'There Had to Be Caring'
CAHF's 60-plus years of service
CAHF began in January 1950 as the California Association of Nursing Homes, Sanitariums, Rest Homes, and Homes for the Aged, or CANH, pronounced “can.” It was an era of long-term care virtually unrecognizable to modern caregivers. But from the earliest “mom and pop” nursing homes – and in the beginning they literally were homes – one theme has remained constant.
“There had to be caring,” said Louise Broderick, who began her long-term career in 1946 and went on to be president of CANH from 1962-1964. “If you care for people, you have to care from the heart every day. You take care of people and develop a reputation for quality.”
The movement toward a professional organization of long-term care providers began before World War II, with the formation of regional groups. By mid-1949 providers in the San Francisco area were staging rummage sales, card parties and similar events to pay the costs of organizing statewide. After preliminary meetings, 29 delegates from around the state gathered Aug. 14, 1950, in San Francisco to agree on articles of incorporation for the California Association of Nursing Homes, Sanitariums, Rest Homes, and Homes for the Aged Inc.
CANH becomes CAHF
The cumbersome name and the inevitable acronym, CANH, lasted until the organization became the California Association of Health Facilities in November 1972.
In retrospect, CANH’s early years seem incredibly modest. The Association continued to rely on rummage sales to raise operating funds, and the "office" consisted of a corner of a facility administrator's desk. But there were growth and activity. In the mid-1950's the Association added new chapters, began its first news publication and starting issuing membership directories. In 1957, after compiling data on actual expenses of nursing facilities, CANH gained long-overdue increases in the payments from the state Bureau of Old Age Security. The increases, the first since 1949, ran from $25 to $45 per month – about 20 percent.
In 1960, CANH reluctantly decided on its first increase in annual dues – from $1 to $2 per bed – enabling the Association to hire its first executive director, C. Robert Harberson, who stayed in that post for nearly 10 years.
Then in a setback to statewide unity, the Los Angeles Chapter dropped its membership in 1961, partly because the Association had decided to establish headquarters in Sacramento rather than in Southern California. But with the growing role of the federal government in health-care regulation, providers needed a solid political front, and in 1966 the Los Angeles County facilities rejoined CANH.
Medicare and Medicaid
The new age of long-term care came with the Medicare Act of 1965, including authorization for Medicaid – called Medi-Cal in California – which went into full effect for nursing facilities in 1967. Although commendable for trying to rationalize the chaotic array of long-term care services, regulations and payment systems, Medicare and Medi-Cal caused increasing frustration among long-term care providers, who found themselves depending on bureaucrats at both the state and federal levels.
In 1972, 22 years after the meeting in San Francisco where it was named, the California Association of Nursing Homes, Sanitariums, Rest Homes, and Homes for the Aged Inc. became the California Association of Health Facilities. By then, many of the pioneering leadership of the old CANH – primarily the women and men of the San Francisco area and elsewhere in Northern California – were being replaced by a new generation which reflected the nationwide trend toward larger facilities and multi-facility corporations.
The “mom and pop” homes were disappearing. Between 1960 and 1970, the number of nursing-facility beds in California increased 500 percent, while the number of facilities merely doubled. The very term nursing “home” had become quaint, and the terms “convalescent hospital” and “skilled-nursing facility” became more common.
Gov. Ronald Reagan took office in 1967, bringing to power an administration dedicated to cutting back government spending. When he proposed in 1970 that the state slash reimbursement rates and demand that providers return $45 million in “overpayment,” many CANH members were ready to revolt. The Los Angeles Times covered the unrest at the Association’s convention and ran a headline at the top of the front page trumpeting: “Boycott of Medi-Cal Urged.” And although Reagan and his successor Gov. Jerry Brown differed in many ways, both their administrations were hard on long-term care. When Brown took office in 1975, he continued efforts to reduce government services.
The state budget-making process was an annual struggle for CAHF, and the results often were a mixture of progress and setback. A good example was 1976. After a major push from the Association’s Governmental Relations Committee, the Legislature voted for a $35.4 million Medi-Cal increase for 1977, only to have Gov. Brown slash the Legislature’s proposal in half.
'Train the Trainer'
By 1972 California administrators were earning licenses in their profession from BENHA, the new state Board of Examiners of Nursing Home Administrators. The Association sponsored a broad program of continuing-education workshops and courses, with the special emphasis on upgraded training of nurse aides. The problem was how to reach thousands of caregivers at facilities throughout the state. The solution was a large-scale “Train the Trainer” program.
CAHF won a $99,000 contract from the federal Department of Health, Education and Welfare to fund the training of 6,000 nurse aides indirectly by preparing 200 registered nurses, who would in turn train the aides locally. Originally designed to run for 18 months, the program was expanded with additional grants. CAHF not only administered this major program, it funded others of its own and in 1977 appropriated $20,000 to help prepare aides for testing.
By the beginning of the 1980s, CAHF had nearly 900 members and 80,000 beds. It stood in the foremost ranks of health-care advocacy and spoke with a firm voice for an often maligned profession which now included a wide array of skilled-nursing, intermediate-care, mental-health and assisted-living facilities.
After three decades, it was time for the Association to reorganize, partly as a result of the increasingly large role of multi-facility providers. First, the 40-member Board of Directors, which had met quarterly, was replaced by a 15-member Board which met monthly – enabling CAHF to act more quickly and with more flexibility than before in dealing with fast-moving health-care issues.
Through mergers, the number of chapters was reduced and made more uniform in size, and CAHF’s five regions were organized. This streamlining went on to include a realignment of the multi-facility members of the Association which formed a new conference with representation on the Board of Directors. Two other familiar CAHF institutions began in this period – a regular newsletter and the Quality Care Health Foundation.
Since at least 1954, CAHF had published several magazines designed for outside audiences. But CAHF traditionally notified member providers of “breaking” news only through random bulletins. Realizing that this approach was out of date in the age of Medi-Cal and Medicare, CAHF started Long-Term Care News, a newsletter devoted specifically to regulatory and legislative news for CAHF members. LTC News proved to be the best way to keep working administrators abreast of the news they needed to know to do their jobs. It grew to include special sections for various licensure categories.
Quality Care Health Foundation
At about the same time, the Association took a major step in education by establishing the Quality Care Health Foundation. Starting in January 1983, after two years of planning, QCHF brought all training programs together under one entity and provided the classes necessary to meet the licensing requirements of the state boards of Nursing Home Administrators, Registered Nursing and Licensed Vocational Nursing.
It was only the beginning. As the regulatory environment became overwhelmingly complex, QCHF went on the road and broadened its offerings to include detailed how-to classes at locations all over the state. QCHF became involved in workforce issues and, with generous financial support from associate members, started the Career Climb Scholarship Fund, later to be renamed the Paul Tunnell Career Climb Scholarship Fund, after a CAHF Board Chair who passed away while in office.
In addition, the Association kept expanding its public-relations efforts. With contributions from dozens of chapters and businesses, CAHF produced a sound-and-slide program available for individual facilities to show and undertook a meet-the-media campaign that brought CAHF leaders together with newspaper editors and television stations around the state, especially in areas where coverage had been sparse or biased.
California Nursing Home Reform Act of 1985
In 1983 a report from the state Little Hoover Commission alleging that lax enforcement and inadequate regulations were creating substandard conditions in some California nursing facilities led to a package of reform bills enacted by the Legislature in 1984 – but vetoed by Gov. George Deukmejian. Realizing that reform was on the horizon, CAHF sought a balanced combination of fair reimbursement for good facilities as well as tightened enforcement for the bad apples.
The next year the effort succeeded, and CAHF was present when Deukmejian signed the California Nursing Home Reform Act of 1985, which authorized improvements in training for nursing-facility inspectors, development of resident councils and increased wages and staffing in Medi-Cal facilities. This was a major victory for CAHF and for the broad coalition of providers, consumers and advocates who were growing increasingly concerned about the quality of care for the elderly.
As it entered its fifth decade, CAHF reflected changes in the long-term care professions by continuing to diversify its offerings. Long-Term Care News started publishing RCFE Report with information tailored for CAHF’s assisted-living members and Declarations of Independence for providers of services to people with developmental disabilities, who joined CAHF in 1993, following the voluntary disbanding of CAIP, the California Association of ICF Providers. In March 1993 subacute care was the subject of a special CAHF meeting, and two months later CAHF was working with the Department of Health Services on a pediatric subacute work group.
Meanwhile, forces and issues were taking shape at the state and national levels in the late 1980s and early 1990s that would resonate to the present day and truly mark the modern era in CAHF’s history. Of these, two words stand out – OBRA and Valdivia. OBRA, the Omnibus Budget Reconciliation Act of 1987, imposed very specific requirements which providers must follow to be compensated for their services and authorized a much more complete program of enforcement and sanctions. The complexity of the measure ensured that there would be confusion among both providers and bureaucrats.
Implementation of OBRA was set for Oct. 1, 1990, but California officials glumly predicted that deadline would not be met. The stage was set for litigation, and residents at a nursing facility filed a class action to cause the Health Care Financing Administration and the state of California to enforce the OBRA provisions.
The case was Valdivia et al. vs. California Department of Health Services, and, following legal twists and turns, it became a high point in CAHF’s history. “In terms of external struggle, OBRA was the big thing, and Valdivia was a victory,” said Jack Markovitz, CAHF president in 1991-93. Concerned that the state would implement OBRA requirements without the reimbursement increases necessary to implement OBRA mandates, CAHF decided to file a motion to intervene in the Valdivia case. “We hit the state head on,” recalled Lori Costa, CAHF director of regulatory programs at the time.
In August 1992 the court rendered a partial decision which settled the consumer portion of the case, leaving the focus on provider issues, and CAHF staff geared up to gather evidence and take depositions from witnesses. Then in July 1993, after 90 days of intense negotiations, Valdivia was settled out of court in CAHF’s favor. It was an intoxicating victory that was showcased by media across the nation. For the short term, the Valdivia settlement provided additional funding for compliance with OBRA ’87 in the form of a Medi-Cal rate increase for nursing facilities of $2 per patient day that was scheduled to last for two years.
In the larger sense Valdivia affirmed the legal principle that the court as third-party arbiter could direct the government to pay the costs of mandated regulations such as those in OBRA.
During Gov. Wilson’s second term, CAHF continued to struggle every year for adequate reimbursement and fair regulation – with mixed results. In 1995, for example, CAHF successfully lobbied against severe Medi-Cal cuts and even found something to praise in the governor’s budget plan – a new short-term subacute program for freestanding skilled-nursing facilities. In 1996 CAHF prevailed against a plan by the Department of Health Services to cut nursing-facility reimbursement rates through a Medicare cost separation, or “carveout,” artificially reducing Medi-Cal cost reports by what DHS estimated would be the cost of care in a Medicare distinct-part facility.
But the state budget process was rougher in 1997, and CAHF was unable to achieve a funding augmentation to offset a “ripple effect” in caregiver salaries created by increases in state and federal minimum wages. In that year, as in so many other years, a budget stalemate caused the state to miss the constitutional deadline for implementing the annual budget, with predictable results for health-care providers who depend on Medi-Cal reimbursement. As the impasse dragged on to Aug. 18, 1997 – the second-longest budget delay in state history – CAHF did what it could to assist members with their financial and business needs during the lag in Medi-Cal payments.
'This is not a widget shop'
And this time CAHF’s efforts to draw media attention to the plight of Medi-Cal providers during a budget stalemate yielded results. On Aug. 7 the Los Angeles Times featured developmental-services providers P. Dennis Mattson and Nancy Kelly in an article which focused on the plight of group-home operators. Mattson, chairman of CAHF’s Developmental Services Conference, told the Times, “This is not a widget shop. We provide services to human beings. You don’t just close your doors. . . . I can assure you that there are many of us who are hanging by a thread.” CAHF member Georganne Slapper appeared on the Today television program, and CAHF got a front-page article in The Wall Street Journal, extensive coverage in other newspapers and on five television stations and at least two radio stations throughout the state.
The next year new CAHF-sponsored legislation authorized the state to keep issuing Medi-Cal payments past the budget deadline, regardless of deadlocks. As a result, providers in 1998 did not face the same agonies as in previous years – even though the 1998-99 budget was 52 days late.
Still, life in the late 1990s was hard for long-term care providers. At the federal level, CAHF and its members coped with criticism from the General Accounting Office and visits to “randomly selected” California nursing facilities. A 1998 hearing by the U.S. Senate Special Committee on Aging under the chairmanship of Sen. Charles Grassley, R-Iowa, elicited sharp responses not only from CAHF but from state Department of Health Services Director Kim Belshe, who took such strong issue with Grassley’s allegations that she refused to send DHS officials to testify.
A poll by McKnight's Long-Term Care News found nursing-facility surveys got tougher in 1999 and were expected to get tougher still in 2000, and the American Health Care Association reported that California had been the hardest hit of all states by cuts in Medicare reimbursements under the 1997 Balanced Budget Act.
Litigation and higher insurance rates
Providers also faced escalating insurance rates triggered by an explosion of litigation. And the labor pool was on a steady decline at a time when the demand for additional labor to respond to the consumer and clinical demand was growing rapidly. But despite misguided “crackdowns” and the seesaw struggle for fair reimbursement, CAHF approached its 50th anniversary with new confidence.
The Association’s agenda was full. The CAHF CNA Task Force worked with the Department of Health Services on issues such as fingerprinting and criminal-background checks for direct caregivers. CAHF also worked with DHS on revision of treatment-authorization requests, or TARs, and CAHF-sponsored legislation directed DHS to develop criteria and a process for utilizing TARs for services provided by ICF/DD, DD-H and DD-N facilities.
The Association streamlined its Sacramento staff, created CCAL – the California Center for Assisted Living – and dedicated a director-level staff position strictly to media and public advocacy. CAHF also launched the most significant audit review and appeal project ever undertaken by a state health association with a goal of reducing Medi-Cal audit disallowance to as low a number as possible. Calling for a dues increase of $2.50 per bed to help pay for media outreach and grassroots campaigning, the CAHF Board of Directors launched the major Challenges '99 initiative to achieve new Medi-Cal funding for facility staff and wage enhancements, improvements in the survey and enforcement system and reform of the rate system.
A high point of public exposure came at the Associations’s May 1999 Legislative Conference, when facility residents, many of them in wheelchairs, joined caregivers and CAHF members and associate members for a Challenges '99 rally on the steps of the state Capitol. At the same time, Challenges '99 promoted a campaign to send nearly 80,000 postcards with a printed long-term care message to legislators.
Although CAHF did not achieve the Medi-Cal funding it sought for a $2 per hour wage increase for direct-care staff, the Challenges '99 momentum was up, and CAHF was ready for 2000. When Gov. Gray Davis proposed his own Aging with Dignity initiative – which included many of the reform proposals he had vetoed the previous year over cost concerns – CAHF Acting President Ron Kurtz responded, "Now that we have the governor's attention, we have an opportunity to make some positive changes.”
Buoyed by the governor's recent revision of the proposed state budget, which included provisions for what was anticipated to be the most significant Medi-Cal reimbursement rate increase in more than a decade, CAHF repeated its impressive Capitol rally during the May 2000 Legislative Conference with even greater turnout.
CAHF took advantage of the mood at the Capitol to gather public support and promote awareness of the funding and staffing crisis faced by many providers through an energetic community-relations push. The Association purchased billboard and bus-stop advertising, ran radio commercials and produced several video news releases in English and Spanish, featuring providers, caregivers and legislators who supported additional funding. “Earned” publicity in the form of sympathetic newspaper articles and editorials and stories on television news programs appeared throughout the state.
The effort and optimism paid off. The 2000-01 state budget, signed in to law on the June 30 constitutional deadline by Gov. Davis, contained the largest-ever Medi-Cal rate increase for long-term care facilities. In addition, there was funding for a wage pass-through for both direct-care staff and other employees, including linen and laundry, plant operations and maintenance staff, housekeeping staff and dietary staff. The total 2000-01 package amounted to an unprecedented $500 million in spending on long-term care.
On CAHF's 50th anniversary, Chairman Roland Rapp said, “Our 50th anniversary is marked by a cooperative spirit with our governor, the Legislature, labor and consumer advocates. The growing credibility of our members, the new partnerships being forged with our Capitol leadership and consumer groups offer great promise that, whatever shape our profession takes in the future, there will be a place for the kind of dedicated and compassionate individuals who make up our membership,” he said. “Our commitment will not change in the 50 years to come.”