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California's In-Home Supportive Services debate: An application and critique of the governmental politics model of the decision-making process

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California's In-Home Supportive Services debate: An application and critique of the governmental politics model of the decision-making process

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CALIFORNIA'S IN-HOME SUPPORTIVE SERVICES DEBATE:
AN APPLICATION AND CRITIQUE OF THE GOVERNMENTAL POLITICS
MODEL OF THE DECISION-MAKING PROCESS
by
Katherine Annette Hansen
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTERS OF SCIENCE IN GERONTOLOGY
MASTERS OF HEALTH ADMINISTRATION
May 1999
Copyright 1998 Katherine Annette Hansen
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UMI Number: 1395132
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UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park
Los Angeles, CA 90089
This thesis, written by
K .& Jrh csclcie Aofjd-fos* [\a____ _______________________
under the director of h e.r Thesis Committee and approved by all its
members, has been presented to and accepted by the Dean o f the Leonard
Davis School of Gerontology and the Dean of: Pu L l.v : A .
in partial fulfillment of the requirements for the degree of
^ .,- r e - ^ r ^ Try & _______________________
Dean
Dean
Date __________________
THESIS COMMITTEE
{ (A ^ U ~^ ~
Chairman
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TABLE OF CONTENTS
LIST OF TABLES.......................................... ii;L
CHAPTER I: INTRODUCTION................................ 1
The Program........................................ 3
The Problem........................................ 7
The Process........................................ 1-0
Chapter Summary............... 1 - 1 -
CHAPTER II: LITERATURE REVIEW.......................... 13
California Political Participants................. 1-4
Conceptual Framework of the Political Process 20
Chapter Summary.................................... 30
CHAPTER III: THE HISTORY OF THE IHSS DEBATE............ 31
Historical Events................................. 31-
Chapter Summary.................................... 41-
CHAPTER IV: METHODOLOGY................................ 42
Measuring Concepts................................. 42
Research Approach.................................. 43
Subjects............................................ 47
Procedures, Strategies, and Limitations.......... 48
Chapter Summary.................................... 31
CHAPTER V: ANALYSIS and FINDINGS....................... 53
The Governmental Politics Model Applied............ 33
CHAPTER VI: CONCLUSION.................................. 65
REFERENCES............................................... 68
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LIST OF TABLES
TABLE_________________________TITLE________________________ PAGE
3.1 IHSS Bills Introduced to the State Legislature 33
3.2 IHSS Consumer/Advocate Meeting Participants 37
4.1 Personal Documentation 4 6
4.2 Data in the Form of Proposals, Reports, and 47
Evaluations
5.1 Interest Criteria Exhibited by Key Participants 55
Under the Governmental Politics Model
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CHAPTER I: INTRODUCTION
There is no crisis, no urgency, no state
budget item, no demand from consumers,
advocates, providers, counties or the
state which compels the adoption of IHSS
budget trailer bill language... which will
cause debate. (T. Porter, letter to
Governor Wilson, July 1995)
The debate over whether states should deliver health
services to homebound individuals by means of the
independent provider or agency provider has been around
since home-based long-term care programs were introduced
about twenty years ago (Doty, Kasper, Litvak & Taylor,
1995) . This debate is not new to California's largest home
health program, In-Home Supportive Service (IHSS).
In recent years, however, the debate has centered on
various attempts by home health care agencies to expand
agency provider services throughout California's IHSS
program. Although counties are authorized but not mandated
to contract with home health care agencies, fewer than 25%
utilize agencies to deliver IHSS (Orange County Social
Services [OCSS], 1995).
Consumer advocates view the expansion of the agency
provider model as unnecessary because the traditional
independent provider model is seen as "the epitome of
privatization, in that, IHSS recipients employ their
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caregivers, not the state and not the county" (R. Hawkins,
letter to Senator Lewis, September 8, 1995).
Despite attempts by advocates to block the expansion of
agency provider services under IHSS, Senate Bill 1780 (1996)
has recently been enacted. This bill establishes a new
model of service delivery managed by home health care
agencies (Chapter 206 of the Welfare and Institutions Code
section 12302.7, 1996).
The decisions and actions leading to the adoption of
this language are the result of a decision-making process
involving a number of key political participants. In an
attempt to explain the IHSS debate, this study is designed
to address the decision-making process through a single
conceptual model. More specifically, this study postulates
that a number of key individuals involved in the debate
influenced the outcome of the political process.
Therefore, the primary objective of this study is to
examine the IHSS debate by means of Graham Allison's (1971)
Governmental Politics Model of the decision-making process.
To achieve this objective, this study utilizes data
collected from an 11-month participant observation case
study.
This case study was conducted while the author was
working for the Public Interest Center on Long Term Care
(PICLTC) in Sacramento, first, from the perspective of a
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policy intern, and second, from, the perspective of a part-
time temporary consultant. The Public Interest Center on
Long Term Care (PICLTC) , a non-profit organization aimed at
sustaining consumer-driven long-term care in California,
played a major role in advocating on behalf of the IHSS
consumer.
The data collected for this study provide descriptive
information discovered through direct observation, archival
records, and written documentation. Furthermore, through an
examination of the IHSS program, problems, political
participants, historical events, and several conceptual
models, this study applies Allison's Governmental Politics
Model to the case study at hand.
The Program
In-Home Supportive Services (IHSS), administered by
each of California's 58 counties, is a home health delivery
program mandated by the California Department of Social
Services (CDSS)(OCSS, 1995). As specified under rhe state's
Medicaid plan, California is mandated under federal law to
provide home care services to eligible aged, blind and
disabled individuals receiving federal assistance. Although
each state establishes its own Medicaid plan, California
chose as part of its plan to provide home care, which is
considered an optional service under federal law. Home
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health services through the IHSS program, hence, must be
provided to all eligible California residents.
Recipients and Services
The IHSS program serves more than 178,000 individuals
annually (R. Lopez, personal communication to Hansen, July
3, 1995) . Recipients of the program include frail elderly
and disabled individuals needing domestic, personal and
paramedical services enabling them to remain in their own
homes (Department of Developmental Services [DDS], 1995;
PICLTC, 1997). Services provided by IHSS vary, depending on
the extent of the recipient's disability, and range from
meal preparation to shopping assistance to personal hygiene
(OCSS, 1995). Furthermore, the type of service delivery is
divided into two separate parts— the Personal Care Services
Program (PCSP) and residual IHSS.
Under the first part, personal and paramedical services
including respiration assistance, bathing, hygiene, grooming
and ambulatory assistance are provided as an option under
Medi-Cal (DDS, 1995; PICLTC, 1997). Residual IHSS
recipients receive domestic services not provided through
PCSP including heavy cleaning, meal preparation, shopping
errands and laundry services (DDS, 1995; PICLTC, 1997) .
Although IHSS services may be authorized under either PCSP
or residual IHSS, eligible recipients are allowed to receive
services only under one part.
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Funding
The IHSS program uses a combination of state, federal,
and county funds for a total funding amount of nearly $1
billion. Based on 1995 figures, the IHSS budget consists of
$250 million in state general funds, $170 million in federal
funds (Title XX of the Social Security Act), $300 million in
federal Medicaid funds (Title XIX of the Social Security
Act) , and $220 million county general funds (Senior Safety,
1995) . The funding of the IHSS program is broken down into
two parts. Approximately $730 million is used directly to
pay IHSS providers, while the remaining $210 million is
block-granted to cover administrative costs (LHC, 1991).
While a number of fund sources contribute to the IHSS
program, the PCSP and residual IHSS are funded differently.
The cost of the PCSP is shared by the county (50%), state
(17.5%) and federal (32.5%) government, however, only the
county (35%) and state (65%) share the cost of residual IHSS
(DDS, 1995). Since there is no federal funding for residual
IHSS, the cost is higher to both the state and county. As a
result, eligible IHSS recipients are usually provided
services through PCSP (DDS, 1995).
Service Delivery Models
The method of service delivery for IHSS varies from one
county to another. The two service delivery models are the
individual provider and agency provider models. Although
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some counties utilize both models of service delivery (LHC,
1991), approximately 45 of the 58 counties exclusively
utilize the independent provider model(OCSS, 1995). All
counties must, however, offer the independent provider model
because under law all severely impaired recipients have the
right to hire their own providers (California Rural Legal
Assistance Foundation [CRLAF], 1990).
The two service delivery models differ in several ways.
The individual provider is hired directly by each recipient
or the recipient's representative, is paid an hourly minimum
wage by CDSS, and usually serves more impaired recipients
(Barnes & Sutherland, 1995; DDS, 1995; PICLTC, 1997; OCSS,
1995). Under this model, severely impaired recipients may
be authorized for up to 283 hours per month while
nonseverely impaired recipients receive a maximum of 195
hours (DDS, 1995).
Through the agency provider model, CDSS allows counties
to exclusively contract with home health care agencies to
provide all IHSS services (DDS, 1995). The home health care
agency hires and pays providers (OCSS, 1995; Barnes &
Sutherland, 1995), and is mandated to serve all IHSS
recipients, except for recipients classified as severely
impaired who, have the option to hire an independent
provider (CCD, 1995). According to DDS (1995), services
provided by an agency provider are tasked-based, not hour-
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based. That is, the agency provider is granted the same
number of hours as the independent provider but can utilize
fewer hours as long as the same services or tasks are
performed as specified by an IHSS assessment (DDS, 1995).
In 1996, a new model of service delivery known as Task
Frequency was enacted under Senate Bill 1780 as Chapter 206
of the Welfare and Institutions Code section 12302.7 (1996).
Although this delivery model has yet to be adopted,
regulations to govern this new model are being developed by
the Department of Health and Social Services ( Long Term
Care News, March 1997).
Similar to the agency provider, the Task Frequency
Model allows home health agencies to manage service
delivery. Specifically, a home health care agency arranges
and provides all services to the IHSS recipient. The agency
holds the responsibility for screening, selecting, training,
supervising and firing the IHSS provider. Thus, service
delivery is not based on the number of hours utilized by the
IHSS provider; instead, service delivery is based on the
number and frequency of tasks performed.
The Problem
Opponents and proponents of the independent provider
model have expressed concern towards the service delivery
methods utilized under the IHSS program. The agency provider
model is seen by its opponents as an unnecessary expansion
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of the scope of privatization (for the purpose of this
study, privatization is defined as the involvement of home
health care agencies in exclusively managing both the
service provider and administrative portion of IHSS).
Traditionally, the independent provider model is
overseen by the California Department of Social Services
(CDSS) and administered by a county agency. Although
independent providers are not governmental employees, the
administrative portion of the program is not 1 , 1 privatized"
under this model. Furthermore, consumer advocates view the
independent provider model as "the epitome of privatization,
in that, IHSS recipients employ their caregivers, not the
state and not the county7 ' (R. Hawkins, letter to Senator
Lewis, September 8, 1995).
Critics of California's In-Home Supportive Service
(IHSS) program, Addus Home Care and United Domestic Workers
of America (UDWA), contend that the traditional service
delivery method— the independent provider— has failed to
provide adequate care to frail recipients. Furthermore,
they suggest that the state does not establish safeguards
against instances of financial fraud, abuse, neglect and
mistreatment of vulnerable individuals under the independent
provider model (Doty, Kasper, Litvak & Taylor, 1995).
The Independent Living Centers (ILC) and PICLTC,
however, advocate on behalf of the "traditional" system by
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supporting the continuation of the independent provider
model. They argue that home health care agencies should not
have the authority to directly manage the IHSS provider. The
IHSS recipient, instead, should have the right to hire,
fire, train and supervise their aides and should either be
permitted to pay their aides directly or participate in
paying them (Doty, Kasper, Litvak & Taylor, 1995; Senior
Safety, 1995) .
Issues have also been raised by the CDSS concerning
IHSS reform and government funding. According to a 1995
Orange County Social Service (OCSS) analysis of an agency
bid, IHSS reform could heighten the debate between the
county, state and federal government about ongoing Medicaid
funding.
Essentially, both state and federal waivers would be
necessary before any changes could be made to the state's
Medicaid plan (OCSS, 1995). Under current law, the state
government mandates an hour-based system for the IHSS
program (OCSS, 1995). As stated earlier, the agency
provider [and the Task Frequency] does not ensure any
specified hours of service, therefore modifying the state's
Medicaid plan. For the same reason, the federal government
has threatened to stop ongoing Medicaid funds to California.
This is an essential element for the state to be eligible to
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receive Medicaid funding (Title XIX of the Social Security
Act) (OCSS, 1995) .
The Process
In an attempt to understand the political process
surrounding the IHSS debate, a method of evaluation is
necessary. One method of examining a policy issue is to
utilize a model that assembles various ideas into a
conceptual framework. Utilizing a conceptual model allows
for the examination of key underlying ideas and assumptions
regarding a political phenomenon and the decision-making
process. This case study applies one such conceptual model
of decision-making to examine the IHSS debate.
In this case study, the Governmental Politics Model is
applied to explain the behavior of participants involved in
California's political process. This model describes a
political process in which decision-makers at the top of
powerful organizations participate in a central, competitive
game (Allison, 1971), acting on their own needs and
perceptions (Lahti, 1996). Under this model, the political
process is not based on decision-makers making informed,
rational choices; instead, decision-makers use negotiating
skills to influence other decision-makers involved in the
process (Lahti, 1996).
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Although from a theoretical standpoint a pure
conceptual model may suffice, applying a single model to a
practical policy issue may not adequately capture all the
essential explanatory factors. Lahti (1996) states that the
use of other models should be considered when assessing
group decision-making. This study, therefore, in addition
to the Governmental Politics Model, examines several
conceptual frameworks in the next chapter. The fundamental
concepts and assumptions along with the criteria associated
with each model are outlined.
Chapter Summary
In this chapter, a foundation for the issues
surrounding the IHSS debate was established. Furthermore,
the method of evaluation, the Governmental Politics Model of
the political process, was introduced. In the next chapter,
California's political participants along with several
conceptual models of the political process are reviewed.
Chapter III illustrates key historical events surrounding
California's IHSS debate, events that have occurred over the
past decade involving a number of political participants.
Chapter IV, the methodology section, focuses on the research
procedure, the sample population and the data collection
process. Moreover, the chapter examines the limitations of
the chosen research approach. Chapter V presents an
analysis and reports the findings of the study,
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specifically, the usefulness of the Governmental Politics
Model. Finally, Chapter VI concludes with a discussion of
the results and provides several recommendations for further
research studies.
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CHAPTER II: LITERATURE REVIEW
This chapter, divided into two sections, provides
background information necessary for understanding the
intent of this study. First, it presents an overview of
various political participants involved in California IHSS
debate. Given the assumption under the Governmental Politics
Model that multiple actors influence decision-making,
identifying key decision-makers involved in state politics
further assists in the analysis of the IHSS debate. Along
with a review of the participants, this section also
outlines California's political arena in which these
individuals are positioned. This discussion is not intended
to center around the formalities of government; rather, the
purpose is to establish a scenario of the environment
surrounding those key participants engaged in policy
formation.
Second, this chapter identifies and describes four
conceptual models used to explain decision-making in the
political process. These models are: 1) the Garbage Can
Model, 2) the Rational Model, 3) the Organizational Process
Model, and 4) the Governmental Politics Model. Although this
case study examines the IHSS debate through one conceptual
model, Allison's Governmental Politics Model, the four
models each suggest different frameworks for thinking about
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decision-making. They provide additional approaches to
explaining the decision-making process.
California's Political Participants
Participants from both the public and private sectors
are actively involved throughout California's political
process. According to Patel and Rushefsky (1995), no one
actor dominates any one stage of the political process;
rather, each contributes to the process to promote his or
her own interests. In order to obtain a better
understanding of this process, the general role of various
political participants involved with the IHSS debate merits
further discussion. Although a vast number of individuals,
agencies and organizations are involved with the IHSS issue,
this case study addresses a selective group rather than an
inclusive group of individual participants.
Inside the Government
Under California's constitution, the government is
divided into three branches: 1) the executive branch, 2) the
two houses of the legislature, and 3) the judiciary (Hoeber
& Price, 1993) . Each branch of government contributes a
different power and activity to the political process.
Executive Branch. Under the leadership of the Governor, the
executive branch has the authority to administer and enforce
laws through various governmental agencies and departments
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(League of Women Voters, 1992) . In addition to the Governor,
this branch consists of the Governors cabinet, state
constitutional officers, agencies and departments, and
various boards and commissions (Ross, 1988). The vast
majority of the executive branch consists of civil servants
directed by high-ranking executive officers. While many of
the state's highest-ranking officials are elected by the
people, the Governor also has the authority to appoint
several high-ranking officials (League of Women Voters,
1992) .
Besides having the power to appoint, the Governor
possesses several other tools that enable him to exert
control over the legislative process. First, the Governor
has the ability to veto an entire bill or line item veto by
reducing or eliminating any item in an appropriations bill
(Ross, 1988) . Even though vetoing an entire bill is not very
common (League of Women Voters, 1992) , the threat of a veto
is almost as important as the act itself (Ross, 1988) .
Second, the Governor has the ability to call the legislature
into a special session. During special sessions, action may
only be taken on topics specified by the Governor, thereby
obligating the legislature to settle specific issues which
have been avoided or been in deadlock (Ross, 1988).
Legislative Branch. The legislative branch, consisting of
an 80-member Assembly and 40-member Senate, has the
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authority to make laws (League of Women Voters, 1992) . The
state legislature is restricted only by the Governor''s veto
in addition to the federal and state constitution. Each
house is organized differently, with power held by the five-
member Rules Committee for the Senate and centered in the
office of the Speaker of the Assembly (Hoeber & Price,
1993).
In the Senate, the Rules Committee is the single most
powerful committee with the authority to appoint members to
committees and assign bills. The president pro-tem is the
chairman of the Rules Committee, with the four other seats
divided between the two major parties (Hoeber & Price,
1993) . Although the Senate is presided over by the
lieutenant Governor, the president pro-tem is the single
most important leader (Hoeber & Price, 1993).
In contrast to the Senate, the Assembly is led by a
single individual— the Speaker— who is elected by a simple
majority. The individual in this position appoints all
committee chairs and committee members (Wilson, 1992) . This
authority to determine committee membership results in the
power that is second only to the Governor's (Ross, 1988).
Together, the Speaker of the Assembly and the Rules
Committee hold the authority to appoint committee chairs and
members. Committee and subcommittee members obtain the
responsibility to take action on certain agenda issues and
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frequently act on behalf of their own interest (Francis,
1989) .
Judiciary Branch. The judiciary has the authority to
interpret and apply laws. This branch operates as a check
to the executive and legislative branches of government. It
is the division of power that assures that the executive and
legislative branches do not make or administer laws contrary
to the state constitution (League of Women Voters, 1992).
Additionally, this branch assures that laws are applied
appropriately and equally in all matters brought before the
court of law.
Under California's constitution, judicial powers are
vested in the California Supreme Court, courts of appeal,
superior courts, municipal courts and justice courts.
California courts are divided into four districts: northern
district (San Francisco and San Jose), eastern district
(Sacramento and Fresno), central district (Los Angeles) and
southern district (San Diego) (League of Women Voters,
1992) .
Although the judiciary is an independent branch, to a
certain extent this branch is impacted by the legislative
and executive branches (League of Women Voters, 1992) . By
way of statutes, the legislative branch determines much of
the court's operations. In addition, the Governor holds the
power to make most judicial appointments.
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Outside of the Government
The division of power within the state government
allows room for political players outside the government to
influence the decision-making process. Specifically, the
dispersion of power gives interest groups an opportunity to
access a variety of decision-makers to influence and promote
policy (Rhodes, 1992).
Interest Groups. Despite the growing influence of the
consumer, individuals, for the most part, rally together and
seek representation in an organized setting. Conceivably, a
smaller group of people supporting an issue of great
intensity could impact government priorities (Kingdon,
1984), but for many, the activities of organized interest
groups are a better means to achieving adequate consumer
protection and improving public awareness.
The relationship between the consumer and interest
groups has proven to be important in two ways. On one hand,
interest groups have become an accessible channel for
citizen participation in the political process. On the other
hand, large consumer representation gives interest groups
the ability to lobby effectively on behalf of a specific
issue.
Several types of interest groups exist to seek policies
for the good of their members. These groups include
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consumer, business, labor, agricultural, professions, race,
and religion groups (Kingdon, 1984) - By definition,
interest groups are private organizations, small and large,
consisting of individuals with the ability to organize and
collectively promote various ideas (Gerston, 1993) .
Frequently, interest groups target the political
process, actors, and institutions (Gerston, 1993), to
influence policy in a specific subject area (Anderson,
1984) . Not only do interest groups aim to promote various
policy issues (Gerston, 1993); they frequently express
demands and alternatives for policy action (Anderson, 1984) .
According to Patel and Rushefsky (1995), interest groups
typically rely on coalition forming, testifying, litigation,
lobbying and participation in regulatory proceedings.
Lobbyists. Lobbyists are also considered a vital link in the
state's political process. They are the connection between
lawmakers and industries, professional associations,
consumer advocates, and other players involved in California
politics (Green, 1995) . In addition to serving as a link
between players, lobbyists are often viewed as providers of
information to public officials, concerning the nature and
possible consequences of policy proposals (Anderson, 1984) .
The provision of information is usually an attempt by
lobbyists to influence legislators on a particular piece of
legislation (Hoeber & Price, 1993) .
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Overall, lobbying can be viewed as an activity used to
build relationships, supply sufficient information and to
pressure decision-makers. Consequently, the growth of
lobbying activity prevents any one advocate or interest
group from asserting control over the legislative process
(Green, 1995). Nonetheless, lobbyists have an important
role in the political arena. Not only have they found ways
to directly impact policy, they have learned to utilize
other players to indirectly provide information to influence
the decision-making process.
Experts. The provision of reliable information is also an
important factor in the political process. Time and time
again, policy-makers who have little knowledge in specific
policy areas rely on * experts" such as academics,
researchers and consultants for relevant data. According to
Kingdon (1984), this group of non-governmental actors is
second to interest groups in importance in the policy
process.
Conceptual Framework of the Political Process
According to Johnson and Joslyn (198 6), providing
scientific explanation for political phenomena is a primary
purpose of political science research. A method of
evaluating such a phenomenon is to utilize a model. A model
is a simplification of reality (Oxenfeldt, Miller &
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Dickinson, 1978; Tansey, 1995) described through several
dimensions (Daft, 1983). In the realm of political science,
models are used to explain political events by assembling
various ideas into a conceptual framework. This framework
also includes underlying assumptions about decision-making
in the government (Holloway, 197 6).
Conceptual models provide a link between a detailed
study and a broader concept (Bowen & Smith, 197 6) . Every
model has underlying concepts that describe the behavior and
attributes of individuals or social groups being observed
(Johnson and Joslyn, 198 6) .
In this case study, the IHSS debate is examined through
one conceptual model. Furthermore, several alternative
models are discussed for the purpose of understanding
various conceptual frameworks available for political
science research. According to Lahti (1996):
Using one particular model should not
preclude the consideration of other
models or means of assessing group
decision-making. If a model is strictly
adhered to without being open to other
potential ideas, valuable information may
be missed due to blatant or
misclassification of the information
(p.2) .
This section provides a review of key concepts and
assumptions that are instrumental to understanding each of
the four models. In discussing these models, several
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advantages and disadvantages are presented for further
cons ideration.
Garbage Can Model
The first framework, the Garbage Can Model, developed
by Cohen, March, and Olsen (1972), is used to explain
political situations with high uncertainty (Daft, 1983).
Situations with high uncertainty are referred to as
"organized anarchies" (Cohen, March and Olsen, 1972) with
three characteristics (Daft, 1983; Kingdon, 1984):
• Problematic Preferences: Problems,
alternatives, solution, and goals are not
clearly defined.
• Unclear Technology: Organizational
members do not understand the organization' s
decision-making process very well, nor the
options for resolution.
• Fluid Participation: Decision-making
participants will be limited in their time
and effort, therefore, drifting in and out
of the decision-making process.
Daft (1983) explains that an organized anarchy only
exists in a non-bureaucratic environment characterized by
rapid change. The importance of the organized anarchy, as
noted by Daft (1983), is that organizations, on occasion,
find themselves confronted with unclear, problematic
circumstances. Under these circumstances, decision-making
is neither logical nor sequential. In other words, the
series of steps taken from identifying the policy problem to
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generating its solution may not be related to each other
(Daft, 1983). Instead, several independent components known
as policy streams are involved in the process.
The four policy streams of decision-making are
problems, solutions, participants, and choice opportunities
(Kingdon, 1984) . These policy streams are independently
combined into a 'garbage can" to produce policy outcomes.
The outcomes for a specific problem are a function of the
independent policy streams connecting at some point. When
various components come together, however, the problem may
or may not be solved (Daft, 1983). Finding a solution to a
problem is thus reliant on a chance alignment of the various
components involved.
The advantage of the Garbage Can Model is that it
provides a real-world representation of decision-making
(Lahti, 1996). It is a conceptual framework for problematic
situations that are limited by time, cost, and information.
Despite this advantage, not all problems are solved under
this model. Kingdon (1984) explains that outcomes are
heavily dependent on the combination of policy streams,
therefore, a viable solution may or may not be generated. In
addition, decision-makers do not set out to solve problems;
rather, solutions are produced even when no problems exist
(Daft, 1983; Kingdon, 1984).
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Rational Model
For most political analysts, the Rational Model is the
dominant frame of reference (Welch, 1992) , based on a
systematic, logical approach to decision-making (Daft,
1983) . This model, often used as the baseline to which other
models are compared (Lahti, 1996), has several versions
(Daft, 1983) . Among these versions, there are common
components utilized to explain the decision-making process.
Each version, for example, explains government behavior
as rational acts of a single decision-maker (Allison, 1971;
Bendor & Hammond, 1992; Welch,1992), that is centrally
controlled (Allison, 1971; Daft, 1983). Additionally, this
decision-maker engages in purposive action to achieve a set
of strategic goals and objectives that are value maximizing
(Allison, 1971). In order to achieve these goals,
alternative courses of action are identified (Daft, 1983) .
For each alternative, the decision-maker is completely
informed about the consequences that follow (Allison, 1971;
Lahti, 1996). That is, all reliable information regarding a
policy issue, including the advantages and disadvantages, is
available to the decision-maker. Of all the available
choices, the most value-maximizing alternative is chosen as
the optimal solution to the policy problem (Allison, 1971).
This single solution to a strategic problem is then acted
upon by the decision-maker. The sum of activity of
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individual governmental actors relevant to a problem, hence,
constitutes what the government as decision-maker has chosen
as its solutions (Cornford, 1974).
The primary advantage of the Rational Model is that it
utilizes a simple, logical approach to decision-making
(Lahti, 1996). In other words, the decision-maker defines
the problem, identifies the alternatives and chooses the
alternative with the highest probability of achieving
desired goals and objectives (Daft, 1983). Similarly, the
simplicity of this approach is viewed by analysts as a
disadvantage. The concept of a unitary actor controlling
the political process is viewed by Allison (1971) as overly
simplistic for some situations. Because the government
consists of a conglomerate of large organizations with
primary responsibility for particular tasks, there are few
important issues that fall into the realm of a single
government organization (Allison, 1971).
Organizational Model
The third model of decision-making is the
Organizational Model. In contrast to the Rational Model,
this model describes the government as a conglomerate of
organizations where government agencies and organizations
are in themselves thought of as separate organizations
(Allison, 1971) . Each organization behaves in its own way
(Tansey, 1995) according to a specific set of operating
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procedures or guidelines (Lahti, 1996; Welch, 1992).
Government behavior, therefore, is constrained by the
routines of these organizations (Welch, 1992).
Under this model, what the Rational Model characterizes
as "acts" and "choices" are viewed instead as "outputs" of
organizations functioning according to regular patterns of
behavior (Allison, 1971) . The outputs produced are the
result of pre-existing organizational procedures and
guidelines. Furthermore, an organization does not act to
achieve a specific set of objectives. Organizational actors
prefer to avoid the adverse effects of long-term planning
that includes the discussion of goals and values resulting
in uncertainty and conflict (Tansey, 1995). Organizational
procedures emphasize short-term feedback in order to prompt
corrective action, thus eliminating uncertainties in the
environment (Allison, 1971).
There are two additional issues to be addressed under
this model, specifically, time events and conformity. First,
the events of an organization's past, present, and future
are used as a basis for making decisions (Lahti, 1996).
Because over time organizations change and learning
gradually occurs (Allison, 1971), time events allow for
further revision of organizational procedures and guidelines
(Lahti, 1996). The second issue is in relation to the
ability of the decision-maker to conform to pre-established
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organizational procedures. If a decision-maker is uncertain
about the outputs of a decision, the decision should be
based on the organization's pre-established guidelines
(Lahti, 1996), hence eluding any uncertainty and conflict.
While the Organizational Model, unlike the preceding
model, employs the behavior of the government to include the
outputs of a conglomerate of large organizations, according
to Welch (1992), it does not examine the decisions made.
Rather, the model addresses the manners in which
organizational policy and procedures confine the formation
of alternatives (Welch, 1992), thereby, excluding any
discussion of the decisions themselves.
Governmental Politics Model
The fourth approach, the Governmental Politics Model,
postulates that the decisions and actions of governments are
political resultants. That is, an outcome is not chosen as
a solution to a problem but rather results from the conflict
and compromise of key decision-makers with diverse interests
and unequal influence. These decision-makers are leaders
positioned at the top of organizations participating in a
centrally competitive game, acting in accordance with their
own goals and objectives (Lahti, 1996) . In addition to
having personal goals, they exhibit interest in a number of
areas (Allison, 1971) . Although they have no consistent set
of strategic goals and objectives (Allison, 1971), each has
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interests stemming from personal characteristics and from
his or her particular position in an organization (Freedman,
1976) .
The bargaining game component is a key concept of this
model. Various decision-makers participate in a bargaining
process with other decision-makers to influence a policy
outcome (Allison, 1971). Specifically, the process involves
each decision-maker trying to get his or her perspective to
be the one of choice (Lahti, 1996). The outcome of this
bargaining game is therefore reliant on three areas: 1)
negotiating skills, 2) resources, and 3) the rules of the
game (Tansey, 1995) .
Negotiating skills play an important part in this
model. These skills are especially useful in influencing
other decision-makers involved in the process (Lahti, 1996) .
Influence in the form of power has an effective impact on
government decisions and actions (Allison, 1971). Sources
of power include formal authority and responsibility,
control over resources, expertise, and information (Allison,
1971).
Under the premise of this model, information is viewed
as an important resource and tool used for bargaining games.
Information is often used to strengthen a given perspective
(Lahti, 1996). Consequently, decision-makers are not likely
to be completely informed about an issue because
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information is frequently held back and incomplete (Lahti,
1996).
Allison (1971) states that "the rules of the game stem
from the Constitution, statutes, court interpretations,
executive orders, conventions, and even cultures" (p. 170) .
These rules vary in practicality, clarity, and stability.
No matter the form, however, the collected rules define the
game. Rules accomplish three things: first, rules establish
various aspects of decision-making positions; second, rules
constrain the range of acceptable government action; and
third, rules sanction certain kinds of bargaining techniques
(Allison, 1971).
The rationale for selecting Allison's Governmental
Politics Model as the conceptual framework for this case
study lies in its dynamic approach to decision-making.
Similar to the Garbage Can Model, this model acknowledges
the personal biases and agendas of the individual decision
makers involved in a policy issue (Lahti, 1996).
Furthermore, conflict is minimized by gaining support of
powerful individuals, which, in effect, is an incentive for
others to follow (Lahti, 1996) .
Unlike the Rational Model, however, the optimal
alternative is not a key aspect of the Governmental Politics
Model. Due to incomplete and withheld information, the best
solution may not be chosen (Lahti, 1996). Individual
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participants do not act in the best interest of the policy
problem; instead, they bargain to produce the most value-
maximizing alternative to meet their personal needs rather
than the needs of society.
Chapter Summary
This chapter explored two areas needed to understand
the objective of this study. First, it presented an
overview of various political participants involved in the
IHSS debate and outlined California's political arena.
Second, this chapter identified four conceptual models used
to explain decision-making in the political process. These
four models each provided an alternative approach in
explaining the decision-making process. Next, Chapter III
identifies a number of important individuals involved in the
IHSS debate along with key historical events.
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CHAPTER III: THE HISTORY OF THE IHSS DEBATE
California's IHSS debate is the product of a number of
historical events involving political participants with
varying interests and ideas. According to Weimer and Vining
(1992), the motivations and beliefs of actors about a
specific policy issue often will be apparent. Since this
case study examines the IHSS debate through a political
model based on the behavior of multiple participants, it is
important to investigate the interests of the individuals
involved. To illustrate these interests, this chapter
identifies and describes key individuals through a number of
events surrounding the IHSS issue. Additionally, these
illustrations establish support for the bargaining game
component of the Governmental Politics Model.
Historical Events
The documentation of historical events surrounding the
IHSS debate dates back almost ten years. A number of
interest groups, agencies, and organizations were, and
continue to be, involved with this debate. More important
to this case study however are the various individual
participants that aim to accomplish specific objectives on
behalf of these organized conglomerates. In order to
sufficiently address the issue at hand, this section
provides a chronological account of key IHSS events along
with the individual participants involved.
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San Diego's IHSS Contract
In September, 1987, Remedy Home and Health Care
("Remedy") , an agency provider of IHSS for San Diego County,
acquired the services of Robert Naylor to assist in the
renewal of Remedy's IHSS contract with the San Diego County
board of supervisors (Walters, 1988). Naylor, former
assembly republican leader and former state party chairman
(San Jose Mercury News, July 25, 1995; Walters, 1988), was
retained through the Sacramento law firm of Nielson,
Mersamer, Parrinello, Mueller & Naylor.
With the support of the United Domestic Workers
Association (UDWA) , the union representing Remedy employees
in San Diego, Naylor assisted Remedy in competing against
Addus ("National") for San Diego's contract. Although the
contract was eventually awarded to Addus, Naylor used his
political influence to direct the contract to Remedy.
Naylor was aided by members of the San Diego County
legislative delegation, the County Board of Supervisors, and
through UDWA's connections to the Democratic Party (Walters,
1988).
Utilizing Agency Providers
Apart from the San Diego County contract, Naylor worked
towards passing IHSS legislation. As noted in table 3.1,
Senator Wadie Deddeh authored a contract provider bill
(Senate Bill 1831) that was circulated by Naylor, UDWA, and
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Remedy (SEIU, 1988). This bill mandated counties to utilize
contracted agency providers for IHSS, unless a recipient
specifically requested an individual provider (Senate
Committee on Health and Human Services, 1988).
Those opposed to Senate Bill 1831 included the Service
Employees International Union (SEIU), the California
Coalition of Independent Living Centers (CCILC), United
Cerebral Palsy/Spastic Children's Foundation (UCPSCF), and
the California Association of the Physically Handicapped
(CAPH). These groups expressed overall concern for reduced
services to recipients, program costs, and the loss of the
consumer's freedom of provider choice (Rouillard, letter to
Senator Watson, May 9, 1988; United Cerebral Palsy/Spastic
Children's Foundation, letter to Senator Watson, May 9,
1988) .
Table 3.1: IHSS Bills Introduced to the State Legislature
BILL: AUTHOR: BILL SUMMARY: OUTCOME:
Senate Bill
1831 (1988)
Senator Deddeh Mandated counties to
utilize contract agencies
for IHSS.
Not
Passed
Senate Bill
35 (1993)
Senator Thompson Permitted counties to bid
for IHSS agency contracts
to serve all non-severely
impaired recipients.
Not
Passed
Senate Bill
278 (1995)
Senator Killea Extended the operation
date of IHSS agency
contracts indefinitely.
Not
Passed
Senate Bill
1780 (1996)
Committee on
Budget and
Fiscal Review
Developed a new service
model that allows home
health agencies to manage
service delivery.
Passed
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Implementing A Pilot Program
After failing to pass Senate Bill 1831 in the regular
legislative session, UDWA made a last-minute effort during
the 1990-1991 budget debate. UDWA's proposed language
required certain counties to implement a contract provider
pilot program (COSSA, 1990) . Although the proposal
suggested that counties could better contain IHSS costs,
several counties declined to support the language (San Diego
County, 1990; Orange County Social Service Agency, 1990) .
Additionally, several seniors groups joined in
opposition to the expansion of the agency provider model
including the Congress of California Seniors (CCS) and the
California Seniors Coalitions (CSC) (Owens, letter to
Assemblyman Brown August 8, 1990; Krebs, letter to Senator
Roberti, August 8, 1990). Howard Owens, President of the
Congress of California Seniors, expressed strong opposition
towards the pilot project requiring counties to utilize
agency providers to serve the non-severely impaired IHSS
recipients (Owens, letter to Assemblyman Brown, August 8,
1990).
Implementing A Demonstration Project
In 1992, a flurry of activity regarding the expansion
of agency providers in the provision of IHSS had begun to
surface within the legislature. Rather than Remedy, Addus
began to employ efforts to increase the use of the agency
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provider model under IHSS. With the addition of Naylor as
its lobbyist, Addus took the lead in expanding the agency
provider model.
Effective November 1, 1992, Addus was awarded an
exclusive contract with the Tulare County IHSS Demonstration
Project ("Demonstration Project") by the California
Department of Social Services. The Demonstration Project,
lasting years, tested whether all eligible IHSS
recipients in Tulare County could be fully and competently
served by Addus at the 1992-1993 fiscal year allocation
levels (Barnes, Sutherland & Johnson, 1995).
Exclusive Agency Provider Contracts
In 1993, the state legislature passed an IHSS budget
trailer bill (Senate Bill 35) , supported by Addus, which
permitted counties to bid for agency contracts to serve all
non-severely impaired IHSS recipients (Long Term Care News,
June 1993) . Although the bill included a repeal date,
consumers expressed anger over the changes made to the
program. Once again, PICLTC utilized its consumer network to
oppose S.B. 35 even after it was enacted.
Expanding the Demonstration Project
In 1994, Addus was unsuccessful in expanding the
Demonstration Project to eight other counties (Long Term
Care News, August 1994). A study of the Demonstration
Project in Tulare County concluded that Addus Health Care,
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the only agency provider for the Demonstration Project, did
not meet the established criteria for the project (Barnes,
1995). A month after Barnes's report was distributed, Alan
Post, a former legislative analyst, rebutted by arguing that
the ISR report lacked an analysis of the management aspects
of managed care (Post, 1995). Addus presented the
information provided by Post at an Assembly Human Services
Committee hearing for the IHSS program on November 9, 1995.
In an attempt to improve its public image due to the
failure of the Tulare County Demonstration Project, Addus
agreed not to introduce language regarding the expansion of
the project during the year's regular legislative session.
Instead, Addus began to work with consumers and advocates
for an IHSS bill to be introduced in 1995.
Building A Consumer Coalition
Since June 1994, PICLTC, a non-profit organization
aimed at sustaining consumer-driven long-term care, along
with other IHSS consumer advocates, senior citizens,
organizations, counties and legislative staff, held several
IHSS Consumer/Advocate meetings concerning efforts to
increase the use of the contract provider (Long Term Care
News, November 1994). As indicated in table 3.2, a number
of participants were involved in the IHSS Consumer/Advocate
meetings.
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Table 3.2: IHSS Consumer/Advocate Meeting Participants
American Association of Retired Persons (AARP)_________________
Older Women's League of California__________________________
Council of Sacramento Senior Organizations (CSSO)______________
California Senior Legislature (CSL)__________________________
California Legislative Council for Older Adults (CLCOA)________
California Commission on Aging (CCA)____________________________
Congress of California Seniors (CCS)____________________________
Triple A Council of California (AAACC)__________________________
California Senior Coalition (CSC)________________________________
Gray Panthers (GP)_________________________________
California Association of Area Agencies on Aging (CAAAA)_______
Aging & Adult Services, Santa Clara County (AAS)_______________
National Association of Retired Federal Employees (NARFE)______
Multiple Sclerosis Society (MSS)________________________________
Alzheimer's Association (AA)____________________ ________________
Sacramento County IHSS Public Authority_________________________
Modesto Independent Living Centers_____________ ________________
Santa Rosa Independent Living Centers___________________________
Service Employees International Union___________________________
Visiting Nurses___________________________________________________
Mercy Health Care Sacramento ______________ _________________
California Association for Health Services at Home (CAHSAH)
San Francisco Home Care__________________________________________
United Domestic Workers of America (UDWA)_______________________
Addus Home Care (a.k.a. National Homecare)______________________
Law Offices of Nielsen, Mersamer, Parrinello, Mueller & Naylor
Senate Subcommittee on Aging_____________________________________
Senate Office of R e s e a r c h _____________________________
Assembly Human Services Committee______________________________
County Welfare Directors Association____________________________
These meetings, held almost monthly, were conducted
with Addus in order to identify areas of agreement upon
which to improve the IHSS program from the standpoint of the
consumer (Porter, letter to Wilson, July 11, 1995). In the
end, the meetings between Addus, IHSS consumers and
advocates did not result in IHSS language acceptable to all
involved:
From the nine half-day meetings it became
clear to all participants and observers
that a proposal which on the surface
appears to make some sense can in reality
have a disastrous effect on IHSS
consumers. (Porter, letter to Governor
Wilson, July 1995)
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Porter further expressed that language proposed to extend
the contract provider model should be openly discussed with
all stakeholders involved before being passed through the
legislative process.
San Mateo Public Authority
UDWA attempted to discredit the IHSS public authority
model (Luce, 1995). The public authority, governed by the
county board of supervisors, provides the delivery of IHSS
in San Mateo to IHSS recipients. Although most IHSS
recipients utilize the independent provider model, those
that require higher levels of supervision and assistance are
offered contract mode services. Employees of the public
authority are not employees of the county. UDWA contended
that the public authority model offered only marginal
program improvements. UDWA further suggested that the
solution to San Mateo's problem was the contract provider
model for all IHSS recipients.
Extending the Agency Provider Repeal Date
On February 2, 1995, Senate Bill 278, introduced by
Senator Killea (R-San Diego), proposed to extend the
operative date of IHSS agency contracts under Senate Bill 35
indefinitely (Long Term Care News, May 1995). Despite
attempts by Naylor to work with Barbara Arnett, Assistant
Secretary of California's Health and Welfare Agency, to
develop some workable IHSS language (Arnett, letter to
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Umemoto, July 14, 1995), by the end of the regular
legislative session, Senate Bill 273 had not passed.
In the summer of 1995, several special sessions of the
six legislative leaders summoned by Governor Wilson were
held to settle the stalemate budget and to address several
budget trailer bills. These leaders consisted of Governor
Wilson; Assembly Speaker Doris Allen; Assembly Caucus Leader
Jim Brulte; Assembly Democratic Leader Willie Brown;
Democratic Senate President Pro-Tem Bill Lockyer and Senate
Republican Leader Ken Maddy. During these special sessions,
the legislative leaders were petitioned by a number of
individuals on behalf of consumer and advocacy groups to
oppose Senate Bill 278. Consequently, Senate Bill 278 was
held over until the next regular legislative session.
Santa Clara's IHSS Contract
In June, 1995, Santa Clara County's board of
supervisors awarded a $4.4 million IHSS contract to the
Council on Aging, a local, non-profit agency; instead of
Addus (editorial, San Jose Mercury News, July 25, 1995) .
Although Addus had held the county's contract since 1990 and
had the lower bid, the board was concerned with the quality
of care to be provided to IHSS recipients. With the support
of the state Department of Social Services however, Addus
proceeded to file suit against the county, alleging "severe
irregularities" in the county's bidding process (editorial,
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San. Jose Mercury News, July 25, 1995). Consequently, the
county, along with the Council on Aging, filed a
countersuit. In the following month, the state agreed to
award the Council on Aging Santa Clara's IHSS
contract (Trotter, 1995).
New Task Frequency Model
In 1996, Senate Bill 278 was again introduced to the
legislature with some modifications. In addition to a
specific repeal date, it expanded the authority of agency
contracts to include all IHSS recipients, as well as
personal care services recipients (PCSP) to the extent
federal financial participation could be obtained (Long Term
Care News, February 1996) . Before the end of the regular
legislative session, Senator Killea withdrew as the author
of Senate Bill 278. Furthermore, supporters of the bill were
unable to find someone else to carry the bill (Long Term
Care News, June 1996).
In late 1996 however, Senate Bill 1780 was enacted as
Chapter 206, Statutes of 1996, and Welfare and Institutions
Code (W&IC) section 12302.7 (Long Term Care News, March
1997). This bill requires the California Departments of
Health and Social Services to permit counties to enter into
non-exclusive contracts to deliver In-Home Supportive
Services under a new model, known as Task Frequency. As
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stated earlier, regulations to govern this new model are
under development.
Chapter Summary
To reiterate, a number of events surrounding IHSS
specific to the expansion of the agency provider model have
occurred over the past decade. For the purpose of this case
study, this chapter explored these events in order to
identify the position and interest of key individuals
contributing to the debate in some form. Some of the most
prevalent individuals identified through personal
memorandums and letters are Robert Naylor, Addus lobbyist;
Thomas Porter of PICLTC; Pete Wilson, Governor of
California; Alan Post, former state analyst; Carole Barnes,
researcher; Barbara Arnett of California's Health and
Welfare Agency; Tom Bordonaro, assemblyman; Rosalyn Hawkins
of Parent to Parent Network; and Allen Davenport of SEIU.
Furthermore, the chapter attempted to provide evidence of a
bargaining game existing between a number of these
individuals.
The next chapter examines the study's research
methodology in detail. The chapter presents the case study
approach, data collection methods, measuring concepts
utilized to analyze the IHSS issue, the study's subjects,
and the limitations to the chosen methodology.
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CHAPTER IV: METHODOLOGY
To reiterate, the primary objective of this study is to
examine the political process behind the IHSS issue by
applying the Governmental Politics Model of decision-making.
To address the study's objectives, this study first
discusses the measuring concepts used to examine the IHSS
debate. Following this discussion, the research methodology
is described in detail. Finally, this chapter illustrates
the limitations to both the case study approach and methods
of data collection.
Measuring Concepts
In an attempt to understand the decision-making process
surrounding the IHSS debate, this study utilizes two
concepts from the Governmental Politics Model. Data
collected through this study are separated into these
concepts to measure the influence of key decision-makers
involved in the IHSS debate over the policy outcome.
Information from the previous chapter, for example, is used
to support the presence of these concepts.
The first concept is the exhibition of individual
personal or professional interests by political
participants. That is, the interests of these participants
stemming from personal characteristics or a particular
position held in an organization. For the purpose of this
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study, individuals identified as key participants either
hold a specific leadership position in an organization,
group or company; or express a special interest in the
debate at hand which is apparent from an interpersonal
characteristic.
The second measurement criterion is the presence of
bargaining components among participants used to sway the
outcome of IHSS policy. The bargaining game process
includes evidence of negotiating skills, resources, and
knowing the rules of the game. Indication of the bargaining
process takes form of political contacts; holding formal
authority from a position; the ability to negotiate with
other participants; special knowledge of issues surrounding
IHSS; or knowledge of the state's legislative process.
Research Approach
This study's evaluation of the IHSS debate through the
Governmental Politics Model is based on the case study
methodology. This case study is based on an 11-month
participant observation study in which the author worked for
the Public Interest Center on Long Term Care (PICLTC) in
Sacramento. From May through August, 1995, observations
were conducted from the perspective of an intern. For the
next seven months, observations were from the perspective of
a part-time temporary consultant acting as PICLTC's
Associate Field Director located in Southern California.
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Although the author no longer held a formal position after
May 1996, PICLTC continued to forward relevant information
for this study in the form of archival records and written
documentation.
Direct Observation. As a policy intern, the author was
responsible for tracking legislation relevant to the long
term care arena (e.g., IHSS, Social Security, Supplemental
Security Income, and the Medi-Cal program). The author was
assigned to follow Senate Bill 278 (Killea) , an IHSS bill
which extended the sunset date of managed care agencies and
broadened the scope of agency authority to include all IHSS
recipients.
The author began tracking Senate Bill 27 8 as a budget
trailer bill being reviewed by the budget committee. This
committee was comprised of several members from both
legislative houses. The Senate Appropriations committee; the
Senate Health and Human Services committee; and the Assembly
Human Services committee had all reviewed Senate Bill 278
before the author's placement with PICLTC. Because the
budget was not passed until early August, the author was
able to attend several budget committee hearings held during
the summer. The author also followed committee hearings by
listening to proceedings through a direct radio box
installed in PICLTC's office.
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Concurrent to the budget committee hearings, the author
followed the activities of the 'Big Six". The 'Big Six"
refers to Governor Pete Wilson and five legislative leaders:
Assembly Speaker Doris Allen; Assembly Caucus Leader Jim
Brulte; Assembly Democratic Leader Willie Brown; Democratic
Senate President Pro-Tem Bill Lockyer and Senate Republican
Leader Ken Maddy. Due to a stalemate, the budget, along
with several trailer bills, was passed along to the 'Big
Six" . Although leadership meetings of the past have been
limited to five, in 1995 the committee was expanded to six
to accommodate both Assembly Speaker Allen and Assembly
Republican Caucus leader Jim Brutle.
As a temporary consultant, the author was not directly
involved with the legislative process; instead, she was
forwarded additional documentation regarding pending IHSS
legislation. On two occasions, the author traveled to
Sacramento; first, to attend an Assembly Human Services
Committee Hearing which identified existing problems in the
IHSS program, and second, to further research PICLTC's
literature and documentation on IHSS.
Archival Data/Written Documentation. Perhaps more important
than observing the legislative committees has been the
written archival data and documentation provided by PICLTC.
To date, PICLTC has provided various pieces of secondary
data from political participants dated over a 10-year
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period. As indicated in table 4.1, a number of personal
letters from various participants involved in the IHSS
Consumer/ Advocacy meetings to the members of the 'Big Six"
were utilized. Letters were used to find evidence of
individual personal and professional interests.
Table 4.1: Personal Documentation
Data Source: Subject:
Memo from Allen Davenport, SEIU, to
Governor Wilson and five legislative
leaders
Opposition to an
Addus proposal
Letter from Barbara Arnett, State Health
and Welfare Agency, to Robert Naylor, Addus
Response to proposed
IHSS language
Informational letter from Paula Brim, UDWA,
to IHSS Coalition Members
Response to attacks
on IHSS contracts
Letter from Kim Kruser, Addus, to Ken
Seaton-Msemaji, UDWA
Report on the Tulare
County Demonstration
Project
Letter from Roslyn Hawkins, Parent to
Parent Network, to Senator John R. Lewis
Opposition to the
contract agency model
Letter from Glory Potts, Organization of
Area Boards on Developmental Disabilities,
to Governor Wilson
Opposition to IHSS
legislative language
Letter from Kim Kruser, Addus, to Thomas
Porter, PICLTC
Invitation to the
Tulare County
Demonstration Project
Memo from UDWA to IHSS Meeting Participants Response to IHSS
principles
Letter from Robert Cummings, Dayle McIntosh
Center for the Disabled, to concerned
citizens
Public alert about
proposed changes to
the IHSS program
In addition to letters, several formal evaluations and
proposals regarding the IHSS program were examined. These
documents include: 1) an analysis by the Orange County
Social Services Agency (OCSS) of a managed care proposal, 2)
a response to a proposal submitted by UDWA, 3) PICLTC Long-
Term Care Newsletters dating from 1993 to 1997, 4) an
analysis by Alan Post (1995), hired lobbyist, regarding the
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Tulare County Managed Care Demonstration Project, and 5)
several evaluations by the Institute for Social Research.
A third source of information used in this case study
was archival records. Archival records were provided from
the State of California Health and Welfare Agency in the
form of budget allocations, IHSS caseloads, and the cost of
the independent provider model.
Table 4.2: Data in the Form of Proposals, Reports, and
Evaluations.
Data Source: Title:
Little Hoover
Commission
(1991)
Unsafe in Their Own Homes: State
Programs Fail to Protect Elderly from
Indignity, Abuse and Neglect
Alan Post (1995) An Overview of the Institute for Social
Research Review of the Tulare County
Managed Care/Capitation IHSS
Demonstration Project
Robert Naylor, Bob
Wilson, Fahari
Jeffers, Ken Seaton-
Msemaji(1990)
Proposal to Reduce Spending in the IHSS
Program
Subjects
The behavior of several groups of subjects inside and
outside the state government were indirectly observed for
this case study. The first group consisted of political
participants within California's government: Governor Pete
Wilson, several members of legislative committees, and state
agency administrators. The second group consisted of civil
servants within the Department of Health Services. The
third group included various participants outside the
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government: consumer groups, labor groups, business groups,
lobbyists, researchers, and consultants.
For the most part, the subjects observed in this case
were not aware of the study. Only the Executive Director and
the Deputy Director of PICLTC were informed that this case
study was being conducted.
Procedures, Strategies, and Limitations
As stated earlier, several different methods were used
to collect data for this study: participant observation,
archival records, and documentation. Although various
advantages have been attributed to using these individual
methods (Elder, Pavalko, Clipp, 1993; Bailey, 1996), most
sources tend to treat data collection separate from other
aspects of the research process (Yin, 1994). This case study
uses a combination of various data collection methods.
According to Yin (1994), when conducting case study
analysis, there are three data collection principles which,
if followed, could help alleviate problems with reliability
and various types of validity:
1) using multiple sources of evidence;
2) creating a case study database; and
3) maintaining a chain of evidence.
In determining the effectiveness of the methodology
used for this study, it is important to look at the
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limitation of the research approach and each method of data
collection.
Case Study Method. The strength and uniqueness of the case
study method is that it attempts to answer "how7 ' and 'why"
questions regarding a decision or set of decisions in real-
life situations (Yin, 1994). For instance, this case study
asks both how and why various political participants were
able to pass legislation reforming the IHSS program.
Although frequently used in policy, political science, and
public administration research, case studies are considered
weak among the social science methods (Yin, 1994).
Yin (1994) states several reasons researchers exhibit
aversion towards the case study method. First, case studies
usually do not follow a rigorous research strategy. They can
be conducted carelessly and allow for biased views. Second,
it is difficult to generalize from a single case study to
others under similar conditions. Third, if a case study
relies specifically on the participant-observation method of
data collection, the study may take too long to conduct.
Participant Observation. According to Bollens and Marshall
(1973), participant observation is used by a researcher to
become involved with the observed activity. The participant
assumes a variety of roles (Yin, 1994); and immerses himself
or herself in an event to better understand the subject
being studied (Bollens & Marshall, 1973).
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There are several limitations to this method of data
collection. The first limitation is that the participant is
not always able to work as an external observer (Yin, 1994).
On occasion, he or she may have to take a position contrary
to the interests of the research study. Second, the
participant-observer is likely to become a supporter of an
organization being studied (Yin, 1994); and consequently be
criticized for not remaining objective (Judd, Smith &
Kidder, 1991). Third, one role may require more attention
than the other; that is, acting in the participant role may
demand more attention than acting in the observer role (Yin,
1994). Finally, the researcher may likely forget, or not
accurately report, certain factors of the situation being
studied (Singleton, Straits & Straits, 1993). Unless a
participant has had extensive exposure to the situation
being studied, it is difficult to fully comprehend the
subject at hand. In an attempt to address the limitations
of participant observation, this case study utilizes
additional data collection methods including archival
records and written documentation.
Archival Qecords/Written Documentation. Archival records
consist of existing documented information (e.g., survey
data, personal records)(Singleton, Strait & Strait, 1993),
that can be used for a case study in conjunction with other
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sources of information (Yin, 1994). Similar to archival
records, written documentation provides an extensive source
of secondhand data for the case study method. According to
Yin (1994), documented information could include letters,
memorandums, agendas, and proposals.
Despite the usefulness of archival records and written
documentation, barriers exist which limit the extent of
their effectiveness in case study research. According to
Yin (1994), documentation should not be used as literal
recordings of past events. Instead, consideration should be
given to the personal motives behind a document's production
(Kidder, 1981). Another limitation of archival records
centers around problems with participant interpretation.
Given that other plausible factors could explain a
relationship (Kidder, 1981), participants should be careful
not to misinterpret documented information.
Chapter Summary
Throughout the course of this chapter, the research
methodology employed for this study was discussed. The
chapter first discussed several concepts of the Governmental
Politics Models to be utilized in the next chapter to
examine the IHSS debate. Second, it examined the case study
method and the various methods of data collection in terms
of limitations. The chapter concluded with a brief
description of the participant observation approach of data
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collection and the study's subjects. The next chapter
provides an analysis of the case study and reports the
findings of the study as it applies to the IHSS debate and
the state's decision-making process.
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CHAPTER V: ANALYSIS AND FINDINGS
California's IHSS debate, centered on a number of
attempts by home health care agencies to expand the agency
provider system, appears to involve a complex decision
making process. In an attempt to examine the process, this
chapter applies Allison's (1971) Governmental Politics Model
assembling various ideas into a descriptive framework.
Moreover, a scenario is established of how individual
interest, with several bargaining game components, lead to
and influenced the enactment of the most recent IHSS service
delivery system, the Task Frequency Model. In an attempt to
better explain the enactment of this model, this chapter
includes chronological occurrences of IHSS events as covered
in Chapter III. The two measurement criteria under the
Governmental Politics Model are therefore supported by
information drawn from this case study.
Although Allison's (1971) model has been chosen to
guide the analysis of the IHSS issue, this case study
expands Allison's framework to include ideas extracted from
other models (Freedman, 197 6; Lahti, 1996; Lyles & Thomas,
1988), hence, the concepts as outlined in the preceding
chapter are applied.
The Governmental Politics Model Applied
Throughout the IHSS debate, several participants have
impacted the enactment of the resultant legislation— the
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Task Frequency Model. By way of interests and bargaining
game tactics, key participants have managed to influence the
decision-making process in an effort to achieve certain
objectives. Nonetheless, the events leading to the
enactment of this new delivery system involved specific
participants playing substantial roles in the matter.
Since efforts to renew Remedy's IHSS contract with San
Diego County, the most significant players have held a
professional interest in the debate. First and foremost,
Robert Naylor, hired lobbyist, driven by the economic gain
facing his clients, has shown lasting support for the agency
provider system.
As a former assembly republican leader, former state
party chairman, and former chairman of the Senate Committee
on Aging, Naylor has held formal authority and
responsibility within the political arena. Because formal
authority and responsibility are a form of power used during
negotiations (Lahti, 1996), Naylor had the ability to
influence other decision-makers. According to Allison
(1971), influence in the form of power has an effective
impact on government decisions and actions.
Naylor's previous roles also gave him the knowledge of
the collected rules of government (e.g., the constitution,
statutes, and court interpretations). As a result, Naylor
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frequently used his political knowledge to draw attention to
IHSS policy.
Table 5.1: Interest Criteria Exhibited by Key Participants
under the Governmental Politics Model
Key Participants:
Personal and/or
Professional
Interest:
Robert Naylor, Lobbyist, Addus Homecare professional
Rosalyn Hawkins, Principal Advocate,
Parents to Parents Network
personal
Thomas Porter, Executive Director,
Public Interest Center on Long Term Care
professional
Tom Bordonaro, Chairman Assembly Health
& Human Services Committee
personal &
professional
Carole Barnes, Executive Director,
Institute for Social Research
professional
Alan Post, Former Analyst, California
Legislative Analyst Office
professional
Barbara Arnett, Assistant Secretary,
State Health & Welfare Agency
professional
Allen Davenport, Legislative Director,
Service Employees International Union
personal &
professional
Pete Wilson, Governor of California professional
Robert Cummings, Executive Director
Dayle McIntosh Centers
professional
Kim Kruser, Regional Manager,
Addus Homecare
professional
Starting with San Diego County's IHSS program, Naylor
used bargaining tactics to renew Remedy's contract. He would
call upon the support of the United Domestic Workers
Association (UDWA), the San Diego County legislative
delegation, and the County Board of Supervisors to influence
members of both the Republican and Democratic Parties.
His tactics to renew this contract nevertheless were
seen by many as aggressive. According to officials in the
Health and Welfare Agency, "Naylor has been pulling every
string he could to steer things toward Remedy and United
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Domestic Workers with a series of meetings and sheaves of
correspondence" (Walters, 1988).
Subsequent to his role in San Diego's IHSS contract
renewal, Naylor played a significant part in the expansion
of the Tulare County Demonstration Project. With
connections in Orange County, Naylor focused on influencing
local politicians. Senator Lewis had already expressed
public support of Addus's effort to extend the Demonstration
Project to Orange County.
Opposing Naylor's efforts, consumer advocates also
concentrated on the same players. Rosalyn Hawkins of the
Parent to Parent Network and long time caregiver to her two
severely disabled sons sent several opposition letters to
Senator Lewis. Because Lewis supported the Demonstration
Project, Hawkins feared that the project would be enacted
and the number of hours allotted to care for her sons would
be reduced. One letter stated, *Your letter and your article
in the Times both reflects National's influence on your
thinking and decision-making... we hope that our voices, as
voters, as taxpayers, and as IHSS beneficiaries, will be
stronger than National's special interests to acquire a
profit from our public services program. As our
representative... we hope that yo u... will cast your votes
according to the needs of your constituency." (September 8,
1995)
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Other advocates along with Hawkins had surfaced to
oppose the Demonstration Project. Robert Cummings,
Executive Director of the Dayle McIntosh Centers for the
Disabled, had been urging Orange County consumers to alert
local politicians about unsolicited changes in the delivery
of IHSS under the Tulare County Demonstration Project.
Through the dissemination of bulletins addressing proposed
changes in the delivery of IHSS in Orange County, Cummings
attempted to convey the ineffectiveness of the agency
provider model (January 24, 1995).
Counter to Cumming's effort, Kim Kruser of Addus
attempted to influence Chairman Gaddi Vasquez of the Orange
County Board of Supervisors, and other community leaders.
Kruser sought an opportunity to discuss concerns and to
clarify some misperceptions as reported by Cummings (Kruser,
personal communication to Cummings, February 14, 1995) .
Because of the project's scope, Naylor also met with
resistance from a statewide alliance of IHSS advocates
spearheaded by Thomas Porter, Executive Director of PICLTC.
Porter's position at PICLTC allowed him to designate
resources and set organizational objectives around the IHSS
program. For that reason PICLTC focused mainly on
preserving the program as a consumer-driven long-term care
system. The involvement of consumers was valued as the most
essential element in dealing with political issues. With
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PICLTC at the forefront, consumers were urged to use public
feedback mechanisms (e.g., letters, faxes, phone calls,
rallies) to impact policy outcome. The consumer's role was
viewed as the common goal among PICLTC's statewide alliance.
Porter's extensive experience in the political arena
served as an important tool in the fight against the agency
provider system. Over the course of the debate, Porter
utilized his relationship with legislative members to spread
research literature opposing such a system. Information,
viewed as an important resource and tool used for bargaining
(Allison, 1971), was used to influence key decision-makers.
For instance, the Chairman of the Assembly Human
Service Committee on Aging, Assemblyman Tom Bordonaro, was a
long-time acquaintance of Porter's. Although Bordonaro
obviously held a professional interest in IHSS, his prior
experience as an IHSS recipient reinforced his personal
interest in addressing problems with the delivery system.
According to Freedman (197 6), personal interests of
decision-makers stem from personal characteristics and the
particular position held in an organization. As a result,
Bordonaro held several interim hearings regarding senior
safety and IHSS.
Porter utilized Bordonaro's hearings as an instrument
to draw attention to the Demonstration Project. At a
hearing held in the summer of 1995, Porter planted damaging
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literature on the project. An analysis written by Carole
Barnes of the Institute for Social Research concluded that
Addus did not meet the established criteria for the project.
It was not uncommon for Porter to use Barnes's reports for
the purpose of obstructing IHSS policy. And although the
Demonstration Project was not on the agenda, the hearing
created a favorable environment for Porter to introduce this
information.
At the same hearing, however, a rebuttal paper was
dispersed by Addus, the agency rendering services under the
Demonstration Project. Addus attempted to restore
creditability to the project by hiring a retired state
analyst, Alan Post, to write the counter argument.
Coincidentally, Post was scheduled to testify at the
hearing as an expert about the agency provider system.
Although congressional committees frequently call on the
expertise of analysts in hearings, meetings, and advisory
panels (Kingdon, 1984), Post testified as a hired analyst
for Addus, not as a non-partisan player. During the hearing
Post injected favorable remarks about the Demonstration
Project. Porter consequently viewed Post as an advocate for
his client rather than for the policy. Client advocates are
known to place primary emphasis on their responsibility to
the client (Weimer & Vining, 1992) .
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Given the negative feedback of constituents, consumer
advocates and Barnes's report (1995), the expansion of the
Demonstration Project was blocked. All told, the Assembly
Human Service Committee public hearing was an ample
opportunity for key players on both sides of the debate to
influence the policy outcome.
With two failed attempts to expand the agency provider
system, Naylor's next undertaking was to pass legislation
(S.B. 278) to indefinitely extend the operative date of
existing agency contracts. To achieve continued prominence
on the political agenda, Naylor used the annual balancing of
the state budget as a means to introduce S.B. 27 8. With his
connection to both the Democratic and Republican Parties,
Naylor used Governor Wilson to introduce the item. At the
request of Wilson, S.B. 278 thus became a budget conference
committee item. Again Naylor encountered opposition from
consumer advocates over his efforts.
The Service Employee International Union (SEIU), a
county-approved home health care agency, was one of several
lobbying to defeat S.B. 278. Allen Davenport, SEIU
Legislative Director, was a key opponent of the agency
provider system. On behalf of SEIU, Davenport held an
economic interest in the debate, in that S.B. 278
jeopardized SEIU's role in the IHSS program. If passed, this
bill would allow any home health care agency to operate in
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any county and serve any recipient who had been authorized
for IHSS services without further approval from the county.
SEIU would thus face additional competition from private
agencies such as Addus.
Because of SEIU's position as an approved agency
provider, Davenport had inside knowledge of the IHSS
program. This knowledge was used to establish a financial
scenario suggesting that the enactment of S.B. 278 would
cost the state additional money (Davenport, letter to the
legislative leader, July 11, 1995).
Opposition to S.B. 278 did not stop with Davenport.
Porter was again involved in Naylor's endeavor to pass new
legislation. Striving to defeat this bill, Porter once again
put to use his relationship with Bordonaro. Wearing his
private consultant hat, Porter was asked by Bordonaro for
advice on S.B. 278. According to Kingdon (1984),
consultants are frequently called upon by the legislature
for input on policy issues. Because Bordonaro looked to
Porter for this information, Porter was in a position to
sway Bordonaro's vote.
While a battle of bargaining game tactics persisted
between Porter and Naylor over S.B. 278, key players inside
the state government also expressed interest in the IHSS
legislation. Moreover, Barbara Arnett, Assistant Secretary
of the Health and Welfare Agency (HWA) , expressed an
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interest in shaping workable legislative language aimed at
providing guidelines for counties contracting for IHSS
services. Arnett held concerns regarding S.B. 278 because
it could set-up expectations that her department could not
meet. Her personal agenda was 'to develop a more
comprehensive plan to address managed care opportunities in
California" (Arnett, letter to Naylor, July 13, 1995).
At Naylor's request, Arnett considered the implications
of S.B. 278 on IHSS. Having Arnett's support of this bill
would strengthen Naylor's position. In spite of this
request, however, Arnett made some minor modifications to
the IHSS language. With formal authority under California's
HWA, Arnett used this opportunity to change S.B. 27 8,
lessening the controversy and protecting her agency from the
impact.
Coincidentally, Porter and Naylor joined forces after
the failure of S.B. 278 in an attempt to shape appropriate
IHSS policy. This effort, however, lead to bickering between
the two players. Letters to legislative members suggested
that Porter and PICLTC alliances were unwilling to
compromise on IHSS language. Nevertheless, Naylor continued
to press the legislation for support of the agency provider
system.
Towards the end of 1996, Naylor's efforts to expand the
agency provider system had transpired. Although Naylor's
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previous efforts had ended in failure, he had found ample
opportunity to promote S.B. 17 80 to higher agenda status.
With the assistance of Governor Wilson, Naylor rallied
support from the Committee on Budget and Fiscal Review to
enact the Task Frequency Model.
Aside from S.B. 1780's position on the state's agenda,
the turning point for this effort was the financial
instability facing Porter's organization— PICLTC. As a
central player in the statewide alliance of IHSS advocates,
Porter fell short of leading the blockage of S.B. 1780 due
to PICLTC's poor financial status. For several months,
Porter had contemplated closing PICLTC's doors. In the
prior year, PICLTC had already minimized its staffing levels
and shifted priorities to fundraising efforts.
With Porter's attention on more pressing issues, Naylor
faced less resistance from a key opponent. Naylor continued
to bargain with political participants, spend resources, and
produce information to support his cause. And despite
Porter's continued effort, he was unable to expend
appropriate amounts of time and resources as he had done in
the past.
Conclusively, a shift of power among key IHSS players
gravely impacted the policy outcome of the debate. Porter's
presence was inevitably central to ceasing the expansion of
the contract provider system; his absence, nonetheless, was
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just as profound. Without Porter at the forefront, the IHSS
alliance lacked power. Influence on state decision-makers
was thus one-sided. Even though Porter continued to hold
the same interests, in the end, he was compelled to shift
priorities. In this case study, the loss of power for one
participant undoubtedly contributed to a gain of power for
players on the other side of the debate.
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CHAPTER VI: CONCLUSION
This thesis has examined the inception of the IHSS Task
Frequency Model (S.B. 1780) by way of Graham Allison's
Governmental Politics Model of the decision-making process.
The application of Allison's (1971) model to the IHSS debate
demonstrates several things about the decision-making
process. Each decision-maker entered the debate with
different goals and interests stemming from their personal
characteristics and/or professional position within an
organization. Furthermore, these individuals used some
level of bargaining or resources to influence one another.
Resources frequently came in the form of an exchange of
incomplete information among participants.
While Allison's criterion appropriately captures the
impact of key participants on the political process, it
lacks thoroughness in defining several key aspects. First,
the model does not clearly differentiate whether the actions
of those individuals positioned at the very top of an
organization are based on professional or personal
interests. Where are the boundaries between an individual's
personal and professional interests under these
circumstances?
Both Porter and Naylor, for example, expressed a
professional interest in line with organizational
objectives. Because of Porter's position, he was able to
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set goals and designate PICLTC's resources accordingly. His
position, however, also obliged him to change his priorities
towards strengthening the financial position of the
organization. Even during difficult times, Porter continued
to expend resources on the IHSS debate. Was Porter acting on
personal interests even when PICLTC could not afford to
designate resources to blocking IHSS legislation (e.g., S.B.
278, S.B. 1780)? Was he acting under the direction of
PICLTC's board of directors? Was Naylor's agenda completely
based on a professional stake in the issue?
Second, Allison's model does not recognize the impact
of key participants possibly acting as individual agents
(e.g., individuals not belonging to a formal organization
but influencing policy outcome just the same). Does an
individual with an interest in a policy issue need the
backing of an established organization to impact the
outcome?
Finally, the optimal alternative is not a key aspect of
this model. With several decision-makers aiming to fulfill
their personal and/or professional agendas, the optimal
solution is chosen based on a balance of all alternative
solutions. The participants involved in this case study did
not determine the optimal alternative for the problem at
hand, instead, the outcome was adopted through bargaining
tactics and a shift of power. The policy outcome did not
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adequately address the issue of the efficiency, cost-
effectiveness and quality of care. Do the decision-makers
involved have complete and accurate knowledge to understand
the consequences of adopting a less than optimal outcome?
In conclusion, the application of Allison's
Governmental Politics Model to the IHSS debate provided some
structure for explaining the decision-making process behind
the enactment of the IHSS Task Frequency Model.
Nevertheless, by exploring answers to the questions above,
one could further examine the plausibility that actions of
key political participants impact the state decision-making
process.
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6 7
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Asset Metadata

Creator Hansen, Katherine Annette (author)

Core Title California's In-Home Supportive Services debate: An application and critique of the governmental politics model of the decision-making process

School Leonard Davis School of Gerontology

Degree Master of Health Administration / Master of Hospitality Administration

Degree Program Gerontology,Health Administration

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,OAI-PMH Harvest,Political Science, public administration,sociology, public and social welfare

Language English

Contributor Digitized by ProQuest (provenance)

Advisor [illegible] (committee chair)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-31702

Unique identifier UC11337038

Identifier 1395132.pdf (filename),usctheses-c16-31702 (legacy record id)

Legacy Identifier 1395132.pdf

Dmrecord 31702

Document Type Thesis

Rights Hansen, Katherine Annette

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA