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Volume 12 Number 186 News: Medicaid State health care officials and other witnesses told the Senate Finance Committee Sept. 25 that there is "an institutional bias" in the Medicaid program that places people with disabilities and the elderly in nursing homes, instead of allowing them to live in their own homes with home and community based care. Speaking at a Sept. 25 committee hearing on "Home and Community Based Care: Expanding Options for Long Term Care," panelists urged support of the Community Care Act (S. 799) that would give Medicaid beneficiaries the choice of either going to a nursing home or getting personal care attendant services in their own homes. Bill sponsor Sen. Tom Harkin (D-Iowa) told the committee that "there is a Medicaid bias where two-thirds of the money goes to nursing homes and a third goes to community care." He added that home and community based services (HCBS) would provide personal attendance services that allow people to live independently and fully participate in their communities, goals he said were part of the Americans With Disabilities Act that became law 17 years ago. 'Mandatory' Option Although Iowa and other states have Medicaid waivers to offer HCBS, Harkin said there are "bureaucratic entanglements" for participating in the services, including a Medicaid spending cap and long waiting lists. "It is time to move beyond the waivers and have broad-based community care," Harkin said. The deputy secretary of the Vermont Agency of Human Services, director of the Iowa Department of Human Services, and the director of Montana Fair Housing echoed the request that Congress pass a law making HCBS a mandatory option offered under the Medicaid program. "By making HCBS a mandatory benefit it would greatly reduce the institutional bias," said Mitchell La Plante, associate professor at the University of California, San Francisco, Department of Social and Behavioral Science. The Community Care Act Harkin introduced March 7 the Community Care Act to amend Title XIX of the Social Security Act to add mandatory coverage community based attendant services and supports for individuals eligible for medical assistance under a state plan, who would have received those services in a nursing facility, or who chooses to receive such services. S. 799 would permit states to provide the services through state plan amendments. States that get a Medicaid plan amendment approval to add the HCBS services between Oct. 1, 2007, and Sept. 30, 2012, would receive an enhanced Federal medical assistance percentage, according to the bill text. The bill was referred to the Senate Finance Committee. Cost Savings Senate Finance Committee Chairman Max Baucus (D-Mont.) said that "Medicaid payment limitations can restrict where people live or receive health care." He added that community-based services give people "independence" and that "states that have enabled people to move out of nursing homes and back into the community generally save money." Vermont's HCSB program, launched in October 2005 under a Section 1115 Medicaid waiver, serves an estimated 500 people and costs the Medicaid program less than nursing home care, said Patrick Flood, deputy secretary for the Vermont Agency of Human Services. "The average cost of keeping an elder at home under the waiver was two-third the cost of average nursing home care," Flood said. "It's not only that people want, people prefer staying in their own homes, but that it is cheaper," Flood said, adding that "it doesn't make any sense. The more expensive service that people don't want is an entitlement, but the cheaper, more desirable service is capped and you have to wait in line for it." Iowa spent $348 million in 2007 on programs on seven home and community based services approved under Medicaid waivers, said state Director of the Department of Human Services Kevin Concannon. The state obtained its first waiver for the HCBS programs in 1984, he said, adding that the program serves 23,000 people today, compared to 30,000 people in nursing homes. CBO Cost Estimates Questioned La Plante testified that the HCBS programs produce savings. He noted one study that found that the Medicaid saves $44,000 per person by providing HCBS instead of a nursing home stay. La Plante disputed a Congressional Budget Office estimate that reported it would cost the federal government between $10 million and $20 million to cover a quarter of eligible beneficiaries under an earlier version of the Community Care Act bill. He said that his own research at the University of California estimates expenses "ranging between $1.4 million to $3.7 million depending on the rate of participation from 30 to 80 percent [of eligible beneficiaries]." La Plante said the CBO estimate includes activities such as shopping not included in his estimate. "The key difference between our estimate and the CBO estimate is the number of people who would be eligible," La Plante said. "Measures of institutional need are typically based on two or more of the basic activities of daily living, which include bathing, dressing, transferring, toileting, and eating. The CBO estimate included people who need help with a much broader set of instrumental activities including shopping for groceries or getting places outside of walking distance." Baucus said he would request a "more realistic estimate" from the CBO. Text of the Senate Committee hearing is available on the Web at http://www.finance.senate.gov/sitepages/hearing092507.htm. Text of S. 799 is available at http://thomas.loc.gov.
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