Randall S. Brown, PhD Mathematica Policy Research, Inc. December 14, 2005

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

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) • 1,700 - 2,000 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 Percent Children Elderly Adults ** ** ** ** ** ** T C NJ T C FL T C NJ T C FL T C FL T C AR T C AR *, ** Significantly different from control group at .05, .01 level, respectively.

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

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

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

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

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

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

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

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

13. Relationship of Consumer toDirectly Hired Worker Percent AR Adults FL Adults NJ Adults FL 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

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 **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 *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 **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