Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. VII. Program Context: The Relation of Medicaid Personal Care to the State Service Delivery System as a Whole


A. An Overview of Other State Programs

The Home Help Services program is clearly the largest source of PAS in Michigan. In addition, Personal Care funds are used by the Department of Mental Health (DMH) to serve roughly 17,000 people in adult foster care, board and care homes, and supported living homes. The DMH also administers a special waiver for roughly 150 people with developmental disabilities which provides supervision, and two small waivers for children with disabilities. The DMH also offers a Family Support Subsidy which is a cash grant to families with severely disabled children which may be used for PAS.

The DSS administers a small program called Physical Disability Services to fill service gaps. Training, home and vehicle modification, transportation, physical, occupational or speech therapy may all be provided through this program. Each county receives a small amount of state money which it may use for any of these services. Service workers say that these funds are very limited, and usually run out well before the end of the fiscal year.

The Office on Service to the Aging (OSA) administers the In-Home Services program for people over 60 years old. There are no unduplicated counts of PAS recipients served, but PAS expenditures were roughly $6.2 million in 1987 for an estimated 30,000 people. There is an extensive waiting list for these services (over 1500 people in 1987). Services are coordinated through the local Area Agencies on Aging (AAAs), and attendant services are purchased from home health agencies. The OSA has started a pre-admission screening program, which currently serves 1500 people. It targets the "frail elderly" at risk of institutionalization or already in nursing homes, and provides intensive case-management and a full range of support services as well as agency attendants. Most recipients don't have informal supports available, and half live alone. OSA administrators believe that this program needs to be expanded, because the high- need elderly population is not being adequately served by the relatively unskilled independent providers used by DSS.

Michigan Rehabilitation Services (MRS) administers two small programs which include PAS for specific populations. One is a joint project with the DSS which targets people with traumatic brain injuries and other severe disabilities, and provides intensive rehabilitation and case management as well as home help. A small pilot program at MRS offers up to $750 per month for PAS for people who work at least 20 hours per week. Independent Living Centers in Ann Arbor and Grand Rapids are coordinating services for approximately 20 recipients. The State Independent Living Council (SILC) is frustrated with the current expenditure level for this program, and thinks that a concerted effort must be made to address the needs of working people who need PAS.

B. Who is Falling Through the Cracks?

Despite the scope of Home Help Services, many groups of people who could benefit from PAS are unserved or underserved. The major groups who fall through the cracks are:

  1. The "frail elderly" and other people who need more intensive support services or skilled services.

  2. Those who don't meet income and asset eligibility. Strict requirements exclude the middle class, despite spend down formulas.

  3. People who want to work. The pilot program offered by MRS could be expanded to meet the needs of this population.

  4. People who are married. Strict income requirements often exclude couples altogether. For HHS recipients, the spouse is required to provide most of the service, despite the strain on the consumer, the spouse, and the relationship.

  5. People with cognitive disabilities. They may end up in more restrictive settings in the Community Mental Health system, although they could live independently with adequate support.

  6. People who need ongoing medical care, e.g. daily injections.

  7. People who need only supervision, e.g., people with Alzheimers.

  8. People who are intimidated or reluctant to enter the "welfare system". Advocates say that older people may not be accessing the service, either because of a perceived stigma or because the procedures may be overwhelming.

C. The Political Future of the Personal Care Program

A severe budget crisis, combined with the advent of a new fiscally conservative Republican administration, make program cuts appear inevitable. The DSS has been directed to present ways of reducing costs by 10% in FY 1992. Likely targets are programs funded solely by state dollars. Recipients who only receive chore services may be dropped completely, as may the "income eligibles" who spend down to Medicaid eligibility. The PDS program mentioned above may not survive the budget cuts because it is totally state funded.

The DSS has directed the counties to increase the number of case-managed recipients to 25% of the total HHS caseload, in order to bill Medicaid for a higher number of home visits. Hiring of new service workers has been frozen for some time, and this will probably continue. The added stress on county offices may negatively impact day to day delivery of services.

Elimination of family providers has also been proposed, but administrators anticipate a considerable political backlash if this tactic is used. Elimination of all exceptions has been discussed, but this would simply force many individuals into institutions and defeat the whole purpose of the program. Spend-down formulas could be restricted or eliminated.

Budget crises are nothing new to Michigan, and state administrators remain fairly sanguine despite the current climate. Long term plans exist to address the attendant withholding problem through implementation of a statewide withholding system. Discussions of increases in attendant wages are occurring. The spend down formulas are being modified to make them a more viable consumer option.

New grassroots political pressure for program expansion and change is coming from a coalition of groups led by United Cerebral Palsy (UCP). The State Independent Living Council (SILC) has a personal care subcommittee which is also working on these issues. In the past, the DSS has successfully worked with such groups to impress upon the legislature the value of the state's disability services.

POSTSCRIPT - After the site visit to Michigan was conducted, the state instituted a series of budget cuts which directly impact the Home Help Program. Chore services were cut completely for all recipients, and those recipients who spend down to income eligibility were dropped from the program. These cuts reduced the program caseload by 400-500 people. Medicaid income eligibility was restricted, cutting an additional 1500 people from the program caseload.

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