In the courtyard garden of the St. Barnabas S. Mark Taper Adult Day Health Care Center stands a beautiful tree. Lusine Nalbandyan, the director of Adult Day Care Services, remembers when, not long ago, the tree was dried and shriveled appearing to all onlookers to be dead. Nalbandyan, inspired by a gut feeling, did not allow the tree to be cut down. With some nurturing, the tree was revived. It stands today, lively and green, in the beautiful garden for all to enjoy.
Like the tree, many people who come through the doors of the St. Barnabas Day Care program have felt the years wear upon them. Some live with debilitating disabilities. Some have psychological disorders. Like the tree, they are nurtured each day.
St. Barnabas provides a community for those who need daily assistance and enables participants, and their families, to enjoy a greater quality of life, increased independence, and the opportunity to grow in a social family environment.
Earlier this year St. Barnabas Senior Services, which is a 102-year-old organization in the heart of Los Angeles, was recognized as one of the top performing nonprofits in LA County by The California Community Foundation (CCF).
Using 96 years of nonprofit expertise, CCF evaluates the effectiveness, efficiency, and quality of services of nonprofits in Los Angeles and releases a publication highlighting those that are the top performers.
Raul Garza, Director of Communications at CCF, emphasized that the title endowed by his organization reflects a public vote of confidence in nonprofits that do the most for vulnerable populations. "St. Barnabas makes a demonstrable impact on Los Angeles," he explains. "They are role models for other organizations."
The day I visited St. Barnabas the clouds shrouded the sun, creating a dreary contrast to California weather typical for July. Inside, I was warmly greeted by smiling seniors. In the background a group of older women melodically sang songs for choir practice. As I moved through the room watching the small groups circled around checkers games, a woman bounded up with a cane and began to pat me on the back. She kissed my hand and said something in Korean. Though I did not understand her, her smile indicated she was happy to talk all the same. She was comfortable communicating in her native language -- the participants in the program hail from all over the world and the center's staff members speak over nine languages.
It was instantly evident to me why the people who come to St. Barnabas thrive. It was almost enough to forget the dreary environment outside -- the melancholy chromaticity, which embodied the malaise caused by the news coming out of the capitol: the budget crisis will take a toll.
Facing a growing budget deficit, California governor Jerry Brown decided to make sweeping cuts to services Californians rely on, including the elimination of Medi-Cal coverage of Adult Day Health Care programs (ADHC) like the one at St. Barnabas.
California previously spent $170 million a year to finance the ADHC program. In the new budget only $85 million has been allotted, though there is no indication yet as to how the money will be utilized -- Brown vetoed language tying the funds to a new program, Keeping Adults Free From Institutions (KAFI). With no replacement program ready, and without appropriate transitions, the future for those who rely on ADHC services remains unclear.
California's ADHC programs currently provide services to over 37,000 senior and disabled adults. This figure does not take into account all the family members who rely on ADHC to help care for their loved ones. It also does not represent the impact ADHC programs have on communities and the state of California as a whole.
When ADHC centers begin to close their doors, thousands of individuals will be left with few options. Some will be forced into institutions. Some will have to rely on emergency rooms. Some will simply have nowhere to go.
"Home and Community Based Services (HCBS) like ADHC, are part of an important safety net" says Stephen Kaye, professor for the Institute for Health and Aging at University of California, San Francisco. "That safety net is unraveling -- there will be people who would have been able to remain in the community who will now be institutionalized," he explains.
According to a study Kaye co-authored for Health Affairs in 2009, HCBS programs like ADHC not only enable participants to remain in the community, they are also cost reducing in the long run.
"...all such programs may offer personal assistance that enables people who need help in performing daily activities to continue to live and thrive in the community, instead of being forced to relinquish their independence and move into an institution ... seems apparent that states offering noninstitutional LTC [Long Term Care] services as an alternative to institutionalization are not only complying with the Olmstead decision and meeting the demands of their citizens with disabilities, but are also potentially saving money."
The Lewin group, an independent health and human services consulting group, released a report last year emphasizing that the state will face enormous expenditure increases if the ADHC benefit is eliminated.
"First, elimination of the ADHC program would result in cost-shifting due to ADHC participants switching to other service settings. We estimate this would result in an increase of $93.4 million in State Medi-Cal spending on nursing homes in 2010-11, with that expense increasing to $152.1 million by 2020-21. In addition, the program elimination would result in an additional $43.4 million spending for Medi-Cal home and community-based services for individuals no longer receiving ADHC in 2010-11."
The report goes on to highlight that the economic impact on the California economy will go even deeper. Lewin estimates that 7,600 ADHC workers will become unemployed which will decrease tax revenue by over $8 million dollars. Reduction in purchases from providers would account for roughly an additional $67 million.
"They are not looking at anything as an investment," says health economist Dana Goldman, Norman Topping Chair in Medicine and Public Policy at the University of Southern California. Goldman emphasized that, from a political standpoint, term limits incentivize representatives to make short term decisions rather than making important long term investments. "They decided to take a very short-term view. In the long run this program will save money and make people healthier," he explains. "They should be cutting things that don't give a positive return. This happens to give a positive return."
Goldman also believes this issue isn't unique to California. "This is exactly the metaphor for what is going on in every state," he says. "Decisions are being made based on the constituency affected in the short term, which are not the kinds of decisions we want to make."
Lydia Missaelides, the Executive Director for the California Association of Adult Day Services (CAADS), agrees that the problem will extend beyond California. "Other states have already put up ADHC for elimination. This will embolden other governors to do the same thing."
California has long been a leader in health and long-term care policy, which suggests other states may follow suit. The Little Hoover Commission, a commission conducted to create a strategy for Long Term Care, indicates that state officials were aware of what is at stake.
"California led the nation in innovating services for seniors and the disabled, pioneering the independent living movement for the disabled and creating an in-home support program for seniors that now is the nation's largest."
The California State Plan on Aging, released in 2009, also highlights that there was an understanding of the importance of ADHC programs at the state level under the previous administration. The plan, which outlined the strategy the government would employ to provide services to the growing population of seniors who require services, indicated the need to strengthen HCBS programs like ADHC.
"By strengthening the infrastructure for home- and community-based services, the State Plan continues to build the foundation for a future in which every Californian has the opportunity to enjoy wellness, longevity, and quality of life in strong, healthy communities."
The plan also emphasizes the need to prepare for a future where people over 60 comprise a greater percentage of the population. It is projected that within the next ten years, 20 percent of California's population will be over 60. The senior population will continue to grow rapidly as the baby boomers begin to reach this age.
"The impact of an aging population, described by some as an "age wave" and others as an "aging tsunami," will be felt in every aspect of society. The economic, housing, transportation, health, and social support implications of this phenomenon must also be viewed in the context of the State's tremendous population growth, which continues to challenge the State's overall infrastructure planning."
At a time when services are needed more than ever, the governor has cut a program that is the final lifeline for those in need before institutionalization. "It is going to be a real crisis of care," Missaelides warns. "Once you are out of the acute care system you are on your own," she explains. "To abolish this model of care is wrong humanistically, it is wrong for policy, and it is wrong for financial reasons. California is making a big mistake -- a huge mistake."
Because the state has not provided a solution or replacement program, Disability Rights California, an advocacy organization for Californians with disabilities, filed a lawsuit to halt the elimination.
According to an article in California Healthline, The Department of Justice filed an amicus brief in support of ADHC. This means that the Department of Justice is viewing the elimination as a violation of the Americans with Disabilities Act, and will conduct a hearing in federal appeals court on July 26.
"If advocates can show that the state actually might not save much money -- due to increased costs associated with nursing home admissions, primarily -- then the judge could decide to salvage the entire program."
On July 14 the Brown Administration announced that it would delay ADHC elimination for 30 days from Sept. 1 to Oct. 1, and would consider extending the elimination date if needed. This indicates that though the future is unclear there may still be hope.
As I stand in the St. Barnabas garden, looking at the tree valiantly growing defiantly against a threatening backdrop of grey clouds, I am reminded that ADHC is not dead yet. We must remind our representatives and our governor of the importance of the smiling seniors and the singing women's choir. We must continue to nurture the tree even if it may look dead. We must regain our voice and pursue a future where all are given the opportunity to grow.
Visit the St. Barnabas Senior Services website for more information about the services they provide.