Countering the 'Woodwork Effect'

If states make it easy for people to get Medicaid services at home, a lot of people will want those services. Now, people rely on unpaid help from family and friends in order to stay out of the dreaded nursing home. This doesn't cost the state or the federal government any money. But once states offer decent in-home services, people will "come out of the woodwork" and start asking for them.

"This service is too popular, so we can't offer it." That's the essence of The Woodwork Effect.

" According to the General Accounting Office, in 1982 there were 139,000 individuals in ICFs/MR (i.e., institutions) and 1,300 in waiver programs. In 1995, the waiver program grew to 142,000 while the [institutional] population remained fairly stable at 134,000," said the American Health Care Association, the nursing home lobby, using the Woodwork argument against ADAPT's attendant services bill then in Congress. "Home- and community-based programs do not lead to major decreases in facility residents."

" Estimates of cost are imprecise due to the uncertain impact of several important factors, including who will be needing care [and] the types of care they will need," said that 1995 GAO report the Association was quoting. The Woodwork Effect suggests that need, and therefore cost, can't be estimated with any certainty.

But it's not really true that there's no way to estimate need.

The total national need for personal assistance services can be estimated with a fair degree of accuracy, says Disability Statistics Center Director Mitchell P. LaPlante, Ph.D.

Using data from the 1994-95 National Health Interview Survey from the National Center for Health Statistics and first made available to researchers this past August, the Center has showed that:

  • 14.8 million adults in the U.S need help with things like bathing, dressing, heavy housework (called "activities of daily living" -- ADLs, and "instrumental activities of daily living" -- IADLs). Over 13 million (13.2) do receive some help with these things, but mostly in the form of informal, unpaid services, primarily from a family member. Few are able to rely on public funding to pay someone to provide these services.

  • 13.2 million adults -- fewer than half of them age 65 or over -- receive 21 billion hours of assistance annually, 31 hours per week on average. Most get their assistance from informal providers, not paid assistants.

  • Only 24.3 percent of this total get paid assistance -- on the average of 18 hours a week.

    According to the Center, which is funded by the National Institute on Disability and Rehabilitation Research, most assistance -- 88.4 percent of it -- is unpaid.

    Other findings:

  • 6.9 million people ages 18-64 need assistance (the hours of assistance they need averages to 53 hours a week).

  • Only 14 percent of people ages 18-64 get any paid assistance. The average number of hours of paid assistance these people get is 17 hours.

  • People ages 18-64 who need assistance get less paid assistance than do people age 65 and over.

  • 6.2 million people age 65+ need assistance. The assistance they need averages 71 hours a week. Slightly over a third (37.5%) of these people get paid assistance. The average number of hours of paid assistance these people get is 18 hours.
  • The National Health Interview Survey is a large national survey that asks individuals about their functional abilities in areas like bathing and dressing. These data were complied from specific questions that asked individuals about their specific personal assistance needs and the hours of assistance they needed.


    Nursing home lobby money and state legislators

    The nursing home lobby that fought back

    What Medicaid spends -- comparisons

    States can offer in-home services under Medicaid now -- if they choose to


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