Protections for home care workers. An improved workforce pipeline for the health care industry. An expansion of Medicaid for people without permanent legal status. Additional services and safeguards across Connecticut’s elder care sector.
Those are among the key health care priorities that will be weighed by lawmakers during the legislative session that begins next month. The 2024 session will run for just three months, from Feb. 7 to May 8.
“We have limitations, but the issues are quite significant, and those issues are impacting our citizens,” said Sen. Saud Anwar, D-South Windsor, a co-chair of the Public Health Committee. “We as legislators have to do the best we can and give it everything we have. I don’t want to lose a year.”
Fiscal constraints this year may be even more vexing than the time restrictions.
Legislators can’t add more than $30 million to the preliminary, $26 billion budget they adopted last June for the 2024-25 fiscal year without shattering the spending cap, Gov. Ned Lamont’s budget office estimated in November. That’s equal to roughly 1/8 of 1% of that plan’s general fund.
And there’s lots of competition for those scarce dollars. Leaders of the Appropriations Committee say they also expect heavy pressure to increase funding for child care, other social services, nursing homes and higher education.
“The time constraint, you can get around by working harder; the budget is the problem,” Anwar said. “The budget is the biggest limitation.”
Despite the challenges, many legislators have ambitious agendas for health care reform. A home care worker’s death last year sparked calls for added protections. Staffing shortages across the health care industry have prompted lawmakers to explore more ways to attract and retain providers.
Legislators have also heard about mounting issues in the elder care sector, from complaints on the quality of care in nursing homes to a lack of oversight in the home care industry. And long wait times for the approval of hospital mergers and acquisitions have inspired some lawmakers to examine changes to the state’s certificate of need process.
Advocates, meanwhile, continue to press for familiar but critical proposals, such as an expansion of Medicaid for residents regardless of their immigration status and the legalization of lethal medication for people with terminal illnesses.
Here are some of the top health care issues that are expected to be debated this session.
Protections for home care workers
Following the death of visiting nurse Joyce Grayson in October, advocates have called on lawmakers to increase protections for home care workers. Grayson’s body was found in the basement of the Reach House, a halfway house for convicted sex offenders, in Willimantic. She had an appointment there Oct. 28 to provide a resident with medication. A resident is suspected of, but not charged with, her death, media outlets in Connecticut have reported.
The calls for action have focused particularly on home settings, where many workers are behind closed doors with patients and vulnerable to dangerous conditions, including physical and verbal abuse. Health care workers who spoke at a November press conference noted that protections focused on home settings are severely lacking, which endangers the workforce, largely made up of women, and, specifically, women of color.
“We are not safe and our companies — it is their responsibility to keep us safe. They’re not,” said Sen. Martha Marx, D-New London, who is a visiting nurse. “We need to pass legislation. We can’t just count on them to do it.”
One proposal expected to be raised is the addition of an escort service for home care workers, which would pair employees with someone from a security agency or with emergency personnel. Legislators are exploring financial support for the endeavor, which they say should be compensated both through Medicaid and private insurers.
Anwar said home care agencies should also be required to develop risk assessment profiles of people utilizing the services and the areas they live in.
“A piece of the puzzle that’s missing is home care agencies and outpatient services at times do not have a risk profile of the patient, even though that information is available,” he said. It could include “some of the very basic things we already know about the patient’s background and risk — if they have been violent in a hospital, if they have a history of violence, and if they have been on registries for being harmful to anyone.
“Many times, the workers are just going in blind, they have no risk assessment,” he said.
Agencies could also develop policies where employees go out in pairs when appropriate, Anwar said, and companies should have a way to track a worker’s location, “in a manner that is safe and not intrusive.”
Marx said agency leaders should talk to law enforcement about what neighborhoods have high crime rates, and escorts should be assigned for employees going to those places. “I don’t want escorts being optional,” she said. “I don’t want the home care staff to decide if they want to take an escort because often … they might not want to [anger] their supervisor. If the supervisor says ‘Well, you don’t really need it,’ they may not want to challenge that.”
People who are convicted of violent behavior or have threatened medical workers should have a notation in their electronic medical records, she added. “I want some kind of red flag that states this patient has … been convicted of violent behavior or has threatened health care workers. Workers deserve to be protected.”
Tracy Wodatch, president and CEO of the Connecticut Association for Healthcare at Home, said she is in favor of the proposals, but they must come with financial backing.
“We support any proposal that will make it safer for home care visit staff to get their jobs done and serve the population,” she said. “However, any mandate that goes into place that requires additional staffing, escort services, additional assessments, etc., we need the funding to be able to do that. We can’t continue with our current funding to provide the services [and] add more requirements.”
Health care workforce
Lawmakers tried unsuccessfully last year to implement mandatory staffing ratios at Connecticut hospitals, citing staffing concerns. Instead, they agreed on an overhaul of hospital staffing committees and a requirement that hospitals produce staffing reports more often.
Under changes included in the state budget, direct care nurses now get majority representation on special committees in hospitals. The committees give workers a voice in each hospital’s staffing plans for the year. The budget adopted in 2023 requires direct care nurses to have one more spot than non-direct care employees on the committees. When developing staffing plans, the groups must evaluate research on patient outcomes, share with hospital workers the procedure for relaying concerns about staffing plans and assignments, and review grievances brought to the committee.
By law, hospitals already are required to submit staffing plans once a year to the state health department that provide “adequate and appropriate patient health care services.” The changes increase the submissions to twice a year.
This session, legislators are planning to focus on the workforce pipeline. Part of that effort would involve the creation of virtual reality programs for children and young adults in middle schools and high schools. The initiative is meant to entice kids and adolescents to enter careers as emergency medical technicians, paramedics, nurses, and certified nursing assistants.
Anwar is hoping to put state funds behind the program. “This is an opportunity to get our students to start learning, and then create a pathway for them to get the training,” he said. “We’re trying to give them a flavor of how this is done and what the requirements are.”
Some schools in the U.S. already use virtual reality programs to give children a look at careers in manufacturing or related fields.
Anwar did not yet have a cost estimate for how much he hoped the state would contribute.
Lawmakers also want to analyze how many people are putting in applications to attend programs for nursing or other medical careers at colleges and universities.
“Do we have enough people in the pipeline to provide care in current times and in the future?” Anwar said.
Elder care reforms
Last year, The Connecticut Mirror reported extensively on gaps in the state’s elder care system — both in nursing homes and home care — and highlighted worsening conditions in many nursing facilities. Serious violations known as immediate jeopardy orders were on the rise, a major nursing home chain faced a bevy of lawsuits, and the chief executive officer of that company acknowledged he was six months behind in paying health claims for employees.
Legislators did pass reforms last year, including a wide-ranging bill that boosts transparency in nursing home finances, increases oversight of homemaker companion agencies and adds protections for residents who are discharged from nursing facilities, among other priorities. But they passed on several other key initiatives, including higher mandatory staffing in nursing homes, funding for the long-term care ombudsman’s office that would have substantially increased staff and ensuring air conditioning was provided in all nursing home rooms.
Among the proposals being considered this year are a moratorium on admissions to nursing homes that do not meet the minimum staffing requirement of three hours of direct care per resident, expanding background checks for home care workers, boosting training opportunities for people taking care of family members, increasing funding for the ombudsman’s office, and launching a program that allows presumptive eligibility for Medicaid.
Advocates have also called for nursing homes to prohibit administrative staff from counting toward direct care, for an expansion of Connecticut’s paid leave law so people can use paid time off to care for siblings, grandchildren, parents and grandparents (current law permits workers to use paid time off to care only for children and spouses), and for caregiver tax credits or other reimbursement programs to offset the costs of caring for a family member.
Mairead Painter, the state’s long-term care ombudsman, is asking for funding for several additional positions, including a supervisor to oversee regional nursing home ombudsmen, another seven regional ombudsmen for nursing facilities, 11 more regional community ombudsmen to serve the home care population (currently Connecticut has one manager and one regional ombudsman for the entire state), and two intake coordinators.
This year’s priorities “go toward keeping seniors safe, and that includes backing the ombudsman’s office with the support they need,” said Rep. Jane Garibay, D-Windsor, a co-chair of the Aging Committee. “We put a number of laws in place, but we also need to give them the tools to enforce them.”
To help people who need access to Medicaid quickly, advocates have urged the state to consider presumptive eligibility.
Under the program, case managers and social workers use screening tools and financial information to swiftly determine if a person qualifies and to offer services. But there is risk involved. If a person ultimately is found ineligible for Medicaid, the financial burden of the services falls on the state or is shared with home care providers.
Medicaid, the primary funder of long-term care services, has a long approval process, sometimes as many as 90 days for verifying eligibility, state officials have said. For people who need elder care urgently, the system can unintentionally steer them toward nursing homes.
“Nursing homes will typically admit an individual pending Medicaid eligibility determination because they are generally able to bear the cost of providing services until they are eventually paid, or even to withstand a total loss if they are never paid,” AARP officials noted in a 2021 report. “In contrast, agencies that provide home and community-based care typically cannot afford to start services without the certainty of being paid right away.”
Garibay said she and other legislators are exploring the cost of launching such a program in Connecticut. At least seven other states offer it.
Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities, said he is open to the proposal of a moratorium on new admissions for nursing homes that drop below the three-hour care threshold.
“It’s consistent with a strong body of law, both at state and federal level, that already requires nursing home to provide sufficient staffing to meet the care needs of the residents,” he said. “But we want to explore further whether or not the proposal could have the unintended consequence of disrupting hospital admissions to nursing facilities, based on just a numerical evaluation, without regard to whether or not the facility can demonstrate that it can meet the care needs of those residents.”
“We are eager to be part of the discussion regarding the various aging services proposals. LeadingAge Connecticut supports the state’s minimum staffing ratio of three hours of direct care per nursing home resident day,” added Mag Morelli, president of LeadingAge Connecticut. “We also believe the state’s recently issued policies and procedures regarding those minimums address concerns raised regarding who constitutes direct care staff.”
Barrett said he hopes legislators in this session also consider imposing caps on the fees that temporary staffing agencies can charge nursing homes and authorizing medication technicians — or med techs — as a classification within the certified nursing assistant field to create a career ladder for people in that line of work.
“There’s no limitation in Connecticut on the fees that temporary nurse staffing agencies can charge Connecticut nursing facilities, whereas Rhode Island and Massachusetts cap the fees they can charge,” he said. “We think that will help address, in part, the staffing crisis.”
Certificate of need changes
Hospital executives and advocates intent on completing a deal for Yale New Haven Health to purchase three hospitals owned by Prospect Medical Holdings have turned a spotlight on Connecticut’s certificate of need process, especially the length of time it takes the state to approve or deny a merger, acquisition, closure or other change.
“It’s a big issue. A lot of things need to improve,” Anwar said.
The state has taken more than a year to issue a decision on the YNHH-Prospect sale, which has frustrated hospital officials and workers who say the Prospect facilities won’t remain financially viable if the deal falls through.
“It’s been incredibly frustrating to me that the CON process has taken so long,” Rep. Jason Doucette, D-Manchester, said during a November rally at the state Capitol. “Let me be clear about this: the CON process is broken. It’s a quasi-legal, quasi-judicial process that needs to be reviewed.”
At public hearings last fall, some stakeholders suggested setting tighter deadlines for completion — including timeframes as short as 30 days, or two weeks for fast-tracked applications. Several people called the process overly cumbersome and said it makes planning difficult. Some suggested applications should be overseen predominantly by people with clinical experience, rather than lawyers.
“It takes too long for an application to be determined,” James Iacobellis, senior vice president of government and regulatory affairs for the Connecticut Hospital Association, said during a September hearing. “We need to establish some deadlines [at] every step of the process, and we need to limit the extensions of time. If we’re going to establish deadlines, we can’t simply then extend them.”
Lawmakers are now debating what proposed amendments they’ll raise this year.
“We have to, as a committee, dive deeply into this conversation,” said Rep. Cristin McCarthy Vahey, D-Fairfield, co-chair of the Public Health Committee. “The timeline is an issue I think we all agree we’ve got to figure out. I’m interested in making sure we continue to safeguard our residents, but I know we’ve got to make some changes to the process.”
Medicaid eligibility expansion
The effort to extend Medicaid to children without permanent legal status has been a gradual and sometimes frustrating journey for many advocates. In 2021, legislators passed a bill opening the program to undocumented kids 8 and younger but delayed the launch until Jan. 1, 2023. In 2022, they broadened the population to include those 12 and younger.
Last year, a measure was introduced expanding it to everyone 25 and younger, regardless of immigration status. The Affordable Care Act allows children and young adults to remain on their parents’ insurance plans through age 26, and the idea was to mirror that policy.
But legislators settled on a pared back version, folded into the state budget, that extends Medicaid to kids 15 and younger regardless of their immigration status. Qualifying children who enroll can keep the coverage through age 19. But those older than 15 when the expansion begins will not be eligible. It takes effect on July 1, 2024.
The measure also directed the state’s social services commissioner to study the cost and benefits of opening the program to those 25 and younger.
“Us and a lot of folks we work with on the ground were very disappointed that the bill was cut [back] last year,” said Carolina Bortolleto, a volunteer with the HUSKY for Immigrants Coalition and a co-founder of Connecticut Students for a Dream. “We’re definitely looking forward to coming back this session and fighting to make sure more people are able to access health care.
“We have seen incremental increases over the last few years, but I think what that shows is our legislators know expanding access to health care is the right thing to do and they’re looking for ways to do it,” she added. “This session we’re hoping to work with our legislators to see what’s possible.”
Rep. Jillian Gilchrest, D-West Hartford, a co-chair of the Human Services Committee, said she hopes to see support for broadening the eligibility to age 18 this year.
“I’d like to at least get to 18. Maybe the ask is seeing financially, can we do it? Can we move it to 18 during this budget cycle?” she said.
Part of the challenge, Gilchrest said, is that the study ordered last year is not yet complete and the latest expansion doesn’t take effect for another six months. “Some folks are going to argue, ‘Let’s let it take shape. We haven’t seen the legislation go into effect yet.’”
This year’s effort could come in the form of a standalone bill or funds appropriated in the state budget.
“The legislature may be leery to act without that study; we know that may be an obstacle in getting support from some legislators,” said Rosana Ferraro, program lead for health justice policy and advocacy at the Universal Health Care Foundation of Connecticut. “[But] we’re very hopeful there will be at least some movement. We’re hoping for as much expansion as possible.”
Aid in dying
Last fall, an advocate at the center of efforts to pass legislation that would allow terminally ill patients to take a lethal dose of medication crisscrossed the state on foot, trekking 300 miles to raise awareness for the cause. Along the way, he stopped at diners and coffee shops, hosting discussions on the issue and promoting the talks on social media.
“If I’m terminally ill, have less than six months to live and want more options than this state allows, I have to seek that care somewhere else,” the advocate, Tim Appleton, said. Appleton is senior campaign director for the Compassion and Choices Action Network, which supports the so-called aid in dying legislation.
The bill has been raised more than a dozen times in Connecticut. In 2021, for the first time, it was voted out of the Public Health Committee. The committee advanced the measure again in 2022 and last year, but all three times, it has hit a roadblock in the Judiciary Committee.
Many oppose the measure.
Advocates for people with disabilities say the proposal puts vulnerable residents at great risk.
“The very real likelihood of misdiagnosis, misprognosis, abuse and error is just enormous,” Cathy Ludlum, head of the grassroots organization Second Thoughts Connecticut, told the CT Mirror in 2022. “And when a life is ended, you can’t go back and say, ‘Whoops, that was a mistake.’”
“We in the disability community have to keep saying that we don’t want to get in the way of anyone’s personal choice,” she said. “But when that choice becomes a threat to us, we have to stand up and say no.”
Despite the short session this year, there is momentum among proponents to revive the issue. But part of the approach might involve holding a joint public hearing with the Public Health and Judiciary committees, since the bill has cleared the former committee but not the latter.
“This bill has passed the Public Health Committee multiple times. With no change in the physical makeup of that committee or the Judiciary Committee, going through the same exercise is not a good idea unless … Judiciary Committee members have the opportunity to be part of the public hearing and listening to advocates and opponents of the bill,” Anwar said.
Rep. Steven Stafstrom, D-Bridgeport, a co-chair of the Judiciary Committee, said he has not yet been contacted by members of the Public Health Committee about a joint hearing, but that such a move would be “highly unprecedented.”
“I think [it would] likely [be] unwieldy to try to do that,” he said. “I can’t recall a time, certainly in my 10 years in the legislature, that the Judiciary Committee has done a joint public hearing during session with another committee on a bill. I’m not entirely sure how that would work, or, frankly, whether it’s even permissible under our rules.”
Stafstrom said his committee has not yet discussed the issue this year, but he noted that the group has the same members and “the bill lacked the votes in the committee last year.”
“I think everybody has their own reasons for either supporting or opposing this bill,” he said. “I don’t think there’s uniform opposition to the bill. I suspect there are certain folks on the committee who oppose it purely on philosophical grounds. I think there are others who oppose it because they’ve heard the opposition from disability advocates in the state. And I think there are others who are concerned about the language of the bill.”
Sen. Gary Winfield, D-New Haven, co-chair of the Judiciary Committee, has been a vocal supporter of the measure, at times tearfully recalling his mother’s health decline during debates.
At a hearing last year, Stafstrom said: “This is an issue that this committee struggles deeply with. I know it’s an issue I personally struggle deeply with. … There are still some outstanding issues and we are right to be cautious on it.”
Asked recently about his personal views on the proposal, Stafstrom declined to elaborate.
CT Mirror Reporter Keith M. Phaneuf contributed to this story.
