Victims of Prosperity
You wont ever see a much happier crowd than the hundreds of nattily dressed people who sat in sunny Plummer Park late last month, celebrating a victory of a sort. The people were home health-care workers, and they were hearing our governor, Gray Davis, exultantly proclaiming how he was bringing them into the gladsome realm of the decently waged and benefited.
Davis saluted the people who have long been handling the home personal-care needs of the elderly and otherwise convalescent. Its a hard job, a messy job and, as of now, a minimum-wage-plus-peanuts job, minus any health benefits.
Davis called the work of those present the dignity option: caring for your parents in their own home, not in the nursing home. The governor announced, in effect, that home health-care workers, whom his administration stinted in the first draft of his fiscal year 2000-2001 spending package, were part of a new, $371 million program in the budgets Ides of May revise. The program is called Aging With Dignity, and it addresses many medical needs for a maturing population. It includes more nursing-home inspections and harsher discipline for homes not meeting legal standards, but focuses on keeping senior (and other) convalescents out of nursing homes.
The aging package includes $100 million to raise the wages of home-care workers -- now officially (if awkwardly) known as ISSPs, or In Home Supportive Services Providers -- to a minimum of $7.50 an hour, plus 60 cents an hour for long-sought health benefits.
They give us so much, Davis said, that its time for us to give something back to them. The governor pointed out that paying caregivers to give care in homes saves the state a great deal of money it would otherwise have to pay to keep those same people in nursing homes, where such care costs more. It therefore makes fiscal, as well as moral, sense to encourage them with better (if scarcely adequate) pay.
All this was wonderful to hear. Last February, you may recall, this column berated the governor for offering the states total 200,000 home caregivers a nugatory $6.25 wage and no detectable benefits -- derisive, considering that these caregivers are themselves key health providers. Since then, it seems, key officers of the Service Employees International Union have spoken to Davis, as did certain members of his own staff, about getting the caregivers into the new aging program. And there we were. Happy End. Oh, but theres just one thing -- the program cant work without county cooperation. And at the moment, that isnt going to happen. At least not in this county: Its the old problem of who pays what.
Wait a minute. What about all that state surplus money? And the countys tobacco-settlement boon? What is our governments problem?
There are two problems, actually. One of them -- the predictable one -- has to do with how the county and state split the costs of care-worker pay. That issues not new. In the recent past, the countys picked up 20 percent of the home health-care costs, while the state paid the rest. At this rate, according to Supervisor Zev Yaroslavsky, the county saves itself about $6 million a year over the costs of treating the same invalids as inpatients.
Now Davis new plan wants the county to up its share to 35 percent of the costs. At which point, instead of saving, the county gets to pay nearly $35 million a year to keep the program going.
But the other, larger problem is a three-way intergovernmental health-care-funding train wreck not directly related to the home health-care issue. This is the expiration this month of the billion-dollar, five-year federal fee-waiver program instituted back in 1995. This special funding concession to the nations most populous county followed said countys near bankruptcy; its probably the main reason that there still are Los Angeles County health services.
The waiver, painstakingly negotiated by former state legislator Bert Margolin, allowed the county to keep health-care money that would have otherwise gone back to Washington. This boon was allowed, however, under the condition that the countys Department of Health Services would have, by this year, transferred a third of patient treatments from inpatient hospitals to more effective and less costly outpatient care. The county so far has managed only a 28 percent transfer, yet its hoping for a waiver renewal until 2005 to balance its upcoming health-care budget. This may yet happen. But the omens are mixed, and, on the possibility that the waiver wont be renewed, the DHS is already cutting back long-planned expansions of its critical outpatient programs. It would make a lot of PR sense -- considering Al Gores lag in the presidential polls -- for the Democratic administration to finance the DHSs shortcomings for another five years. But the feds may also think that it would make even more sense for the DHS not to be in this mess in the first place.
Regardless, the countys attention probably isnt going to be focused on resolving the health-care-worker problem in the near future. And if that waiver isnt renewed, any further form of county health expenditure is going to be a very hard sell.
Waiver or no, however, county officials object to Davis home-care wage-hike plan. Supervisor Zev Yaroslavsky says that, while the $35 million extra cost may not seem like a lot in this years overall $15 billion county budget, his staff researchers see an escalating county commitment to the program that could eventually cost $400 million. And thats assuming the state plays by the rules. There is also a long-standing county-state trust issue. Once burned, twice shy, the supervisor warns. Hes recalling that, back in the middle of those shaky early 90s, the state glommed itself a huge hunk of county property taxes just when the county most needed the money. Suppose, he asks, Sacramento did that again? Or suppose the county did commit itself to the proposed 35-65 home health-care split and the state raised that split to 50-50?
The economy is great now, but what if it turns around? Yaroslavsky asked, once more invoking that disastrous county budgeting of 1992 to 1994.
Well, indeed, what if? But how well I recall sitting in the county boardroom all through that time, soaking up the dire fiscal news while fantasizing about a flusher future decade. When the state and county both might be loaded with cash, and would accordingly be starting up new, long-needed health and relief programs instead of busily cutting back on the old ones. That time happens to be now: The state is squatting on a $15 billion surplus, while the county is about to acquire some $130 million of tobacco-settlement money.
There may indeed come a day when our elected officials can scream hardship again, but it sure isnt now.
At least, not as far as state and local government is concerned. The health-care workers are another story. According to a recent report USC researchers did for the Oakland-based California Health Care Foundation, 80 percent of all home caregivers are poor or near-poor.
It also found that 45 percent of the 73,000 local caregivers have no health insurance, while most of those who do have such benefits get them on a spouses benefit program. Of the uninsured workers, 90 percent live near or below the poverty line. It goes without saying that barely half of all the caregivers get anything like adequate health care. And there lies the fundamental irony: They cant count on getting what they give to others.
This is intolerable. There simply has to be some good-faith negotiating of state-county differences. Surely, the state could afford to support the key plank in Davis Aging With Dignity program by assuming another 5 or 10 percent of the caregiver wage-increase and benefit costs. Surely, this county might request or attach a condition to its participation in that program specifying that it could drop out if the state arbitrarily changes the contribution disparity. What is bothersome is that neither side seems to be reaching for such a compromise. Instead, each agency points its thumb at the other, saying, Its their fault.
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