Designing the Cash and Counseling demonstration and evaluation

Health Services Research, Feb, 2007 by Pamela Doty, Kevin J. Mahoney, Lori Simon-Rusinowitz

A Willingness to Take Some Risks. In addition to agreeing to implement a randomized experiment with sufficient numbers of enrollees, states selected to participate in the CCDE would have to be willing to participate in some bold experimentation. To the management team and funders, this meant willingness to mount a large-scale demonstration within Medicaid. States that would consider only small pilot tests--for example, including only a state-funded program or only the state's share of Medicaid funding--were disqualified. States also had to agree to recruit elderly Medicaid beneficiaries into the demonstration, in addition to younger adults. Because many elders have physical frailties and cognitive impairments, their suitability for consumer direction has long been debated by policymakers; the CCDE was meant to generate definitive evidence to resolve this debate. Selected states had to demonstrate a willingness to grant CCDE participants a great deal of choice. For example, in addition to hiring workers of their choice, they had to be allowed to purchase assistive equipment and make home modifications that would enhance their independence. Selected states would be required to allow CCDE participants to hire family members as paid caregivers if they chose to--a controversial issue in many states (Linsk et al. 1992; Simon-Rusinowitz, Mahoney, and Benjamin 1998; Simon-Rusinowitz, Mahoney, Loughlin et al. 2005). Finally, states in which more than small numbers of beneficiaries already hired/fired and supervised individual workers were considered less desirable test sites for the CCDE. The funders preferred to test the Cash and Counseling model in states where the contrast between traditional Medicaid PCS and the experimental alternative would be greatest.

The Successful Candidates. Seventeen states submitted letters of intent to apply for CCDE grants; 11 were invited to submit full proposals; and, in summer 1996, four were selected for site visits. These four were Arkansas, Florida, New Jersey, and New York. Arkansas and New Jersey both had well-developed interventions and strong leadership. Florida and New York were particularly attractive because they had large numbers of potential enrollees. Florida also was of interest because it proposed to include both children and adults with MR/DD in its target population, and was "cashing out" a wider range of services covered under their waiver program, including some skilled services, and supplies (such as adult diapers). New York was attractive because it had a rich service package and diverse population. Other states were dropped from consideration because it was felt they could not meet sample size requirements for the evaluation or they were unwilling to comply with some of the nonnegotiable aspects of the demonstration. Although the CCDE funders had originally intended to select only two states to participate in the demonstration, after the site visits they were convinced to include all four that were visited. More states would give CCDE results a greater likelihood of being perceived as applicable to other states and some insurance in case one or more states pulled out of the demonstration. This proved a prescient decision; New York dropped out of the demonstration before implementation (Sciegaj, Simone, and Mahoney 2007).