Change and Inertia in the New York State Medicaid Personal Care Services Program: An Institutional Case Study

Abstract

This study analyzes how competing logics (belief systems) of stakeholders have influenced patterns of change and inertia in the development of the New York Medicaid Personal Care Services (PCS) program. A case-study methodology was used to collect documents, statistics, and interview data from four key stakeholder groups: state and city officials, PCS agencies, a labor union, and consumer advocates covering the period 1999 to 2005. The New York PCS program is one of the oldest, largest, and most stable programs in the United States. Its early unionization of workers resulted in relatively generous wages and benefits and made New York number one nationally in PCS spending per capita. In spite of wide support from stakeholder groups, the overall number of participants has gradually declined since 1999. A consumer-directed model of personal care developed in 1995 challenged the status quo and has grown steadily. Resistance by public officials, agency providers, and union representatives to the consumer-directed model has resulted in a small program that is often targeted toward individuals labeled “difficult to serve.” Dominant stakeholders in New York have ensured a stable personal care program that has resisted change and led to program inertia.

Keywords:

• consumer direction
• long-term care
• Medicaid personal care services

Acknowledgments

This research was supported in part by a grant from the National Institute on Disability and Rehabilitation Research #H133B031102. We thank the UCSF PAS Center Team for their support over the course of this study, especially (former) research analyst Micky Willmott. To each of the government officials, personal care service providers, union representatives, consumer advocates, and members of the consumer-directed program interviewed for this study, thank you for your time and willingness to participate.