65 with disabilities and the difficult financial prospects most of them face throughout their lives. G. William Hoagland, senior vice president at the Bipartisan Policy Center, reminded workshop participants of some of the fiscal realities facing the nation. Joshua Wiener, distinguished fellow and program director for aging, disability, and long-term care at RTI International, rounded out the discussion by asking what society can afford to pay for long-term services and supports and what it wants to pay.


Henry Claypool American Association of People with Disabilities

Many people with disabilities are living in dire circumstances, Claypool said. They often do not have access to long-term care insurance, and they do not have many options for meeting their future needs.

Claypool said he considers long-term services and supports to be health care–related services because these services and supports have a significant influence on health outcomes. The interactions between people’s disabilities and the society in which the people with those disabilities find themselves constitute the social determinants of health, he said.

Better skills and better training are essential for this population, Claypool said. Society has a huge opportunity to invest in a relatively low-wage workforce that can perform needed services, often for others who have chronic health conditions and functional limitations. Individuals who are given training can promote basic health literacy while at the same time benefiting from that information. They can become more integrated into the community while engaging in exercises that will improve their quality of life. Together, the direct-care workforce and the people they serve can become a laboratory for future investment.

Several initiatives in the Deficit Reduction Act were designed to move state Medicaid programs toward greater balance—that is, toward providing more home- and community-based services (HCBS) for the beneficiaries of the program. States have embraced this option as a way to make a limited pot of money serve more people. Turning Medicaid into a program of block grants will not address the central issue, Claypool said, because it will put all the responsibility on states to meet the needs of their populations.

Misaligned Incentives

Modest work incentives for the working-age Medicaid population have been instituted in the past. Many individuals with significant disabilities could earn fairly significant incomes—say, $30,000 per year or more—with

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