The theory behind In-Home Supportive Services is simple -- and appealing. If low-income elderly and disabled people can be helped in their homes with cooking, bathing, shopping, housecleaning or taking medications, they can be kept out of much more expensive nursing homes and have a better quality of life.
But this concept has exploded into California's fastest-growing social services program.
Caseloads have doubled in the last decade, going from 208,000 to 430,000. Over that same period, IHSS costs have tripled, rising to $5.5 billion this fiscal year.
About 6,300 Stanislaus County residents receive these services at a total annual cost of $52 million. The county's share of that total is about $7 million.
Not surprisingly, the size and growth of IHSS has made it a major issue in state budget talks.
The state's final budget for 2009-10 eliminated or reduced services for some of the lesser-impaired clients, but advocates went to court and a judge blocked the proposed cuts.
In his 2010-11 budget, Gov. Schwarzenegger proposes to eliminate in-home services for all but the most vulnerable -- those receiving the most hours of assistance and who likely would end up in a nursing home without this aid.
Schwarzenegger also is convinced that fraud is driving up in-home care costs.
That view was bolstered last month with a report by the state controller's office showing that in 2008, as much as $11 million may have been paid out in cases where either the providers or the recipients were deceased.
We have no doubt that fraud is a problem -- as it is in any high- dollar program. And we support closer monitoring to ensure that clients really need the services and that providers truly are providing them.
But we think a more sensible and effective approach to controlling IHSS costs is to reduce eligibility across the board.
A new report from the Legislative Analyst's Office -- "Considering the State Costs and Benefits: In-Home Supportive Services Program" -- concludes that it costs the state and counties more to provide in-home services than it saves in nursing home costs. Why? Because an unknown percentage of IHSS recipients would not go into nursing homes even if benefits were cut off completely.
The LAO's report challenges a basic assumption of the IHSS program -- that without help in their homes all or even most IHSS recipients would go into very expensive skilled nursing facilities. Those facilities cost about $55,000 a year, compared with the average of $13,000 spent on in-home services.
The analyst's report contends that if in-home services are reduced or eliminated, most recipients will not go into nursing homes. Some won't meet the criteria that would make them eligible for state- supported nursing home care. Others will choose to stay in their own homes or move in with family members.
Several factors have contributed to mushrooming costs of IHSS:
The growing number of elderly, who tend to qualify for more hours of care each month, thus raising the costs.
A push in 2000 for better pay for care providers, and to allow them to unionize. Those changes took place during the same era in which the Legislature and governor approved higher public employee pensions and expanded other social services -- apparently with little sense of how the costs would snowball.
There is no cap on the number of cases, and virtually no waiting list for assistance.
The LAO -- and the governor -- suggest limiting IHSS to those most likely to end up in nursing homes without it. The analyst also suggests a second tier of aid -- cash for people to buy equipment or care services on their own.
Finally, a philosophical issue that is receiving little attention in the debate is the fact that two-thirds of IHSS providers are being paid to take care of a family member, often a parent.
We recognize that some families rely on this income to get by, and that some people are not able to work outside the home because their caregiving role is so demanding. But we also believe that for most people, caring for aging relatives is a family responsibility.
The immediate challenge for the state is to rein in costs for a social program that otherwise will only continue to mushroom.
Providing services only to the most impaired appears to be the best use of public dollars.