House Committee on Human Services – December 12, 2015 Hearing

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The House Committee on Human Services met to hear invited testimony concerning interim charges on difficulties facing aging Texans and the Governor’s statement prohibiting refugees in Texas.

Refugee Program Discussion

Steve McCraw, Director, DPS

At least ½ million Syrian refugees are fleeing to Europe and the United States
Not so concerned about vetting process, rather concerned that Texas does not have the data to properly vet refugees
Texas is treating the danger of the Islamic State seriously
Chair Richard Raymond asks if authorities have confirmed if the Paris attacks were conducted by refugees
- Paris attacks were conducted by asylum seekers
Chair Raymond asks what happened to the 8 refugees in Laredo
- Unsure, discretion of the federal government
Chair Raymond wants to know the federal process for intake of refugees, thinks that Texas could make some suggestions to improve the federal process
- McCraw will provide this information to the legislature
Rep. Four Price asks if the Texas processes are thorough and sufficient, wonders about McCraw’s issues with the process
- Data issue, without proper data it does not matter how much refugee information is checked
Price asks what McCraw would want to do about the problem
- No refugee inflow would be best until the security problems are resolved
- ISIS is very effective at recruiting disaffected people on US soil
Rep. Elliott Naishtat is concerned that refugees currently in Texas might pose a risk to public safety or if DPS is looking into this
- DPS is unable to vet refugees currently residing in Texas, this has been left to federal authorities and any information has not been shared
- Progress on any of this is dependent on federal information sharing
Rep. Stephanie Klick asks after the asylum process and foreign nationals who seek asylum in the US
- Does not have information on this process, subtleties exist between refugees and asylum seekers
Klick asks if authorities are looking into any issues such as fake passports etc.
- DPS is aware of these activities, these are challenges DPS deals with on a routine basis
- However, DPS does not know of all terrorists or radicals
Klick asks if the only way DPS would be aware of the threat is if federal authorities shared information
- Generally yes, the federal government cannot share information it does not know
Rep. Mark Keough comments that if the current vetting process is not useful without data, then perhaps a different process should be adopted such as intake questions or lie detector tests, asks how hard it is to procure interpreters
- Tests can be conducted with proper interpreters, federal authorities should be aware of where these assets are
Rep. Susan King asks if DPS is concerned about both asylum seekers and refugees
- Yes
King asks if there are some refugees in Texas currently
- Yes
King asks when frontend processes would occur, aka on foreign or domestic soil
- Process should be treated as a continuum due to the danger of radicalization
Rep. Donna Howard asks if DPS could “re-vet” refugees if appropriate information was made available to DPS
- Federal government should have this information, current situation in Syria makes it difficult to procure
- The directors of the FBI and CIA have expressed concerns over this issue
Howard asks if this is a difference of opinion between people who believe resettlement is possible and those that do not
- Generally yes
Howard asks if polygraph tests would be sufficient and if McCraw would be comfortable with this process in place
- Polygraphs would help, would prefer no resettlement due to lack of resources
Naishtat notes federal government comment that states do not have the ability to refuse refugees based on federal law
- “I’m not qualified to comment on that”
Naishtat notes that AG Paxton attempted to get a temporary restraining order on the grounds that terrorist organizations have infiltrated the refugee program, while Rep. Michael McCaul said that terrorist organizations had just targeted the program; the court found this to be speculative; asks for a comment
- No comment
Pena notes to Naishtat that the challenge is nobody knows for sure that the refugee program has or has not been infiltrated
Keough references federal law, comments that it requires federal government to listen to the opinions of the state

Chris Traylor, HHSC

Refugees are defined as persons living outside country of origin who cannot return to home country due to persecution and designated before they come to the US, asylum seekers are the same, but designated after they come to the US
Refugee situation is new to the state, some unexplored territory
Price comments that many local governments are required to provide resettlement services at financial detriment to them
- Local governments are bearing a lot of the cost (Houston, Dallas, Fort Worth, Austin, San Antonio, Abilene, Corpus Christi, Amarillo)
- State had asked federal government to slow down on resettlement in Amarillo due to cost and service burden (ESL, housing, care, etc.)
- Refugees are able to access medical program even after the 8 month refugee care period
King asks if the current batch of Syrian refugees will follow the typical refugee paths
- Yes, in Houston, Dallas, and Fort Worth mainly
- Same expectations exist for these refugees to wean of refugee services and move into citizenship
King asks if refugees have always been questioned over ties to terrorist activities or if these questions are new to the process
- Patrick Randall, Refugee Program Manager, HHSC, comments that he is unable to speak for the national level vetting process
- HHSC does not vet refugees themselves
Naishtat asks if HHSC has given any thought to the unstable regulatory environment that resettlement nonprofit/volunteer organizations are facing due to the disagreement between state and federal policy
- Resettlement organizations are clearly in conflict, but this is the subject of litigation and HHSC cannot comment
Rep. Toni Rose asks if federal government is not working with local governments to resettle
- Not saying there is no cooperation, but local service agencies and school districts carry some burden particularly when a wide variety of refugees are resettled
Chair Raymond asks for statistics
- 54,000 refugees have been resettlement in the last 5 years, from locations such as Burma, Cuba, Iraq, Bhutan, Somalia
- Afghanistan is 2,700 over last 5 years, Iraq is 11,081 over last 5 years
Naishtat comments that agencies are requiring nonprofits to provide immediate and ongoing consultation
- This applies to federal partners and resettlement organization, little information has been provided for the 21 refugees who have been resettled since Governor’s statement
Naishtat asks if HHSC has submitted amendments to federal partners for the refugee resettlement plan
- Position designation only
Klick asks if Texas has any say where refugees end up
- As of now it is a federal decision, have made requests of federal partners to have some say, but they have not yet been responsive
Klick asks what the process is for reporting security threats
- Litigation concern and the domain of the state government
Keough asks how Texas compares to other states for resettlement
- Texas has the highest resettlement rate per capita, roughly 10% of total
Keough asks if the amount of assistance given to refugees is really necessary
- Randall comments that HHSC has frequent communication with federal partners over the cost and types of services provided
Chair Raymond asks after the cost breakdown
- In 2016, $68 million in federal dollars will be spent
Keough has concerns that refugees would want to take advantage of the services available rather than actually needing the services provided
- HHSC has not made this case to federal partners, argued on security concerns until now
Raymond comments that refugees would receive the federal assistance regardless of the state they are in, perhaps the argument should be made to Ways and Means
Naishtat comments that refugees leave their countries because they have to, rather than because they would receive welfare assistance

Heather Reynolds, Catholic Charities Diocese of Fort Worth

Catholic Charities’ mission is annihilate poverty, refugee resettlement is one strategy they use
Reynolds shares anecdote about Jimmy from the Democratic Republic of the Congo
Security and compassion are not mutually exclusive
Refugees have better results than domestic impoverished persons in becoming self-sufficient
Chair Raymond asks after the physical movement of refugees and how long they must wait
- Typically these refugees move into camps around the area in question, typically refugees wait 1 and ½ to 2 years to get placed in the US
Chair Raymond thought that Syrian refugees were fast-tracked, but perhaps these are refugees who fled before ISIS became as powerful as it is now
- Unsure
Chair Raymond asks if Texas should not worry about refugees from areas with Islamic extremism
- The threat of terrorism is very real and refugees flee their countries due to this activity
Chair Raymond asks if refugees would have issues with answering security question
- Refugees are typically very grateful to be here in the US
King asks where the Syrian refugee camps are located and after the timeline of naturalization
- A good number move into citizenship, typically takes 5 years

Jennifer Sime, International Rescue Committee

Chair Raymond asks how long refugees typically wait to get to the US
- War started in 2011, a little over 4 million refugees are in Turkey, Lebanon, and Jordan
- In those countries they can be in camps or they can be within cities
- Refugees must register with the United Nations to receive benefits or be resettled
- Refugees have likely been waiting for quite some time

Judge John Specia, DFPS

DFPS provides foster care for unaccompanied refugee minors, state does not have conservatorship of these children, rather Catholic Charities has conservatorship
DFPS is merely a pass through for $6 million annually
No children currently from Syria

Interim Charge 1. Study the ten year anticipated growth, the geographic distribution, and the projected economic impact of aging Texans. Review state services and programs available to seniors, including independent living services, and determine the capacity and effectiveness of the programs. Determine if Texas is prepared for the increased demands of aging Texans.

Dr. Lloyd Potter, Texas State Demographer

In the next 10 years the population 65 and older is going to increase
The population in Texas is generally aging, baby boomers are going to be retiring and increasing this population
This shift will increase demands on the healthcare system moving forward, including increases in diabetes and obesity
This population will affect Houston, Dallas, Fort Worth, Austin, and San Antonio
Rural area healthcare is lacking and could cause problems for aging populations in those areas
Chair Raymond asks if the burden on senior services is going to be significant
- Without question, assisted living demands, diabetes, and obesity etc.
Chair Raymond asks if these projections have been ongoing for some time
- Started forecasting these demands in 2010
- Diabetes data has not been looked at too intensively, but can look at it very easily
Keough asks after taxes and coverage of costs, asks if Texas expects the aging population to cover some of their costs
- One of the key issues is lack of infrastructure, doctors, facilities, etc. take a long time to develop
Keough asks if infrastructure availability wouldn’t be better served by the free market
- Theoretically the labor demand would dictate these needs are filled
Chair Raymond comments that part of the reason for the hearing is to review revenue sources and solutions to the growing cost problems
Rose comments that these are citizens of Texas and they have contributed to the success of Texas
Keough comments that he “sees dollar signs” attached to all of these problems, wonders if the infrastructure issues are the charge of the state

John Weizenbaum, DADS

In many cases aging citizens continue to work, however, by 2031 the “over 85” sector of the Texas population will grow significantly
Likelihood of disabilities increases with age
Transportation for aging individuals will be critical as time progresses
Vast majority of individuals who receive assistance live in private homes, a small fraction uses paid assisted living
Families tend to be the primary caregiver for individuals with IDD
Caregivers are aging as well
Price comments that it will be more costly to the state to ignore aging and related issues
- Personal assistant services costs are going to increase
- Goal of state is to allow individuals to live how and where they wish to, but pay for assistants is challenging and good personnel are hard to find
- Big picture, prevention of long-term care is very cost effective, but hard to find a solution for this
- Very much a quality of life issue for Texans
Naishtat comments that in 2014 quality of care and life in Texas was 49^th in the nation, very poor situation
Many programs in Texas, including personal assistant services, “adult daycare,” PACE, managed through STAR+PLUS and fee for service
Also trying to work with local governments to plan for gaps in services and again populations
Naishtat asks if Texas’ ability to provide services for current senior citizens is stressed
- Difficult to answer, Texas is currently able to provide services to many people, but quality depends on the people who provide the services and this in turn is dependent on pay
- Investments in workforce and training will likely be necessary
Naishtat asks if there are incentives for healthcare professional to provide services for geriatrics
- Some programs exist for reimbursement for family practice, etc., but unsure specifically for geriatrics
- Definitely a need for something like this
Naishtat asks if there are programs to allow care providers to take leave for appropriate reasons and retain their jobs
- Believe so
Rose asks what type of services aging individuals might be waiting on
- Typically for pass through dollars which are not necessarily governed by the state, disbursements to smaller organizations which in turn only have a small amount of care they can provide
Klick asks if there are programs or workgroups looking at new solutions to allows aging individuals to remain in their homes
- Yes, there are a number of medication tracking, video monitoring, etc. technologies that should facilitate this moving forward

Britta Edwards, Brookdale Senior Living

Assisted living communities vary widely in terms of format and number of occupants
Brookdale serves people with functional ADL deficits, including dementia
These patients typically need assistance with basic living and supportive care for severe issues
Majority (~85%) of people in assisted living pay for themselves, however some people are turned away due to inability to pay
Many times residents who are unable to pay must wait for someone to leave assisted living
Brookdale is very concerned over personnel, will need 23,000 new hires to care for the aging population in the coming decades
Medium annual cost is around $3,500 a month, can reach $6,000 for people with severe conditions
Keough asks what this will look like in 10 years
- Brookdale has a small number of Medicaid beds, continues to grow in a private pay mindset

Rachel Hammond, Texas Association of Homecare and Hospice

Texas can support its commitment to its senior citizens, providing access to care in the home, Providing respite services for family caregivers, preventing unregulated group home activities, and appropriately funding community-based Medicaid programs
Medicaid will continue to be the primary payer for community0based services and supports
Development of technologies mitigating disabilities and aging population will increase demand on long-term healthcare commitments
Home health is one of the fastest growing professions in Texas, home healthcare support is a primary way for Texas to mitigate costs for aging healthcare
Homecare agencies are reimbursed on a fixed rate, part of which goes towards attendant salaries and part of which goes to operation costs
Home health needs adequate rates to properly fund the cost of business, current cost reporting does not reflect the actual costs involved (e.g. overtime pay)
Texas has serious challenges in maintain a stable and adequate attendant workforce
EVV rollout was flawed; service providers are responsible for many costs that were allocated to the state in the pilot, fee for service allowed agencies to be efficient
STAR+PLUS programs are 6.6% underfunded, fee for service are roughly 2% underfunded
Quality-based contracting and managed care should be supported by the legislature, regulatory requirements should be streamlined and improved
Homecare tries to work with hospitals to lower re-hospitalization

Kevin Warren, Texas Healthcare Association

THA has 500 nursing homes and assisted living facilities
Members are very concerned over how to prepare for the aging problem
Members have difficulty paying quality home attendant staff now, will likely get worse as time goes on
Stress of giving quality care is mounting, staff turnover is very high in the long-term care industry, many have left with regrets (“drawbacks outweigh the benefits”)
Regulatory environment that exists today is a barrier to employment and hampers the long-term care employment pool, negative stories and concerns over funding propagate amongst potential employees
Naishtat asks if number of facilities within the association has decreased recently
- 1,200 in Texas total, THA has 500 within its organization
Chair Raymond would like a 3 item assessment of the current problems that will be pressing next session

George Linial, LeadingAge Texas

Represent not-for-profit sector of assisted living in Texas
By 2030, 1 million Texans will be over 85
Texas must evaluate effectiveness of current programs and the current punitive regulatory structure which limit care (Medicaid payment methodology especially)
Texas should incentivize better models of care for the elderly and explore long-term care finance reform
- 29% of the population has not saved anything for retirement, long-term care insurance market is not a good solution as it is expensive and cumbersome
- Plans to encourage people to save would be good
Promote innovation and flexibility in the field, i.e. branch out from institutional models
Costs long-term care provides have incurred over the last decade are substantial, a big problem area is dementia payments
State should explore regulatory changes to allow assisted living facilities to take care of higher acuity individuals instead of leaving them for nursing facilities
Medicaid rates paid to nursing homes are underfunded by roughly 15%
Service care coordinators can help to mitigate cost issues, but many of these positions have been defunded over time
State should look at TDHCA to sustain service enabled housing projects, many injuries (such as falls) are preventable and cost US $34 billion per year
50% of nurses are over 50, 64% of nurses over 54 plan to retire in the next 3 years
Geriatricians are sorely needed, roughly 35% of 65+ population will need a geriatrician, would need 30,000 geriatricians by 2030, academic and work based incentives should be used to get specialists into the field
Chair Raymond asks how much of $34 billion fall injury cost figure is from federal money
- Unsure, but can get this information
Chair Raymond would like much more specific information
- Will work on this and provide this to the legislature
Naishtat asks how many facilities are in LeadingAge
- Around 250, 800 facilities between LeadingAge and THA
Klick asks if wound care technicians, etc. are needed
- Nursing care facilities might need this type of personnel, typically deal with high acuity patients
- Warren responds that re-hospitalization rates and costs should be looked at with a mind to quality of care especially with pressure on shorter hospital stays
Klick would like some research on best practices and effectiveness of shorter stays versus other care initiatives

Jamie Dudensing, Texas Association of Health Plans

Association represents commercial health insurance and MCOs
STAR+PLUS was expanded in September 2014 to include additional populations
Most of the acute care costs for aging population is Medicare, many disability costs are being attributed to this
Fall prevention, medication adherence, and education programs are the target of many state dollars, idea is to prevent higher costs at a later date
Per capita spending has been decreasing consistently as managed care expands even though program costs have been expanding
STAR+PLUS pilot savings came from reducing hospital visits and ER visits by integrating care, however, the real effect was a 70% increase in long-term care, thus merely a shift in care strategy
Healthplans are at risk for 4% of premium, and are measured on preventing hospital visits, ER visits etc., goal is 44% reduction on spending on potentially preventable admissions
HHSC also measure plans on consumer satisfaction
Community care has increased dramatically, nursing home case loads have decreased over the last 10 years
Naishtat asks why consumer directed services has increased with managed care
- MCOs are required to educate consumer through service coordinators and can directly hire their own attendants
As STAR+PLUS was expanded, at the SSI level CBA became an entitlement, so as each expansion happened waiting list patients were receiving service
Everyone in SSI automatically receives services now
CBA waiting list is now populated by individuals from just above to 300% above SSI, more than 60,000 have been taken off the waiting list
Dental health coverage is a very big issue, provided piecemeal in some of the waivers and some plans provide as value-added benefits
Housing and workforce problems are other target areas
Chair Raymond asks after the status of TAHP
- Hopefully well
- A lot of room to grow quality wise on the long-term care side, HHSC has a funding program that flows through premiums to help with collaborative quality of care projects (staff/work ratios, innovations, quality of care projects)
Chair Raymond asks if TAHP has heard complaints from nursing staff concerning payments etc.
- There are a few, but HHSC has done a very good job of bringing MCOs and Nursing Home companies together
- Nursing homes face some issues with reimbursements depending on the number of involved organizations and the size of the home

Amanda Frederickson, Texas AARP

Roughly 2 million members, typically 50+
Much of the work AARP does is prepare people for retirement
Should have a person who directly reports to Executive Commissioner and who reviews projects and leads policy in Texas
While there are many great programs in the state, no one entity evaluates and coordinates all of these efforts
Improving the quality of care in nursing homes should be a priority for Texas moving forward, AARP was pleased to see the passage of SB 304
Network adequacy issues need to be addressed by HHSC
Chair Raymond asks what percentage of AARP’s Texas membership is in nursing homes, assisted living facilities, receiving home care etc.
- Does not have this information, typically AARP does not ask about living arrangements
Chair Raymond thinks it would be good to track these numbers, would provide valuable information
AARP is looking into ways to support family caregivers, 3.4 million unpaid family caregivers exist in Texas providing the equivalent of roughly $35 million of care and support for these caregivers would help the state save money
- Respite care, currently linked to Medicaid programs in Texas and the Lifespan Respite programs (receives only $500,000 for grants to respite care programs)
Naishtat asks how Lifespan money is disbursed
- Moves through DADS in grant selection program
Notification to family when patients are discharged can help family caregivers, likewise wound care and other information
AARP is also focused on helping Texans boost long-term retirement security, Sept. 2014 found many Texans 40-64 have little to no financial security
Direct deposit for paychecks dramatically increases ability of Texans to save for retirement
AARP is looking at voluntary, market-based approaches to encourage savings which would allow workers to commit some portion of their direct deposit paycheck to retirement savings

Rosemary Castillo, Texas PACE Association

Was developed to help individuals remain within the community and receive care
Receives perspective capitated payments from Medicaid and Medicare to provide a seamless healthcare delivery system, it is the only program which allows citizens to receive long-term and acute care through one delivery system
Increases quality of care while providing a savings to Texas taxpayers
Large portions of the served population have serious medical issues including dementia and diabetes
90% are dual-eligible, 3% are Medicaid only
TPA has very high retention due to education, competency training, and inclusion of family members into the program
Lack of understanding about PACE has challenged the effectiveness of the program
Rate reimbursement methodology is another big challenge for PACE, managed care system is not very well integrated as opposed to fee for service system
Would like to see how costs compare between managed care and PACE for medically fragile patients
Enrollment process is very lengthy, can take 90 days to get a patient into the system
PACE is very cost-effective, individuals typically do not experience any cost when they come into the system

Mary Teeters, Meals on Wheels

300 Meals on Wheels programs exist in Texas
Meals on Wheels delivery costs less annually than one hospital visit
5% of Meals on Wheels recipients entering nursing homes would mean $200 million cost to Texas

Stephen Fields, Himself

Texas is not ready for increased demands of aging Texans, money management support would greatly benefit senior citizens
Money management is the less restrictive alternative to guardianship and can allow people to live independently
No money management services are offered by any state agencies
Keough asks why it is the responsibility of the state to provide money management services
- Lack of proper judgment is typically involved in money management issues (e.g. depression, addiction, etc.)

Chris Kyker, Texas Silver Haired Legislature

Texas has been asking this question since 1957
Texas should handle this issue seriously and implement programs responsibly
HHSC should establish an office to coordinate program collaboration

Norma Baker, Texas Legal Services Center

Many senior citizens call into Texas Legal Services Center to receive answers to question involving benefits and receive advice over abusive caregivers
Abuse by caregivers needs to be addressed
Seniors face many financial problems

Chase Bearden, Coalition of Texans with Disabilities

Attendant wages are too low to provide quality care

Inez Russell, Friends for Life

Many elderly people face problems with household maintenance that do not necessitate long-term or serious care
The assistance that elderly individuals need to live independently does not exist in many counties(guardianship and money management, basic home maintenance)

Dr. Monica Aleman, Texas Nurse Practitioners

Individuals over 60 have special healthcare needs, from basic treatment to medications, etc.
Holistic care is needed to properly care for elderly individuals and workforce reform is desperately needed
Keough asks after her relationship with physicians
- Wishes to work more collaboratively with Texas physicians without threat of losing jobs etc.
- Texas regulations governing supervisory roles of physicians over nurse practitioners are unnecessary and impair access to care (allow nurse practitioners to see certain patients for some issues)

Kyle Piccola, The Arc of Texas

Parents are oftentimes the caregiver for people with IDD
Would like to see investment in community0based services to allow people with IDD to age with their communities

Bob Kafka, ADAPT of Texas

Care focus should be on the community, effort should be made to avoid guardianship at all times

Lynda Ender, Senior Source
Sarah Whitby, Senior Source

Senior source provides money management services for seniors, many seniors have difficulty managing money as they age and it is an important part of caring for elderly Texans

Vivian Armstrong

LGBT people are aging as well and face some unique problems, LGBT elderly are typically more isolated and have fears of financial insecurity
Naishtat has concerns that not enough people are trained to handle the geriatric community

Joe Flowers, Guardianship Services Inc.

Many seniors appreciate money management programs