Randall S. Brown, PhD Mathematica Policy Research, Inc. December 14, 2005 Cash & Counseling Demonstration Evaluation

2 Original Cash & Counseling Demonstration Overview Demonstration States  Arkansas, Florida, New Jersey  Study Populations  Adults with disabilities (Ages 18-64)  Elders (Ages 65+)  Florida only: Children with developmental disabilities  Feeder Programs  Arkansas and New Jersey: Medicaid personal care option programs  Florida: Medicaid 1915c Home and Community-Based long-term care waiver programs

3 Study Design and Methods  Randomly assigned applicants (AR, FL, NJ)  1, ,000 adults per state, 1,000 children (FL)  Data Consumer survey at 9 months Primary unpaid caregiver survey at 10 months Survey of paid workers at 10 months Medicaid claims for two years

4 Receiving Paid Assistance at 9 Months Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL **

5 Very Satisfied with Overall Care Arrangements Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL **

6 Had an Unmet Need for Help with Personal Care Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** * *

7 Contractures Developed or Worsened Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** * *

8 Very Satisfied with Way Spending Life These Days Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** *

9 Informal Caregivers Very Satisfied with Overall Care Percent Adults Children TT T T C C C C ARFL NJ FL ** *, ** Significantly different from control group at.05,.01 level, respectively.

10 Informal Caregivers Experienced Less Emotional Strain Percent Adults Children TT T T C C C C ARFL NJ FL ** * *, ** Significantly different from control group at.05,.01 level, respectively.

11 Informal Caregivers Experienced Less Physical Strain Percent Adults Children *, **, *** Significantly different from control group at.10 (*),.05 (**), or.01 (***) level. TT T T C C C C ARFL NJ FL **

12 Informal Caregivers Experienced Less Financial Strain Percent Adults Children TT T T C C C C ARFL NJ FL ** *, ** Significantly different from control group at.05,.01 level, respectively.

13 Relationship of Consumer to Directly Hired Worker Percent AR AdultsFL AdultsNJ AdultsFL Children

14 Hours of Care Provided by Directly Hired Workers  Paid Hours per Week – 12 (Arkansas) to 20 (Florida, New Jersey)  Unpaid Hours per Week – 59 to 74% provided some unpaid hours – 25% provided more than 41 unpaid hours

15 Working Conditions Directly HiredAgency Hourly Wage AR FL and NJ $6.00 $10.00 $6.30 $9.00 Receives Fringe Benefits 2 to 5%17 to 24% Very Satisfied with Wages and Benefits 41 to 50%19 to 23% Very Satisfied Overall 79 to 85%69 to 83%

16 Training and Preparedness of Directly Hired Workers  Half trained in personal care or routine health care On the other hand—  Felt well-informed about care recipient’s condition ( ~ 90%)  Felt fully prepared for job (>90%)  Injuries and physical strain similar to agency workers providing equal hours of care

17 Worker Well-Being  Directly Hired Workers More Likely to: Experience emotional strain Want more respect from consumer’s family

18 Worker Well-Being (cont’d) Percent Feels Emotional Strain Wants More Respect

19 Effects on Medicaid PCS/HCBS Expenditures—Year 1  Significantly Higher for Treatment Group in Each State  In AR and NJ, Mainly Because Control Group Received Substantially Less Care Than Authorized  In FL, Mainly Because Children and Adults With Developmental Disabilities Got Larger Benefit Increases After Assigned to Treatment Group

20 Effects on Medicaid PCS/HCBS Expenditures—Year 1 ARFLNJ Adults Nonelderly+124% ($3,005)** +20% ($3,696)** +21% ($1,946)** Elderly+88% ($2,021)** +4% ($433) +12% ($1,241)** Children--+26% ($3,319)** -- **Significantly different from zero at.01 level.

21 Effects on non-PCS Medicaid Expenditures  Other Medicaid Costs Moderately Lower For Treatment Group in Each Age Group in All Three States  The Best Example: In AR, Compared to Control Group, Treatment Group Had 40% Fewer Admissions to Nursing Facilities in Second Year

22 Effects on non-PCS Medicaid Expenditures—Year 1 ARFLNJ Adults Nonelderly-17% (-$1,743)* - 6% (-$369) -7% (-$1,132) Elderly-4% (-$320) -5% (-$296) -5% (-$413) Children---15% (-$2,439)* -- *Significantly different from zero at.05 level.

23 Effect on Total Medicaid Costs  In AR, No Significant Difference by End of Year 2 Reductions in NF and other Waiver Costs Off-Set Increase in Personal Care Costs  In NJ and FL, Costs Up 8-12%, But States Learned How to Control Costs  Higher Costs in AR and NJ Due to Failure of Traditional System

24 Effect on Total Medicaid Costs— Year 1 vs. Year 2 ARFLNJ All Adults Year 1 Year 2 +14%** +5% +9% +12%** +4% +12%** Children Year 1 Year % +8% -- **Significantly different from zero at.01 level.

25 Policy Implications  Can increase access to care  Greatly improves quality of life (all ages)  Caregivers also benefit greatly  States may be concerned about costs But have learned how to control them

26 Lessons on Controlling Costs  Consider limiting program to current recipients  Use standardized assessment tool and independent staff to set allowance  Adjust allowance amount to reflect expected use  Use incentive-based contracts for counseling services  Set clear and fair recoupment policy for unspent allowances  Monitor reassessments and costs