Now is the time to transform Medicaid Home and Community-Based Services

By Margaret Danilovich @margaretdptphd

In the living room of my client Jamess home, his bed pads, diapers, gloves, and wipes are stacked in a corner. He lies in a hospital bed, watching the Chicago Cubs baseball game while visiting with a former work colleague as his home care aide cooks one of his favorite meals.

James is 75 years old, diagnosed with a progressive muscle disease, and is bed-bound. Despite his health condition, he lives in his own home, directs his own care, and participates in his community because he has Medicaid.

Cuts to Medicaid threaten Jamess autonomy and his ability to live.

I am an assistant professor at Northwestern University and research older adults and their caregivers in the Medicaid system. Through my work, I have visited the homes of hundreds of older adults like James who receive Medicaid Home and Community-Based Services , a program that provides over 1.5 million people in the US in-home care as an alternative to institutionalization.

Without Medicaid in-home services, millions of people like James could not live on their own and would need to rely upon family members for assistance or be forced to enter a nursing home.

In the recent healthcare debates, a primary focus of reform has been on Medicaid expansion and the medical services Medicaid provides to low-income individuals.

However, an often-overlooked aspect of these debates is that Medicaid is the primary source of long-term care services for older adults via nursing homes, medical home health services, and in-home, non-medical care. One example of a non-medical care service is home care aides or homemakers who assist clients with tasks such as bathing, cleaning, and running errands. While not technically skilled medical services, the important tasks home care aides provide are essential to daily life.

At a recent home care agency meeting, an aide cried while describing her fear Medicaid budget cuts would harm her client. Her client has no family and is unable to leave his home without her assistance. The only days of the week he bathes or has a conversation with another person are when she is there. While it could be argued that these services are not medically necessary and thus, a potential source of reducing Medicaid costs, loneliness kills and social isolation is a documented factor in early mortality. The companionship and care home care aides provide is an essential Medicaid health service that cannot be spared.

Medicaid funds these services through a waiver program in which states can elect to participate. States that offer Home and Community-Based Services receive federal funds to administer the program and set their own eligibility criteria. If federal Medicaid funding to states decreases, these elective services are particularly vulnerable to cuts in service.

Both Republicans and Democrats argue for healthcare reform. What we need instead is for healthcare to be transformed. We need an expanded package of Medicaid Home and Community-Based services aimed to improve physical functioning and increase home safety.

We need to expand Medicaid Home and Community-based services to assist clients with challenges encountered in the home. Medicaid-eligible older adults have low incomes and are often unable to financially or physically keep up with home maintenance tasks. This is particularly problematic when items like stair banisters, shower grab bars, and elevated toilet seats are simple and low-cost modifications that can drastically improve home safety and accessibility.

The CAPABLE program at Johns Hopkins has found that when a handyman, occupational therapist, and nurse address specific issues an older adult has at home, there is a $10,000 per person Medicare cost savings by preventing nursing home admission and hospitalization.

My published research shows Medicaid caregivers can safely and effectively lead exercise with their clients. Regular exercise participation improves strength, walking, and prevents falls. Conversely, poor function is costly as the loss of mobility and the ability to care for ones self predicts entry into a nursing home.

To transform Medicaid, exercise programs need to be integrated into usual care services for all Home and Community-Based Services clients to improve their physical health and delay or prevent nursing home placement.

Certainly, transformation does not come without cost and increasing the breadth of services offered to Medicaid clients will require a greater up-front financial investment. But the long-term pay-off will be substantial.

There is a tremendous value in preventative and rehabilitative services. In light of an aging US population , we need to focus on a transformation of healthcare services rather than stop-gap measures to solve budget crises. Transforming Medicaid services through proactive and comprehensive Home and Community-Based Services will allow older adults not only to survive, but thrive.

Margaret Danilovich is an assistant professor at Northwestern University Feinberg School of Medicine Department of Physical Therapy and Human Movement Sciences.