Governor Walker's Self-Managed Medicaid Mishaps

Wisconsin Governor Scott Walker's op-ed in the New York Times last week advocated for a Medicaid that promotes innovative, self-managed and flexible care that would allow individuals to stay in their own homes. Despite these statements, Governor Walker is eliminating a Wisconsin Medicaid innovation that worked toward these stated principles, a newly-created and relatively inexpensive statewide registry that helps vulnerable people with disabilities stay out of assisted living facilities and control their home healthcare.

In his New York Times piece, Walker writes in favor of a Medicaid "that recognizes that the delivery of health care is fundamentally personal and local," and that allows "flexibility to help patients who require some nursing services, but not round-the-clock care" by permitting individuals to stay in their own homes. He also praises some of Wisconsin's Medicaid innovations that give "individuals greater control over their care."

The Wisconsin Quality Health Care Authority (WQHCA) would appear to satisfy all of these principles, but buried in Governor Walker's budget repair bill passed by the legislature (and halted by Judge Maryann Sumi) is a provision dissolving it. The WQHCA is a relatively new entity that, according to its Executive Director Patti Becker, "facilitates matches between quality independent home care workers and individuals receiving medical assistance who self-direct their in-home care." It has been developing and overseeing a web-based statewide registry that screens and evaluates home care providers, a resource that allows persons with disabilities to self-manage their homecare by finding a trusted caretaker (particularly on short notice). Dane County Supervisor Barb Vedder says "the registry connects people with jobs, and workers with consumers," and "can help people stay in their homes." The WQHCA registry was recently praised in a study from PHI* and the SCAN Foundation.

Becker acknowledges that Walker's op-ed did not reference the WQHCA, but "if the governor believes self-managed, flexible, and innovative approaches to health care are important, I am puzzled by the motivation to eliminate a program that contributes to that end."

WQHCA registry

"Prior to the WQHCA, a person needing homecare assistance would find a provider on places like Craigslist," says Becker, noting that beneficiaries of the program included the elderly, veterans with brain injuries, persons with physical disabilities, or families with children who have behavioral difficulties. "The home care worker might meet the minimal state qualifications, but once hired, we would hear stories about providers stealing from their client, or worse," she says. "There was a clear need to develop a central, searchable database giving people access to a screened workforce." Becker says the WQHCA's statewide registry screens and evaluates home care providers to provide a much safer system.

It is the registry's efficiencies, though, that truly help persons with disabilities remain independent and avoid institutionalization. Dane County Supervisor Vedder, who became quadriplegic after a car accident, has personally benefited from the system since its inception as a Dane County pilot program. "It is especially important for respite help," she says, when one's regular provider is sick or has time-off: the registry allows persons with disabilities to find a provider to fill-in on short notice. "Without that option, it would be very difficult to stay in my home." For those who live alone, Vedder says that "not being able to find a fill-in provider on short notice is very dangerous. They can die in their house if they do not have a homecare worker available."

Dismantling WQHCA reverses five years of progress

The effort to create the registry began in 2006, and a pilot program in Dane County was operating successfully by Fall 2009. Health care advocates, legislators and Department of Health Services officials collaborated to scale the program statewide and the WQHCA entity was approved in former Governor Jim Doyle's 2009-2011 budget. The registry was finally becoming functional when Governor Walker introduced his budget repair bill repealing the WQHCA's enabling legislation. Walker's budget removes all funding for the registry.

"The absence of a registry will make it much harder for people to be in control of their own lives and care," says Becker. Persons needing homecare will have no choice but to find their own unscreened provider, and going through an agency can be prohibitively expensive. Without the WQHCA registry, Becker says, many people will have no choice but to enter structured living facilities like nursing homes. Becker has been told by a Dane County care management agency they have concern that "the first to be impacted could be children with autism, who may have no choice but to enter out-of-home placement if their families cannot find a homecare provider."

Dane County Supervisor Vedder notes that the registry would have benefited 12,000 "consumers" needing home care, and by abolishing it, "Walker is drastically, seriously hurting people who are vulnerable, people with disabilities and the elderly. He is picking on the poorest of the poor."

"This is downright shameful."

What now?

According to Becker there is speculation that Governor Walker is eliminating the WQHCA because its enabling legislation also permitted the homecare workforce to unionize. While individuals self-direct their care by hiring their provider, the Department of Health Services sends their paycheck through medical assistance payments.

She adds that some legislators believe the WQHCA's work can be privatized, but Becker questions whether private industry will choose to do so. She notes that she has recently learned that two large agency home care providers have ended services in parts of Wisconsin due to low reimbursement rates.

Becker had initially hoped "[the legislature] would not zero out our budget, so we can at least try to maintain the registry," but with that prospect unlikely, she has issued letters of termination to all WQHCA employees (including herself), and will shut down the program and searchable registry on June 30. Becker has worked with Dane County and consumer groups to "cryogenically freeze" the statewide registry's software and data in case it can be resuscitated when the political winds shift. Individuals will still have access to funds for home care services, but without the benefit of the searchable registry.

Governor Walker's belief that Medicaid should provide self-managed, flexible, and innovative care should imply support for the WQHCA registry. With his budget repair bill stalled in the courts, perhaps the governor has time to take a more careful look at the program.

Correction: The study praising WQHCA was originally attributed to the Public Health Institute, but the correct organization is PHI (formerly known as the Paraprofessional Healthcare Institute). We apologize for the error.