We want to be more generous with eligibility.’ But it’s unclear how much impact that had on the final algorithm. It feels like the vendors have a lot of power in these relationships. The state agency, they have to rely on these vendors to implement this stuff, and the vendors are the only ones with the expertise to understand the algorithm.
What are the concerns about these algorithms and the decisions they drive?
It’s important to remember that these algorithms are not neutral or objective. They’re political. They’re the decisions that the state is making to allocate resources in a certain way. … The issue is that they’re opaque and hard to understand, and they’re not subject to public input or scrutiny. It feels like the people impacted by these decisions are not at the table. … We’re not talking about, like, is this algorithm going to be better at measuring need or not measuring need. We’re talking about, like, are we going to give this state agency the ability to cut a certain percentage of people from the program because they don’t want to spend as much money.
What are the potential consequences of these decisions?
The consequences are that people are going to be denied care. The other thing is it’s going to be based on a determination that the state is making, that the state is saying, ‘We don’t think you need this care.’ And that’s a very different kind of decision than saying, ‘We don’t have the resources to give you this care.’ It’s saying, ‘We don’t think you need it.’
It’s hard to predict what the effects of these decisions are going to be. But it’s very clear that when people are denied care that they need, they suffer. They end up in nursing homes. They end up in institutions. They end up being isolated. And that’s not good for them, and it’s not good for their families, and it’s not good for society.
What can be done to address these concerns?
I think there’s a number of things that could be done. The first thing is just transparency, making these algorithms public, making the data that goes into the algorithms public, making the results of the algorithms public. The second thing is public input. When these decisions are being made, it’s not just the state agency and the vendors in a room. It’s also the people who are impacted by these decisions.
There’s a lot of work that needs to be done to make these decisions more transparent, more fair, more just. And it feels like the disability community is not at the table in these discussions. And they should be.
The importance of ensuring that individuals who need services are found eligible is crucial in the realm of Medicaid home and community-based services. However, behind closed doors, there are conversations happening where vendors come in with recommendations based on algorithms that may not always strike the right balance. These discussions are not unique to one state, as similar conversations are likely occurring nationwide.
In Missouri, for example, there was transparency in the revision of their algorithm for determining eligibility. When the initial version was published for public comment, it was found that a significant percentage of currently eligible individuals would be deemed ineligible. Advocates raised concerns, leading to revisions that aimed to reduce the number of individuals cut off from services to a more manageable percentage.
The history of these determinations dates back to the early ’80s when there was a push for Medicaid home and community-based services as a cost-effective alternative to institutional care. The focus was on limiting eligibility to those who would otherwise require nursing facility care, rather than solely based on need.
The issue at hand is that these determinations are not always made for health reasons, highlighting the need for a more standardized approach. The Home and Community Based Services Access Act in Congress seeks to establish a basic eligibility definition based on physician assessment. However, simply standardizing at the federal level may not be the ultimate solution.
The reliance on automation in these determinations can depoliticize the question of who receives home care. It is essential to recognize that these algorithms are political tools rather than purely objective measures. Advocates must engage with the algorithms in a critical manner, understanding that they are not solely technical exercises but rather political instruments.
In conclusion, the conversation surrounding eligibility for Medicaid home and community-based services is complex and multifaceted. By shedding light on the political nature of these determinations and advocating for a more nuanced approach, we can strive towards a system that truly serves those in need.
