Were you reading the same article that I was? The one where the author claimed that the existing system is, in fact, more expensive than providing non-nurse home-care? Or are you referring to other articles & studies that I should know about? If so, please post the names and/or links so I can read them.

Thanks

Here in eastern Canada, we’ve already been moving toward that model. The bar, so to speak, of independent living is being raised higher and higher, so that the care requirements of those in long-term facilities are much greater than they were even a few years ago. Everyone else, they’re in home care to one degree or another, the greatest focus there being on independence. The agency I’m placed with right now for clinical experience has over 400 clients in home care. And even at that, there are huge staffing shortages.

I know the Powers That Be in the US are loathe to adopt a Canadian model, but really. The amount of money we’re saving, and the quality of life preserved, is incredible.

It is true that for a given individual, home care can be less expensive than nursing home care. But for some people, institutional care is cheaper.

I’m actually a big fan of home and community-based care. But the cost argument for it is tricky. Whether and to what extent states save money depends on how they design their system, and if they expand home care without limiting institutional care and taking other steps, they may actually spend more. Disability advocates argue against the woodwork effect, but just opening up HCBS without other measures will drive up costs. If you put the right design elements into place, though, you can save money, at least on some of your population.

A Wiener/Sullivan report (at http://www.uwex.edu/ces/familyimpact/reports/fis12two.pdf) noted, for instance, that serving people who might otherwise go into an ICF-MR in the community can be cheaper. But “Studies show that
in demonstration projects offering expanded home care to older adults, total costs
rose rather than declined (Wiener & Hanley, 1992).”

Here are a few other places that discuss the cost and woodwork effect issues:

http://www.ncsl.org/programs/health/forum/cost/strat5.htm
http://www.ncsl.org/programs/health/forum/shld/11c.htm
http://www.hcbs.org/resources/one/Cost-Effectiveness%20of%20Home%20and.htm

I understand why people use the cost argument. I used to work for a state legislator and in a state Medicaid agency (I was a long-term care person). States tend to do stuff if they think they’ll save money in their Medicaid programs. But to me, the argument for HCBS is a moral one. We should help people with disabilities and chronic health needs achieve independence and self-direction. Dumping people into facilities may be cheap and convenient, but social policy should strive for what is right, not what is easy.

Thanks for the links. Having read through them I cannot agree that the “woodwork effect” should have any bearing on this issue. If such a thing happens, that is because there are people who need those services now but who would rather not voluntarily imprison themselves. It is just a way of saying, “Hey, if we don’t offer services, we save money.” Which is morally reprehensible.

It seems like there is little doubt that HBC will cost less per-person, on balance. The fear seems to be that we will need to provide services to more people. “Let them rot, if we create a system where services are delivered in the most odious way possible we can provide services to fewer people and save money!” seems to be the argument against HBC.

So I guess that I’m agreeing with you WRT it being a moral argument. It’s just that I don’t see the monetary argument against as valid. But, then again, that’s why I place where I do on the political spectrum.

You’re right about what the woodwork effect means. There are, in fact, people who forgo institutional care but who would jump at the chance to get home and community based care. It does, in fact, mean that states limit their waiver programs to a set number of people and deny care to others until they get to the top of the waiting list and a slot in the waiver becomes available.

HCBS sometimes cost less but sometimes more, depends on the needs and informal supports of each individual. Some people with intensive needs are cheaper to serve in institutions. That’s why I don’t like the cost argument - if you say we should provide HCBS because they are cheaper, you leave yourself open to those who say “If they are not cheaper, we should not provide them.” We should provide HCBS services even if they are more expensive than facility-based services. If we save money on some people, great. (And we should certainly try to structure programs to be as efficient and effective as possible.) But if they aren’t cheaper — well, the right thing is not always the cheapest thing.