- Associated Press - Sunday, February 5, 2017

BROWNSVILLE, Texas (AP) - On a bright, windy day in this town on the southern tip of Texas, Sandalio Mata sat in a rocking chair, doing a crossword puzzle outside his postage-stamp house off an alley.

The Houston Chronicle (https://bit.ly/2k0cVkp ) reports Mata, still spry at 91 after a life working as a migrant farm laborer, had just returned from a community center for elderly, where he finds companionship and care paid through Medicaid, the federal health care program for the poor. Medicaid also pays for the care of his wife, Maria, 85, whose arthritis-swollen knees make it difficult for her to move around and keeps her at home.

That care comes from their daughter, Nina Newell, who works for a home health agency, earning just above minimum wage to do small chores around the house, make sure Maria takes the right medications, and keep her company. “I love to work with the elderly,” Newell said in Spanish, holding her mother’s frail hands.

Newell’s occupation is astonishingly common in Brownsville, a city of about 180,000. Personal home care attendants account for more than one in 10 jobs here - five times the Texas average and the greatest concentration of home health aides in the country, according to Labor Department and Federal Reserve Bank of Dallas.

In many ways, Brownsville and other border cities represent the future of care for America’s aging population, since there’s increasing recognition that “aging in place” is healthier and more cost effective than sending people to nursing homes. At the same time, state policy is making it difficult to expand that model across other parts of the state.

In locales with higher living costs, particularly urban centers, the $8 an hour provided for by Texas Medicaid’s reimbursement rates won’t be enough to draw qualified workers that will be needed. The Texas Workforce Commission projects the home health industry, which already employs 260,000, would grow by another 102,000 jobs - if workers can be found to fill them.

To some extent, the dominance of the home health care profession in Brownsville and other border cities results from a simple economic equation: The Rio Grande Valley is among the poorest regions in the country, and has the highest rates of chronic diseases like diabetes and hypertension. At the same time, the cost of living is low, and few other jobs are available for those without college degrees.

“Thus, you have the demand: The sick elderly population,” says Jose Pena, CEO and medical director at RGV ACO, a health benefits manager in the area. “And the supply: Low-educated middle age population available to work as home aides.”

That works out fine for the Mata family - but other poor seniors may end up going without help.

Despite a reputation for low taxes and skimpy services, Texas has long been generous in providing services for people who can’t leave their homes.

In 1989, Texas Sen. Lloyd Bentsen pushed through a change to Social Security that allowed states to expand eligibility for personal attendant services beyond income limits set by Medicaid. That meant the program could pay for home health aides for people who weren’t desperately poor - dramatically increasing participation in the program, since Texas opted to offer the benefit.

“Texas has decades of capacity building, so there’s more of a familiarity with attendant services,” says Anne Dunkelberg, who studies health care policy at the Austin-based Center for Public Policy Priorities.

About 482,000 people receive home health and personal assistance services through state-licensed agencies, and about 146,000 of their providers are paid through Medicaid, according to the Texas Health and Human Services Commission. But they’re not distributed equally throughout the state.

For example, Cameron and Hidalgo counties, where Brownsville and McAllen are respectively located, make up about 4.5 percent of Texas’ population, and have 11.6 percent of the clients of home health agencies. The same is true of adult day cares, where health aides help people like Sandalio Mata.

Hidalgo and Cameron counties have 195 adult day cares. Harris county, with nearly four times their combined population, has only 41.

So why the high density of attendant services in the Rio Grande Valley?

The first reason is poor health. Local public health researchers have documented diabetes rates approaching 30 percent, compared to 11 percent statewide, as well as elevated rates of high blood pressure, or both at once. Those conditions make daily life difficult, but don’t require hospital admissions, making it common for doctors to approve home and personal health care aides instead - even for relatively young seniors in their 60s.

The second reason: poverty. Brownsville had the highest poverty rate in the nation in 2015, at 32.4 percent, just slightly above McAllen and Laredo. That creates a concentration of people eligible for both Medicare, the government program for the elderly, and Medicaid, making it financially viable to cater to that population.

“It does create some different market possibilities for providers,” says Dunkelberg. “The possibility of creating a model that really grows on Medicaid patients is way more financially there than it would be in other parts of the state.”

The third reason has to do with culture: Hispanic families are more likely to keep elderly folks at home, often in multi-generational households, rather than sending them to assisted living facilities.

But another reason comes up when talking about the proliferation of community health services in the Rio Grande Valley: Local entrepreneurs there have proven adept at milking government revenues. The problem of over-billing, sometimes to the point of fraud, was dramatized in a 2009 New Yorker article that identified McAllen as having the costliest health care in the country.

Roberto Zamora, who owns La Plaza Adult Day Care in Brownsville, recognizes that problem. He opened his own facility about 20 years ago after getting tired of working at other day cares that he described as skimpy on activities and laser-focused on profits. “Every time they would have a meeting, all they would talk about is money,” he said. “I used to hate that.”

Zamora is trying to change that perception, by putting as much as possible of the $4 per client per hour he gets from Medicaid into enrichment activities. On a Friday in mid-December, La Plaza held a traditional Christmas celebration called the Posada, in which people parade to each door off the main hall, singing gustily to a guitar. After that comes a snack of tripe tacos - special for the holiday - and a sewing project, followed by a dance contest.

“Baila, baila!” yelled Janie Toledo, 71, from the sidelines. She retired a couple years ago as a home health aide herself, never making enough to exceed the income threshold for Medicaid. But that gave her an appreciation for staying active, and she prefers La Plaza’s high-energy environment to other day cares, where the main activity is chalupa, a game akin to bingo.

“Over there where I was, all we did was get there, have breakfast, play chalupa, eat, play chalupa, go home,” Toledo said. “I have arthritis, and doesn’t want to get stiff, because that would mean going into a wheelchair. I see what happens to them when they stop moving.”

As useful as home attendant and community services can be, they’re few and far between in some parts of the state, for one reason: money.

Partly because of Texas Medicaid’s low reimbursement rate, the median wage for personal care aides in the state is $8.51, according to the Paraprofessional Healthcare Institute - the second lowest in the country after Mississippi, which pays a nickel less. The median wage for home health aides is only slightly higher, at $8.89. For that reason, finding attendants for Medicaid beneficiaries is difficult where housing costs are high and labor markets tight.

Take Austin, where Andrew Hodge owns and operates a home health agency. He doesn’t accept Medicaid, because it’s not worth trying to find people who’ll work for near minimum wage when private insurance reimburses enough to pay caregivers $10 to $12 an hour.

“I don’t know how anybody does it,” Hodge said.

The same is true of adult day cares, of which there is only one in Travis County.

The problem of low wages was supposed to be solved in part by the Affordable Care Act’s move toward managed care, which funnels Medicaid and Medicare dollars through medical organizations that take care of the full spectrum of patients’ needs. That gives these “managed care organizations” the flexibility to pay more for caregivers if it saves money by preventing expensive hospitalizations.

Still, it hasn’t made it easier to recruit home health aides in places where Wal-Mart pays more than $10 an hour. Advocates warn the health care system could face a serious shortage of people willing to do the job.

“I talk with consumers, people who need those services, they’re dependent on those providers,” said Kay Ghahremani, the director of Texas’ Medicaid programs until 2015 and now CEO of the Texas Association of Community Health Plans, a trade group for managed care groups. “When you have fast food restaurants paying more, from the Medicaid director’s perspective, it’s a big concern.”

Business and consumer advocacy groups are pushing the Legislature to give community health attendants a raise. In its budget request, the Health and Human Services Commission asked for money to boost wages by 50 cents an hour, but the Coalition of Texans with Disabilities, an Austin nonprofit, says that’s not nearly enough. Instead, the advocacy group has proposed raising the minimum wage for home health attendants to $13 by 2019 at a cost of $1.25 billion over two years.

That would be matched by the federal government, and could save money through lower turnover and less need for paying other safety net benefits like food stamps. Still, it’s a big ask in a legislative session focused on cutting programs to account for reduced revenue.

But Dennis Borel, the coalition’s director, warns that shortchanging caregivers could lead to the kind of scandal that faced Child Protective Services last year: Overworked and underpaid staff falsified records and left kids in danger, prompting a judge to declare the program unconstitutional and recommend fixes costing millions.

“At some point, you have CPS copied in other programs,” Borel says. “They failed to pay adequate wages to those people most responsible, and now they’re throwing money at it left and right.”


Information from: Houston Chronicle, https://www.houstonchronicle.com

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