Why Medicaid Expansion is a No-Brainer

Based on an Interview with Jenny Gadd, MSW, LCSW

Note: An edited version of this article was published on the Women AdvaNCe blog.

Medicaid expansion is the talk of the town in North Carolina this week with the state legislature coming back into session. But do you really know where your taxpayer dollars that go toward Medicaid are actually spent? We regularly hear from some politicians that public programs like Medicaid waste money or are exploited by fraud, but Medicaid provides essential services for our fellow citizens. Other complaints include the bureaucratic red tape involved with government agencies. However, the way that North Carolina’s Medicaid program is flexing during the COVID-19 pandemic illustrates a government program’s ability to be nimble during an unprecedented situation. Building on the processes created for situations like hurricanes and other natural disasters, Medicaid has extended waivers through Appendix K to make sure that those who qualify for services receive them, no matter where they are receiving services within the state. This flexibility has been essential during the pandemic because situations change on a daily basis and the services are as well. As all citizens and taxpayers, we should be better informed about the way that Medicaid provides benefit to those who qualify for benefits. As one example of how this flexibility in Medicaid has worked, we will look at the case of an agency that serves clients with mental illness and intellectual and developmental disabilities.

Those who live in congregate settings (an environment where a number of people reside, meet, or gather in close proximity) are more at risk of contracting the virus. Some of the most vulnerable citizens, those with severe mental illness and intellectual and developmental disabilities, live in group homes run by agencies under the authority of the NC Department of Health and Human Services (DHHS). I wanted to know what adjustments to care have been necessary to ensure the health (as much as possible) of those citizens. I was fortunate enough to secure an interview with Jenny Gadd, MSW, LCSW, the Chief Compliance Officer of Alberta Professional Services. Alberta Professional Services serves people statewide with Intellectual and Developmental Disabilities (IDD) and severe mental illness in both group home settings and Alternative Family Living (AFL) settings. AFLs are families or individuals who house and care for Alberta Services clients and receive Medicaid reimbursement for those services. Additionally, Alberta serves youth in about thirty foster homes and runs day treatment programs for I/DD clients.

What adjustments have you had to make in the group homes to keep your clients safe and healthy?

Jenny reports, “The main goal right now is infection control. We have not had anyone ill or test positive yet, and the goal is to keep it that way.” As a result, staff that is usually shared between group homes are now assigned to one home to reduce the possibility of spreading infection from one home to another. Staff is also working longer shifts including some overnight shifts. This has affected the ability to have back up staff plans but is a necessity in terms of not sharing germs from one house to another.

Each group home has from three to six clients in addition to the staff. While typically the clients are supervised in cleaning their own homes, the staff is now following behind and doing a more thorough cleaning three times a day and keeping documentation of the cleaning. On an individual level, staff members are working with clients to help them understand the importance of thorough handwashing.

In dealing with a client base where people have all sorts of physical and mental challenges, plans are person-centered with individualized goals. They have written new goals that include daily temperature checks and improving handwashing techniques. It is not always realistic for some of the clients to wear a mask for physical reasons or because it might be irritating and/or anxiety-producing. So if clients cannot be compliant with some measures, the staff knows that there needs to be additional cleaning and hand-washing. Hand sanitizer is available at all times.

What about for the clients who are not living in group homes. How are you serving them?

“Initially, Alberta kept the day support programs open, but in smaller groups. Then the next week, it became apparent that those measures were not enough to protect clients and staff. The week after that the day support programs closed the building they were operating out of and brought the one-on-one service to the client’s homes. Additionally, Medicaid has also made it possible for many of the services to be provided by telehealth (two-way video), ensuring that those beneficiaries continue to be supported even when staff can’t be there in person. This is a surprising option that would normally not be available for this service.”

On a more personal level, how have you, the staff, and the clients responded emotionally?

“It’s the human condition to not really know how to respond to a crisis you can’t see,” Jenny responded. She went on to point out that their infection control training has been focused primarily on blood-borne pathogens, but not other modes of transmission. “It’s hard to get folks to respond appropriately to a threat that is not visible. Especially early on, as an agency, we wondered ‘Is this really happening’?” But once the statewide shutdown happened, they knew that changes were necessary. One of the most challenging parts of this has been the pace. Every week, new information comes out and the agency has to make adjustments. This is particularly difficult when working with a population that thrives on routine.

“Emotionally at times, I have been overwhelmed. The stress creeps up on you. Most of the staff have needed a good cry at some point. When the outbreaks started happening in long-term care and especially in Orange County, that really upset me. Those are our people and I realized now the threat is at our doorstep”

Parents of the residents are also affected. Mary Harrison, the mother of a resident, says, “They [Alberta] are really following the guidelines. I didn’t know what they would do at first. I was worried, but they are handling it well.” She went on to say that the daily check-ins with the Club Nova staff “has been a significant part of his [her son’s] being able to handle the situation.”

For the clients of Alberta, there were initially a lot of unanswered questions. Fortunately, the Department of Health and Human Services (DHHS) provided some great handouts that gave the staff pointers on how to explain the disease and the need for changes. When I asked Alex Harrison, a resident of one of the homes how he was coping, he replied, “I’m ok with not going to Club Nova (the day program), but it’s very isolating. There is only so much hanging out we can do. I’m getting tired. But, we are doing surprisingly well considering. There have been no horrible screaming matches or arguments. I know how to give people space.”

Have there been any silver linings to the situation?

Jenny replied, “I am impressed with the way Dr. Mandy Cohen, Secretary of the NC Department of Health and Human Services, has led the department and has found ways to bring Medicaid to where clients are at.. The county health department checks in with our licensed facilities daily. We report on any changes in symptoms and our PPE supplies (Personal Protective Equipment) or if we have other needs. We feel supported.”

She went on to explain that the COVID-19 situation has caused Medicaid to be flexible with their services in ways that she never thought possible, particularly so quickly. Because some clients are staying at home with their families and cannot attend day treatment programs, those families are now able to be compensated for the care and support they are providing that normally would have happened in the group homes. For clients who are in Alternative Family Living situations, either the family or roommate with whom they are living are eligible for additional pay for the additional support they are providing because clients can no longer attend day treatment programs. This is all new territory, and the Medicaid payment flexibility has been a much-needed asset to keep clients safe and caregivers compensated.

Without Medicaid, the North Carolinians mentioned in this article would have no place to turn. Unfortunately, the waiting list for group homes like the ones that Alberta Professional Services run is years long. Medicaid expansion would help to solve this problem. As you ponder the need for programs like Medicaid and where your tax dollars are spent, remember that many people are working hard supporting those in our community who need our help most. And while there may be problems that arise occasionally, because that too is part of the human condition, the majority of the dollars allocated to Medicaid are spent on people who really need our help.

I am curious about so many things and love researching and writing about things I find interesting. https://chaiselounge.substack.com

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