Commentary: social experimentation at its best: the Cash and Counseling demonstration and its implications

Health Services Research, Feb, 2007 by Peter Kemper

The Cash and Counseling demonstration was the most significant long-term care policy experiment undertaken in more than a decade. It is an archetypal example of the ability of research to play an important role in public policy (Kemper 2003). It has altered thinking about the effects of consumer-directed care and led a number of states to incorporate consumer-directed care in their home care programs (Mahoney et al. 2007). The funders who conceived and paid for it, the national program office that ran it, the states that were willing to be laboratories to test it, and the research team that evaluated it all should be commended for their achievement. This paper assesses the demonstration's strengths and weaknesses and explores its implications for social experimentation and policy.

CASH AND COUNSELING

Having a long-term disability is a risk that all people face and is largely outside their control. Current policy treats long-term care like acute care: Medicaid insures specific services provided by agencies to assist in living with disability. Thus, current policy recognizes that long-term living with disability requires support. However, current policy fails to recognize the many ways of living with disability and the importance of personal preference in choosing among them.

An alternative is to model long-term care programs after disability insurance rather than acute care insurance. Social Security Disability Insurance provides income to people who cannot work due to disability. This model could be extended to long-term care by paying people with disability a regular cash benefit that depends on the level of disability. Such a policy would permit consumers to choose to live with disability in different ways according to their individual preferences.

Interest in cash disability programs has grown in recent decades as it has been adopted abroad. It became a matter of national policy discussion when it was included in President Clinton's health reform proposal (Wiener et al. 2001). However, policy makers have hesitated to adopt cash disability programs out of concern that consumers would use the cash for things other than needed assistance, that paying family members would substitute for care that they would provide without pay, and that the attraction of cash benefit would increase program participation and Medicaid expenditures.

Despite its name, Cash and Counseling was not a cash disability program. It was a consumer-directed care program providing a cash-like benefit within the constraints of Medicaid's service delivery model. It was conceived as a "paradigm shift in the delivery of long term care ..." that was "primarily intended to give Medicaid beneficiaries ... the same degree of choice and control over how to best meet their needs ... as private payers ..." (Dory, Mahoney, and Simon-Rusinowitz 2007). Federal officials also were interested in its potential "to provide a less costly approach to delivering Medicaid waiver and personal care services" and "help expand the labor pool (e.g., by allowing consumers to pay family and friends ...)" according to Knickman and Stone (2007).

A MODEL SOCIAL EXPERIMENT

Several features of the demonstration and its evaluation contributed to its success.

Significant Policy Issue Calling for Evidence. Social experiments are costly and take a long time to yield results. Justifying an investment in them requires an important debate that depends on unanswered questions about the effects of a policy change. Cash and Counseling was a response to such a need for evidence.

Rigorous Experimental Design. Random assignment of participants to either Cash and Counseling or traditional agency services ensured the internal validity of the results. More generally, in designing the evaluation Brown and Dale (2007) considered potential threats to validity, addressing those they could and qualifying findings when they could not.

Focus on the Full Range of Effects. The evaluation was designed to estimate a wide range of effects on consumers, family caregivers, workers, service use, and expenditures. As a result, the study was able to observe unintended as well as intended effects.

Emphasis on Implementation. Intentional use of qualitative and quantitative information to understand the program's implementation and identify ways of improving the program was a great strength of the evaluation. The papers by Phillips and Schneider (2007), Schore, Foster, and Phillips (2007), and San Antonio et al. (2007) show the value of qualitative research in doing so. The evaluation also used quantitative data effectively to identify lessons for program implementation. For example, Dale and Brown's (2007) analysis of care plan cost estimates (which determined allowances) identified increasingly generous allowances the longer consumers' were enrolled. This led them to recommend operational changes to control care plan costs. The evaluation's emphasis on implementation led to many operational lessons for states adopting consumer-directed care.