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.
These are gloomy days for anyone trying to understand where and when we took a turn for the worse and began to see dependence, unemployment, poverty, disability, and mental illness as an affront to our way of life, worthy of scorn and contempt.
People with developmental disabilities are not immune from this meanness of spirit, even within the "disability community". Federally-funded disability advocacy groups along with our misguided U.S. Department of Justice, seem hell-bent on bringing down the infra-structure of specialized services and residential options, especially those for people with the most severe disabilities, in the name of freedom and integration. Parents, other family members, and friends are dismayed by the seeming lack of understanding and compassion for their loved-ones. They are casually dismissed as interfering with the judgment of professionals, left out of decisions affecting their family members, and even blamed for keeping people with permanent life-long disabilities in a state of dependence.
This story from the Detroit Free Press, "Kalamazoo Promise has changed more lives than just the students'" by Bob Jorth, 5/24/14, has nothing directly to do with developmental disabilities, but it is an example of how a small city in southwestern Michigan took on the daunting challenge of providing their children who graduate from Kalamazoo's public high schools with scholarships to any of Michigan's state colleges and universities. 65% to 100% of tuition, depending on the number of years of attendance in the public school system, is paid by anonymous donors to the Kalamazoo Promise .
According to the Detroit Free Press article, the Kalamazoo Promise benefits more than just the students:
"… Students graduating from Kalamazoo Public Schools will be graduating with the Kalamazoo Promise and its assurance that they can go to any of the 43 state-supported universities and community colleges tuition-free. This gift will allow them to focus on their dreams and passions rather than concentrate on how to pay for their education. To date, about 40% of Promise graduates are earning their degrees debt-free, and the median debt for others is less than $5,000
"We’ve seen improvements in K-12 test scores, average grade-point average, behavior and attitudes of students, parents and school staff and a decline in the drop-out rate. There is a 20% improvement in student performance at Kalamazoo Valley Community College, where many first-generation students begin. And more than 90% of all graduates are now starting college in a district where 70% of its students receive free and reduced lunch." [emphasis added]
"…Measuring the full impact of the Kalamazoo Promise has just begun, and the work is difficult at best. Enrollment in the Kalamazoo Public Schools has increased nearly 25% since the announcement of the Promise."
And that is how generosity of spirit overcomes the impulse to turn away from our problems and lash out at our fellow citizens.
More on the Kalamazoo Promise from the New York Times, 9/13/12: "Why These Kids Get a Free Ride to College" by Ted Fishman.
H.R. 831 is a bill in the U.S. Congress that would phase out special wage certificates under the Fair Labor Standards Act of 1938 under which individuals with disabilities may be employed at subminimum wage rates.
Workers with disabilities who are able to engage in competitive employment, with or without supports, should not be exploited in workplaces that profit off their labor but pay the workers sub minimum wages. The special wage certificates that are now issued, however, allow people with more severe cognitive and other disabilities to work at their own pace in skill development centers (sheltered workshops, usually in community settings) and receive pay adjusted to their abilities and how fast they work. To eliminate the special certificates would apparently, in effect, also eliminate this important option for people who can and want to work but would otherwise be unlikely to obtain employment in regular competitive workplaces. In the opinion of many who benefit from these programs, too little consideration has been given to what will happen to these people other than many more of them sitting at home with nothing to do.
This is an Action Alert from ACCSES, a national provider organization for employment programs for people with disabilities that opposes the bill:
Action Alert
NFB Push on H.R. 831
Next week, the National Federation of the Blind will be coordinating several action days to rally support for H.R. 831.
- Tuesday, May 6 – Twitter Tuesday
- Wednesday, May 7 – Call Wednesday
- Thursday, May 8 – Email Thursday
We strongly encourage you to get the word out to your parents and allies regarding these action dates. Organizations like the NFB do not speak for all people with disabilities. Let your representatives know that skill development centers are needed and wanted and that you do not support H.R. 831.
We also want to alert you to a free webinar featuring New York Times columnist Dan Barry that will be taking place on Tuesday, May 6th.
This webinar is hosted by the National Center on Disability and
Journalism and will cover Barry’s recent New York Times piece, “The Boys’ in the Bunkhouse.”
Barry will be discussing how he developed the story and will be
offering “advice for others covering disability issues or people with
disabilities.” While Mr. Barry produced an outstanding article, we are
deeply troubled by the media’s negative focus on skill development
centers and want to ensure that journalists in attendance know that the
full story is not being told. The types of abuse that occurred at
Henry’s Turkey Farm and in Rhode Island is already illegal and should be
investigated and the organizations and individuals responsible should
be punished, but that if legislation like H.R. 831 is passed, they will
be telling an equally troubling story about jobs, paychecks, and social
networks for people with the most severe disabilities disappearing.
These are excerpts from the May 2014 Newsletter from Ed Diegel of DDadvocates of Michigan. Ed is responding to a survey that went out to people who receive services through the Detroit/Wayne County Mental Health Authority (DWCMHA). The questions are specific to Wayne County, but many of Ed's answers apply more generally to people in other parts of Michigan.
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...Areas of concern:
- The current Recipient Rights process does not require [providers or provider networks] to make systemic improvements. If a [provider] refuses job supports to an individual, and the RR process requires the individual to be served, the [provider] is under no obligation to serve all the others they have refused but who have not raised a claim.
- Currently the Authority relies on [provider networks] for performance metrics; these metrics tend to be quantitative not qualitative. The only way to measure success or failure is for the Authority to have its own set of metrics collected from the persons being served. In today’s world we have the absurd situation of a senior [provider network] executive offering a family to reconsider its refusal for day supports IF the family agrees to not submit a rights claim ie raise the issue with Authority...
- CLS [Community Living Services] is allowed to take a ‘high ground’ stance against congregate settings…(avoiding or minimizing funding for workshops and other settings like the PEP Center) but is not required to develop and support meaningful options...
- I understand the political and philosophical posture to reduce sheltered workshops and AFC settings but it has to be done with the understanding that this may be done for persons who have the ability and the desire to move into less restrictive settings. I know persons in these settings who love where they live and work and it should be their choice to stay or to move on, regardless of how many of their friends live or work in the same building. Everyone should have the right to try something and have it succeed or fail, but if they have no choice in the trying, or in the staying, then it is not a right at all—it becomes living according to the will of another which becomes the most basic of concerns. [emphasis added]...
- I challenge the [CMH] Authority and the [provider networks] to quit pontificating on these issues and to start creating the environment that we want for the people we serve. This environment needs to include a full range of supports – required for each person from the most needy to the most independent. Don’t defund and push people out of workshops, draw them out with better more successful programs. In the meantime, make the workshops the best they can be for the persons using them. [emphasis added]
What suggestions do you have for the Detroit Wayne Mental Health Authority as we move forward?
Operate in such a way that in 10 years when your grandchildren ask what you accomplished in your tenure, you will be able to say that “I listened to the persons with developmental disabilities and their families and acted accordingly.”
Ed Diegel,
Advocates for Persons with Developmental Disabilities in Wayne County.
ddadvocates@gmail.com
and now at ddADVOCATES.com
My best dog-friend died last week in a freak accident and we are heartsick. Lucy was eleven years old, in good health, and in fine shape, but her luck ran out. Now we must do what she would have wanted: carry on, live for the moment, be kind to our animals, and do not get too angry when the dog gets into the garbage.
Lucy was a Labrador Retriever and Treeing Walker Coonhound mix. This is not an ideal combination if you are looking for a calm dog with good social skills to build rapport with neighbors and visiting relatives. She was hyper alert, always watching us to see what our next move would be and whether it would involve food. She also scouted continuously for new hunting opportunities. In her younger years, before she mellowed with age, she caused me some embarrassment when we went for walks together. When a neighbor with a dog approached us, Lucy would go into a low crouch, expertly stalking the neighbor or the dog, it was hard to tell which, as they passed nervously by. She never actually attacked or bit anyone, but try telling that to someone who is being stalked by a hunting dog.
Lucy was insanely happy, as most Labs are. She possessed a goofiness that was as entertaining as it was sometimes disconcerting. Fortunately for the cats, she did not treat them as prey, but she did instigate playful combat with them. A recliner chair that also rocks and spins around in circles was the perfect venue for such combat. One cat sat up on the back of the chair to watch while the other stationed herself in the seat. Lucy thrust her nose threateningly at the lower cat, who then set in motion a carousel-like ride, propelled by the cat slapping Lucy’s muzzle with her paw every time the chair spun around to meet the thrust of Lucy’s nose.
With the exception of her often troubled puppyhood, Lucy never had a sad day. She loved to wake up in the morning, she loved to sleep away half the day, and she could sit for hours in the evening, always on the furniture that allowed her to observe us at eye level, watching to make sure we didn’t do anything without her. Her loyalty to her immediate family was beyond reproach. She protected us from deer, other dogs, and strangers approaching from half a block away.
Lucy made us better people for her time with us and we could not have hoped for a better dog.
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"
The Michigan Developmental Disabilities Council approved a policy called "Employment First in Michigan" in August of 2013 which was then submitted to the Michigan Department of Community Health (MDCH) for consideration as state policy. [As a new member of the DD Council, I did not attend any Council meetings until September 2013 and did not vote on the policy.] The vote by the DD Council was not unanimous.
A meeting was held on November 20, 2013 with representatives of the Michigan Department of Community Health (MDCH) to discuss the proposed policy where many good suggestions were made to make the language consistent with the Americans with Disabilities Act, the Supreme Court Olmstead decision interpreting the ADA, and to honor the right to choice and self-determination.
The proposed policy, however, was not changed to reflect any of the comments from the November meeting. Bob Brown, a parent of an adult with developmental disabilities and a member of the DD Council wrote to James Haveman, the Director of MDCH, voicing his concern that if changes were not made, the document would lead "…to an outcome that restricts and diminishes an individual's choices rather than expanding them." Bob is most concerned that the policy as currently worded will be used to eliminate the choice, based on individual need and preferences, for programs where people like his daughter receive community-employment through a center-based program that also offers skill-building services for people with cognitive disabilities.
I would further emphasize the broad spectrum of people with disabilities, many of whom can work successfully in integrated employment settings and others who, like my sons, are unlikely to achieve anywhere near this level of accomplishment without a miraculous recovery of functioning or some other unlikely medical breakthrough. High expectations and lofty goals for achievement can be inspiring for some, but demoralizing and damaging for others, taking the focus off appropriate services that help individuals achieve realistic goals and assure safety, good health, appropriate care, and well-being.
You can see Bob Brown's comments here. His recommendations include changes that are consistent with federal law regarding employment for people with disabilities. A Word version of the proposed policy, without comments, can be found here.
If you wish to support Bob's comments (or not) on the Employment First Policy or add comments of your own, address them to:
Mr. James Haveman, Director
Michigan Department of Community Health
Capitol View Building
201Townsend Street
Lansing, Michigan 48913
You can e-mail comments to Nancy Grijalva at grijalvan@michigan.gov or Sharon Danielis at danielis@michigan.gov in Mr. Haveman's office.
