ABOUT US   |   SUBSCRIBE    |   E-MAIL EDITOR   |   HOME
May/June 2000

"States often use waivers to control how many people they will allow to be free, by limiting the numbers," says ADAPT. "They allow just enough of us to live in the community to keep disability advocates quiet -- and keep the rest of us in the institutions to keep the big nursing home industry quiet."   States can offer in-home services under Medicaid now -- if they choose to   The Personal Care Services Option was made available to states in 1975; states that make this option part of their State Medicaid Plan can use Medicaid funds to pay for attendant services. The PCS Medicaid benefit lets states offer "unskilled personal care services" as a part of the states' Medicaid benefit package. PCS benefits must be offered to all "eligible individuals." Although states that choose this course cannot restrict the services as they can with waivers, and the PCS benefit must be available to anyone who's eligible for Medicaid, in fact, states may limit the PCS benefit through two mechanisms: "medical necessity" and "utilization control": states can , for example, limit the hours of service provided each day or impose limits on the type of services provided. According to the Disability Statistics Center, only 28 states allow Medicaid funds to be used for personal assistance services outside the home -- for assistance at the grocery, the bank or at work, for example. Home and community-based services waivers were introduced in 1981 by Medicaid. The passage of Medicaid waivers was based in part on the theory that providing certain nonmedical services (such as housekeeping, personal care, and adult day care) in the home or community "could delay or eliminate institutionalization," says the General Accounting Office. " The popularity of HCBS waivers is evidenced by their growth rate," says the General Services Administration in its May, 1999 report, Adults with Severe Disabilities: Federal and State Approaches for Personal Care and other Services. "From 1987 to 1998, expenditures under HCBS waivers grew at an average annual rate of 31 percent, compared with 16 percent for home health and 10 percent for the PCS benefit." To receive an HCBS waiver, states must demonstrate that the cost of the services to be provided under a waiver (plus other state Medicaid services) is no more than the cost of institutional care (plus any other Medicaid services provided to institutionalized individuals). Waivers permit states to cover a wide variety of nonmedical and social services and supports that allow people to remain in the community, including personal care, personal call devices, homemakers' assistance, chore assistance, adult day health care, and other services that are demonstrated as "cost-effective and necessary to avoid institutionalization." Yet they also allow states to limit geographic availability, restrict services to specific populations or conditions, limit the number of individuals served, and cap expenditures. "The consumer direction field, in particular, relies heavily on waivers to achieve reform," writes the National Council on Aging's Tom Yatsco in its Spring, 1999 issue of Consumer Choice News. "Yet waivers are only temporary solutions." ADAPT calls waivers "band-aid solutions" -- for the "MR/DD population, people with AIDs, people with brain injuries and so on" -- and say they "create gaps and keep our people fighting each other for valuable service dollars." "We cannot have government by waiver," Health and Human Services Secretary Donna Shalala said in 1993. Yet that's pretty much what's happened; "nearly every state is operating part or all of its Medicaid program with a federal government waiver," writes Yatsco. "States often use waivers to control how many people they will allow to be free, by limiting the numbers," says ADAPT. "They allow just enough of us to live in the community to keep disability advocates quiet -- and keep the rest of us in the institutions to keep the big nursing home industry quiet." Nursing home lobby money and state legislators The nursing home lobby that fought back What Medicaid spends -- comparisons Countering the 'Woodwork Effect'   Back to our main story