HCBA Waiver Waiting List
The HCBA Waiver has a limit on how many people can be enrolled in the program.
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The limit is very low!
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In 2023, the limit was 8,974 people.
In 2024, the limit will be increased by 1,800 - the new limit will be 10,774 people.
in 2025, the limit will be 12,574
In 2026, the limit will be 14,374
In 2027, the limit will be 16,174.
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There are currently more than 4,000 people on the waiting list.
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California is a state of 40 million people.
More than 15 million people are enrolled in MediCal.
More than 100,000 people live in nursing homes and other institutional care
But only 10,000 people are able to get nursing care at home.
Why is there a waiting list?
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Our health care system has an institutional bias. That means the system pays for care that happens in hospitals and nursing homes automatically, but it only pays for care at home in special circumstances.
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California is legally allowed to set a limit on how many people can enroll in the HCBA Waiver, but we're not required to set a limit. That's a policy choice that California makes.
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California operates another waiver - the HCBS-DD Waiver - that provides access to care at home for children and adults with intellectual disabilities. The HCBS-DD Waiver does not have a capacity limit - anyone who needs services from the HCBS-DD Waiver can get them.
That's the right way to do things!
It's good that we don't put people with developmental disabilities on a waitlist.
It's bad that we put people with physical and medically intensive disabilities on a waitlist.
What is rationing?
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Rationing is when the system limits the amount of medical care that people can get.
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Rationing can mean that individual people get less care than they need, or it can mean that some people get care and other people don't.
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Our health care system rations care all the time - but it's usually a little bit more complicated and tied up with money. In this case, the rationing is tied up with money, but it's happening in more complicated ways that make less sense.
The situation right now with HCBA Waiver is pure rationing - the state has decided that 10,174 people can be enrolled in the waiver. Since more than 10,174 people have applied to be on the waiver, the extra people just have to wait in line.
What is the most fair way to ration care?
That's a trick question - there is no fair way to ration care and we should not be rationing care.
One option is to say "first come first served" and just provide services to people based on who applies first.
Another option is to "triage" applications and decide that some people's needs are more urgent than others.
The state is doing a mix of both.
Does the HCBA Waiver save the state money?
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It does - here's the math:
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For a child who would otherwise be institutionalized in a pediatric subacute facility, the cost of institutionalization is about $1300 per day - that's about half a million dollars a year baseline. Kids in pediatric subacute spend a ton of time in the ICU. of acute care hospitals, because institutionalization comes with more and worse exposure to germs. Back of the envelope math if a pediatric subacute kid spends 50 days in the acute care ICU, yearly institutionalization cost at least one million dollars a year, not including medications and interventions.
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Give that same kid 24/7 private duty nursing at home, the cost is:
$44.12 (agency hourly rate for PDN) x 24 x 365 = $386,491
That's a cost savings for the MediCal system.
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But.... no one is actually getting 24/7 nursing coverage at home because it's impossible to find and maintain 24/7 coverage. Family members are absorbing a lot of the care, sometimes through paid program like IHSS and sometimes without being paid.
Let's be more realistic about how much nursing kids are getting at home:
$44.12 x 40 hours/week x 52 weeks/year = $91,769
$44.12 x 80 hours/week x 52 weeks/year - $183,539
$44.12 x 8 hours/day x 365 days/year = $128,830
$44.12 x 16 hours/day x 365 days/year = $257,660
The cost for adult institutionalization at the subacute level of care is a bit less - $1100 per day instead of $1300 per day, so only $400,000 per year instead of half a million. Adults in subacute also spend a ton of time in acute care hospitals because of infections and health problems that can't be handled in long term care, so again, a million dollars a year is still a reasonable estimate on the cost of institutionalization.
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CURRENT WAITING LIST INFORMATION:
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https://www.dhcs.ca.gov/services/ltc/Pages/HCBA-Waiver-Current-Enrollment-Dashboard.aspx
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MEDIA COVERAGE ON THE WAITING LIST:
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https://www.latimes.com/california/story/2023-11-15/the-unusual-way-a-catholic-health-system-is-wielding-an-abortion-protest-law - this article is about a waitlist for a different waiver - the Assisted Living Waiver. Is the hospital helping patients get enrolled in a waiver program that will help them get necessary are at home? No, they're suing the patients, their families, and their advocates for unlawful trespass.
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