One of the challenges of policy making is that bills must go before the Congressional Budget Office (CBO). CBO has one of the toughest jobs in Washington. Their job is to dispassionately look at policy and evaluate the cost of the bill to the federal treasury. Sometimes that means splashing cold water on the high-minded aspirations of policy makers. And CBO’s brand of actuarial water can be icy cold.
In health care, one of the most perplexing areas for policymakers is convincing CBO that providing additional services to individuals can lead to lower cost outcomes. Obesity reduction was a particularly problematic policy area. Advocates argued that through the deployment of intensive supports, individuals could lose weight and keep weight off thus improving their overall health outcomes. CBO did extensive research and found that weight loss only had an effect on health outcomes for the most morbidly obese. If you are only moderately overweight (BMI 25 to 30), weight loss or gain has no effect on health outcomes. So go enjoy that donut.
What CBO depends on in reviewing bills is evidence. They carefully follow current research in guiding their thinking. This week, the National Bureau of Economic Research (NBER) published a paper that could make a significant difference in policy making with regard to home and community based services (HCBS) and long term support services (LTSS).
Policymakers have lived under a general rule in making LTSS policy for many years. There is a significant amount of informal care being provided by family in the home in an effort to stave off putting grandma in the nursing home. If policy allowed that care to be formalized and reimbursed, the cost would be astronomic. This is often referred to as the ‘woodwork effect.’
The NBER research examined the Cash and Counseling Demonstration and Evaluation program to gain causal estimates of the effect of family involvement in home-based care on health care utilization and health outcomes. The research finds that “family involvement significantly decreases Medicaid utilization. Importantly, we find family involvement significantly lowers the likelihood of urinary tract infections, respiratory infections, and bedsores, suggesting that the lower utilization is due to better health outcomes.”
For folks who work in disability policy, this high caliber research gives policymakers a new argument to make before CBO that the woodwork effect is overstated. Policymakers are constantly confronted by the challenge of providing resources to individuals with disabilities. This research may create new opportunities to move creative policy forward in Congress in the future.