Home and Community-Based Services for Older People and Younger Persons with Physical Disabilities in Alabama

This research was supported by Health Care Financing Administration Contract No. 500-96-0005. In this contract, the Urban Institute is a subcontractor to the Lewin Group. The opinions expressed in the report are those of the authors and do not necessarily reflect the position of the Health Care Financing Administration or the Urban Institute.

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INTRODUCTION

Alabama is a fairly small Southern state with substantial low-income and minority populations.¹ The Medicaid program is heavily dependent on intergovernmental transfers and provider taxes to fund the state share and funding crises have been routine.² By and large, Alabama's Medicaid program relies on minimum federal requirements to determine eligibility and coverage policy.³ Most of Alabama's social programs are severely constrained because of the relatively limited tax base, the fact that most tax revenues are earmarked for education, and the strong anti-tax sentiment of the state. The low levels of revenue leave policymakers with little choice but to provide health and welfare benefits at fairly minimal levels.

Although public officials are committed to expanding home and community-based services for older people and younger persons with physical disabilities, the state's long-term care system is dominated by nursing home care. Home care accounts for only a small proportion of Medicaid expenditures for long-term care for older persons and younger people with physical disabilities and there is little funding for noninstitutional services outside of the Medicaid program. In addition to mandatory home health coverage, the Medicaid program funds two home and community-based services waiver programs for older people and younger persons with disabilities—the "elderly and disabled" waiver which serves a generally disabled population and the "homebound" waiver which primarily serves younger people with very severe disabilities, such as traumatic brain injury. Most day-to-day administration of the waivers is done by the Alabama Department of Public Health and the Alabama Department of Senior Services. Waiver services are fairly traditional, with no consumer-directed home care or nonmedical residential care included.

Since state funding of the regular Medicaid program is often problematic, cost containment is a major concern and the state has not funded all of its places or "slots" for the elderly and disabled waiver, despite there being a substantial number of people waiting for services. Like other state health departments in the south, the Alabama Department of Public Health is a major direct provider of home health and its home health services have experienced substantial cutbacks in staffing and funding as a consequence of the reimbursement and other changes in the Balanced Budget Act of 1997.

This paper analyzes the home and community-based service system for older people and younger persons with physical disabilities in Alabama, focusing on the state administrative structure for home and community-based services, eligibility and assessment, services covered by Medicaid and other programs, and quality assurance. This paper does not address home and community-based services for persons with mental retardation or developmental disabilities or for children. Information was obtained from public documents, state of Alabama web sites, and interviews with state officials, providers associations, and other stakeholders. Interviews were conducted in person and by telephone in Montgomery, Alabama, during January 2000. Questions were asked using an open-ended interview protocol. To encourage candor in their answers, respondents were told that they would not be quoted by name.

Notes

1. For an overall discussion of health care in Alabama, see: Joshua M. Wiener, Susan Wall, David Liska, and Stephanie Soscia. 1998. "Health Policy for Low-Income People in Alabama." Assessing the New Federalism. Washington, DC: The Urban Institute.

2. A recent budget crisis was created when the courts ruled that the state's franchise tax, which charged out-of-state companies far more than in-state companies, was unconstitutional. Tobacco settlement funds could be a source of Medicaid funding for home and community-based services, but most of the money is earmarked for services for children.

3. Many Medicaid covered services have severe limitations in the amount, duration and scope. For example, hospital care for adults is limited to 16 days a year.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

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