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.     

Paid personal assistance services:an exploratory study of working-age consumers' perspectives

This study examined the experiences of individuals who use paid personal assistance services (PAS). Structured interview data were collected from a convenience sample of 24 working-age individuals from diverse backgrounds recruited from Centers for Independent Living in nine states. Respondents described their general satisfaction with current paid PAS, but many reported previous experiences with poor care related to the low wages, lack of training of PAS providers, and an inadequate supply of providers. Respondents reported many unmet needs because of a shortage of hours provided by state programs and the lack of help with daily living activities, transportation, childcare, and social activities. The respondents strongly preferred consumer-directed care.     

Medicaid State Plan personal care services: trends in programs and policies

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.     

Peer assistance for personal assistance: analysis of online discussions about personal assistance from a Swedish web forum for disabled people

This paper describes and analyses a community of disabled people in Sweden that use an online forum to discuss personal assistance issues. The forum is a community of practice (CoP) that has its roots in everyday living with personal assistance. The contributions to the forum were studied over a 4½ year period, including a total of 2755 postings from 146 persons. The levels of the CoP learning system were analysed using the FACE tool, which examines function based on attitude, control and enabling. The results indicate that a learning system was established within the CoP that made it possible for disabled people to complement, confront and counterbalance the influences of existing learning systems, theories and methods of professionals in the area of personal assistance.     

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.     

Emerging services for community-based long-term care in urban China: a systematic analysis of Shanghai's community-based agencies

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

Toward a community-based national rural policy: the importance of the social services sector

Although discussions of rural America's challenges have surfaced at regular intervals over the past half-century, the issue is receiving significantly greater substantive policy discussion today, as a dialogue regarding the development of a more integrative, community-based, national rural policy begins to emerge. This article outlines this unique "rural policy moment," assesses the potential for a community-based rural policy for our nation, and discusses the critical role rural social services practice and policy play in supporting these opportunities to address the significant challenges faced by rural people.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

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.     

Equity and efficiency in the allocation of the personal social services

This paper investigates two issues of equity in the receipt of the home help service, one about territorial justice, the other about sex discrimination. It uses GHS data for 1980. An argument is developed about the efficiency with which services are targeted on persons who by normative criteria would appear to have most need of them. Efficiency is of two types: horizontal efficiency, the proportion of persons judged in need who receive services; and vertical efficiency, the proportion of services allocated to persons judged in need. The findings are that there is evidence of inequity both between different areas and between the sexes. Metropolitan areas are advantaged compared with rural areas, and this cannot be explained by differences in social support nor by the availability of other domiciliary services. Among the elderly living alone, neither sex is advantaged, but in elderly married couple households the home help service is more frequently provided in the case of a husband caring for a disabled wife than in the case of a wife caring for a disabled husband.     

The effect of health insurance coverage on personal bankruptcy: evidence from the Medicaid expansion

Review of Economics of the Household - This paper investigates the effects of health insurance coverage among low-income people on personal bankruptcies at the county level and the state level,...     

Race and gender differences in the distribution of home and community-based services in Florida

This article examines the distribution of home and community-based services (HCBS) under Florida's Medicaid waiver program. Controlling for personal and community characteristics, it was found that gender and race significantly affect the access of the disabled adult population to HCBS services, with women and nonwhites significantly more likely to be receiving HCBS services. At the county level, the likelihood of one's being in the waiver program is contingent on the racial composition and level of segregation of the county. People residing in counties with substantial proportions of nonwhites are less likely to receive HCBS services--whatever their race. However, the higher the rate of racial segregation in the county, the higher the probability that the Medicaid disabled adult population will receive HCBS services. The Medicaid waiver program allows older, disabled black women to remain in their home neighborhoods rather than having to move to predominantly white areas where nursing homes are concentrated. Thus, the HCBS program not only provides them with a form of care that is preferred by most older people but also resolves market problems stemming from the lack of nursing homes in segregated areas by taking advantage of support systems in black households.     

Socioeconomic determinants of the need for personal assistance reported by community-dwelling elderly: Empirical evidence from a French national health survey

A bivariate probit model with sample selection is used to estimate the conditional probability of reporting a need for personal assistance (NPA) with at least one activity of daily living among French community-dwelling elderly. 71.8% of men and 77.3% of women reported impairments and among those who reported impairments, 7.5% of men and 10.8% of women reported NPA. NPA is associated not only with age (i.e., the oldest individuals, for women only) and health status (such as a specific type of impairment), but also with socioeconomic (living with intermediate income; living with someone, partner or other) and environmental factors (having and using assistive technologies).     

Health,personal mobility and the use of health services in rural Norfolk

Trends towards the centralisation of both primary care and hospital services are increasing the distances that rural residents must travel to receive health care. Contradicting the widely held image of the healthiness of rural people, data from social surveys in Norfolk show that some of the remoter rural areas have populations with a relatively high need for health care. Furthermore, the groups with most need for health care (the old, the disabled, the poor, etc.) are also those with low levels of personal mobility, for whom travelling long distances to centralised health services is particularly difficult. After adjustments have been made for variations in need, it is shown that people in the remoter areas receive much less health care than comparable people in more accessible areas. However, branch surgeries do seem to make the general practitioner service more accessible, particularly to less mobile rural residents.     

Distribution and utilization of home- and community-based long-term care services for the elderly in North Carolina

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.     

Consumer‐directed personal assistance and ‘care’: perspectives of workers and ventilator users

‘Consumer‐directed personal assistance’ has been a central tenet of the North American Independent Living Movement since its inception. There is, however, surprisingly little research that explores how consumer‐directed assistance gets played out in practice. We conducted a qualitative study that explored the relationships between disabled ventilator users and their personal support workers (PSWs) in supportive housing environments in Ontario, Canada. The results show that while all participants agreed that they adhered to the philosophies of ‘independent living’ embedded in ‘consumer‐directed personal assistance’, how this was understood and enacted varied considerably. Narrow interpretations focused on the task‐oriented aspects of PSWs’ work, while broader interpretations included interpersonal aspects of care, respect and mutuality. We discuss how a conceptualization of consumer‐directed personal assistance can be elaborated to accommodate a notion of ‘care’ while retaining the core tenets of the independent living philosophy.