California’s Adult Day Health Care System: Transition to Nowhere
By Assemblymember Mariko Yamada
Chair, Assembly Committee on Aging and Long Term Care
Almost forty years ago, California pioneered a system to keep frail elders and persons with disabilities in supportive community day settings. In response to the highly publicized, disturbing stories of nursing home abuse in the ‘70’s, the Adult Day Health Care Center (ADHC) model emerged as a more humane and less costly alternative.
Today, there are 37,000 low-income nursing home-eligible seniors and disabled adults enrolled in over 300 ADHC’s throughout the state. These clients are served by over 7,000 care providers—physical therapists, nurses, social workers, nutritionists and more—who provide a constellation of health and social service interventions to keep adults free from institutions. This daytime care model is as important to a frail elder as childcare is to a toddler. In neither case is it moral, ethical, or legal to leave a dependent individual home alone, unsupervised and without care. Also, in each case, a working adult family member has some peace-of-mind—if he or she is still lucky enough to have a job in today’s economy.
The late 90’s saw an explosion in adult day health care, after the Legislature lifted the restriction against “for profit” centers. Regrettably, relaxation also allowed unscrupulous operators to proliferate, particularly in southern California. By 2004, the Legislature enacted a statewide moratorium on new ADHC Medi-Cal certifications, effectively capping program enrollment.
Since then, an ever-growing population of impoverished and disabled older adults, many with complex chronic conditions, along with the State’s continuing rocky financial condition, has put the “optional” adult day health care benefit at the crux of the annual game of “budget chicken”. Both Republican and Democratic governors have proposed either severe cuts or outright elimination of the program. Along the way, the courts have provided measured but short-term relief while ADHC clients, their families, and those who cared for them were cast-about in the stormy seas of fiscal uncertainty.
In March of this year, I, along with every other Democrat in the Assembly, voted to support Governor Jerry Brown’s proposal to eliminate the optional ADHC benefit in California. It is a vote I regret daily. The unified Assembly majority support came tempered with the belief that our Governor would provide for a scaled-down transition program, “Keeping Adults Free From Institutions” (KAFI). KAFI would continue the program using the underlying principles of the adult day health care system—an integrated model of social and medical services.
Incomprehensibly, on Monday, July 25, the Governor vetoed AB 96 (Blumenfield, D – Van Nuys), legislation that would have allocated $85 million, with 100% federal matching funds doubling to $170 million, to establish the “KAFI” program with eligibility based on medical acuity. Our scaled-down approach vanished.
Although recent state and federal administrative actions have extended the ADHC benefit to December 1, an expected court hearing challenging the original ADHC cuts has been continued to November 1, plunging existing centers further into chaos and confusion.
Without a clear transition vehicle, and a judicial decision expected less than 30 days prior to the federal deadline for elimination, 17 ADHC’s have already closed and many more will not risk keeping their doors open. The Assembly Committee on Aging and Long Term Care which I chair will convene a hearing on Tuesday, August 16 at 2 p.m. in the State Capitol to assess the costs and consequences of these closures.
Over thirty years ago, State Senator Henry Mello issued a paper establishing the need for 600 adult day health care centers in our state. Yet now, we have less than half that many in operation, with more closing each day. The “silver tsunami” is at our doorstep; the fastest growing age cohort is 85-100, and thousands of persons with autism will be coming of age in the next decade. Instead of protecting and preserving a cost-effective, integrated system of community care, we are in the process of destroying not only the innovation, but the spirits of all those who have fought so valiantly to continue this program. Once this now maimed system is eliminated, and clients are shunted to less appropriate and more expensive services, many family members will have to quit their jobs to care for their aging or disabled loved ones. This, along with the ripple effects in a bad economy puts our State in a more precarious fiscal situation. Beyond the financial deficit we face, the elimination of the adult day health care model in California reflects a moral deficit from which I am not sure we will ever fully recover.