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Last updateTue, 18 Sep 2018 1pm

Rob Lyman of didn’t know what to do.

The Redwood City resident was helping his aunt, Sharron Evans, who had early-onset Alzheimer’s disease and needed constant supervision. A former teacher, she had run out of money and had no income. She qualified for government health-care assistance, but it appeared she’d need to go to the only setting that would be covered: a nursing home.

“Basically, that’s a hospital setting, and that was our only choice,” Lyman said.

To him, that didn’t make sense.

“My aunt just needed a safe place to be; there was nothing physically wrong with her,” Lyman said. “She didn’t need that level of care. It’s inappropriate. It costs the state a lot of money. But this is what people do. That’s the default choice.”

The baby boomers are aging. By the end of the next decade, 11.1 million Californians will be 60 or older, and the number of people 85 and older will jump 37 percent, to the 1 million mark, according to state officials. One in six Americans is expected to develop dementia, and care can be expensive enough to force even middle-class families into poverty and onto the public payroll.

For low-income seniors who can’t afford care at home and don’t need the full medical services of a nursing facility, the state’s few options aren’t enough to meet demand. A middle-ground choice—assisted living—requires special permission under government rules and is available to fewer than 4,000 Californians, although state health officials and lawmakers are both proposing increases. Taxpayers currently pick up the more-expensive nursing-home tab for more than 20,000 people who may not need it, by one advocate’s estimate.

Evans, now 69, was lucky enough to land a permitted spot in a Sacramento-area assisted-living home after nearly a year’s wait. The cost didn’t matter much to her or Lyman, because it was paid by Medi-Cal, the state’s version of the federal Medicaid program. The lower price tag for assisted living saves the state money, while also providing a more home-like setting and the right level of care for Evans.

For more than a decade, the state Department of Health Care Services has been trying to address the need for more-appropriate, less-costly care. But Medicaid pays only for what is “medically necessary,” such as nursing-home care, unless states ask for waivers. The state budget deal struck last week would provide administrative costs for a waiver to cover an additional 2,000 assisted-living slots.

That’s not enough, said Assemblyman Ash Kalra, a Democrat from San Jose. Kalra’s Assembly Bill 2233 proposes adding nearly 13,000 more, to cover a total of 18,500 people over the next five years. That would basically triple the number of Medi-Cal recipients with access to assisted-living care—assuming waivers, which last five years, can be secured.

“We’re hitting a crisis point with our senior care,” Kalra said. “It costs us twice as much for skilled nursing care.” His bill, which has no organized opposition, passed the Assembly and is now in the Senate.

The federal and state governments each pay roughly half of Medi-Cal expenses. A legislative staffer pegged savings for the state’s share at slightly more than $23 million over the five years, once all 18,500 patients are placed in assisted living. According to the Department of Health Care Services, which oversees Medi-Cal, the state’s share of the average cost for assisted living is about $22,000 a year per person—roughly half the $42,000 annual cost of a nursing-home.

“I have visited skilled-nursing facilities, and the nurses … told me that many of the patients don’t need that level of care. So we could be saving money for the state dramatically,” Kalra said.

According to the Department of Health Care Services, California has about 53,000 Medi-Cal patients in long-term institutional care, such as skilled-nursing facilities. A legislative analysis shows an estimated 11,000 of them have lower-care needs and could be fine in assisted living.

That figure could actually be twice as high, said Mark Cimino, who runs assisted-living homes in the Bay Area and around Sacramento, including the one where Evans lives. He said assisted-living facilities provide a wide range of care that could serve upward of 20,000 Medi-Cal patients who are now in nursing homes.

California’s first waivers, approved in 2004, covered about 1,000 people. That figure doubled in 2009 and nearly doubled again to about 3,700 in the most recent period, which runs out in March 2019.

“There’s a huge trajectory here,” Cimino said. “The question is: Is the expansion of the waivers enough?”

And there’s the human side of the equation, he added: “The assisted-living community is more home-like,” he said. “No one wants to spend much time in a (skilled-nursing) unit.”

The state “has specifically worked to expand access to assisted-living services,” said Department of Health Care Services spokeswoman Carol Sloan.

It’s hard to go any faster, she said by email, because the state has to check for “requirements, monitoring and oversight responsibilities, staffing, adequacy of available provider network and other resource limitations” before requesting more waivers.

As for the nursing-home industry: “If a resident can be shifted to a lower level of care, we think that’s a good thing,” said Deborah Pacyna, spokeswoman for the California Association of Health Facilities, a trade group. “We always support people getting the appropriate level of care for their needs.”

That won’t hurt business, she said: “The boomers are coming.”

For Rob Lyman, a move toward assisted living is a no-brainer.

“If the state, and we as a community, are going to provide assistance, we have to do it in a cost-effective way,” he said. “Putting people in skilled nursing when they don’t need it—that’s not good stewardship of public dollars.”

CALmatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Local Issues

Days after Tim Grayson won election to the Assembly, a Sacramento lobbyist greeted him at a reception with sheepish congratulations. Her client had supported his opponent during the campaign, the lobbyist explained, but now that he’d won, she told him she wanted to move past the election and forge a good working relationship.

Oh and by the way, did he need any money to cover costs from the campaign?

“Make-up money” is what it’s called in Sacramento—the contributions that flow to newly elected officials from interest groups that backed a losing candidate during the campaign. It’s a completely legal way of saying, in political terms, “Let’s kiss and make up.”

Grayson has not taken advantage of the offer; campaign statements to date show no contributions to the Concord Democrat from clients of the lobbyist who introduced herself in November. But conversations like theirs often occur in the months after an election, as interest groups shift from betting on a winner during the campaign to lobbying those who won a seat in the Capitol.

“The best way to make amends, fortunately or unfortunately, is a contribution,” said GOP political consultant Mike Madrid. “It’s not uncommon to have a strategy where somebody spent six figures against (a candidate), with approval to write them a check to rebuild the relationship” if that candidate ends up the winner.

In other words: make-up money is built into the budget for interest groups that spend big on politics. Those groups had a lot at stake in the 2016 legislative races, because it marked the last time for the next eight years that a significant number of Assembly seats would be vacant. A review of campaign finance reports from last year’s most contentious races shows plenty of make-up money in the mix. It came from trade associations, corporate interests and labor unions.

Some examples:

• In the race for a Malibu-area state Senate seat, the dentists’ trade association spent nearly $50,000 opposing Democrat Henry Stern. After he won, the dentists gave him $4,200.

• In the race for a San Jose-based Assembly seat, the Realtors association spent more than $483,000 attacking Democrat Ash Kalra. After he won—and landed a spot on the Assembly’s Housing and Community Development Committee—the Realtors group gave Kalra $8,500.

• Realtors made another losing bet in the Democrat-on-Democrat race for a Glendale-area Assembly seat, spending nearly $253,000 to support Ardy Kassakhian. After his opponent, Laura Friedman, won, the Realtors’ group wrote her a check for $6,800.

Friedman said she met with the Realtors after the election—just as she met with many other interest groups—for a version of the “let’s move on and have a good relationship” conversation. The money, she said, doesn’t impact how she’ll vote on their issues.

“I don’t feel like I’m holding a grudge, but I’m certainly not going to not work with them, not take their meetings or not take in their perspectives,” Friedman said. “My goal is to represent my constituents and my conscience.”

The dentists and Realtors associations are among the biggest spenders in legislative races, pouring millions into recent election cycles. Both groups declined requests for interviews. The dental association provided a statement saying its political action committee “puts a great deal of consideration” into choosing which candidates it supports.

Interest groups that spend smaller sums of political money have done some flip-flops, too:

• In the race for a Palo Alto-area Assembly seat, two local labor unions—one for firefighters, another for school support staff—that gave to the losing candidate have since written $5,000 checks to the winner, Democrat Marc Berman.

• PG&E and the pharmaceutical industry association both donated to the campaigns of the losing candidate for a Salinas-area Assembly seat. Weeks after the election, the businesses wrote checks to the winner, Democrat Anna Caballero.

• In October, the prison guards’ union gave $4,200 to Grayson’s opponent in the race for his Assembly seat. Two months later, the union wrote a check for that amount to Grayson.

Grayson, who previously worked as the chaplain for the Concord Police Department, said his relationship with the prison guards’ union stems from his own career in law enforcement—not from the money they donated.

For interest groups he doesn’t really know, Grayson said he finds offers of “make-up money” awkward. He said he never followed up to seek a donation from the lobbyist who introduced herself at the post-election reception.

“My first desire is to meet and have a conversation in which they can get to know me, who I am, what I am and how I am,” he said. “What they choose to do after that, that’s their business.”

There is nothing illegal about giving “make-up money” to a politician, said Jessica Levinson, a law professor who is president of the Los Angeles Ethics Commission. Political contributions break the law only when they involve a direct exchange of money for governmental action.

But, she said, giving money to the winner of an election—after backing an opponent—shows that donors are looking to curry favor with whomever has the power to make decisions.

“It brings into stark relief what we all know, which is that people give money to get something,” Levinson said. “You’re not expressing support; you’re buying access and influence.”

Laurel Rosenhall is a contributor to CALmatters.org, a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Politics