At first glance, Family Care seems like a great idea. The state's new plan for long-term care is supposed to help the elderly and people with disabilities by eliminating lengthy waiting lists.
'In the current system, there are many times when people don't get services,' says Sinikka Santala, head of the state's Disability and Elder Services Division, part of the Department of Health and Family Services. Currently, 11,700 elderly and disabled people statewide ' including 641 in Dane County ' are on some kind of waiting list. Notes Santala, 'Sometimes people end up in a nursing home because they've had to wait so long.'
Under Family Care, those people would receive immediate help. Each county would run an Aging and Disability Resource Center to act as a 'one-stop shop,' screening applicants for eligibility and counseling them about services.
A Care Management Organization ' run either by the county or a private entity ' would provide the services, functioning similarly to an HMO. The state would pay the organization a flat rate for each individual, using Medicaid dollars. The organization would then have to manage its budget carefully so that every person who asks for help receives it.
Getting rid of the waiting lists delights Karen Musser, head of Elder Care of Wisconsin. 'Right now, the only entitlement for people is a nursing home,' she says. 'We all believe Family Care is great.'
But advocates for people with disabilities are afraid that Family Care will force their clients into group homes. Ken Golden, who manages Wisconsin's Community Integration Program, doubts whether the state can afford to eliminate the waiting lists without substantial new funding.
'You can't do it with existing funds, in my opinion,' says Golden, who stresses that he is speaking for himself, not the Department of Health and Family Services. 'To cut costs, people will be grouped more, and we will not be able to address the system's existing problems.'
And in Dane County, which has always spent more than mandated to keep people with disabilities in the community, that's alarming news.
'Dane County has a fantastic system of support for people with developmental disabilities,' says Kim Turner, head of Options in Community Living and chair of the Developmental Disabilities Coalition. 'A lot of people living in the community would be in an institution if they were residents of another county.'
Turner fears that controlling costs under Family Care will force disabled residents to choose between living independently and having extra services, like job coaches.
'Will they be able to live their lives the way they are now?' she wonders. 'We worry about it.'
The state dismisses such concerns, saying service reductions are not expected. 'While we want Family Care to be cost-effective, we do not accept that it would be anything but high-quality,' says Santala. 'We expect every person's needs to be met.'
But Golden says the state refuses to have a frank discussion about Family Care's flaws and notes many state employees are afraid to speak up. The Doyle administration, he says, has 'an unwillingness to accept criticism, seeing it as disloyalty.'
Five years ago, Dane County briefly considered becoming one of the pilot counties to test Family Care. But even then, county officials were concerned that the state did not have enough money to run the program.
'We thought it would be another unfunded mandate, and we decided not to apply,' says Lynn Green, head of Dane County's Human Services Department.
Green notes that the state ended up pouring millions of dollars into the five counties ' La Crosse, Milwaukee, Richland, Portage and Fond du Lac ' just to make Family Care work. Like Golden, she questions whether the state has the funds to expand Family Care statewide, particularly when it's facing a $1.6 billion budget deficit.
'It's a wonderful idea,' says Green. 'But can the state really afford it?'
The state spent $5.8 million in start-up costs for the five pilot programs. But now that the pilot counties have an infrastructure, with phone systems and business plans, 'those systems are available for other organizations to use,' says Chuck Wilhelm, head of the state's Bureau of Long-Term Support. 'We don't intend to provide more money.'
In fact, the state argues that Family Care actually saves money. An independent study in 2005 found that the state saved, on average, $452 per month for each person in Family Care versus other programs.
That seems paradoxical: How can the state eliminate waiting lists ' caused by a lack of funding ' and still save money?
'We do it by serving people in assisted living or in their homes, instead of in nursing homes, which are more expensive,' says Wilhelm. And all of the money used is state or federal Medicaid dollars. 'We're taking money already in the system and using it more efficiently.'
But Green says one way the state funds Family Care is by taking money from the counties. Each county has been asked for a one-time 'local contribution,' based on what that county spends for long-term care, above and beyond what is covered by Medicaid.
The problem is that counties don't spend equally. Milwaukee County spends an extra $7 million a year on additional services. Juneau County spends less than $1,000.
Dane County spends more than $20 million.
'Our system is hugely unique because we do so much extra,' says Green. 'We've chosen to provide a higher level of service.'
The counties had hoped that Gov. Jim Doyle would include more state funding for Family Care in his 2007-2009 budget, but he did not. Instead, the state has said it will work with each county to decide what its local contribution will be. And right now, the state wants Dane County's entire $20 million.
'They've told us they can't afford it without our local contribution,' says Green. 'We said we're not handing over $20 million. In your dreams.'
Negotiations are ongoing, and so is planning for the new program. While it may be several years before Family Care begins here, Dane County will have its plans in place by this fall.
La Crosse County was one of the first in the state to pilot Family Care, pioneering its program in 2000.
'There was some apprehension, to be honest,' says Gerald Huber, La Crosse County's human services director. But officials there decided a managed-care approach for the elderly and disabled was, as Huber puts it, 'the wave of the future.'
Today, La Crosse no longer has waiting lists. And no county tax dollars go for these services. The entire $44 million cost of running Family Care in La Crosse is paid by Medicaid.
But there have been bumps in the road. Care Management Organizations must carefully budget their funding to cover every single person who requests services. One year, La Crosse County had a deficit of $2.5 million, but was able to cover this using surpluses from earlier years.
And keeping up with growing caseloads ' the county now serves about 1,700 people ' is a constant challenge. 'We're like a new business that keeps growing,' says Huber.
But adopting this model here may mean a lower level of care overall. Options' Turner says Dane County currently spends about $4,600 a month per disabled resident. Under Family Care, the state has capped spending for La Crosse County at about $2,200 a month per resident.
'It's not reasonable for the developmentally disabled in Dane County to lose what they have,' says Turner. 'And it's hard to see a scenario under Family Care where they won't.'
Golden also worries about a decline in monitoring to ensure client's health and safety. 'The state currently sees people regularly,' he says. 'We get incident reports within five days and can make sure the county is handling abuse situations correctly.'
Under Family Care, says Golden, agencies would be policing themselves, and the program would only get incident reports once a year. As he puts it, 'The program seems to be designed not to find problems.'
