Choices for Care: Consumer Choice and State Policymaking Courage Amid Medicaid’s Shifting Entitlement to Long‐Term Care

Abstract

In Choices for Care: Consumer Choice and State Policymaking Courage Amid Medicaid’s Shifting Entitlement to Long-Term Care, Professor Bach analyzes a leading state program intended to encourage the delivery of care in the home and community, thereby avoiding admission to nursing homes. Choices for Care, Vermont’s Medicaid Demonstraion Waiver program, has clearly enabled more Vermonters to receive health care in their homes. After its first two years, it is seen as a model by other states and the federal government. But Bach questions the results. She argues that CFC is reshaping the landscape of long-term care providers, with resulting industry effects both intended, on nursing homes, and unintended, on home health agencies. Moreover, she observes that the initial success in shifting care away from institutions does not provide a clear answer to the cost trade-off between nursing home and home and community-based care. To date, Vermont has not shown that CFC has solved the overall long-term care spending problem. Likewise, the question of whether expanding home and community-based services for those on the eligibility edge successfully staves off their eventual admission to a nursing home is still an open one. Finally, the demographic question about the home care provider pool underlines the fact that the experience of CFC, as a very small state experiment, might be hard to replicate in other states. In this article, Bach puts the CFC results into the perspective of long-term health care system design.