Introduction
Most Californians wish to age of their properties and communities, slightly than in institutional settings like nursing amenities. To stay dwelling at dwelling and energetic of their communities, many individuals need assistance with private care and different help. Medicaid, not Medicare, is the principle payer for most of these helps, often known as House and Neighborhood Based mostly Providers (HCBS). In California, Medi-Cal helps almost one million older adults and folks with disabilities dwelling locally by way of its HCBS applications.
The supply and extent of HCBS protection, nevertheless, could be unsure. It is because below federal legislation, states have the choice to offer these providers, however they don’t seem to be required to take action. Consequently, throughout finances shortfalls—whether or not attributable to federal Medicaid funding cuts, a recession, or different monetary challenges—states incessantly take into account lowering non-compulsory advantages like HCBS to stability their budgets.
This reality sheet offers an summary of HCBS in California, their important function in supporting the well being and well-being of older adults and disabled folks, and makes the case for why California should decide to sustaining and increasing these important helps even throughout fiscal downturns.
What are House and Neighborhood-Based mostly Providers
Medicaid-covered HCBS are providers that assist older adults and folks with disabilities with actions of each day dwelling in settings of their selection, together with their properties, assisted dwelling amenities, and grownup day well being facilities. Helps embody, for instance, private care help, care coordination, medically-tailored diet, transportation, medicine administration, dwelling modifications, and, for people with excessive care wants, 24-hour nursing and supervision. California’s HCBS applications embody:
- Assisted Residing Waiver offers care and supervision in licensed board and care settings comparable to Residential Care Amenities for the Aged and at a restricted variety of public backed housing websites.
- Neighborhood-Based mostly Grownup Providers Program offers social, therapeutic, diet, and private care providers at grownup day well being facilities.
- California Neighborhood Transitions/Cash Follows the Particular person assists residents in expert nursing amenities transition to neighborhood housing by figuring out, adapting, and organising housing.
- House and Neighborhood -Based mostly Different Waiver offers private care, 24-hour nursing, and different helps to folks with complicated wants.
- House and Neighborhood-Based mostly Providers for the Developmentally Disabled coordinates and purchases assist providers for shoppers with developmental disabilities by way of the Division of Developmental Providers’ Regional Facilities.
- In-House Supportive Providers (IHSS), a consumer-directed private care program serving over 800,000 older adults and folks with disabilities, offers help with actions of each day dwelling like dressing, bathing, consuming, and family chores.
- Medi-Cal Waiver Program offers case administration and private care providers to people dwelling with HIV/AIDS as an alternative choice to nursing facility care.
- Multipurpose Senior Providers Program consists of intensive care and repair coordination, social helps, dwelling repairs, and grownup day applications for older adults age 65 and over.
- Program of All-Inclusive Take care of the Aged (PACE) offers coordinated well being and residential and community-based providers to older adults at site-based PACE facilities.
HCBS are a Lifeline
Medi-Cal’s array of HCBS applications assist folks stay of their properties and communities slightly than having to obtain care in an institutional setting, like a nursing facility. These applications improve high quality of life, promote dignity, and enhance well being outcomes. In addition they supply important assist to household caregivers by way of respite care and paid help, amongst different helps. Merely put, HCBS are a lifeline.
Daniel’s Story
After a medical disaster and prolonged hospitalization, Daniel, a Black older grownup, was discharged to a talented nursing facility to recuperate. Unable to climb the 36 stairs on account of extreme edema, he couldn’t return dwelling with out assist and spent two years within the facility. Because of the California Neighborhood Transitions program and the House and Neighborhood-Based mostly Alternate options Waiver, he secured an house the place he now lives independently with each day caregiver help for bodily remedy and a bi-weekly nurse go to. His situation has improved, permitting him to do the issues he loves most—cooking, mentoring his nephews, and doing occasional freelance graphic design tasks—from the consolation of his own residence.
“Most individuals usually are not comfy with another person setting guidelines and dictating phrases—it’s like a jail. You eat three meals a day on the identical time, sleep at a sure time, stand up at a sure time, there are particular actions out there at sure instances. It’s all restrictive. Being in expert nursing was good for getting my well being again however not for getting my life again. I wanted to go away with a purpose to be myself and dwell my greatest life.”
Ellie’s Story
When Ellie’s mom, Jane, was recognized with Alzheimer’s, Ellie tried to proceed working whereas offering for her mother’s growing care wants. When Jane was hospitalized, Ellie saved a go well with together with her within the hospital so she might attend work conferences and nonetheless keep together with her mother in a single day. However when Jane returned dwelling from the hospital, Ellie was now not capable of stability a demanding job and full-time caregiving. She left her job so she might deal with her mother. However with out her earnings, Ellie was unable to financially assist each her household and her mother and father. She was grateful to turn into her mother’s, and later, her dad’s IHSS caregiver, and obtain the monetary assist she wanted to maintain her mother and father cared for at dwelling.
“Having the ability to hold my mother at dwelling the place issues are acquainted, and to be cared for by household and by individuals who converse your language was an unbelievable present. IHSS let my mother and father be cared for by the individuals who know how you can take care of them greatest, within the consolation of their dwelling and of their final stage of their lives after they deserved to be honored and cherished.”
The Penalties of Reducing House and Neighborhood-Based mostly Providers: A Historic Perspective
Historical past demonstrates that when states expertise fiscal uncertainty, they typically resort to reducing HCBS. Such was the case following the 2009 Nice Recession when each state lowered HCBS spending both by reducing advantages or limiting eligibility. California was no exception, putting in a 7% across-the-board reduce to IHSS private care hours, a discount that was in place for over a decade earlier than hours had been completely restored. California additionally tried to completely get rid of the CBAS program, an effort that was overturned by way of litigation. Equally, when California anticipated a finances shortfall at first of the COVID-19 pandemic, the state proposed, however finally deserted, eliminating the MSSP and CBAS applications and reinstating the 7% discount in IHSS hours. Utilizing state funds, California additionally offers well being care protection to undocumented immigrants, and equally has turned to reducing HCBS for this inhabitants in finances downturns. In 2024, California proposed reducing IHSS for undocumented immigrants, which the state finally didn’t pursue. Most not too long ago, within the 2025 Might Revision, the Governor is proposing reducing all HCBS and long-term care in nursing amenities for undocumented immigrants.
The implications of reducing HCBS are extreme. Individuals who don’t obtain enough assist usually tend to have problem leaving the home, searching for groceries, and have the next danger of experiencing medicine errors. For individuals who want help, the lack of HCBS might depart them no selection however to maneuver right into a pricey establishment to obtain care. Analysis exhibits, for instance, that individuals 50 years and older who want, however don’t obtain HCBS are almost 5 instances extra prone to have a nursing facility keep than individuals who have enough assist. Nationally this interprets into 3.1 million extra nursing dwelling stays, growing nursing dwelling expenditures, that are 4 instances dearer than HCBS.
Cuts to HCBS expenditures will subsequently enhance prices to California. For instance, nationally, a 15% reduce in HCBS spending will increase nursing facility spending by almost $470 million, and a forty five% reduce will increase nursing facility spending by $1.7 billion.
Cuts to HCBS additionally translate into extra prices for household caregivers. In the present day, roughly 4.4 million Californians act as a caregiver for a member of the family. Almost half (44.4%) expertise important monetary pressure, stemming from elevated bills, lowered work hours, or the necessity to depart their job to offer care, disproportionately impacting girls of colour. Moreover, one in seven caregivers stories experiencing bodily or psychological well being challenges on account of caregiving. Cuts to HCBS would worsen these points, forcing household caregivers to tackle much more accountability and jeopardizing their financial safety, well being, and the well-being of these they take care of.
Proposals that declare to save cash by reducing HCBS will finally show to be dearer for the state, whereas inflicting important hurt on older adults, folks with disabilities, and their households, who will lose entry to important providers.
How Can California Shield and Strengthen Entry to HCBS
California has made important progress in increasing entry to HCBS. But, many Californians who want HCBS are nonetheless unable to get them, and should go with out care, transfer into nursing amenities, or depend on household caregivers to fill within the gaps. On the identical time, the necessity for long-term care providers is predicted to enhance as California’s inhabitants ages. California should discover sustainable methods to guard HCBS throughout fiscal uncertainty whereas concurrently increasing entry to those important providers by:
- Rising income for Medi-Cal to guard and broaden entry for California’s growing older inhabitants and to fill gaps in protection in the present day.
- Increasing the variety of folks financially eligible for Medi-Cal who don’t have any technique of acquiring care, together with reforming the Medi-Cal Share of Value Program.
- Constructing an enough statewide community of HCBS suppliers.
- Implementing insurance policies to get rid of delays and waitlists for HCBS.
Conclusion
HCBS are important for enabling older adults and folks with disabilities to dwell with dignity in their very own properties and communities. Policymakers should prioritize methods to extend income, and safeguard the progress California has made in increasing HCBS availability, whereas additionally implementing insurance policies that additional improve and enhance entry to those important helps.
