Medicaid State Plan Personal Care Services

Abstract

Policymakers face mounting pressures from consumer demand and the 1999 Olmstead Supreme Court decision to extend formal (paid) programs that deliver personal care to the elderly, chronically ill, and disabled. Despite this, very little is known about the largest program that delivers personal care: the Medicaid State Plan personal care services (PCS) optional benefit. This paper presents the latest available national program (participant and expenditure) trend data (1999–2002) on the Medicaid PCS benefit and findings from a national survey of eligibility and cost control policies in use on the program. The program trends show that, over the study period, the number of states providing the Medicaid PCS benefit grew by four (from 26 to 30), and national program participation, adjusted for population growth, increased by 27%. However, inflation-adjusted program expenditures per participant declined by 3% between 1999 and 2002. Findings from the policy survey reveal that between 1999 and 2002 there was a marked decline in the range of services provided, and by 2004, almost half the programs operated a cap on the hours of services provided.     

Medicaid home- and community-based services: impact of the affordable care act

The Affordable care Act (ACA) legislation of 2010 has three important voluntary provisions for the expansion of home- and community-based services (HCBS) under Medicaid: A state can choose to (1) offer a community first choice option to provide attendant care services and supports; (2) amend its state plan to provide an optional HCBS benefit; and (3) rebalance its spending on long term services and supports to increase the proportion that is community-based. The first and third provisions offer states enhanced federal matching rates as an incentive. Although the new provisions are valuable, the law does not set minimum standards for access to HCBS, and the new financial incentives are limited especially for the many states facing serious budget problems. Wide variations in access to HCBS can be expected to continue, while HCBS will continue to compete for funding with mandated institutional services.     

Special foster care for exceptional children:: A review of programs and policies

This article reviews programs and policies regarding alternative home care for exceptional and special-needs foster children. While some focus is placed on program evaluation and efficacy of these specialized foster homes, the major thrust of the review is to identify major procedural underpinnings of successful programs for special needs foster children. These include: (a) appropriate selection of qualified therapeutic parents; (b) preservice training of parents; (c) matching of child to abilities of parents; (d) high-intensity and high-frequency casework and consultation; and (e) professional status for the specialized foster parents. Special foster care programs which have been evaluated offer generally high levels of success and goal attainment at much lower per diem rates than institutional care. Summary policies and recommendations are forwarded.     

Estimating the expense of a mandatory home-and community-based personal assistance services benefit under Medicaid

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability. DESIGN AND METHODS: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS. RESULTS: New expenditures for PAS are estimated to be $1.4-$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA). IMPLICATIONS: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Foster care and Medicaid managed care

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.     

Cross-state variation in Medicaid programs and female labor supply

Using a pooled cross-section data set from the 1980 through 1993 Current Population Survey March Supplements, we test if different Medicaid benefit levels across states impact the labor supply behavior of female heads of households. The ordinary least square (OLS) results support the prediction that Medicaid expenditures reduce labor supply. Controlling for state fixed or random effects alters the effect of both AFDC and Medicaid on the decision to participate as well as the number of hours worked. We also find that while the effects of program generosity are sensitive to the inclusion of state effects those of variation in eligibility thresholds are not.     

Change and inertia in the New York state medicaid personal care services program: an institutional case study

This study analyzes how competing logics (belief systems) of stakeholders have influenced patterns of change and inertia in the development of the New York Medicaid Personal Care Services (PCS) program. A case-study methodology was used to collect documents, statistics, and interview data from four key stakeholder groups: state and city officials, PCS agencies, a labor union, and consumer advocates covering the period 1999 to 2005. The New York PCS program is one of the oldest, largest, and most stable programs in the United States. Its early unionization of workers resulted in relatively generous wages and benefits and made New York number one nationally in PCS spending per capita. In spite of wide support from stakeholder groups, the overall number of participants has gradually declined since 1999. A consumer-directed model of personal care developed in 1995 challenged the status quo and has grown steadily. Resistance by public officials, agency providers, and union representatives to the consumer-directed model has resulted in a small program that is often targeted toward individuals labeled "difficult to serve." Dominant stakeholders in New York have ensured a stable personal care program that has resisted change and led to program inertia.     

State expenditures on home and community based services and use of formal and informal personal assistance: a multilevel analysis

Despite wide state variation in commitment to home and community-based services (HCBS) for functionally impaired older persons, little is known about how such variation affects older adults' strategies to compensate for their functional limitations. This study examines the association of state HCBS expenditures with use of formal and informal personal assistance among non-institutionalized older Americans aged 70 and older with functional limitations. We conducted multilevel multinomial logistic regression analysis using data from the first wave of the Assets and Health Dynamics among the Oldest Old Survey, combined with data on state HCBS expenditures. Controlling for individuals' demographic, socioeconomic, and care needs factors, persons residing in states with higher HCBS expenditures were more likely to use formal personal assistance, but not less likely to use informal assistance. Our study suggests state variation in HCBS expenditures leads to inequitable access to formal personal assistance, especially among those with high functional limitations.     

Disaster mental health services: a personal perspective

1. Services that may be provided by psychiatric-mental health nurses following a disaster include education, intervention, problem solving, advocacy, and referral. 2. Nurses providing disaster mental health services must be flexible and creative. Strong observational skills and teamwork are also essential characteristics in disaster settings. 3. Psychiatric-mental health nurses who wish to receive training for disaster mental health volunteer opportunities should contact their local chapter of the American Red Cross.     

Implementing public policies and services in rural Japan: issues and problems

While the sharply increased services for the elderly in the revised Gold Plan--announced in 1994--are noteworthy, implementation of the revised Plan is expected to present numerous issues and problems, particularly in the rural areas of Japan, because of unique circumstances such as depopulation and the presence of a disproportionately large number of elderly; geographical and physical isolation; a conservative and tradition-bound political climate; and conservative attitudes of the elderly. This article examines the current state of policy implementation, identifying issues and problems that are being encountered in the rural areas of Japan. Such issues as economic and family life, health care, and service delivery for the elderly are examined.     

Evidence-based programs in children's services: A critical appraisal

Evidence-based programs (EBPs) are increasingly being implemented in children's services agencies in developed countries. However, this trend is meeting resistance from some researchers, policy makers and practitioners. In this article we appraise the main critiques, focusing on scientific, ideological, cultural, organizational and professional arguments. We contend that some of the resistance stems from misconceptions or an oversimplification of issues, while others represent valid concerns that need to be addressed by proponents of EBPs. We set out implications for the development and evaluation of programs and how they are introduced into service systems, and conclude with broader recommendations for children's services.     

Long-term care: a comparison of policies and services in Israel and the United Kingdom and implications for the United States

The issue of long-term care continues to be a main concern in the United States. As the country wrestles with the development of policies and services, the experiences of Israel, whose system rests upon national insurance, and that of the United Kingdom, which is based on grants to local authorities, can act as valuable teaching aids in the development of programs in the United States. Although both countries focus on community care with virtually universal access, concern over resources is forcing each to target their services increasingly to the most frail. The findings underscore the necessity for accurate planning and adequate resources if services are to meet the needs of the frail elderly population.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.