New Medicaid Program Provides Cash
by Christina Medvescek
If you were eligible for a personal care assistant through Medicaid,
would you rather: a) let the state assign you one from an agency;
or b) be given the money and decide yourself how to meet your personal
care needs?
For those who chose "b," theres good news in the form
of a program that gives cash instead of standard agency services to
eligible individuals. The program, called Cash and Counseling, was
tested in three states beginning in 2000, and is being offered to
10 more states, thanks to the Robert Wood Johnson Foundation, the
U.S. Department of Health and Human Services (HHS) and the U.S. Administration
on Aging.
Astronomical Differences
First tested in Arkansas, Florida and New Jersey, Cash and Counseling
gave monthly allowances to 6,700 elderly or disabled Medicaid enrollees,
while a control group received traditional agency-directed services.
Within limits, Cash and Counseling participants could spend the money
as they saw fit, including hiring family members and friends as caregivers,
or buying assistive devices and making home modifications instead
of getting services. Participants received counseling to help plan
their purchases.
The program resulted in "astronomical differences" in consumer
satisfaction, says Kevin J. Mahoney, project director and associate
professor at the Boston College School of Social Work. Participants
reported the program had a positive impact on their quality of life
and family caregivers, resulted in fewer unmet needs and had no negative
impact on their health.
Program participants had fewer complaints about their care workers
performance and reliability, and were able to fire and rehire workers,
not merely complain to an agency.
Among Arkansas participants was a mother being paid to care for her
20-year-old son with Duchenne muscular dystrophy. (See interview 27
at www.hhp.umd.edu/AGING/CCDemo/Products/AR.html.)
The program was evaluated by Mathematica Policy Research of Princeton,
N.J., which has posted results at www.mathematica-mpr.com/3rdlevel/cashcounseling.htm.
State Funding Available
States that dont win one of the next 10 Cash and Counseling grants
can implement the program by applying for waivers through the Centers
for Medicare and Medicaid Services, Mahoney recommends. Another new
program, Real Choice Systems Change Grants for Community Living (www.cms.hhs.gov/systemschange),
also can be used to switch to a cash-and-counseling approach.
Several bills now pending in Congress propose to give more choice
and control to people with disabilities who use government benefits.
They include: the Medicaid Community-Based Attendant Services and
Support Act (MiCASSA), which mandates state Medicaid coverage
of community services and support in certain cases; the David Jayne
Medicare Homebound Modernization Act, which grants some recipients
of home health care services the freedom to leave home; and the Inclusive
Home Design Act, which requires minimum standards of accessibility
in new housing.
President Bush has proposed a Money Follows the Person initiative,
which is similar to Cash and Counseling but also provides federal
funding for the first year of operation.
Bob Williams, co-director of Advancing Independence: Modernizing
Medicare and Medicaid (AIMMM, www.aimmm.org),
praised the "strength and beauty" of Cash and Counseling,
saying it uses "limited Medicaid dollars in ways that best ensure
independence and basic well-being."
But he cautioned that the approach works best if the individual already
has a support network of family and friends to tap for assistance;
and the monthly allowances are adequate and can be adjusted if needs
change.
"One of my greatest fears," he told the health subcommittee
of the House Energy and Commerce Committee this summer, is that at
least some states will take advantage of consumer choice as a way
to cut Medicaid costs.
