Can seniors afford home caregivers?

By N. Clark Judd

Gov. David Paterson has proposed shrinking the budget for Medicaid home care programs by nearly $380 million over two fiscal years.

That’s on top of more than $1.2 billion less in expected spending for hospitals and over $750 million less for nursing homes.

These cuts are serious, and will likely have a heavy impact on the Riverdale community, with its large population of seniors. But as long-term care providers and policymakers respond to an increasing number of people seeking help so their loved ones can grow old in their homes, budget cuts and reimbursement formulas are just the most visible part of a wide-ranging debate over the future of home care and Medicaid’s role in providing it.

People are living longer, and as the number of older New Yorkers increases — there are now over 3 million people over age 62 in the state — so does the need to care for their illnesses.

Some experts estimate that by 2050, one in five New Yorkers will either have Alzheimer’s or be caring for someone with the disease. But the current system is not equipped to deal with a rising number of patients with dementia who will need round-the-clock monitoring.

“You know when this works? When there’s family that are right there and will do it. But many people, their relatives are all over the country, or deceased, or are not willing. It’s almost a full-time job to take care of an elderly person,” said Theresa McGrant-Stoeth, an elder law attorney based in Riverdale.

The alternative is a nursing home, which can cost $10,000 to $18,000 a month for a stay at an institution in Riverdale. In most cases, home care is far cheaper; in 80 percent of cases, state officials say friends and family provide care informally.

If they can’t do it themselves, those families and friends have hefty bills to pay. The high cost of long-term care insurance means that fewer than 300,000 New Yorkers have it. Medicaid, designed to provide health care for the very poor, has increasingly become the system of last resort for the middle class as well.

A person can get Medicaid to pay for help around the house in as little as a month after proving they can’t pay for care themselves. To become eligible for Medicaid to pay for a nursing home stay, or more medically oriented home care, rules are more stringent.

In both cases, people must have slightly less than $14,000 in resources and a home with less than $750,000 in equity to qualify for Medicaid without penalties. There are 2,836 people in Riverdale nursing homes that are on Medicaid and 1,079 in Kingsbridge, and just under 300 people in both neighborhoods in the Medicaid personal care program, a city spokeswoman said.

And round-the-clock home care is difficult to get.

24-hour care

New York has opted to provide 24-hour personal care for people who are found to need it, said Valerie Bogart, director of the Evelyn Frank Legal Services Program at Selfhelp Community Services.

“The problem is, as the years have gone on and [home] care has gotten more expensive, the localities … have all tried to cut back and find ways to rationalize denying care of people with dementia,” she said. “And they have done it through different assessment tools.”

Even for people who successfully navigate the maze of eligibility requirements necessary to make it onto the Medicaid rolls, another tangle of overlapping programs and services awaits.

In New York City, for example, the city Human Resources Administration determines eligibility for the most commonly used Medicaid home care program. Within that program, state officials say, staffers at many local offices inconsistently apply the rules that govern how many hours of care each person receives.

More control?

“The data shows you have wildly different authorizations for services depending on what neighborhood you live in in the city,” said Mark Kissinger, a deputy director at the state Department of Health. By having the state contract directly with a private service, cutting out HRA, the state would have more control, Mr. Kissinger said.

In many cases, HRA’s case management responsibilities also overlap with those of other long-term care agencies in New York, according to a policy paper released earlier this year. This can lead to patients, already suffering from a disability or disease, having to deal with multiple case managers and several different state agencies. The author of the paper, the CASA Association of New York State, is a grouping of county-level agencies — including HRA — that administer Medicaid programs.

Mr. Kissinger says the state is seeking to replace HRA in the Medicaid system with a private contractor as part of an effort to change to meet the changing needs of New Yorkers, though the state has no further details than that.

Ms. Bogart, the elder law expert, is uneasy about that decision.

“Now we have the devil that we know,” she said, “and this is changing it to the devil that we don’t know.”

This is part of the March 5, 2009 online edition of The Riverdale Press.

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