With all the concern about cuts to state-funded direct care, I decided to look back at the history of Minnesota’s personal care assistance program. There were several recurring themes throughout the program’s history; but guess what the main concern has been since 1977? Fraud. From 1977 to 1988, PCAs were paid directly by the department of human services (DHS). DHS was very concerned about fraud but the “fraud” that most prominently existed then was that PCAs were not paying their self-employment taxes. Was it really fraud or was it that PCAs were not knowledgeable enough about self-employment to know to pay the quarterly tax? Or was it that they did not know how to budget their poverty-level income well enough to save the money required? There is no need to argue now about what happened back then; there were problems on both sides. A lot of PCAs got in serious income tax trouble and had to dig themselves out, and the state lost money on taxes from those PCAs.
In 1988, Personal Care Provider Organizations (PCPO) were put in place, and as I recall, the main issues were that these agencies were expected to take fiscal responsibility, reduce potential fraud and oversee the program. PCPOs were responsible to make sure PCAs only got paid for what they were allowed to do, and they were obliged to maintain some sort of backup for the vulnerable adult recipient. As the program became better known,and deinstitu- tionalization began taking place in earnest, the costs of the program continued to rise—as adults who couldn’t direct their own care, children with developmental disabilities and TEFRA (families above the poverty level that needed supports for a disabled child) availed themselves of services necessary for community-based care. The number of eligible recipients increased faster than expected and costs increase much faster than expected.
In 1991, PCA services spending was cut because of allegations of fraud: this time, concerns about what a PCA can do and who could do PCA work. In 1992, a cost-effectiveness test was added to eligibility testing so that the in-home care costs couldn’t be higher than the nursing home costs. Categories of need were set up which reduced the effect of some of the cuts from the 1991 legislation, but still, the ‘cost of living’ increase for the PCAs was eliminated. In 1995, Governor Carlson pretty much disassembled the program with a 22% cut, that eliminated from eligibility almost everyone who had come into the program under 1988 eligibility rules. A year later, in 1996, in a legislative session with outcry and grassroots involvement from the disability community, most cuts to the program’s budget were reinstated.
Fast forward ten years. In 2005, Bailit Health Purchasing (a private firm that advertises that they have “assisted over 50 clients since 1997 to improve methods for purchasing or regulating health and human services”) worked with the state’s Long Term Health Task Force to complete a study that cited findings of (yet again) fraud in PCA services through managed care health plans.
And now, in 2009, the Minnesota Legislative Auditor issues a report with “significant concerns about fraud and oversight.” Many of the report’s recommendations are good legitimate ideas that I fully support, but each of these recommendations result in higher administrative costs and higher costs to the PCAs. So who’s going to pay for qualified professional supervision provided by RNs when the reimbursement rate to the provider is decreasing by 3%? Who’s going to take over the administration, and the clients, of AXIS, the managed care program in Minnesota? PCAs should have mandated training, says the report—but without any increase in wages. These are people taking care of our most vulnerable citizens, and they should have decent wages and good training. Instead, the recommendation is for decreasing wages, making them lower than employees make in the fast food industry. If these are to be professionally trained people with high levels of expertise (and they should be!), they should be making professional wages. And whoever takes advantage of vulnerable children or adults should be prosecuted to the fullest extent, after intent to defraud has been proven. The agencies should be required to maintain appropriate documentation or be disenrolled—not for two years, but forever!
I urge you again, contact your legislator, and tell them your story. Explain what a PCA does for you. And how your life would be without them—tell your legislators that your life really does depend on the quality of the PCA program. Ask them to consider all the money they’ve spent on transportation, on curb cuts, on education, on building accessibility. Then make sure they understand that if you can’t get out of bed because you don’t have a PCA, all that spending has been a wasted.