John J. Flanagan
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A. Have you ever worked with CDPA consumers or the disability community in a private or professional capacity?
B. On a scale of one to five (1-5), one being the least familiar and five being the most, what is your understanding of Medicaid long term services and supports (LTSS)?
C. Are there any changes you would make in the administration or provision of home care services, including CDPA?
Where any changes may be needed, it is important that efforts continue to be concentrated on ensuring appropriate reimbursement rates for care; ensuring appropriate oversight of fiscal intermediaries while maintaining adequate consumer choice; and ensuring that the aging and disabled populations have access to quality health services.
D. What do you consider your primary accomplishments in relation to LTSS?
It is critically important that there is appropriate access to long term care services under Medicaid to ensure the State’s aging and disabled populations have the opportunity to remain in a community setting near their families and friends. Without such access, these individuals would face premature placement in a nursing home, which may not be the ideal setting for their care and which oftentimes can be more expensive. I have consistently supported actions in the state budget that ensures the funding for those types of programs, as well as programs that give eligible providers access to capital funding to ensure their sustainability.
E. If elected, will you commit to meeting with CDPAANYS and representatives of the disability community and seek their input on issues impacting the delivery of their care?
Yes. Receiving input from providers, advocates and representatives of the community is always invaluable when evaluating policy matters.
Research has shown that CDPA meets the goals of the Triple Aim seamlessly by achieving better health outcomes, increased patient satisfaction, and lower costs. Because of this, as well as the program’s ability to offer flexibility and independence, New York’s Olmstead Plan identifies that CDPA should be the first choice for Medicaid recipients in need of long-term care.
Despite this, rapid growth within CDPA has led to attacks on the program from numerous sides. Proposals, some of which have been enacted, have sought to slow the growth of Medicaid by limiting the free speech rights of fiscal intermediaries in advertising services to consumers, limiting consumer choice of FIs, and facilitating institutionalization over community-based services.
Further, as the state continues to age, the increased need for long-term supports and services, both within Medicaid and among those who do not qualify for the program, is placing the entire system and those who rely on it under increasing strain. According to AARP, almost 2.6 million family caregivers provide 2.4 billion hours of uncompensated care each year in New York, at an estimated value of $31.3 billion. However, this care is far from free, as the impact to the economy in lost worker productivity is tremendous. This lost productivity also results in burn-out amongst family trying to balance caring for their loved ones while holding down a full-time job and often results in the early institutionalization of those who require services. Those who provide the services, usually women, often see their careers hindered due to lost promotions and raises because of the time they are taking to care for loved ones.
The continued reliance on unpaid family supports is not a viable long-term solution, nor is it consistent with New York’s values. We must ensure that individuals have adequate supports to provide them with the services they need, in the community, from the individuals they wish to provide them care, whether or not they are Medicaid recipients. In some instances, this may be paid or unpaid familial supports. In other cases, they may want paid home care providers, either through CDPA or a traditional home care agency.
B. If elected, will you oppose any policy that encourages institutionalization over community-based care?
C. If elected, will you support and implement policies aimed at promoting the New York State’s Olmstead Plan’s priority of ensuring CDPA is the first option available to all who need it?Yes. It is important to ensure individuals receive all appropriate and necessary care and services in the least restrictive environment possible.
D. If elected, will you support efforts to expand CDPA beyond a program that is only available to those on Medicaid and the Expanded In-Home Services for the Elderly Program (EISEP)?
Yes. Ensuring access to efficient, high quality, sustainable health care is important, and this requires effective care management and a delivery system that integrates and coordinates patient care.
E. Will you oppose any effort infringing on consumer choice as it relates to CDPA or community based services, including efforts to limit the number of fiscal intermediaries who administer services on behalf of consumers?
Yes. It is important to ensure those in need of community-based services have access to quality care and services in a cost efficient manner.
F. If elected, will you ensure that long-term supports and services such as CDPA are included in any single payer proposal, such as New York Health?
A single payer health care system presents many serious questions and concerns, not the least of which are affordability and accessibility to care and services, as well as the significant estimated costs for its implementation and sustainability. That being said, any model of care must provide for sufficient and quality long-term care and services.
Home care, and in particular CDPA, has been one of the primary growth industries across the state over the last five years. Despite that, New York State finds itself in the midst of a workforce crisis for individuals receiving services at home. A CDPAANYS report entitled “The High Cost of Low Wages” revealed that more than half of consumers lived up to six months without essential support for critical activities of daily living while seeking a personal assistant (PA), and the majority of PAs cite low wages as their reason for quitting. There are many reasons that the state is in the midst of a workforce crisis; however, all of them are related to wages.
In 2006, Personal assistants (PAs), the workers in CDPA, earned approximately 150% of the minimum wage. Today, due to Medicaid reimbursement that is, on average, lower than it was a decade ago, being a PA is often a minimum wage position. Even fast food and retail jobs in the same regions often pay more per hour due to the higher minimum wage for fast food workers, a trend that will be made permanent Upstate, where the fast-food wage goes to $15.00/hr. while the minimum wage for all others stops at $12.50/hr.
While those who rely on homecare suffer because the government doesn’t invest in workers, that same government spends disproportionate sums of money on economic development projects that produce relatively few jobs for the investment. A recent investment of $750 million in Buffalo to build a new facility for SolarCity, amounts to, under the most generous calculations, spending $160,000 per job. Based only on the manufacturing and sales jobs they promised to create, it is closer to $541,000 per job.
Meanwhile, Medicaid reimbursement rates for CDPA have remained stagnant or decreased. This is true even though the cost of doing business continues to rise and the fact that personal care and CDPA are the fastest growing industries. According to Mercer Consulting, New York is facing a projected shortage of 20,000 homecare workers by 2022. Reimbursement rates were formerly adjusted according to what is commonly referred to as the trend factor, which ensured they were consistent with inflation. The trend factor was eliminated during the financial crisis in 2009 and has not been reinstated, despite the steady growth in costs since that year. The fallout from this stagnation has worsened since 2011 and made it increasingly difficult for FIs to remain financially solvent, forcing many to stop offering PAs pay raises, and in some cases, cutting hourly pay. A lack of transparency or accountability with managed care plans has exacerbated the downward spiral in reimbursement rates.
A. If elected, will you commit to a funded PA wage that is at least 150% of the state minimum wage with indexing to ensure that these jobs remain competitive with restaurant and retail work?
B. If elected, will you commit to restoring the trend factor adjustment to Medicaid, once again allowing wages to increase with inflation?
C. If elected, will you commit to increasing transparency and accountability for managed care plans by requiring that they reimburse providers a sufficient amount to cover the basic costs of doing business?
Yes. It is important to ensure providers have a fair and adequate reimbursement methodology and rate schedule that enables them to deliver the appropriate level of care and services.
D. If elected, will you commit to investing economic development money into home care and CDPA in order to ensure that the workforce exists to provide needed services to those who need them?
Yes. Investing in the long-term care sector is critical to ensuring the delivery of quality services in the least restrictive environment, and also helps to ensure the efficient and cost-effective use of funds.
The disability community fought for and won a provision in the Affordable Care Act (ACA) called the Community First Choice Option (CFCO). CFCO incentivizes states to provide services to nursing home eligible individuals in the community by increasing the federal medical assistance percentage (FMAP), also known as the federal matching funds, for those services by 6%. In 2012, New York pledged to move forward with implementation of CFCO. New York received federal approval for these funds in October 2015; however, CFCO services critical to allowing individuals to live independently in the community remain unimplemented.
Further, reimbursement practices the Federal Centers for Medicare and Medicaid Services (CMS) has flagged as discriminatory based on an individual’s disability type continue. The New York State Department of Health indicated that Fiscal Intermediaries in CDPA are reimbursed about $3 less per hour than licensed home care service agencies (LHCSAs), who provide personal care, and about $20 less per hour than community habilitation agencies within the developmental disabilities system. When CFCO was approved, the state was given one year to address this discrepancy. Despite the fact that the state has collected over $500 million in additional revenue through the extra 6% in additional FMAP funding, this problem remains unaddressed.
Yes. The CFCO benefit package should be carefully evaluated and efforts should be made to ensure nursing home eligible individuals can access appropriate, safe and quality care in the least restrictive setting.
B. If elected, will you ensure New York becomes compliant with CMS requirements and equalize reimbursement between CDPA, personal care, and community habilitation?