How political lobbying pays: a look at Ohio

Nursing Homes, Oct, 2005 by Ann McDermott

If the Assisted Living Federation of America presented an award to the state affiliate with the greatest legislative success story this year, it would go to the Ohio Assisted Living Association (OALA). Executive Director Jean Thompson's leadership and skill led to two major wins for the assisted living field, and both will have far-reaching implications for providers, residents, and families.

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Over the next two years, Ohio will implement two assisted living--related programs: The Medicaid waiver program will allow SNF-eligible Medicaid recipients the option to receive services in residential care facilities (RCFs), the term used to describe assisted living services; the second program creates a medication aide training program that will allow trained aides to administer medications in the skilled nursing and residential care settings. Both cases required a number of lobbying tools to achieve victory-grass-roots advocacy, coalition building, and direct member lobbying.

A Medicaid waiver program for RCFs is not an entirely new concept. Gov. Bob Taft tried to get the program approved in a previous budget, and independent bills had been introduced for a number of years. This year's plan was to create a voluntary program that would guarantee 1,800 slots for SNF-eligible Medicaid recipients. Once the governor's budget was announced, OALA quickly joined in support of the waiver proposal.

The Ohio House of Representatives, charged with approving the governor's budget first, dramatically altered his plan, reducing the number of slots to 1,000 and adding some unusual conditions. For example, an RCF could participate in the waiver program only if a skilled nursing facility is on-site.

Although dismayed by the House's action, Thompson and OALA did not give up the fight and turned their attention to the Ohio Senate Finance and Financial Institutions Committee. Chairman John Carey had cosponsored a Medicaid waiver program before the release of the governor's budget, so Thompson was cautiously optimistic that changes to the House proposal might be possible.

Major metropolitan newspapers were critical of the House action, and the Departments of Health and Aging stated that they were unsure that the House amendments would be approved by the federal agency, the Centers for Medicare & Medicaid Services (CMS). Two additional allies proved to be extremely valuable to Thompson--AARP, which had made the Medicaid waiver program one of its top three priorities, and the Area Agencies on Aging, the group that would be the gatekeepers for the program.

OALA members aggressively lobbied Senate Finance Committee legislators, and Thompson met with these legislators continuously to advance OALA's support for Taft's original proposal. The work paid off--the Senate approved the plan and the proposal accepted during House/Senate conference committee negotiations on the budget. Placement of Medicaid residents in RCFs will begin on June 30, 2006. Participating providers will be paid an average of between $60 and 70 per day for direct-care services. Additional details will be negotiated as the state moves to implement regulations over the next year.

The second issue involved medication aide training. Last fall, Thompson assembled an internal OALA workgroup, composed heavily of nurses affiliated with RCFs, to craft possible legislative language. When the governor's office heard about this effort, staff contacted OALA and requested draft language.

Before the governor's budget was released, early in December 2004, an emergency meeting of the various medication aide stakeholder groups, including OALA, was called at the direction of two other associations in an effort to move an amendment creating a medication aide training program through the legislature in the final days of the session. Some stakeholder groups were upset that they had not been consulted in advance. And OALA objected to a provision that would have required 24-hour on-site nursing supervision, a provision that most RCFs would be unable to meet.

Concerns prompted the Senate Health, Human Services and Aging Committee to not act on the proposal before the end of the session. The medication aide training issue was resurrected a few months later when the governor's 2005-2007 budget was announced. On this issue, Thompson worked closely with the state nurses' association, which accepted the program with reservations, offering recommendations and recognizing that a critical shortage of nurses exists and that medication administration is a vital issue in long-term care delivery. The nurses' association helped ensure that OALA and others were included in Senate Finance Committee meetings on the issue. Last-minute attempts to exclude residential care settings from the pilot project were defeated, and the program was approved.

Under the plan, 40 RCFs and 80 SNFs will participate in a yearlong study that will end on July 31, 2007. Barring any major problems, the program will become operational statewide the following month. Participating RCFs must be deficiency-free in skilled nursing care and medication administration. Participating RCFs must obtain written consent from residents, and they must pay a fee to the Board of Nursing (since additional funding was not provided).