Commonalities and variations in the Cash and Counseling programs across the three demonstration states

Health Services Research, Feb, 2007 by Barbara Phillips, Barbara Schneider

In Arkansas, Florida, and New Jersey, Cash and Counseling was offered as an alternative to traditional, case-managed supportive services in which individuals with disabilities receive personal care from agency employees, who are previously unknown to them. While such agency care has important advantages, its recipients typically have limited choice about how and when their care is provided as well as by whom (Mahoney, Simone, and Simon-Rusinowitz 2000). Some traditional programs offer more than personal care services; access to these additional goods and services is controlled by case managers (Doty, Kasper, and Litvak 1996).

Obviously, a program's design may affect its results. Program design may affect the number of individuals who enroll, with possible effects on program efficiency (as well as on the ability to measure impacts). Design may affect the characteristics of enrollees, which, in turn, may affect program results as individuals may vary in their ability to benefit from the program. If a program faces opposition, its implementation may depend upon whether the program's designers are able to address the opposition's concerns, or at least avoid depending on the opposition for referrals, information, or staff resources. Designing methods to limit potential for exploitation of consumers may be critical to ensuring adequate quantity and quality of care. The financial success of a program may depend on the design of methods to control the cost of direct services (in this case, the cash allowance) and to administer the program.

The grant solicitation for states to design and implement Cash and Counseling programs laid out the basic tenets of such a program. The funders required that a program offer a flexible allowance that consumers could use to hire their choice of workers and to purchase other goods and services. Further, consumers were to be required to develop a plan for the use of the allowance to meet their needs for supportive services and then to manage their services under the plan. Consumers who were unable or unwilling to manage their services themselves were to be allowed to designate a representative, such as a trusted family member or friend, to help them. Further, programs were required to provide counseling (to assist consumers with planning and managing their services) and fiscal services (to assist consumers with payroll and bookkeeping).

The Cash and Counseling programs were expected to operate as demonstrations under Section 1115 of the Social Security Act. Thus, they were required to adhere to the federal regulations governing an 1115 demonstration, including those limiting eligibility and federal funding.

Consistent with these tenets and regulations, each of the three states made decisions that shaped its Cash and Counseling program. Their decisions were influenced by the philosophy of consumer empowerment, to which each was committed. Many decisions were shaped by the work of the Cash and Counseling National Program Office (NPO), and some were the joint work of all three programs in collaboration with that office. (The NPO was funded by The Robert Wood Johnson Foundation to assist the states with demonstration design and implementation.) At the same time, each state had somewhat different goals and operated in a different Medicaid and political environment. The result is that the three programs have many features in common, but each also has features that set it apart. Table 1 summarizes the key features of the three Cash and Counseling programs.

Providing background for the other papers in this volume, this paper describes the major program design decisions faced by the demonstration states, factors and issues shaping their decisions, and how each responded-giving rise to commonalities and differences in their programs. It also illustrates how such differences might lead to differences in program impacts.

The design decisions faced by the three demonstration states involved all major components of the Cash and Counseling model: choice of program to which Cash and Counseling was to be an alternative, eligibility and appropriateness, outreach and enrollment, permissible services under the allowance, determination of the amount of the allowance, and organizing and paying for counseling and fiscal services.

The primary data sources for this paper are on-site interviews with program staff and other stakeholders conducted about 18 months after each program began operating, as well as program materials and discussion with key program staff for the duration of the evaluation. The features of each program are described in detail in three reports (Phillips and Schneider 2002, 2003, 2004).

WHICH PROGRAMS TO CASH OUT AND FOR WHOM?

The central question the funders posed for the demonstration was: How does Cash and Counseling compare with traditional case-managed supportive services? States interested in participating in the demonstration were free to propose providing Cash and Counseling as an alternative to Medicaid personal assistance services, which is an optional Medicaid state-plan service; Medicaid home- and community-based waiver services; or programs funded by state general revenues. Any of these could be "cashed out" (i.e., considered in the calculation of the allowance), provided they were not consumer-directed programs.