Home Help Services in Michigan : Some reforms, but are they enough?

On November 10, 2016, I wrote a blogpost on fraud and abuse in the Medicaid-funded Personal Care Services program. Michigan's version of this program is known as Home Help Services. This is a follow-up on updated information on MIchigan's program of in-home support for people with developmental and other disabilities.

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In June 2014, the Michigan Auditor General released a report on the Michigan Home Help Program that revealed multiple problems with fraud and abuse in the system of Medicaid-funded home care for people for with developmental and other disabilities. This was covered by The DD News Blog along with reforms approved by the state including criminal background checks on caregivers. 

My two adult sons with DD live in a group home and do not receive services through the Home Help Program. These services are included in the care that the group home provides along with other services to meet their extensive needs for care and supervision. The Home Help Program is set up to provide non-medical services in one’s own home or in the home of another such as a relative or friend. They include help with activities of daily living.  Community Living Supports that facilitate an individual’s independence, productivity, and promote inclusion and participation are usually provided under Michigan’s Medicaid waiver program for DD. These services are not the same as Home Help Services and are administered and funded under a different program.

I have heard complaints about the computerized system that the state has set up for registering with the Home Help program and receiving payments for services, but beyond that, I don’t know much about it. If anyone would care to leave a comment on this blogpost on how well the Home Help program is working, I would be glad to hear from you.

More information on the Michigan Home Help program:

Here is the Michigan Home Help Website. 

This includes an update on the Electronic Verification System (EVS) for Home Help Providers who are often parents or other relatives of the person receiving care. To my mind, the most important item here is the Provider Hotline at 1-800-979-4662 for assistance with the EVS. 

There are links to all kinds of information. I linked to Provider Trainings and came up with this message: “Contact your local DHS (Department of Human Services) office for information available in your area.” Apparently, training is handled locally, but I don’t know if there are state guidelines for what is available. 

Here are Frequently Asked Questions (FAQs) about the Home Help program with important contact information on all aspects of the program for providers. 

One revealing link is to pay rates by county for caregivers and agency providers, as of 1/1/16.  Most counties pay $8.50/hour to individual providers with a few paying up to $11/hour. Wow! This is hard work, but don’t expect that to be reflected in individual pay rates.

Michigan has a registry for providers, but does not have a link to a list of home care workers. For people interested in providing services for additional clients, call 800-979-4662 to be placed on the registry.

There is more detailed information on the Website that will be of interest to providers of services.

Fraud and abuse in the Medicaid Personal Care Services program

“Stunning” is the word that comes up most often to describe this week’s election. 

The GOP has promised to repeal Obamacare with few detailed plans, as yet, to replace it or preserve parts that have worked and are generally popular. This uncertain future makes it hard to comment on policy regarding Medicaid-funded healthcare and caregiving for people with DD. Nevertheless, an article, “Report Finds Caregiver Fraud Widespread” by Melissa Bailey, 11/8/16, that examines Medicaid in-home Personal Care Services is relevant for now and will continue to be relevant as long as these services are publicly funded. [The article appeared in Kaiser Health News (KHN) and was republished by Disability Scoop.]

According to the article, the Medicaid Personal Care Services program (known as Home Help Services in Michigan) is “rife with financial scams, some of which threaten patient safety…” A report from the Office of Inspector General (OIG) for the US Department of Health and Human Services recommends that the federal Centers for Medicare and Medicaid Services (CMS) improve oversight and monitoring of the program "...to prevent and detect improper payments, facilitate enforcement efforts, and reduce the risk of beneficiaries being exposed to substandard or otherwise harmful care.” 

Personal Care Services “provide non-medical assistance to the elderly, people with disabilities, and individuals with chronic or temporary conditions so that they can remain in their homes and communities. Typically, an attendant provides PCS. In many States, PCS attendants work for personal care agencies, which are enrolled in the Medicaid program and bill for services on the attendants' behalf…”

More from the KHN article:

“The OIG has investigated over 200 cases of fraud and abuse since 2012 in the program, which is paid for by the federal government and administered by each state. These caretakers, often untrained and largely unregulated, are paid an average of $10 per hour to help vulnerable people with daily tasks like bathing, cleaning and cooking.

“The report exposes vulnerabilities in a system that more people will rely on as baby boomers age. Demand for personal care assistants is projected to grow by 26 percent over the next 10 years — an increase of roughly half a million workers — according to the U.S. Department of Labor.

“‘This type of industry is ripe for fraud,’ warned Lynne Keilman-Cruz, a program manager at Alaska’s Department of Health and Social Services who has investigated widespread fraud. The risks increase because the care takes place out of view in people’s homes, and because neglected patients may not advocate for their own care.”

The OIG report calls on CMS to “establish national qualifications, including background checks, and ensure every claim identifies the worker and time of service. It also called on CMS to require states to enroll all personal assistants, so they can be tracked by unique numbers.” These are all sensible recommendations to reduce fraud and protect Medicaid beneficiaries. 

CMS, however, is “treading lightly” in deference to disability groups who fear that stricter regulations may limit beneficiaries’ access to caretakers. This fear is not unfounded, but why are disability advocates willing to trade access to caretakers for the perpetuation of abusive and fraudulent practices that undermine the program and risk the safety of people with disabilities? Is it too much to ask advocates who claim to represent our family members with disabilities to take a stand in favor of both access and high quality care? 

Instead of mandatory background checks and training for Personal Care Services, CMS has opted to give $50 million in grants to 26 states to set up background check programs. Instead of requiring mandatory training, CMS has offered states the option of offering basic caretaker training “without usurping beneficiary decisions on what skills are most appropriate for their home care workers”. These measures may be a step in the right direction, but why not require training specified in a plan of care based on individual need and preference, rather than leaving it up to chance as to whether the home care worker has the skills to do the job he or she is hired to do?

Here are excerpts from another article from Kaiser Health News on California’s In-Home Supportive Services Programs,  “Lots Of Responsibility For In-Home Care Providers — But No Training Required” by Anna Gorman, 1/6/15:

“No overall training is required for the more than 400,000 caregivers in California’s $7.3 billion In-Home Supportive Services Program (IHSS) for low-income elderly and disabled residents. Without instruction even in CPR or first aid, these caregivers can quickly become overwhelmed and their sick or disabled clients can get hurt, according to interviews with caregivers, advocates and elder abuse experts.”

…

"IHSS was never intended to be a medical program. The caregivers are distinct from visiting nurses and the certified home health aides often dispatched after a hospital stay. IHSS caregivers are not certified or licensed and are hired to do personal care and household tasks.

“But more than a quarter of IHSS clients are 80 or over, and many have chronic health conditions or dementia. In these and other cases, caregivers can end up providing basic medical care–helping to administer insulin shots, manage other medication or dress wounds, for instance.”

Here again the issue of training is controversial:

“A union that represents caregivers ... sees advantages to a minimum level of training.

“SEIU-United Healthcare Workers West proposed a statewide initiative last year that would have required 75 hours of training, but the union didn’t get enough signatures to put the measure on the ballot. SEIU plans to try again for the 2016 ballot.

“Requiring training would ‘save lives,’ said Loretta Jackson, who serves on the union’s executive board and is an IHSS caregiver in Sacramento. It would also reduce the risk of injuries to caregivers, she added.”

But disability advocates balk at requirements that might threaten access to caregivers. 

“Eileen Carroll, the deputy director of the California Department of Social Services, said the program doesn’t have a lot of training requirements because it was set up to give clients the choice of how they want their care delivered.”…

“Carroll said the state is in a tough situation. Training is a positive thing, she said, 'but you have a very strong adult disabled community in this program who … oppose any mandatory training.’

"Many disability rights advocates say a training mandate would make it more difficult for IHSS consumers to find caregivers, chip away at clients’ autonomy and drain resources from the program.

“‘The idea of choice is really paramount,’ said Deborah Doctor, legislative advocate at Disability Rights California. ‘Anything that puts a requirement that erodes that choice is a problem.’”

Again, why not tie the training for the home care worker to the individual needs of the person receiving care with that person’s participation in determining what is needed? That way the appropriate level of training would be provided leading to both access and higher quality care without compromising the beneficiary's right to choice.

The cost of improving the Personal Care Services program is the unspoken issue influencing the CMS decision on whether to impose higher standards on states to better ensure the safety of people needing care. These costs also stoke the fear of disability advocates that access to caregivers will be adversely affected. 

Is it too much to ask of federal regulators, state agencies, and especially disability advocates to take a more nuanced approach to the costs and benefits of a system that reduces abuse and delivers better care to those receiving services? It may be that having higher standards reduces many costs over time. And if it costs more to deliver better care and avoid the tragic consequences of allowing abuses of the system to continue, this may be a cost that the public is willing to bear. After all, more and more families are affected by the responsibility of taking care of aging and disabled family members and would rather see a system that provides higher quality care that they can rely on, than one that limps along failing to provide even a basic level of care that protects their loved ones from harm.

Michigan: Recommendations to stabilize the Home Care Workforce

This if from the PHI National Blog about a recently released report from Michigan. It is about the need to stabilize the workforce of Direct Support Professionals who work with people with disabilities and the aging population. PHI is a national organization “working to strengthen the direct-care workforce and prepare our nation to care for a growing population of elders and people with disabilities by promoting effective national and state policy solutions.”

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From the PHI blog:

REPORT: Better Wages and Benefits Needed to Stabilize Michigan Home Care Workforce

by Matthew Ozga
May 25, 2016

Michigan's inability to retain a "qualified, competent" workforce of direct support professionals (DSP) must be remedied by, among other measures, immediately improving DSPs' wages and benefits, a specially convened workgroup concluded.

The Workgroup on the Direct Support Workforce, convened by the legislature last year to study the stability of the DSP workforce in the face of increased staff vacancies, unanimously recommended that DSPs earn at least two dollars per hour more than the state minimum wage (currently $8.50/hour and rising to $9.25 by 2018).

The average starting wage for Michigan DSPs is just $8.69/hour, and experienced caregivers earn an average of just $9.62, the workgroup reported. Nursing assistants in Michigan, meanwhile, earn an average hourly wage of $13.25.

The Workgroup also said that immediate steps should be taken allowing DSPs to earn paid leave….

Read the full report here… 

Direct Support Professionals, in their own words:

“In my home I have six staff and five subs who currently work under me. All of them have been with me for more than a year. Some have been working with developmentally disabled individuals as long as I have (37 years). We are African, African American, Asian, and white. We are young college students, single moms, and middle aged fuddyduddies. And when I asked all of them why they do what they do they simply reply ‘I like it’. This work tends to grab a hold of you. It tends to redevelop who you are. I even know a teacher who after teaching all day comes and work for us.”

"This is an important job, not a starter job or a stepping stone job. The people we serve are important people who play an important role in our society.”

Wage Protections for Home Care Workers Reinstated

This is from an article in Disability Scoop by Michelle Diament, August 21, 2015:

…A federal appeals court has upheld a rule requiring that in-home care workers assisting people with disabilities be paid minimum wage and overtime.

…Labor Department regulations issued in 2013 extended minimum wage and overtime protections to home care workers for the first time. Under the rules, most caregivers must receive at least the federal minimum of $7.25 per hour and qualify for time-and-a-half if they work more than 40 hours per week.

The wage protections …were struck down in January by U.S. District Judge Richard Leon who said the Labor Department had overstepped its authority.

On Friday, however, a three-judge panel found otherwise…Trade groups representing agencies that employ many in-home care workers brought the court challenge. They said the pay hike could make such care unaffordable.

Some self-advocates have also argued that the pay increase could leave people with disabilities without the care they need to remain in the community.

Read the full article...

There is more to this story:

The lawsuit to stop the Department of Labor wage and overtime regulations from going into effect was brought by the Home Care Association of America, ADAPT, a disability rights group, and the National Council on Independent Living filed a brief against the Department of Labor regulations and supporting the Home Care Association.

In an earlier article from Disability Scoop, January 2015, ADAPT made this statement:

“The Department of Labor developed this rule without adequate involvement of the disability community which was concerned that without additional Medicaid funding, attendants would lose income that is vital to their lives and individuals with disabilities would be forced into institutions...ADAPT stands ready to work with organized labor and worker groups to fight for improvements in attendant wages and benefits in a manner that doesn’t sacrifice the rights and freedom of people with disabilities.”

Home Help Services is a mandatory Medicaid-funded service, meaning that it must be provided to all eligible people on Medicaid. That includes people with disabilities who live in their own or their family's home who need in-home service providers who can assist with daily activities. The question is, will the federal government and the States increase funding to cover the extra costs of home care, or will they avoid the problem by cutting the number of hours available to people with disabilities or making other adjustments that interfere with people getting the services they need?

Home Care for people with disabilities : How direct care wages negatively affect quality of care

From the PHI Chart Gallery

PHI (Paraprofessional Healthcare Institute) issued a report in February 2015 showing how the home care workforce is negatively affected by poverty-level wages, thereby degrading the quality of care for millions of elders and people with disabilities.

This is an especially timely topic with the federal government and federally-funded advocacy groups for people with developmental disabilities aggressively pressuring states to close institutions and other types of congregate care and services, often against the wishes of the people receiving this care and their families. The new rule for Home and Community Based Services (HCBS) from CMS, the federal agency that regulates Medicaid and Medicare, as it is currently written, will inevitably lead to people with DD moving to less regulated settings, cared for by workers who are paid less with fewer benefits or other incentives to remain in their jobs.

The PHI Website explains the effect of low wages on care quality as reported in “Paying the Price - How Poverty Wages Undermine Home Care in America”: 

Poor wages and nonexistent benefits are tied to high turnover rates within the home care workforce, Paying the Price reports. Roughly one out of every two home care workers leaves her job every year.

High turnover correlates with poorer care outcomes for elders and people with disabilities, who come to rely on home care workers to ensure their quality of life.

"When people can't find the care they need for the family members they love, it is a genuine family crisis," the report says. "The outsized growth in our population of elders is going to make this problem far worse in the decades to come."

The report notes that demand for home care jobs is expected to grow by approximately 50 percent between the years 2012 and 2022, a rate five times higher than overall job growth during that span.

The wages of people working in the three main categories of direct care (personal care aides, home health aides, and nursing assistants) have fallen from 2003 to 2013 overall with only a small number of states showing an increase in wages.

This is from a PBS Newshour Special, 3/16/15:

                    
 

Insights into HCB settings controversy: seniors and the continuum of care

I have recently begun to follow a New York Times reporter, Paula Span, at The New York Times Blog “The New Old Age - Caring and Coping”. Paula Span covers issues relating to seniors and their caregivers, who, as it turns out have some things in common with people with developmental disabilities and their caregivers. 

A recent column by Span,  “Dementia, but Prettier”, is a comment on movies that tackle the subject of dementia. She notes that many attractive actresses have taken the leading roles of people being swallowed up by this progressively disabling condition. While praising the acting and some of the films on dementia, Span has doubts that caregivers will see these movies as anything but prettied-up versions of real-life that disguise and deny the realities of the experience.

In another recent blog post, “Unmet Needs Continue to Pile Up” 12/9/14, Span discusses a recent study that compares how well or poorly seniors do in terms of how many needs go unmet across a continuum of living situations. As Span explains,”’Unmet needs,’ …refers to care or help you require but don’t get. If, when you’re elderly or disabled, you aren’t able to shop or cook, you lack the strength to go outside, you can’t keep track of your bank account or your medications — and no one assists you with those functions — you have unmet needs.”
 
In the debate about whether congregate care can provide people with disabilities the care they need and “integration appropriate to their needs”, the study offers some insight: it all depends on how needy the person is and how well those needs can be met satisfactorily over the continuum. Span also asks the question of whether moving into an assisted living facility or nursing home is worth the extra costs involved in meeting the needs of seniors - “…how often those supposed solutions actually provide enough services to merit their very high price tags. When someone is spending $3,500 a month for assisted living… are there fewer activities the resident can’t manage? Does he or she have fewer unmet needs?”

The national study is entitled “The Residential Continuum From Home to Nursing Home: Size, Characteristics and Unmet Needs of Older Adults”. It is published in the Journals of Gerontology,  and the authors are Vicki A. Freedman (from our own Institute for Social Research at the University of Michigan) and Brenda C. Spillman. Here are the results of the study as published in the abstract for the Journal: 

"Of 38.1 million Medicare beneficiaries ages 65 and older, 5.5 million (15%) live in settings other than traditional housing: 2.5 million in retirement or senior housing communities, nearly 1 million in independent- and 1 million in assisted-living settings, and 1.1 million in nursing homes. The prevalence of assistance is higher and physical and cognitive capacity lower in each successive setting. Unmet needs are common in traditional community housing [living in one's own home] (31%), but most prevalent in retirement or senior housing (37%) and assisted living settings (42%). After controlling for differences in resident characteristics across settings, those in retirement or senior housing communities have a higher likelihood of unmet needs than those in traditional community housing, while those in independent or assisted living settings have a lower relative likelihood." [emphasis added]
 
Although it is apparent at first glance that people have more unmet needs in congregate care, the numbers need to be adjusted to take into consideration the higher need for physical assistance and the lower cognitive capacity of seniors in congregate care. This translates into  a lower prevalence of unmet needs in congregate care. This adjustment for the severity of the disabilities, the increasing needs that go with severity, and how well those needs are met over a continuum of settings is often missing in discussions of where is the best setting for people with disabilities to live.

On the issue of costs, Span says of the study result, 

“…[it] looks like a classic good news/bad news finding. On the one hand, seniors and families are getting something for that $3,500 a month and more (frequently way more) in assisted living: Even though they are older and more physically and cognitively impaired, they don’t have more unmet needs than younger, healthier seniors in their own homes.

“The bad news, though, is that unmet needs remain too high in all these settings. In their own homes, in senior housing and retirement communities, in assisted living, lots of people aren’t getting the help they manifestly need.”

Michigan: Proposed criminal background checks for personal care providers

Following a state audit of the Medicaid-funded Home Help Services Program in Michigan, the Michigan Department of Community Health has proposed new policies for screening personal care providers. This will standardize criminal background checks of all providers of personal care services provided by the Michigan Medicaid State Plan, including the Home Help Program. 

The state audit, released in June 2014, found that of the approximately 70,000 individual providers of Home Help services, 3,786 had felony convictions prior to Jan. 2, 2013. "This included…572 convictions for violent crimes ranging from assault to homicide; 285 convictions for sex-related crimes; 1,148 convictions for financial crimes such as fraud, identity theft and embezzlement; and 2, 020 convictions for drug related offenses."

The proposed criminal background check policy will apply to all providers of Home Help Services, including parents and other family members who provide these services. According to Brian Barrie at the state Medical Services Administration, screenings will be done as part of the provider enrollment process.  All providers will be placed in the CHAMPS system [CHAMPS is the state computerized Medicaid Processing System]  and the screenings will be done then.  Any additional cost will be absorbed by MDCH.

Comments on the proposed policy are due by July 25, 2014.

Mail comments to:

Brian Barrie
Bureau of Medicaid Policy and Health System Innovation
Medical Services Administration
P.O. Box 30479
Lansing, Michigan 48909-7979

Telephone Number: (517) 335 - 5131
Fax Number: (517) 241-7816
E-mail Address: Barrieb@Michigan.gov

The effective date of the policy is September 1, 2014.

The proposed criminal background checks are required by the Affordable Care Act. Section 1128(a) of 42 U.S.C.1320a-7 (the Social Security Act) prohibits individuals or entities from participating in programs funded under the Act if they have been convicted of any of the Mandatory Exclusion offenses outlined in the policy.

Here are excerpts from the proposed policy:

Mandatory Exclusions: Providers (any individual or entity) MUST be screened for and, as required by the State of Michigan, MUST disclose the following excludable convictions. Any applicant or provider found to meet one of these four categories is prohibited from participating as a service provider for Medicaid or the Home Help program. The mandatory exclusion categories are:

1. Any criminal convictions related to the delivery of an item or service under Medicare (Title XVIII), Medicaid (Title XIX) or other state health care programs (e.g., Children's Special Health Care Services, Healthy Kids), (Title V, Title XX, and Title XXI)
2. Any criminal convictions under federal or state law, relating to neglect or abuse of patients in connection with the delivery of a health care item or service.
3. Felony convictions occurring after August 21, 1996, relating to an offense, under federal or state law, in connection with the delivery of health care items or services or with respect to any act or omission in a health care program (other than those included in number 1 above) operated by or financed in whole or in part by any federal, state, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct
4. Felony convictions occurring after August 21, 1996, under federal or state law, related to unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

Criminal Background Screening: All providers and applicants covered under this policy must agree to a criminal background screening…Individual provider applicants must agree to a criminal history screening by completing and submitting MSA-4678 Medical Assistance Home Provider Agreement to MDCH. Approved and existing individual providers will be periodically reviewed and rescreened by MDCH.

Provider agencies will be held to the same requirements for their employees.

Sanctions: For any provider found to be in violation of any of the four mandatory exclusions listed above, MDCH may terminate or deny enrollment in the Michigan Medicaid program.

Providers will be notified within 90 days of initiation of a payment suspension. The notification will include the general allegations as the to nature of the suspension action, the period of suspension, and the circumstances under which the suspension will be terminated. Providers may submit written evidence for consideration through the administrative appeal process. All payment suspensions will include referral to the Office of Health Services Inspector General.

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For complete information on criminal convictions, sanctions, appeals processes, etc., refer to the proposed policy.

Michigan Home Help Program Audit finds Felons on the Payroll

The Home Help Program audit conducted by the Michigan Office of the Auditor General looked at the criminal records of individual providers, direct care workers providing services in clients' homes. Of the approximately 70,000 individual providers, 3,786 had felony convictions prior to Jan. 2, 2013. "This included…572 convictions for violent crimes ranging from assault to homicide; 285 convictions for sex-related crimes; 1,148 convictions for financial crimes such as fraud, identity theft and embezzlement; and 2, 020 convictions for drug related offenses." 

About 75% of the elderly or disabled clients employ family members or close friends to provide care. According to the audit report, it could not be readily determined how many of the providers with felonies were related to the clients they served. The report says, "…the client's ability to hire a relatives poses a unique circumstance in that clients may be fully aware of their relatives' criminal history. Although we concur that client choice should be encouraged and honored, it should be made with full disclosure, balanced with client safety and security, and consideration of the potential liability to the State." 

The overall recommendation of the auditor is that, "DCH and DHS should consider conducting criminal history checks for individual providers and requiring agency providers to conduct criminal history checks for their employees and/or subcontractors. By not conducting criminal history checks, DCH and DHS may be unaware of unsuitable individuals who may harm to their vulnerable client population." [emphasis added]…"Of particular concern are providers who are not related to the clients they serve because the clients are less likely to be aware of the providers' criminal past."

In response, DCH and DHS agree that they should be conducting criminal history background checks for individual and agency providers.

According to the report, DCH has developed a criminal history background check policy. The draft policy is under review and will be impemented once the review process is complete. They will also seek legislative solutions "that potentially could warrant disqualification as a provider."

See also this article from USA Today, 6/17/14, "Felons on Michigan payroll as home caregivers"

More on the Michigan Audit of Home Help Services

"I read audits so you don't have to."
 
Reading reports such as the "Performance Audit of the Medicaid Home Help Program", is tedious at best, but they often reveal nuggets of useful and interesting information that you rarely find in one place. Below are some of those nuggets:

Home Help Services are a dual responsibility of the Michigan Department of Community Health (DCH) and the Michigan Department of Human Services (DHS) and are paid for by a combination of federal and state funds.
 
The overall conclusion of the report is that "DHS and DCH efforts to operate HHP consistent with selected laws, rules, regulations, and policies were not effective." 

Findings in the audit include improper payments for Home Help Services of an estimated $160 million, 17.9% of the $893.7 million HHP expenditure from 10/1/10 to 9/30/13. Also, "…DCH and DHS could not ensure that clients timely received the most appropriate type and quantity of services for their conditions."

Qualifying for Home Help Services
 
According to the audit (page 9), services are available to people who have functional limitations resulting from a medical or physical disability or cognitive impairment who live in settings other than nursing homes, licensed group homes, mental institutions, or homes for the aged. They provide personal assistance to individuals with "activities of daily living" (ADLs) and "instrumental activities of daily living" (IADLs). ADL services include assistance with eating, toileting, bathing, grooming, and mobility. IADL services offer help with medication, meal preparation, shopping, and light housework. In addition, complex care services are available for clients with certain medical conditions.

To qualify for services (page 10), an individual must be an active Medicaid recipient, obtain a certification of medical need from a physician, and have a need for services indicating a functional need of 3 or greater for at least one ADL [activity of daily living]. A local DHS office must receive a referral for the prospective client. The DHS office contacts the client to obtain a certification of medical need. An adult services worker (ASW) from DHS conducts a functional assessment rating for each activity, with 1 being independent and 5 being dependent. The ASW allocates time for each task assessed at 3 or greater based on the actual time required for completion of the task. DCH and DHS can place limits on the amount of time allocable for each Instrumental Activity of Daily living, except medication.

(Having gone through this process many years ago with my older son and hearing from other parents who have done the same, the assigning of numbers and time allocations to various tasks can seem arbitrary and subjective, although the use of numbers provide a veneer of scientific objectivity.)

Lack of staffing likely contributed to many of the problems revealed in the report
 
This is brought up a number of times in responses to the audit by DCH and DHS. The state agencies were constrained by limited resources and staff to carry out functions required by Medicaid policies. Inadequate staffing and systems for cross-checking data from different departments in state government likely resulted in improper payments of Medicaid funds.

For example, on page 71 of the report, is Exhibit 6, showing Adult Services Clients and Adult Services Worker (ASW) Counts from 1999 through 2013:

The number of  Home Help Services clients increased steadily from 46,309 in 1999- 2000. Adult Protective Services clients are also served by ASWs and the figures for both are combined to show a total increase in clients from 55,373 in 1999-2000 to 85,710 in 2012 - 2013.

While the number of clients served increased steadily from 1999 to 2013 by 54.8%, the number of Adult Services Workers decreased by 25.3%, from 541 in 1999 to 404 in 2013.
 
In 2013 there were 404 Adult Services Workers. As of March 2014,153 of the Adult Services Workers had caseloads of over 200 clients. 60 had caseloads of 300 or more clients.
 
[DCH and DHS note that not all caseloads are the same. Therefore the data cannot be used to compute meaningful average caseload sizes per ASW.]

Pay rates for Home Help Providers 

During the audit period pay rates ranged from $8 to $11 per hour for individual providers and from $13.50 to $15.50 per hour for agency providers.


Perspective on Medicaid Expenditures for Home Help Services
 
Medicaid Expenditures by Category
October 1, 2010 through September 30, 2013
 
Page 65 of the report, Exhibit 3, shows a colorful pie chart of Medicaid expenditures. While the flaws in the Home Help Program are significant, it helps to put the program in perspective by comparing it to the total expenditures for Medicaid over the three year period that the audit covers:

• Hospital costs and Medicaid Health Plans make up 49% of Medicaid expenditures with over $5 billion spent on hospitals and over 12 billion for Medicaid Health Plans.
• Community Mental Health services constitute 18% of expenditures at over $6 billion.
• Long Term Care accounts for 14% of expenditures at over $5 billion.
• The Home Help Program constitutes 2% of expenditures at $894 million.

For my money, anything that can reduce costs for medical care through the Medicaid Health Plans and hospitalizations would offer the most bang for the buck, but it is  often the case that there is less of an appetite to focus on spending that involves powerful political and financial interests than to concentrate on services to low-income people with disabilities.

Home Help Program for people with disabilities: Michigan audit finds shoddy oversight, poor management, and improper payments

Michigan's Medicaid-funded Home Help Program that provides services to elderly and disabled people in their own homes is fraught with problems, according to a perfomance audit by the Michigan Office of the Auditor General.

According to the Lansing State Journal from 6/17/14, "Audit: Michigan improperly spent $160M on Medicaid", expenditures on improper payments (where the state failed to obtain sufficient documentation from service providers) accounts for 18% of the $894 million spent on the Home Help program that served about 67,000 people per year over a three year period.

In addition, "...Auditors said nearly 3,800 of roughly 70,000 home health providers had felony convictions, including 572 convictions for violent crimes…"

According to the  Lansing State Journal: 

"The audit also found that the state:

• overpaid 80 agencies $6.8 million by not making sure they met requirements to get higher fees than individual aides.
• hired a contractor in 2008 for $1.4 million to visit DHS [Department of Human Services] county offices over three years to review home health cases, yet the case file reviews were not forwarded to the offices for corrective action on time. The Community Health Department blamed a lack of staff for the delay.
• inappropriately paid $3.5 million for home services when the patients were instead being hospitalized or in nursing homes.
• did not review thousands of W-2 forms returned as undeliverable, missing a chance to crack down on clients fraudulently getting services or their relatives providing a false address to avoid cuts in the clients’ authorized service level.
• failed to create a process for caseworkers to refer suspected fraud to the attorney general’s office."

What is the significance of a dysfunctional Home Help Program?
 
Home Help Services are mandatory under Medicaid, meaning that they must be available to all eligible individuals. Medicaid funding for Home Help Services, paid for by both federal and state governments, is a significant factor in allowing many people with developmental and other disabilities to live in their own homes. It is almost always a component of providing care in unlicensed supported living settings. The findings in the audit of Michigan's program, however, exemplify problems more generally with community care, especially for those with severe, profound, and complex disabilities: funding and the provision of services is so fragmented that the system of care is often unmanageable. This is aggravated in this case by cuts in funding to state government that, if they had not been a legislative priority, might have allowed more and better oversight, ultimately saving taxpayers money and improving the lives of people with disabilities.

Under these conditions, accountability for the provision of services and the expenditure of funds, in addition to assuring the health and safety of the people receiving services, is illusory at best. Federally-funded disability advocacy groups and the Centers for Medicare and Medicaid Services (CMS), the federal agency that regulates Medicaid and Medicare, are pressuring states to turn away from any kind of congregate care and service settings (settings that serve more than three people with disabilities together), just when innovative care in congregate settings and maintaining high quality care in settings that are considered "institutional", might be a solution to the problems of fragmentation, mismanagement, and lack of accountability. Those who choose and would benefit from care in congregate settings, usually people with more severe and complex disabilities, also cost more to care for regardless of where they live. Congregate settings that offer economies of scale contribute to cost-efficiency and better use of taxpayers' money.

Michigan Disability Advocates and Campaign Finance Shenanigans

An article in the Detroit News from March 10, 2014, "Mich.slaps health care union with 2nd largest elections fine ever", by Chad Livengood, covers campaign financing law violations by the Service Employees International Union (SEIU) during a campaign to support a ballot proposal in the November 2012 election. The headline does not convey a surprising fact: Michigan disability advocates were involved as the treasurers of the campaign fundraising committees that were investigated and called to account for their handling of campaign funds and failures to meet reporting requirements in the law. The body of the article goes into some detail about Proposal 4, which was defeated in the election, and the campaign committees 
supporting it.

The article summarizes the actions by the Michigan Secretary of State:

"Secretary of State Ruth Johnson’s office slapped the labor union with a $199,000 fine for multiple campaign finance violations after it used a nonprofit corporation to funnel $9.36 million in contributions into a ballot campaign seeking the passage of Proposal 4 in 2012. The fine is the second largest in Michigan elections history...

"The ballot campaign, Citizens for Affordable Quality Home Care, received nearly all of its funding from a single company called Home Care First Inc., which received its funding from SEIU and Michigan-based affiliates, according to a Bureau of Elections investigation.

"Home Care First Inc. 'belatedly' set up a ballot committee that reported after the November 2012 election that all of its money came from SEIU and its affiliates, an investigative report states.

"The state found SEIU and campaign treasurers for the two committees violated the Michigan Campaign Finance Act for 49 transactions of commingling funds in multiple bank accounts, 31 contributions involving incomplete or inaccurate campaign statements and three late contribution reports."

Dohn Hoyle, the Executive Director of The ARC Michigan, a state advocacy organization for people with developmental disabilities, was the treasurer of the Citizens for Affordable Quality Home Care (CAQHC). Norman G. DeLisle, Jr., who has been the Executive Director of the Michigan Disability Rights Coalition (MDRC) since 1997, was the treasurer of Home Care First Incorporated (HCFI). 

The campaign committees were both formed in March 2012. CAQHC received donations funneled through HCFI without disclosing that the HCFI funds came entirely from SEIU-affiliated organizations. HCFI did not file all required forms with the state until just before the 2012 election and did not reveal the source of its funding until after the election. 

Hoyle, DeLisle, and the SEIU did not admit guilt and no criminal charges were filed as a result of the investigation. Instead,  a conciliation agreement was reached with the Secretary of State's Office with regard to the complaint, D'Assandro v Home Care First, Inc and Citizens for Affordable Quality Home Care and the $199,000 fine was levied by the Secretary of State. The SEIU and the disability advocates admitted that "mistakes were made" and claimed that they had not fully understood the campaign financing law. This is surprising, since presumably both the SEIU and the committee campaign treasurers had access to attorneys to advise them when they set up the campaign committees. 

Filling in the blanks: Why were disability advocates involved in a ballot proposal campaign?
 
Proposal 4, a statewide ballot proposal that was defeated in the November 2012 election, was meant to amend the Michigan constitution to continue to allow union representation and collective bargaining rights for Medicaid-funded Home Help Workers and to reinstate the Michigan Quality Community Care Council, which had been defunded by the legislature, and rename it as the Michigan Home Quality Care Council. The Council would continue to be made up mostly of advocates for people with disabilities and seniors and would act as the representative for employers of Home Help Workers for the purposes of collective bargaining with the state. The employers of home help workers are the seniors and people with disabilities who receive Medicaid funding to pay for help with household chores and personal care in their own homes. The Council would also have maintained a registry of workers who had passed background checks and would offer training to improve job skills. 

Other relevant facts:

The financial stake in the pro-Proposal 4 campaign was significant: The SEIU collected about $6 million per year in dues and fees from Home Help Workers and, prior to being defunded, the Council received about $1.1 million per year from the state. 

Many factors make Home Help Workers a difficult and unusual population to unionize:

• About 75% of the Home Help Workers in Michigan are family members or close friends of the seniors and people with disabilities who hire them. Often the employee is the parent or another family member. Even more complicated is the fact that the employee may also be the legal guardian of the employer, the senior or disabled person. 
• In 2005, when the election for unionization of Home Help Workers was held, only about 20% of those employed voted. There was confusion, especially among family members, about whether unionization applied to them at all, because many of them did not consider themselves "employees".
• Because the work takes place in the employers home, it is difficult to assess or regulate working conditions.
• The union was limited in how much it could bargain for increased wages because of  appropriations decisions made by the legislature.

It does not appear that seniors and people with disabilities had any say in who represented them in the collective bargaining process. 

The Home Help program has been around since the 1980's and its continued existence was not threatened by either the passage or defeat of Proposal 4.

Advocacy for whom?

The financial entanglements of the disability advocates with the SEIU during the proposal 4 campaign seems to be a conflict of interest with the advocates' representation of people with disabilities and seniors.
 
When advocates and their organizations claim to represent people with disabilities, they need to maintain their independence and avoid conflicts of interest. In this convoluted campaign to amend Michigan's constitution, advocates allied themselves with a labor union while simultaneously seeking to continue to represent seniors and people with disabilities in collective bargaining with the union. The participation  of disability advocates in campaign shenanigans of this magnitude certainly did not enhance the lives of people with disabilities nor did it protect the reputations of their organizations.

More information:

Michigan Secretary of State press release on the finance campaign investigation.

For more information on Proposal 4, see The DD News Blog.

To see documents relating to the complaint investigation, link here to the Secretary of State's website. Then scroll down to 8/30/2013, D'Assandro v Home Care … and link to documents in the right hand column, parts 1 - 12.

More news coverage on the campaign finance violations from Mlive and the Detroit Free Press

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P.S. - Irony Alert!

During the campaign for Proposal 4, a report from MIRS Capitol Capsule for April 10, 2012, quoted Mr. Hoyle as he complained about the the Governor signing a bill to reverse the ability of home help workers to unionize as state employees and the defunding of the MQCCC:

" Hoyle said he doesn’t understand people who have not talked with or dealt with MQCCC but are 'so bent on changing things without regard for what it does to people.'

"'To me it is just an ideological problem when people get so bent in one direction and ignore people who are on the other end of it, those with disabilities and those who are older,' he said. 'That’s just sad in my mind.'"

Many families will appreciate the irony of Mr. Hoyle's complaints, considering his own ideological bent and the adverse effects it has on people with disabilities. See "The ARC Michigan to state: Stop funding congregate settings" and "The ARC Michigan: Our way or the highway" 

Disability Advocates: How much involvement in a political campaign is too much?

This is old news, but I think it is instructive to look back at the 2012 political campaign for Proposal 4, a ballot proposal to amend the Michigan Constitution primarily to assure continued union representation of organized Home Help Care workers by the Service Employees International Union (SEIU). These workers are paid from Medicaid funds that seniors and people with disabilities can use to assist them with  personal care and household chores.

Both Proposal 4 and Proposal 2, another proposal to write collective bargaining rights into the  Michigan Constitution, were defeated. Following their defeat the Michigan lame-duck legislature passed a law that makes Michigan a "Right to Work" state, a devastating blow to labor unions. These controversial union issues became entangled with the Home Help program that almost everyone supports as a way to help seniors and people with disabilities stay in their own homes. The Home Help program has been around for more than 25 years and its continued existence was not threatened by either the passage or defeat of Proposal 4.

[If you want to read more about unions in Michigan, here is a pro-union article, "This is not Wisconsin. It's Worse.", from the American Prospect, 12/10/12, by Rich Yeselson. It covers Michigan labor history, the United Auto Workers, and how unions have in many respects been weakened by past successes.]

The support by seniors and disability advocates for Proposal 4 focused on part of the proposal that would have maintained the MIchigan Quality Community Care Council (MQCCC) under a new name, the Michigan Home Quality Care Council (MHQCC).  The MHQCC, an organization of advocates for seniors and people with disabilities with representation from the MIchigan Department of Community Health (MDCH), would have continued to represent the employers of Home Help workers, seniors and disabled people in the Home Help program, in bargaining with the workers through the SEIU. The MHQCC would also have continued to operate a registry of Home Help workers who had passed background checks and could receive training to improve their job skills. State funding from the MDCH for the MQCCC had been about $1.1 million per year until the legislature defunded the organization in October 2011. Since then it had received help in maintaining the registry from advocacy groups and the SEIU.

Senior and disability advocates were the face of the pro-Proposition 4 campaign. Most, if not all, of the advertising for it emphasized safety through the maintenance of the registry of home help workers. The advertising did not mention, however, that 75% of Home Help workers are family members or friends of the senior or disabled person, unlikely to use the registry, and not subject to background checks. Nor was there much mention of the more controversial union issue.

According to the 12/5/12 updates on the funding of the pro-Proposal 4 campaign called Citizens for Affordable Quality Home Care, funding came almost entirely from Home Care First, Inc. Home Care First got its money, $9,360,000, entirely from SEIU affiliates. The treasurer of Citizens for Affordable Quality Home Care was Dohn Hoyle, the Executive Director of the ARC Michigan. The treasurer of Home Care First, Inc., was Norm Delisle, the Executive Director of the Michigan Disability Rights Coalition.

Here is the campaign statement details for Citizens for Affordable Quality Home Care. This is the campaign statement details for Home Care First, Inc.

The financial stake in the pro-Proposal 4 campaign, was significant: the SEIU collected about $6 million per year in dues and fees from Home Help workers and the Michigan Home Quality Care Council hoped for renewed funding from the state that had been about $1.1 million annually.

One of the primary functions of advocates and their organizations should be to protect the rights of seniors and disabled people and the services they need to survive. To do this successfully, however, they need to maintain their independence and avoid conflicts of interest. In this convoluted campaign to amend the Michigan Constitution, advocates allied themselves with a labor union while simultaneously representing seniors and people with disabilities in collective bargaining with the union. The executive directors of two influential disability organizations were treasurers of the $9.3 million pro-Proposition 4 campaign and the committee that financed it with money entirely from union affilliates.

Seniors and people with disabilities and their advocates played a prominent role in promoting the uncontroversial aspects of the ballot proposal without acknowledging the more controversial union issues. There is a lot to be said for the quality and reliability of unionized workers who are adequately paid and trained and their role in improving the quality of care for people with disabilities, but, as far as I know, these arguments were not made in promoting the ballot proposal. Even if Proposal 4 had passed, the union and the advocacy organization representing seniors and people with disabilities were ultimately limited in their ability to improve the standing of Home Help workers. Although these workers were technically state employees, they received none of the benefits of most state employees and bargaining for better wages depended mostly on convincing legislators to provide adequate funding for the Home Help program.

Fortunately, the Home Help program is still intact and available for those who qualify for it. Beyond that, the chief beneficiaries of the ill-fated Proposal 4 campaign were the PR firms and the media outlets that ran advertising for it. Seniors and people with disabilities are probably no worse off, but advocates who were so intimately involved in this political campaign seemed unable to draw the line between themselves and outside interests and they probably undermined their credibility as advocates.

More on Proposition 4 from the DD News Blog

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.

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: 

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PROPOSAL 12-4
A PROPOSAL TO AMEND THE STATE CONSTITUTION TO ESTABLISH THE MICHIGAN QUALITY HOME CARE COUNCIL AND PROVIDE COLLECTIVE BARGAINING FOR IN-HOME CARE WORKERS

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.

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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

and

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.

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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.