Dear Editor,
Medicaid is a joint federal-state health coverage program that provides essential medical services to low-income individuals, including children, families, seniors, and people with disabilities. It is not a welfare cash program or universal healthcare; eligibility and benefits vary significantly by state, with federal matching funds supporting state-administered plans.
Medicaid waivers, particularly Section 1915(c) Home and Community-Based Services (HCBS) waivers, allow states flexibility to provide non-institutional care—such as personal care assistance, respite, adult day services, and home health aides—to individuals who meet a nursing facility level of care.
These waivers are not unlimited entitlements; they must demonstrate cost neutrality compared to institutional care and can target specific populations. Most states operate multiple 1915(c) waivers (or equivalent authorities) to help people remain in their homes and communities rather than entering costly nursing facilities.
In stark contrast, Arizona stands nearly alone. While 46+ states and the District of Columbia offer 1915(c) HCBS waivers (with many providing several targeted programs for the elderly, physically disabled, or those with developmental disabilities), Arizona delivers its long-term services primarily through its Arizona Long Term Care System (ALTCS) under a Section 1115 demonstration waiver. This structure effectively offers zero dedicated 1915(c)-style waivers for flexible in-home supports short of full nursing facility-level care. The result is a binary system: individuals who are largely independent receive minimal help, while those needing ongoing assistance often face institutionalization or go without, with no meaningful middle ground for in-home medical or personal care.
Only a handful of other states (historically including Vermont and Rhode Island) have avoided traditional 1915(c) waivers, but they have implemented addendums or alternatives within their 1115 frameworks to preserve crucial home-based services. Arizona has not.
This gap harms real people. I am one of them. As a disabled resident who relocated to Arizona, I have personally experienced the disruption and resulting decline in health and quality of life.
For the thousands of disabled poor Arizonans reliant on Medicaid, the absence of accessible in-home supports means unnecessary suffering, increased risk of institutionalization, higher long-term costs to the system, and eroded dignity.
Arizona’s approach, while innovative in managed care, leaves a critical void that other states have filled to better support community living.
I urge you to investigate this disparity, advocate for expanded HCBS options (whether through new waivers, ALTCS enhancements, or state plan amendments), and work toward parity with the majority of states. Meaningful reform could prevent harm, promote independence, and align Arizona with national best practices for long-term care.
Please contact me with any ideas, questions, or concerns. I am eager to discuss solutions and provide additional details.
Asher Norell Browne
drippingtruth@gmail.com
