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Today, in most states, whether you are an elderly individual or a younger person with disabilities, ifyou are covered by Medicaid and need assistance to perform major activities of daily living like bathing, dressing, using the toilet, transferring from one place to another, or eating, you will not have much say over who helps you or when they come- never mind what they actually do. For years, people with disabilities have been saying, "IfI had more control over my services, my quality of life would improve, and I could meet my needs for the same amount of money or less." The project described in this article is, at its heart, a policy-- driven evaluation of this conviction. The Cash and Counseling Demonstration and Evaluation, funded by the Robert Wood Johnson Foundation (RWJF) and the Office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services, provides a test of one of the most unfettered forms of consumer direction, offering consumers a cash allowance in lieu of agency-- delivered services.
IMPLEMENTATION PHASES AND CURRENT STATUS
Before discussing lessons from planning and early implementation, it seems useful to provide some historical context and an update on the current status of the project. The Cash and Counseling Demonstration and Evaluation has gone through three distinct stages.
Stage one was from January 1996 to January 1997, and consisted of choosing states and the evaluator. The University of Maryland Center on Aging, which is coordinating this demonstration on behalf of the RWJF and the Office of the Assistant Secretary, sent out a call for proposals to all states. The volume and quality of the responses were unexpected: Forty-two states called for additional information. Seventeen applied, and, by the end of 1996, four were chosen-Arkansas, New York, Florida, and New Jersey The other major accomplishment of the first year was a national open competition for a program evaluator and the selection of Mathematica Policy Research, Inc., for this critical role.
Once the players were selected, the planning began in earnest. The preparation stage, from February 1997 to November 1998, can be seen as having five major parts. The first was waiver negotiation. In order for the demonstration to proceed, the states needed the approval...