California's Public Authorities: An Emerging Model for Consumer-Directed Personal Assistance Services Comes of Age.

An Emerging Model for Consumer-Directed Personal Assistance Services Comes of Age

Created in 1973, California's In-Home Supportive Services program (IHSS)--with approximately 200,000 consumers and 180,000 providers--is the largest personal assistance services program in the United States. IHSS delivers personal care, domestic, paramedical, and other services necessary for seniors and younger people with disabilities to live independently at home and to avoid institutionalization.

In its first 15 years, IHSS pioneered the delivery of personal assistance services through the individual provider (IP) mode which gives consumers the right and the responsibility to select, hire, train, supervise, and fire their own providers. While counties had the option to deliver IHSS services by using their own employees or by contracting with private agencies, the IP mode proved to be the least costly and the best liked by consumers.

By the late 1980's, over 80 percent of IHSS customers statewide were being served by individual providers. However, despite its comparative popularity, the IP mode had profound, perpetual problems stemming from serious, structural flaws. These failings, which gravely undermined the quality of services for consumers and the quality of work for providers, included, but were not limited to:

* the lack of a registry system to link consumers in need of ongoing, respite, or emergency services with prescreened providers seeking employment or expanded work hours;

* the lack of training opportunities and technical support, both for providers seeking to enhance their skills and for consumers seeking assistance to instruct and to supervise their providers;

* the lack of sufficient, formalized consumer input in the governance of the IHSS program;

* the lack of an employer of record for purposes of collective bargaining with whom providers could negotiate over wages, benefits, and other terms and conditions of employment and to whom providers could address work-related grievances; and

* the compensation of providers at the minimum wage with no benefits, leaving these caregivers--mostly middle-aged women, disproportionately people of color, and recent immigrants, many of them members of consumers' families--in or near poverty, with no sick leave, no holiday pay, no vacation time, no health insurance, no pension, and annual turnover rates of 40 to 60 percent.

Over the past decade, to address the IP mode's deficiencies while building upon its commitment to consumer direction, consumers and providers throughout California have banded together to develop, promote, and win funding for what has been hailed nationally as an "emerging model for consumer-directed personal assistance services"--the Public Authority.

The Emergence of the Public Authority Model

In the late 1980's, California consumers and providers were each intensifying their efforts to address the shortcomings of IHSS.

Consumer activists, seeking to enhance their direction of services, to increase the availability of hours, and to establish more dependable access to providers, were alarmed as private agencies aggressively courted counties to address IHSS problems by converting to the contract mode. Disability activists in particular had been extremely dissatisfied with agency-based IHSS services and feared that an expansion of the contract mode would result in less consumer control, fewer hours, and a diversion of scarce funds to profit and administrative overhead.

Independent providers, working with the Service Employees International Union, were organizing to win an employer of record for purposes of collective bargaining and commitments of funding for wage and benefit improvements. However, their initial efforts-by protest and by administrative, legal, and political action--to get either counties or the state to assume responsibility for their terms and conditions of employment met with stiff resistance.

In light of these challenges, the two stakeholder groups--who were always mindful of their interdependence but who had previously experienced tensions over threatened tradeoffs between hours of service and levels of compensation-joined forces to work toward a solution that would, in the words of a contemporary slogan, "Keep what works, fix what's wrong, and fund it!"

Perhaps even more important than the groups' agreement on programmatic demands regarding consumer direction and provider compensation was their commitment to ensure that both consumers and workers had formal representation and a strong voice in the design and management of the service system.

In 1992 and 1993, after several years of organizing around the problems of the IHSS program and the deficiencies of the IP mode, consumers and providers won their first major victories toward establishing a new model and new standards for personal assistance services.

After long refusing to do so, California filed a Medicaid State Plan Amendment establishing the Personal Care Services Program (PCSP) under Medicaid's personal care option, thus qualifying some 65 percent of IHSS services for federal financial participation and immediately drawing an additional $200 million of federal revenue into the state.

The legislature took action authorizing counties to establish Public Authorities as independent public entities to administer the IHSS program and requiring that such Public Authorities:

* establish registry and referral systems to match providers who meet screening requirements with consumers in need;

* provide access to training for providers and consumers;

* be governed by a body consisting of at least 50 percent present or past IHSS consumers or be overseen by an advisory committee of similar composition in the event that the county board of supervisors served as the governing body; and

* serve as the employers of record of independent providers (IP's) for purposes of collective bargaining while guaranteeing consumers the right to select, hire, direct, and fire their providers.

While requiring counties to bear the state share of any administrative costs incurred and any wage and benefit increases agreed to by Public Authorities-thus placing them at a fiscal disadvantage to agency contractors whose costs were fully shared by the state up to overall caps--California did provide registry startup funds for Alameda, Los Angeles, San Francisco, and San Mateo Counties and filed an additional Medicaid State Plan Amendment claiming federal financial participation for Public Authority PCSP hourly program costs up to 200 percent of the state minimum wage.

At this point, despite the fiscal obstacles to establishing fully functional Public Authorities--and the efforts of agency contractors to address the IHSS program's woes by promoting a managed care model for personal assistance that would cut costs by curtailing consumer direction and reducing hours of service--the trend toward the Public Authority model was clear. While advocates fought in vain to capture the federal revenues generated by PCSP for IHSS program enhancements, they quickly began planning their next state policy initiatives and organizing support for Public Authorities in counties throughout California.

By the beginning of 1997, some 90 percent of IHSS consumers were receiving their services from IP's; agency contractors' share of services had decreased from a 1987 high of 16 percent to less than 4 percent; Public Authorities had been established in Alameda, San Francisco, and San Mateo counties; Santa Clara County had adopted a Public Authority ordinance; and Public Authorities were under consideration in Contra Costa, Los Angeles, and Sacramento Counties. After nearly a decade of effort by consumers and providers, the Public Authority movement was on the verge of major breakthroughs.

1997-1998: The Public Authority Movement Comes of Age

Over the course of 1997, the Public Authority movement achieved its first major improvements in IP wages and benefits and won state and county legislative gains that set the stage for seeking California's full commitment to the Public Authority model:

* San Francisco County, using its own funds to generate federal financial participation, committed to raise hourly pay to $6.40--65 cents above the new state minimum wage--by early 1998 and to establish a health insurance plan for IP's;

* legislation passed which required full state participation in Public Authority administrative costs and set a precedent for considering state participation in the costs of Public Authority wage and benefit increases; and

* Los Angeles County, whose almost 90,000 consumers and over 80,000 providers make up some 45 percent of the IHSS program statewide, passed an ordinance calling for the establishment of a Personal Assistance Services Council (PASC) in conformity with the Public Authority statute.

In 1998, having recently won an additional Public Authority ordinance in Contra Costa County, consumers and advocates moved aggressively to consolidate and expand these breakthroughs and to win legislative and organizing victories that would decisively establish the Public Authority model as California's preferred mode of delivery for personal assistance services. During the 1998 state legislative session, Public Authority supporters and their allies fought to:

* win adoption of the California Legislative Analyst's Office recommendation-proposed in previous years by legislators but rejected by the executive branch--to qualify share-of-cost and other "income eligible" IHSS clients for participation in the PCSP, generating millions of dollars in savings for the state and for counties, all or part of which could be dedicated to IHSS program enhancements;

* obtain enhanced state reimbursement of county costs for those counties which dedicate their "income eligible" savings to provider wage and benefit increases; and

* establish full state sharing of Public Authority costs for wage and benefit increases up to the hourly program cost cap of 200 percent of the state minimum wage, thus establishing fiscal parity between Public Authorities and agency contractors.

These goals, while audacious, were within reach. All three pillars of the campaign had State Assembly and State Senate leadership endorsements, broad rank-and-file legislator support, and the backing of numerous senior, disability, and worker advocacy organizations. However, Governor Pete Wilson firmly rejected these initiatives, with the exception of the plan to qualify "income eligibles" for federal financial participation. He first blocked inclusion of the other items in the budget settlement, then vetoed the trailer bill which embodied them, despite its passage with nearly two-thirds support by both the House and the Senate. These measures will be reintroduced in 1999 and new Governor Gray Davis has signaled his support in principle.

The Next Frontier: The Los Angeles County PASC

The next frontier for winning significant IHSS standards improvements is the very site that holds the greatest challenges and opportunities for developing the Public Authority as a model for the reconfiguration and enhancement of personal assistance services throughout California and the nation: the Los Angeles County PASC.

Over the summer and fall of 1998, consumers and providers worked to establish the governing board and develop the administrative structure of the PASC and organize the required 10 percent show of interest to trigger a union representation election for LA County's approximately 82,000 IP's. This election will take place in January 1999 and over the following few months the parties will work to negotiate an initial collective bargaining agreement. In this work, advocates and administrators will begin addressing challenges and opportunities that can be grouped into three categories:

* The mammoth scale of the PASC--currently encompassing over 90,000 consumers and 80,000 providers and growing at a rate of over 3 percent per year--will require the development of substantial infrastructure to implement the registry and referral services, the training opportunities, and the enhanced service coordination envisioned by its proponents. The PASC's scale will also require that such infrastructure be designed and built systematically in a manner that can be replicated elsewhere, in whole or in part.

* The enormous diversity of PASC consumers--spanning the full range of ages, chronic and disabling conditions, cultural and linguistic communities, personal lifestyles, and relationships with their caregivers--and the similarly impressive diversity of PASC providers will require that service enhancements be established in a manner that is accessible and responsive to all of the program's participants. The development of the general systems and the specific accommodations necessary to ensure that all PASC consumers and providers benefit from program improvements will provide an important case study and template for addressing questions of equity and accessibility in the design of consumer-directed personal assistance services nationwide.

* The chronic fiscal crunch in Los Angeles County--which led the county to prohibit the PASC from unilaterally imposing any new costs upon it--will require that the PASC seek additional sources of federal financial assistance in order to take major first steps toward establishing more responsive services for consumers and living wages and benefits for providers. At a time when Congress and the Administration are both exploring options for the expansion and enhancement of personal assistance services, the PASC provides an important test case for determining which new forms of federal financial assistance would be most effective in promoting program improvements and what mitigating medium and long-run cost savings could be generated by improving the availability and the quality of home and community-based services.

Conclusion

In a unique coalition effort, California consumers and providers of personal assistance services have banded together to develop a new model--the Public Authority--that will advance the aims of these key stakeholders on service and compensation issues while addressing the liability concerns and mitigating the cost impact of program enhancements upon the state and county governments. This unprecedented alliance required not only that each stakeholder group support the other's programmatic claims, but that both demanded formal standing and an organized voice in the service system.

However, while the Public Authority model shows great promise as an example of consumer and provider coalition work and as a template for the improvement of personal assistance services, in order to achieve its promise it will require the direct attention and sponsorship of federal partners. The advances in consumer direction and governance, provider compensation and training, and service improvement and integration made possible by Public Authorities will only come to fruition with the additional federal commitment to and investment in quality home and community-based services that has been long overdue. Public Authorities are vital vehicles for change but they provide no substitute for focused federal action.

If, for the time being, the promise of Public Authorities swells the growing chorus of voices calling for increased federal support for home and community-based services and strengthens federal attention to consumer direction, quality of work, and organized representation of stakeholders in the service system as measures of progress and success, it will have done much good.

Mr. Kumar is Senior Health Policy Specialist, Service Employees International Union (SEIU), Washington, DC.