Most Americans (nearly 90 percent of people over at 65) want to stay in their homes as long as possible as they get older. For people with disabilities, staying in one’s home represents decades of hard-fought court battles against forced institutionalization. For both seniors and people with disabilities, in-home care is vastly less expensive than a residential nursing facility, and in-home care usually means better health outcomes. In-home care is a win for all, from individuals needing the care to their families, friends, and communities.
Still, many people cannot afford to be cared for inside their homes without help from public services. For Oklahoma’s low-income seniors and people with disabilities, access to those in-home supports may be financed by Medicaid through the state’s Department of Human Services. But with the state now facing another year of flat budgets amid rising costs, those services are at risk. Despite warnings from DHS director Ed Lake that DHS needed $733 million to maintain services, and that their budget cut scenarios range “from the terrible to the unthinkable,” the Legislature gave DHS just shy of $700 million for SFY 2018. This appropriation of about 5 percent less than the agency needs to stay whole is going to mean more cuts — and in-home care services appear to be on the chopping block.
DHS coordinates several programs providing in-home care for people with disabilities and seniors. One is the ADvantage program, which is funded by a combination of state and federal matching dollars. It provides physical therapy, home-delivered meals, home modification, skilled nursing, and more to roughly 20,000 low-income Oklahoma seniors and adults with disabilities every year. About 300 people enroll in the ADvantage program per month, and roughly the same number leave it. Roughly three-quarters of ADvantage members are over age 60. And according to the providers that ADvantage contracts with, DHS is considering freezing enrollment in the program in an attempt to generate cost savings for the agency.
If enrollment is frozen, the hundreds of Oklahomans who would join the program every month may be directed to a nursing home. Some will likely go without the help they need altogether. And freezing enrollment will actually cost the state more in the long run. Rather than removing inefficiencies, freezing enrollment will simply shift even higher costs onto another state agency. According to DHS, a nursing facility costs more than $42,000 per member per year, a cost that would be paid by the Oklahoma Health Care Authority. By comparison, as the graph shows, ADvantage costs DHS less than $11,000 – about $30 per day.
This isn’t the first time the ADvantage program has recently been threatened by the Legislature’s refusal to adequately fund core programs. In FY 2017, the legislature only appropriated ten months of funding to DHS for Oklahomans who are elderly or have disabilities, including ADvantage, and had to pass a supplemental appropriation in April to keep those programs afloat. Then, there were no direct impacts on ADvantage program members. Now, if enrollment is frozen, current members shouldn’t be directly affected, but individuals who would have been members if they had enrolled prior to the freeze will be. In addition, a freeze would mean a decline in the number of individuals served by ADvantage contractors, eroding already slim profit margins for businesses that do everything from providing in-home medical equipment to helping individuals bathe and dress.
As DHS hasn’t yet made any official announcement on what or where it will cut, it’s possible that ADvantage could be spared, but cuts to important services of some kind will almost certainly have to occur. DHS could cut a different in-home care program, for instance. It could cut or eliminate other programs serving thousands of Oklahomans who are elderly and have disabilities. It could eliminate state funding to an early childhood education program. It could slash state funding for job training and vocational education, making it harder for low-income adults to get jobs and possibly jeopardizing the state’s basic cash assistance program. It could cut child welfare contracts previously protected due to the Pinnacle Plan. Enrollment in the child care subsidy could be frozen again, just as it was last year. However, many of these measures would only yield a fraction of the savings DHS needs to realize. And unless the Legislature truly reverses course and invests what’s needed in core state services, what isn’t cut now may very well be on the block next year.