Trinidad Contreras enjoys gardening and playing dominoes at his adult day health care center, but a state ruling has the 79-year-old fearfully anticipating an isolated existence.
"At this age, being old and being in the apartment alone, I'm afraid to be alone. I'm afraid I'll get depressed again," he said, speaking in Spanish through an interpreter.
He began to cry.
Until this year, California paid for him to attend Gardner Adult Day Health Care in San Jose.
To save money, the state limited Medi-Cal coverage for such care to those with the most serious needs. Contreras, who sometimes needs help eating because of Parkinson's disease tremors, did not make the cut.
The state this year found about 7,000 seniors ineligible out of 35,000 participants in a program originally meant to save money by keeping medically fragile people out of more costly nursing homes and high-cost emergency rooms.
Some 1,800, including Contreras, have appealed, and some centers, unwilling to leave people without services, are sagging under the financial pressure of keeping their doors open to people the state no longer pays for.
The cutback is difficult but necessary, state health leaders say. "The unfortunate fact is that the state is in a very difficult budget situation," said Norman Williams, spokesman for the Department of Health Care Services.
The centers' budget situations also are difficult.
Gardner has paid some $10,000 since April 1 to accommodate its eight ineligibles. Program director Sonia Garcia said she has little choice.
"They have their sense of community here," she said. "To deny them that, ethically I couldn't do that."
Elsewhere, an El Sobrante center is putting up about $7,200 a week to keep caring for its 27 ineligible elders.
"My resources are being strained, but I don't believe, as human beings, we have a choice," said Peter Behr, who runs Guardian Adult Day Health Care Center.
Flurry of appeals
The state will reimburse the centers only if ineligibility is reversed, and the hearings could take months.
"I could see them taking until the end of the year, if not longer," said Elissa Gershon, an attorney for Disability Rights California.
Several hundred people in Alameda County are appealing, said county Supervisor Wilma Chan. "The transition hasn't been smooth. It's been a nightmare for the clients and the providers."
Using money from a half-cent sales tax for health care, Alameda County supervisors set up a $300,000 fund to help local centers pending the appeals.
The programs typically have physical, occupational and speech therapists, nurses and social workers.
People usually attend several days a week for activities such as arts and crafts, seated volleyball, singing, dancing, board games and current events discussions.
The new Community Based Adult Services itself is a scaled-back program the state set up to settle a lawsuit challenging the elimination of adult day health care for Medi-Cal recipients.
Critics question whether the new program will save money. They note that last year the state spent $158 million on adult day health care. This year the new program's budget, with 20 percent fewer people, is $144 million.
The state expects costs to drop.
"Starting a new program requires some very intensive resources," Williams said. "We expect to generate greater savings as we move forward."
People ineligible for the new program will have enhanced case management to help them be independent, Williams said.
Ineligibility raises different issues for seniors' relatives. Some may quit work to care for an elder, others will consider nursing homes or they may simply leave the senior at home alone.
Richmond resident Darlene Drapkin's 89-year-old mother, Rosa, was found to be ineligible. She uses a wheelchair, is diabetic and needs help to dress and use the restroom.
Having Rosa at Guardian Adult Day Health Care Center enables Drapkin to work. And it gives her mother a purpose, Drapkin said.
"She likes it. Otherwise, she sits at home and there's not much for her to do."
The family has appealed.
The ineligibility appeals also are drawing complaints. By the first week in June, the state had held about a dozen hearings among more than 1,800 appeals.
A program director who went to one of the first hearings said she left incensed.
"The state geared up for this hearing as though they were doing a criminal trial," said Debbie Toth, CEO of Rehabilitation Services of Northern California.
The state sent an attorney and three officials to the hearing for a 90-year-old Walnut Creek man. It lasted seven hours, Toth said.
Williams said the initial hearings are test cases that require more staffing to understand the issues that will arise. The subject of the hearing, Elya Kamenetsky, has had two strokes and a heart attack. His wife, 87-year-old Liba, has diabetes, severe headaches and uses a walker.
The couple said it was physically difficult for them to sit through a seven-hour hearing. "We've never had a court experience before and now we understand how awful it is," he said, speaking in Russian through an interpreter.
"I was in a lot of pain during the hearing," Liba Kamenetsky said. "I was very, very anxious and scared about what was happening to my husband."
A ruling on his appeal is pending, and they will have to return for Liba Kamenetsky's hearing.
Williams said the state is "dedicating the resources to resolve any delays to get these hearings moving as quickly as possible."
The co-owner of Grace Adult Day Health Care Center in Sunnyvale said he is upset that a supervisor went against the recommendations of an interviewing nurse who found many of his participants eligible.
Williams said the nurses had no authority to make final decisions and reviewers looked at each person's medical plan and history.
Ultimately, 78 of the 150 seniors at Grace were deemed ineligible. Nearly all have appealed, none has hearings scheduled, and they continue to come to the center.
"We cannot really let them stay home," said co-owner Manooch Pouransari.
"They're too sick. They need attention. I'm borrowing as much as I can, but I don't know how much longer I can absorb the cost."
Sandy Kleffman covers health. Contact her at 510-293-2478. Follow her at Twitter.com/skleffman.
Participating seniors: 35,000
Medi-Cal recipients declared ineligible: 7,000
Number appealing decision: 1,800
Program budget last year: $158 million
This year: $144 million