December 29, 2018
History of Long Term Services and Supports in Colorado
We have a lot going for us in Colorado when it comes to the quality and access of long term services and supports (LTSS). Colorado actually ranks eighth in the nation, according to the AARP Long-Term Services and Support Scorecard! Colorado is also one of only a few states that uses Medicaid dollars to serve more individuals needing LTSS through home and community based services (HCBS) than nursing facilities.
With this in mind, let’s look at the history of LTSS in Colorado. Here are the landmark highlights of federal and state events that paved the way for access to quality LTSS in Colorado.
1929 – 1939
The Great Depression
The impact of The Great Depression was experienced long after the actual economic downturn between 1929 – 1939. Because many of the elderly population experienced extreme poverty during this time, various pension schemes were introduced.
Townsend c. 1939, Harris & Ewing [Public domain], via Wikimedia CommonsThe most influential of these schemes was the Townsend Plan, started by a 66 year old doctor named Francis E. Townsend. Dr. Townsend was disturbed when he witnessed three elderly women looking for food in a trash can. He proposed a plan that every American over age 60 be provided a federal pension of $200 monthly. At one point there were over 2.2 million Americans who considered themselves Townsend Plan club members who were actively working to make The Townsend Plan the old age pension system of the American government.
As a response to the economic impact of the Great Depression, Franklin D. Roosevelt set up the Committee on Economic Security to study the matter of a federal old age pension system for America. The committee produced a report, which recommended legislating old age and unemployment benefits, as well as public health, child and maternal health programs, and aid to dependent children. The report did not recommend benefits for people with disabilities but it did mention the issue of illness by stating, “illness is one of the major causes of economic insecurity,” and “one-third to one-half of all dependency can be traced to the economic effects of illness.”
President Roosevelt signs the Social Security Act: Social Security Online [Public domain], via Wikimedia CommonsAfter considering the recommendations of Franklin’s committee, congress passed the Social Security Act. President Roosevelt signed it into law on August 14, 1935. The act provided old-age benefits funded by payroll taxes. The means-tested welfare program was intended to bring immediate relief to families affected by the Great Depression. The old-age insurance program was not designed for immediate relief—first payments were not scheduled until 1942. The final bill included public assistance for people of advanced age, for dependent children, and for people with blindness.
Public programs for LTSS were not included in the original Social Security Act except for aid to people with blindness. However, it was an ongoing topic of concern in America, due to huge financial losses experienced in the private disability insurance sector. With America entering into World War II, Roosevelt created a program to help civil defense workers who became disabled while working. This was called the Civilian War Benefits program and it paid partial, full, temporary and permanent disability benefits.
Lyndon Johnson signing Medicare bill, with Harry Truman, July 30, 1965, White House Press Office [Public domain], via Wikimedia CommonsWhile not funded immediately, the Advisory Council on Social Security to the Senate Finance Committee recommends disability benefits for disabled workers.
The Social Security Act Amendments of 1950 created the Aid to the Permanently and Totally Disabled (APTD) program.
President Lyndon B. Johnson signed the Social Security Amendments into law, which approved Medicare and Medicaid, on July 30, 1965.
Edward V Roberts, Unnamed DOR Employee [Public domain], via Wikimedia CommonsCongress passed a law that enabled qualified individuals under the age of 65 with end-stage renal disease to enroll in Medicare, which until that time was strictly an age-based program. This was groundbreaking because it was the first time a medical condition could qualify someone for Medicare.
1972 was also pivotal as Ed Roberts, who was the first student with significant disabilities to attend UC Berkeley, founded the Berkeley Center for Independent Living (CIL). CIL is a nonprofit that advocates for people with disabilities. Ed is widely recognized as the father of the independent living movement.
The forerunner to today’s Individuals with Disabilities Education Act (IDEA) was enacted by congress. The purpose of this law was to protect the education rights and meet the education needs of children with disabilities.
The Omnibus Budget Reconciliation Act of 1980 expanded the home health care benefit of Medicare
Section 1915(c), an amendment of The Social Security Act of 1981, established Medicaid home and community based (HCBS) waiverswhich allowed for LTSS to be provided at home and at intermediate levels of care instead of strictly nursing home settings.
Colorado implemented the first HCBS Waiver: Home and Community-Based Services for the Developmentally Disabled (HCB-DD). Colorado was one of the first states ever to implement a LTSS waiver. 1983 was also the year that the Colorado Indigent Care Program (CICP) was established to reimburse physicians and other providers for serving uninsured, indigent individuals.
Colorado implemented the Elderly, Blind and Disabled waiver (EBD)
The Omnibus Budget Reconciliation Act of 1987, signed by President Reagan on December 22nd, legislated new quality controls and penalties for nursing homes, including training requirements for nurses aides. (The Independence Center CNA Training Programutilizes these training requirements and more.) The law also required the Department of Health and Human Services to establish training standards for employees of home health agencies. Annual home health agency assessments, including home visits became required. This law was pivotal for people receiving home health care; it guarantees home health care patients/clients receive the same rights as those in nursing homes. This includes the right to be informed in advance of any treatment, to be involved in planning their own care, and the right to voice grievances.
1987 was also the year The Independence Center was founded, as Southern Colorado’s disability resource center and home health provider.
President Bush signs the Americans with Disabilities Act on the South Lawn of the White House. Sharing the dais with the President as he signs the Act are (standing left to right): Rev. Harold Wilkie of Clairmont, California; Sandra Parrino, National Council on Disability; (seated left to right): Evan Kemp, Chairman, Equal Opportunity Commission; and Justin Dart, Presidential Commission on Employment of People with Disabilities. 26 July 1990 Photo credit: George Bush Presidential Library and Museum. Executive Office of the President of the United States [Public domain], via Wikimedia CommonsCongress passes the Americans with Disabilities Act (ADA), a civil rights law passed by the senate in 1989, protecting Americans with disabilities from discrimination in five key areas of public life. President George H.W. Bush signed the act into law on July 26, 1990.
1990 was also pivotal for Colorado’s children. It was the year Colorado implemented the Children’s HCBS waiver. Legislation that created the first insurance program for low-income, non-Medicaid children in Colorado was also passed in 1990. It was called Colorado Child Health Plan (CCHP),
Total Longterm Care was founded in Denver, Colorado. It was one of the first nationwide Medicare and Medicaid funded Programs of All-Inclusive Care for the Elderly (PACE).
1991 was also the year Colorado legislated the beginning of the Single Entry Point (SEP) system for LTSS. The SEP is a single access point within a geographical area where individuals with disabilities, advanced age, or certain conditions can be screened for LTSS. SEPs provide case management and intake functions. Prior to the SEP system, Colorado operated on a county-based system. The SEP system allows for greater quality assurance because Colorado’s Department of Health Care Policy and Financing has contractual relationships with the SEPs.
Colorado implemented the Persons Living with Aids waiver. (This waiver expired in 2013.)
Colorado implemented the Persons with Brain Injury (BI) waiver.
1996 Colorado implemented Children’s Habilitation Residential Program (CHRP), Children’s Extensive Support (CES), and Supported Living Services (SLS) waivers. See all state waivers here.
1996 was also the year Colorado state legislature voted to withdraw from the federal Medicaid program due to spiraling Medicaid costs and a taxpayer bill of rights (TABOR) that capped state spending increases at 6%. Governor Romer vetoed the legislation.
1997 Children’s Health Insurance Program (CHIP) was established as a federal-state partnership administered by each state to provide health insurance to children who don’t qualify for Medicaid or have access to other forms of insurance.
The Balanced Budget Act of 1997 establishes the Program of All-Inclusive Care for the Elderly (PACE) model as a permanent Medicare and Medicaid program.
Lois Curtis, the plaintiff in Olmstead v. L.C., (center) presents President Barack Obama with a self-portrait of herself as a child that she painted. Joining them are, from left, Janet Hill and Jessica Long, from the Georgia Department of Labor, and Lee Sanders, of Briggs and Associates. The Oval Office, 20 June 2011; Official White House Photo by Pete Souza [Public domain], via Wikimedia CommonsThe U.S. Supreme Court’s ruling in Olmstead vs. L.C. found that states are obligated to make sure people with disabilities are not forced to remain institutionalized if home and community based care can appropriately meet those needs. The basis of this decision is the ADA; the court found that undue institutionalization is a form of discrimination against people with disabilities.
Colorado’s Health Care Task Force, established by the General Assembly, recommended expansion of the PACE project and creation of In-Home Support Services (IHSS), among other initiatives.
Colorado implemented the Community Mental Health Supports (CMHS) waiver
SB 02-027 was signed by Governor Bill Owens, which created participant directed options for LTSS: In-Home Supportive Services (IHSS) and Consumer Directed Attendant Support Services (CDASS).
Governor Bill Owens, 2002 Ariarmstrong CC BY-SA 4.0 from Wikimedia Commons
Centers for Medicare & Medicaid Services approves Colorado participant-directed CDASS and IHSS programs. The participant-directed programs then became available to participants on the Elderly, Blind and Disabled (EBD) and the Children’s HCBS (CHCBS) waivers in 2004.
Colorado implemented Children with Autism Waiver (which expired 2018).
Colorado implemented Children Living with Life-Limiting Illness waiver.
IHSS becomes available to participants on the Spinal Cord Injury (SCI) Waiver when Colorado HB 14-1358 is passed.
Colorado ranks 8th in the United States for quality of care and access to long term services and supports. The AARP’s Foundation Scorecard projects the following Impact of Improved Performance (Quoted directly from the Scorecard):
“If Colorado improved its performance to the level of the average of the top-five-performing states,
- 158,480 more place-based subsidized units and vouchers would be available to help low-income people with LTSS needs afford housing;
- 40,203 more people of all ages would receive Medicaid LTSS to help them with daily activities;
- 12,040 more home health and personal care aides would be available to provide care in the
- 7,837 more low-/moderate-income adults with disabilities would have Medicaid coverage;
- $134,700,000 more would go to home-and community-based services instead of nursing homes.”
Continued advocacy will enable Colorado to remain high on the list of states that provide quality care and services to people with disabilities in their homes and communities.
If you or a loved one need LTSS, The Independence Center is here to help point you in the right direction. Contact our Home Health Office Administrator at 719-471-8181, ext. 130 for help getting started.