A historic long term care victory for Hoosiers Citizens Power, Citizens Action Coalition of Indiana newsletter May 2003 The 2003 General Assembly has set the stage for dramatic change in Indiana's long term care system with the passage of Senate Enrolled Act 493. The enactment of this new law is a historic long term care victory that will benefit all Hoosiers. The immediate beneficiaries of the changes will be persons with disabilities of all ages (children, adults, and senior citizens) and their families because the legislation will eventually put in place a truly comprehensive system of home and community based long term care services. The new act will also benefit taxpayers and all citizens by lowering the public cost of long term care and by improving the economy and the quality of life in the state. Here are highlights of the new law: ▪ The law establishes a full array of home and community based services that includes the CHOICE program, adult foster care, adult day care, assisted living, personal care services, and other services necessary to keep persons out of institutions. ▪ The law sets income eligibility for all home and community based Medicaid waivers at 300 percent of the federal Supplemental Security Income level. The current Medicaid waiver for aged and disabled services is only 100 percent of SSI, or about 75 percent of the federal poverty level. ▪ The rights of persons receiving home and community based services through Medicaid waivers are expanded by the new act. ▪ Under the new law persons who are receiving Medicaid funded nursing home care, and who are suitable for home care services, can choose to move back home, or into a home like setting. Their new services will be paid for by the same Medicaid dollars that were being used to cover their nursing home care. ▪ The law allows Medicaid dollars saved by moving people out of nursing homes back into home and community based care to be used to purchase home and community based services for other persons who need those services. ▪ The law establishes spousal impoverishment protections for home and community based care for persons using Medicaid waiver services. ▪ The law establishes a process to encourage best practices by nursing home providers and a bonding process to finance nursing home conversions to other purposes. The Public's Role in Passing SEA 493 Senate Enrolled Act 493 represents a major victory for CAC members and for the seventy organizations that are members of the Indiana Home Care Task Force. Passing the new law, and protecting the state's existing and nationally recognized CHOICE home care program, were the primary objectives of the Task Force and CAC heading into the 2003 legislative session. Both objectives were achieved because the Task Force organizations were able to mobilize their members throughout Indiana to call, write, email, and meet with their legislators. Groups like AARP, United Senior Action, the Indiana State Council of Senior Citizens, CICOA The Access Network and other area agencies on aging, the Alzheimer's Association, the Indiana Minority Health Coalition, and many others found their members willing and wanting to engage their state senators and representatives to vote for Senate Bill 493. The result was the legislation's unanimous passage into law. The public's response to the legislation was especially evident to CAC canvassers throughout the state. Bev Myers, a long time CAC telephone canvasser in Indianapolis, commented during the course of the legislative session: "Talking about home care reform, and Senate Bill 493, is good stuff. It is something our members want and believe in." Mike Comini, the CAC staff director in South Bend, found an equally enthusiastic response from CAC members in northern Indiana: "Yes, they very much like CHOICE, and they like our work on this issue." Responses of this type were typical throughout the state and were reflected in the strong rank and file support the legislation had among members of the General Assembly. Credit for the public's strong response to SB 493 should also be given to The Generations Project. The project is a collaborative of ten organizations, including CAC, and is managed by the Citizens Action Coalition Education Fund. Since the fall of 2001 the project has conducted public education activities regarding the merits of re-balancing Indiana's system of long term care. In November 2002 the project hosted a statewide summit at which national long term care policy experts discussed reform models with 120 community leaders and 11 policy makers from across the state. Many of the ideas reviewed at the summit later became points of discussion throughout Indiana and were reflected in SB 493. In January 2003, the project conducted a series of media events with the Indiana Home Care Task Force on re-balancing issues. Other activities and publications by The Generations Project have also heightened the public's understanding of long term care issues. CAC members interested in the project and in obtaining literature from it should contact Will Phillips, the associate director, at 317.423.7102 or at wphillips@generationsproject.org. What Happened at the State House The legislation was developed over a period of several months through the collective efforts of the Task Force and was drafted by its chairperson and CAC legislative director, John Cardwell. He also coordinated the multifaceted, inter-organizational lobbying campaign at the State House that contributed to the bill's passage. State Senator Greg Server, R-Evansville, was the enthusiastic author of the legislation and its wise and skillful shepherd through the state Senate. He was mightily assisted in the House by State Representative Charlie Brown, D-Gary. Together, Server and Brown managed to keep SB 493 out of the many traps that usually snare major new policy initiatives at the State House. From their perspective the challenge facing SB 493 was two fold: avoiding the cross hairs of the state's fiscal crisis, and keeping legislative leaders as upbeat about the proposed new law as their colleagues and the public. In an absolutely adroit display of legislative statesmanship and charm, Server and Brown worked with their colleagues and the Task Force to get the bill through the legislature without a single dissenting vote. Truly an amazing achievement given the significance of SB 493 and its alleged long shot chance for passage coming into the 2003 session. The full cast of people responsible for the passage of SB 493 through the General Assembly included many people. The critical players included State Senators Vi Simpson (D-Bloomington), the gubernatorial candidate who helped garner bipartisan support for the bill, and Pat Miller (R-Indianapolis), who established the parameters for passing the bill through the Senate Health and Provider Services Committee that she chairs. Other key Senators were John Broden (D-South Bend), the bill's original co-sponsor, and Connie Lawson (R-Danville), who helped build consensus support for the legislation. In the House, Charlie Brown was joined by Representatives Vaneta Becker (R-Evansville), Andy Thomas (R-Brazil), and John Day (D-Indianapolis) as sponsors of the bill. These dedicated legislators were joined by House Speaker Pat Bauer (D-South Bend), Ways and Means Chair William "Bill" Crawford (D-Indianapolis), and other legislators in building consensus support for the bill. Among the many advocates that supported SB 493, June Lyle and Charlie Fields of AARP put in long State House hours skillfully assisting the bill through the process. It should also be noted that throughout the legislative process no outward opposition to the legislation emerged from any advocacy group or trade association. In fact, all three trade associations for the nursing home industry testified for the legislation at State House hearings, including the Indiana Health Care Association. Sadly, the only publicly stated opposition against the legislation came from the Indiana Family and Social Services Administration, in testimony presented to the House Public Health Committee. The FSSA testimony was not well received by legislators nor the public. Privately, SB 493 had to undergo grueling negotiations to survive the legislative process. In the Senate numerous hard nose negotiations took place after hours, and legislators and advocates did some very serious head knocking with the State Budget Agency once the bill was in the House of Representatives. Because of the state's deficit spending crisis in all these closed door negotiations the primary challenge facing the bill was its potential impact on the state budget. Legislative leaders in both parties, and O'Bannon administration officials, insisted that any provisions that might add any costs to the state budget in the upcoming two years had to be removed if advocates wanted the bill to move through the General Assembly. Therefore, the outcome of these meetings was the removal from the bill of the following: deadlines for providing home care services for persons who are on waiting lists, a temporary transition fund for moving people on waiting lists into services, the mandatory use of all savings generated by the bill to purchase additional home care for persons on waiting lists, and de facto entitlement status for home care to offset the budget and service distortions caused by the entitlement status of nursing home care. According to CAC's John Cardwell, a participant in the negotiations, the most critical aspects of the legislation were saved in the process: "The items dropped from the bill did not change its fundamental structure nor was its intent altered. The legislation still fundamentally changes the legal parameters and mission of Indiana's long term care system. In other states laws of lesser scope have been used to establish comprehensive, accessible and affordable home and community based systems while dramatically reducing the over utilization of nursing home care. The SB 493 that passed the General Assembly can still meet that test. The public will be closely scrutinizing the O'Bannon administration's implementation of the law to insure that is the case." The Real Test For citizens needing home and community based services in Indiana the real test of Senate Enrolled Act 493 will not be skillful legislative maneuvers, nor the outcomes of State House negotiations. The real test will be whether or not the legislation leads to home and community based care being available to all Hoosiers who need that care, when they need it, as they need it, and at a price that is affordable to consumers and taxpayers alike. In other words, will the state administration act quickly so the new law can begin to really transform the parameters of long term care in Indiana by the summer of 2004, when the changes it mandates in Medicaid waivers should be fully on line? Nancy Griffin, AARP's Indiana director and another veteran of the SB 493 State House negotiations, puts it this way: "SB 493 is a great piece of legislation. But for the new law to work the current state administration will have to demonstrate its willingness to enforce and implement its provisions and programs. "We know Governor O'Bannon believes in home health care and its benefits for citizens and taxpayers, but heretofore his administration has been terribly slow to act. With the passage of SEA 493 such caution will no longer be acceptable. The General Assembly has now set clear legal and policy parameters. Governor O'Bannon now has a green light to implement comprehensive long term care reform. It is time for him to meet this test and to finally fulfill the promise of freedom and dignity that home care embodies for persons with disabilities," concluded Griffin. Meeting that freedom and dignity test will be the challenge of Senate Enrolled Act 493 going forward. That is a challenge the organizations of the Indiana Home Care Task Force and the Citizens Action Coalition of Indiana will address in partnership with their members and all Hoosiers in the days ahead.