The "Woodwork" Myth

Steve Gold's Informational Bulletin #286 (6/09) For years, we have heard cries, fears and woes from elected officials about "the woodwork" effect. No, these officials are not talking about cockroaches. Then what do they mean? Under Medicaid, there is a federal statutory entitlement to institutional long-term services - people with disabilities have a statutory right to enter a nursing home or an intermediate care facility. However, these same people with disabilities do not have a federal statutory right to receive the same long-term services in their homes and community. Why an institutional bias? In part, it was a historical accident when Medicaid was enacted in the 1960s. In part, Congress tinkered with addressing it by enacting "Waivers" in the 1980s. But then why doesn't Congress just amend Medicaid and eliminate the institutional bias? One reason is nursing homes and other institutions have fed at the federal troughs for so long, made so much money, and politically contribute so much that they are now a political force. Keeping the status quo suits the nursing home industry just fine. Also, many elected congressional folks probably do not recognize or view discrimination against people with disabilities as a fundamental civil rights issue and violation. But that is not polite or pc to admit. So instead, they invent a "woodwork" myth. Here's how it goes. If people in nursing homes were to have an entitlement to receive services in the community, then they would leave the nursing homes and live in the community. The myth then posits that new people with disabilities - they're the people in the woodwork waiting and waiting - would then enter the nursing homes. So the feds and states would have to pay for both persons who have left the nursing home and new persons who now go into the nursing home. The "woodwork" myth is premised on two fallacies. One, people do not enter a nursing home because there are no available beds. Two, people might enter a nursing home so that they could then leave the nursing home to receive services in the community. Let's look at both fallacies. First, the "woodwork" myth would have validity only if the reason that people with disabilities do not enter nursing homes is because there are no available beds for them. But that is not accurate or true. For many years there has been a national vacancy rate of nursing home beds of about 13%. Yes, even if no one moved out of a nursing homes, there are 13% beds empty. These vacant beds could be filled immediately and are not dependent on anyone moving out. If there are people who want to move into a nursing home, they do not need to wait for people to move out. Therefore, the reason people do not enter nursing homes has NOTHING to do with whether people in the nursing homes leave or not, or whether there are beds available or not. People could enter an institution as long as there are vacancies. Their entitlement to institutional services has nothing to do with other people leaving these facilities. Second, it is really hard to imagine anyone would enter a nursing home solely or even primarily to gain eligibility for community-based services. Living in a nursing facility is not like a hotel! Nursing facilities and ICFs are institutions with loss of privacy and other basic rights. Moreover, if this were a real reason for not eliminating the institutional bias, there are any number of ways to address and control it. It's just an excuse to continue denying people with disabilities their civil rights. What compounds the issue is that the data clearly shows that it is much, much less expensive to provide services, on average, to people in the community instead of in institutions. Providing Medicaid long-term services in the community to people in nursing facilities and other institutions will save substantial federal and state funds. So, next time you hear someone talking about the "woodwork" effect, tell them it's a myth. Talk to them about civil rights of people with disabilities. Steve Gold, The Disability Odyssey continues