking care of people in their own homes may welcome unionization depending on the benefits they can get through collective bargaining. When Home Help workers voted on whether to have the SEIU represent them in 2005, fewer than 20% participated in the election. Much of the opposition to Prop 4 comes from family members who object to paying union dues (or fees if they opt out of the union) for what they see as little benefit to themselves or their disabled family member.

Dohn Hoyle from the ARC Michigan sees the unionization issue as a distraction from the real purpose of Prop 4, which he says is to write into the constitution The Michigan Quality Home Care Council to replace the MQC3 and maintain a registry of workers who have passed background checks and have access to training. Although both Hoyle and Wilcox agreed that the registry, background checks, and training are important, the MQC3 registry only lists 900 plus providers and could continue without inclusion in the Michigan Constitution. Background checks are required only for providers who want to place their names on the registry and are only a first step in assuring safety and quality care.

Looking at the events that led up to the unionization of Home Help workers, it seems obvious that designation by the state of the MQC3 as a co-employer of Home Help providers and the representative of seniors and people with disabilities in collective bargaining was crucial to forming a public employees union. Without the MQC3, there would not have been an "employer" for the union to bargain with. All in all, it is a peculiar arrangement. Home Help workers at least had the opportunity to vote for representation from the union while seniors and people with disabilities did not have a say in their representation by the MQC3.

Athough Dohn Hoyle asserted several times that without state funding the registry is not being maintained, he finally conceded that it is being maintained, just not with sufficient state funding to the MQC3. The union, SEIU Healthcare, contributed $12,000 to the MQC3 before the MQC3 signed the last extension of the union contract, according to Mr. Wilcox. This appears to be a conflict of interest between the union and the MQC3 who are supposed to bargain with each other, the SEIU on behalf of workers and the MQC3 on behalf of employers.

One argument for Prop 4 is that it will allow people to live at home rather than have to go to expensive nursing homes. The Home Help Program has been available for more than 25 years and will continue whether or not Prop 4 passes. Home Help services in no way replicate the level of care that is available in nursing homes. There are other Medicaid funded services through Medicaid waivers that provide for much more care than the Home Help Program. Home Help services are invaluable for many seniors and people with disabilities, but they are only part of an array of services needed by people with significant disabilities.

I had a question about how a family member or other Home Help provider who does not want to belong to the union, can opt out. This is what I heard from another parent in Southeast Michigan who looked into this:

For questions about union representation and opting out, contact SEIU Healthcare at 1-866-734-8466 and ask for Steven Cousins. He was very helpful to this parent and explained what the dues are for and can answer other questions that you may have.

Then, send a letter to:

Secretary Treasurer
c/o Sandra Mcmillan
2604  4th Street
Detroit,  MI   48201

"I was told by SEIU Healthcare Michigan that I have the choice to opt out of the union as a Home Help Provider.  I would like to opt out, and not have any future dues deducted from my paychecks.  I understand that I will still have to pay a small monthly agency fee to remain under the Union contract, but will not have to pay union dues anymore."

In addition, provide all your contact information - name, address, phone number, and especially your Provider Number. Sign and date the letter.

Saturday, October 20, 2012

Election 2012: Michigan's Proposal 4 and Home Help Services

Proposal 4 is a controversial ballot proposal that takes a non-controversial Medicaid-funded service for people who need help to remain in their own homes and places it at the center of a debate over left-right politics, public employee unions, the role of advocates for seniors and people with disabilities, and a formerly state-funded organization - the MQC3 - that may or may not disappear unless Proposal 4 passes.

Whether or not Proposal 4 passes, Home Help Services will continue to be provided for people on Medicaid. The Home Help Services program has been around for over 25 years. If you are on Medicaid, you are entitled to these services based on your need for them.

The following is the wording for Prop 4: 


This proposal would:

  • Allow in-home care workers to bargain collectively with the Michigan Quality Home Care Council (MQHCC). Continue the current exclusive representative of in-home care workers until modified in accordance with labor laws.
  • Require MQHCC to provide training for in-home care workers, create a registry of workers who pass background checks, and provide financial services to patients to manage the cost of in-home care.
  • Preserve patients’ rights to hire in-home care workers who are not referred from the MQHCC registry who are bargaining unit members.
  • Authorize the MQHCC to set minimum compensation standards and terms and conditions of employment.
Background Information and Analysis of Prop 4

To understand proposal 4, the best place to go for an objective analysis of the issues is to a report from the Michigan Senate Fiscal Agency (SFA) that provides background information on the proposal and explains the ramifications of a "yes" or "no" vote.

The Introduction to the SFA report lays out the issues involved in this proposal:

"Proposal 12-4 relates to workers who provide in-home care to Medicaid-eligible recipients of services under an existing State program called Home Help Services. These workers, who are hired by the recipients and paid by the State, are often relatives or friends of the recipients. The workers belong to a labor union, SEIU [Service Employees International Union] Healthcare Michigan. For this purpose, the workers are considered public employees of an entity called the Michigan Quality Community Care Council.

"In April 2012, legislation was enacted to prevent these workers from being considered public employees, and to prevent SEIU Healthcare Michigan from being recognized as their bargaining representative. A Federal lawsuit was filed to challenge that law. In June, the judge issued a preliminary injunction, preventing the law from taking effect for the time being. The Attorney General has filed a motion to appeal."

The Home Help Services Program is administered by the Michigan Department of Human Services and is paid for with state and federal Medicaid funds. The program supports services to seniors and people with disabilities on Medicaid who need assistance with personal care activities and household chores. For more information, see The DD News Blog According to the SFA report, Proposal 4 reflects current practice with regard to recipients being allowed to hire and direct individual providers paid for by the state. Proposal 4 would not change this program.

The Michigan Quality Home Care Council (MQHCC) would replace the Michigan Quality Community Care Council (MQC3) and do what the MQC3 was doing, at least while it had funding: provide training for in-home care workers, create a registry of workers who pass background checks, and provide financial services to patients to manage the cost of in-home care. The MQC3 Board is made up of advocates for seniors and people with disabilities including Dohn Hoyle, the Executive Director of the ARC Michigan, who was the first Chair of the Board of Directors for MQC3. Here is a link to the MQC3 Web site.

According to the SFA, the MQHC "would set compensation standards, subject to appropriations by the legislature, and other terms of employment for the providers by program participants." Participant-employed providers would have the right to collectively bargain as public employees who do not belong to the civil service. "The providers would not be considered public or State employees for any other purpose, and would not have the right to strike," according to the SFA report.

Other pertinent facts are: 

  • The MQC3 was created in 2004 to coordinate personal assistance services provided by Home Help Services and to create a registry of providers. 
  • An election to organize Home Help Workers was held in 2005 with ballots sent out to 43,000 providers. Only about 8500 of them voted, with "yes" votes winning about 7 to 1 over "no" votes. 
  • According to a report from the Anderson Economic Group on "The Role of MQC3 and Home Help" from 2011, about 75% of the total number of home help workers are family members or friends of seniors or people with disabilities and 80% have only one client. 
  • In 2010 there were 53,516 consumers of home help services;  In 2008, there were on average 44,000 home help providers each month. 
  • MQC3 had an annual budget of about $1.1 million from the Michigan Department of Community Health. Its registry contains the names of about 900 providers.
Objections to the organizing of home help workers have come from many of those who are family members or friends of the person they are caring for in their own homes who do not consider themselves State employees. Others object to paying 2.75% of their meager wages (about $8 per hour) in union dues. They may opt out of belonging to the union but they still pay a fee to the union for representation.  As I understand it, the Michigan Department of Community Health deducts union dues and fees from Home Help workers pay checks, which are then sent through the MQC3 to SEIU Healthcare Michigan.

Others believe that the legislature, by passing Public Act 76 in April 2012 that amends Michigan's Public Employment Relations Act,
has undermined collective bargaining rights and that a constitutional amendment is necessary to protect these rights.  The law excludes people who receive government subsidies for their work from the definition of "public employee" and prohibits recognition of bargaining units made up of non-public employees. A Federal lawsuit challenged the law and an injunction has prevented it from going into effect.

The MQC3 has been defunded by the legislature and passing proposal 4 will put it back on its feet as the MQHCC. The organization's training programs and the registry of providers seem to be helpful, but whether it needs to be part of the Michigan Constitution is up to the voters.

One question that I have that I have not seen anyone address has to do with the MQC3 (and potentially the MQHCC) representing the "employers" of home help workers, seniors and people with disabilities who generate the Medicaid funding to pay for services.  Were these "employers" ever asked if they approved of the MQC3 representing them or if they wanted such representation? It appears that the State assigned the MQC3 to represent seniors and people with disabilities without their knowledge or participation.  

For Pro and Con views on Proposition 4, see opinion pieces in the Detroit Free Press from October 19, 2012:

Prop 4: Proposal assures higher standards for home caregivers, greater safety for patients by Dohn Hoyle


Prop 4: Family and loved ones providing home health care shouldn't be forced to pay union dues by Robert and Patricia Haynes

There will be a live chat on Proposal 4 at noon on Tuesday, October 23, 2012, sponsored by the Detroit Free Press. Go to the Web site  to submit questions in advance.

I will be the first to admit that I am not an expert on many of these issues. I am just doing the best I can to piece together the information available to me. If you have  questions, corrections, or comments on this blog post, please say so in the comments on my blog. I will publish them as long as they are civil and coherent. A diversity of views and opinions on this issue are welcome.

Friday, October 12, 2012

Parents Night Out Video

Washtenaw County, MI: Parents Night Out!

From the Web site of the St. Luke's special needs ministry of Ann Arbor, MI:

Parents Night Out is a respite program for parents who have children with special needs.  This program is offered from 6-9 p.m. on the first Friday of every month from October-June at St. Luke Lutheran Church-Ann Arbor, MI.  Parents can enjoy a break while leaving their children in the care of responsible volunteers. This program is FREE and open to anyone who has a need. Children enjoy activities such as open gym play, crafts, music, and a movie.  Snack time is also provided.  We have no restrictions on age of children or ability level.  Siblings are also welcomed and encouraged to come.  Registration and an R.S.V.P. is required for each evening.  Space is limited to the first 25 children signed up.  

For more information, see the Web site. Watch the beautiful video from the Parents Night Out Program. So many familiar faces.

A Different Path newsletter for parents of special needs children

Washtenaw County, Michigan, is the home of A Different Path newsletter, a non-profit quarterly publication that relies solely on individual donations to cover mailing and printing costs. I have posted the Fall 2012 newsletter here.

As always, A Different Path is written and produced by local parents and is both heartfelt and informative. This issue has an especially good article written by two parents on approaches to using assistive technology with two different children with cerebral palsy. Access to assistive technology is best viewed as an "engineering challenge" that allows children with CP to overcome physical barriers to give them more control over their environment. There is advice on who to talk to and costs for setting up assistive technology systems that work for the child.

Throw a few bucks their way by sending a check to: 

Different Path
P.O. Box 8276
Ann Arbor, MI 48107-8276

Wednesday, October 3, 2012

Penny Wise and Pound Foolish: States cut Medicaid dental coverage for poor and disabled adults

An article in The Huffington Post by Daniel Lippman - "States Drastically Cut Dental Care For Adults on Medicaid" (10/02/12) - describes how states are cutting Medicaid dental services to restrain Medicaid spending.

According to the article, states that have recently cut Medicaid coverage of dental care for adults include: Pennsylvania, Massachusetts, Illinois, California and Washington. States are limiting or eliminating dental care for adults because they can. Dental care for adults is an "optional" service under Medicaid and is therefore an easy target for cost-cutting when budgets are tight.
  • Washington State has preserved coverage for developmentally disabled adults and people in long-term care, while eliminating care for other poor and disabled adults. 
  • Massachusetts will cover fillings, dentures, and root canals for front teeth hoping to make it easier for people on Medicaid to get and retain jobs, but back teeth (out-of-sight, out-of-mind?) are not covered.
  • Illinois used to cover front teeth, but no longer. They will still cover emergency procedures such as extractions. 
  • According to an NPR report on the lack of Medicaid coverage for adults in California, "In interviews with dozens of dentists and safety-net clinics around California, providers say patients are forgoing routine cleanings and delaying care until the pain is unbearable." 
  • Pennsylvania has reduced Medicaid dental care for adults to basic services - cleanings, fillings and extractions.
Michigan is not mentioned in the Huffington Post article. Although the state continues to cover dental services for adults, the number of dentists who will see people on Medicaid has been drastically reduced by low reimbursement rates. This makes the program a virtually rationed system available to those who are lucky enough to find appropriate care or can find other ways to pay for it. Whether this saves money for the state is doubtful. There is increased reliance on emergency room visits to obtain painkillers and antibiotics to treat dental problems and more hospitalizations resulting from poor care.

Here is more coverage of dental issues in The DD News Blog.

This is the Medicaid Data Base describing Michigan's Medicaid coverage of dental care.