The attraction of home- and community-based services

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You can’t ignore the signs. A new bill would allow states to use funds for home- and community- based services. A pending proposal would permit states to combine three separate HCBS Medicaid waivers. Even the “Affordable Health Choices Act” would give people the wherewithal to stay in their homes with a disability.

There is more than enough evidence to indicate that HCBS is growing, and the government is committed to expanding it.

And is that so bad? HCBS is an exciting new frontier in eldercare. There are plenty of good, innovative programs that are working around the United States. “Cash and Counseling” allows people to spend Medicaid funding as they choose for their care services. The PACE (Programs of All-Inclusive Care for the Elderly) program offers a comprehensive set of services to keep people at home, and pools federal, state and private funds to do so.

And more stories about effective home programs are emerging everyday. The Providence Journal recently highlighted Beacon Hill Village in Boston, a nonprofit program in which members pay dues for services that allow them to stay independent.

On the other hand …

But there are other sides to the issue. If all anyone needed was home care, then why have nursing homes at all? Of course, the answer is they provide care to the most frail and vulnerable. If they were growing obsolete, why does the government spend more Medicaid dollars on nursing homes than any other type of care?

But it seems that the government doesn’t want to hear it—at least right now. And here are a couple possible reasons why. For one, HCBS seems like an easy solution: The idea of staying at home satisfies people (or voters). It makes them happy—at least while they are able-bodied.

But there may be another underlying reason why Washington is leaning so heavily toward funding HCBS. They are hesitant to tackle the extremely complicated financial structures they have created that underlie the nursing home system. Medicaid? Post-acute payments? Not going to touch it.

Perhaps that is why true so-called “long-term care reform” remains elusive at this point. It would mean cracking the code of unbelievably complex systems.

So, what is the answer? Invest adequately in both. HCBS is good, and the trend toward increasing it is more positive than negative. But nursing homes are a significant part of our culture and economy too.

Sooner or later, Washington is going to have to face this fact.
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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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