A person receiving Medicaid-funded Home- and Community-Based Services (HCBS) may spend several years developing the confidence and practical skills to manage more aspects of daily life independently. Their provider might support them to travel, prepare meals, maintain employment or participate more actively in their community. Yet the organization's reimbursement may continue to depend largely on the number of authorized service units delivered rather than the independence achieved.
This creates a fundamental question for American community-based care: could Medicaid increasingly reward providers for helping people achieve meaningful outcomes rather than primarily paying for service activity? The question sits at the center of emerging discussions about value-based payment and outcomes-led service design, particularly as states examine how public funding can support both quality of life and long-term sustainability.
The issue extends beyond payment mechanics. It concerns how Medicaid agencies, managed care organizations, providers and people receiving services define success, distribute financial risk and protect individual rights. These wider purchasing and accountability questions are explored through the Commissioning, Funding and System Design Knowledge Hub. Any shift toward independence-focused funding must also be grounded in rights, consent and supported decision-making, because independence cannot legitimately become a payer-defined obligation to accept less support.
The central opportunity is to recognize outcomes that conventional reimbursement often overlooks. The central risk is that poorly designed incentives could reward service withdrawal, discourage support for people with complex needs or confuse reduced expenditure with improved quality of life. A credible future model must address both.
1. Why Traditional Medicaid Payment Can Undervalue Independence
Many Medicaid-funded community services operate through reimbursement arrangements linked to defined service units, such as hours of personal assistance, direct support or other authorized activities. The precise structure depends on the state Medicaid authority, covered benefit and delivery arrangement. Some programs use daily rates, case rates, managed care payments or other methods, so hourly reimbursement should not be treated as universal.
Unit-based payment has important advantages. It provides an auditable connection between authorized support, documented delivery and reimbursement. It can also protect access where a person needs ongoing assistance and where reducing service intensity would be inappropriate.
However, the payment mechanism may not fully recognize improvements in capability, confidence, community participation or self-direction. A provider that invests in intensive skill development may eventually support someone to complete tasks with less assistance. Under a purely unit-based arrangement, the provider's revenue could decline even when the person's quality of life improves.
This is particularly relevant to restorative and independence-focused support models, where carefully planned intervention can help people regain or develop functional abilities. The challenge is different for people with progressive conditions or lifelong disabilities whose preferred outcomes may involve maintaining stability rather than reducing support.
The distinction matters because independence is not synonymous with doing everything without assistance. Someone may exercise greater independence by directing their own support workers, making informed choices about daily routines or accessing employment with consistent assistance. Their need for funded services may remain unchanged.
A future payment model therefore needs a broader definition of value. It should recognize progress toward individually meaningful goals, while protecting the continuing support that makes autonomy possible.
2. Federal Medicaid Rules Create Opportunities and Boundaries
Medicaid is jointly financed by federal and state governments, but states administer their programs within federal statutory and regulatory requirements. This creates substantial variation in how HCBS benefits are structured, authorized, purchased and reimbursed.
Community-based support may be delivered through Medicaid state plan authorities, Section 1915(c) waivers, other applicable HCBS authorities or approved Section 1115 demonstrations. Each has distinct conditions, populations, services and administrative requirements. A payment approach that can be developed within one state program may require different approvals or implementation arrangements elsewhere.
The Centers for Medicare & Medicaid Services establishes federal requirements and reviews relevant state program arrangements. States determine many operational details, including provider qualifications, payment methodologies, assessment processes and service definitions, subject to applicable federal rules and approvals.
The federal HCBS settings framework also provides important protections relating to community integration, person-centered planning and individual rights for services within its scope. Payment reform cannot legitimately override those protections or turn individual choice into a mechanism for restricting access.
Medicare should be distinguished from Medicaid. Medicare may cover qualifying home health, rehabilitation and other medically necessary services, but it does not generally finance comprehensive ongoing personal assistance or long-term custodial support. An independence-focused Medicaid model therefore cannot assume that Medicare will fund any continuing needs left outside a redesigned Medicaid payment.
Before developing alternative reimbursement arrangements, states and plans need to establish:
- Which Medicaid authority covers the population and services concerned.
- Whether the proposed payment methodology is permitted or requires approval.
- How assessed need, service authorization and individual appeal rights will be protected.
- Which organization carries financial and performance accountability.
- How payment integrity, quality reporting and federal-state oversight will operate.
The Regulatory Readiness Gap Analyzer can help organizations structure an initial examination of relevant requirements and evidence gaps. It does not determine whether a proposed Medicaid payment arrangement is legally permissible or replace state and federal approval processes.
3. Defining Independence Without Turning It Into a Cost-Cutting Target
The most difficult element of independence-focused payment may be defining the outcome itself. Conventional performance measures often emphasize service utilization, hospital admissions, completed assessments or documented care-plan goals. These can provide useful information, but none offers a complete measure of autonomy.
For a person with intellectual and developmental disabilities, independence may involve choosing where to live, developing friendships, managing personal finances with support or directing their own daily schedule. For an older adult recovering from illness, it may mean regaining confidence with mobility or preparing meals safely. For someone with serious mental illness, it may involve stable housing, meaningful relationships and greater control over recovery decisions.
These outcomes are not interchangeable. A payment model that rewards reductions in assistance could disadvantage people whose needs remain substantial despite excellent support. Similarly, rewarding employment without accounting for individual goals, disability-related barriers and local labor markets could create incentives to prioritize easier-to-serve participants.
Effective outcome measurement should distinguish between changes in functional ability, personal agency, community participation and sustained wellbeing. It should also recognize maintenance of an important outcome, such as remaining safely in a chosen home, where deterioration would otherwise be likely.
The strongest measures combine structured assessment with the person's own account of what matters. Family members, guardians and advocates may contribute where appropriate, but their preferences should not automatically replace those of the person receiving services.
There is also a need to distinguish independence from isolation. A reduction in paid support may appear favorable in financial reports while leaving someone dependent on an exhausted caregiver or unable to participate in community activities. Such a result should not qualify as improved independence.
For this reason, any financial reward should depend on a balanced assessment of quality, rights, continuity and outcomes rather than a single reduction in service intensity.
4. The Economics of Outcome-Based Medicaid Funding
Outcome-based payment can take several forms, ranging from modest performance incentives alongside existing reimbursement to more substantial prospective payments or shared-savings arrangements. Each model allocates financial risk differently and creates distinct operational requirements.
A limited pay-for-performance arrangement may reward providers for achieving agreed quality or person-centered outcome measures while retaining conventional payment for authorized services. This can be relatively straightforward conceptually, although reliable measurement and attribution remain challenging.
A case-rate or episode-based model may provide a defined payment for an agreed intervention period, such as time-limited restorative support. Such an approach can encourage flexibility in how services are organized, but only where the payment adequately reflects participant complexity and protects access to additional support when needed.
Shared-savings arrangements could theoretically reward organizations when improved coordination reduces avoidable expenditure. However, determining whether savings genuinely result from better care is difficult. Changes in hospital utilization may reflect health status, access barriers, unrelated clinical decisions or wider economic conditions.
Strong rate-setting and cost modeling must therefore precede meaningful financial risk transfer. Providers need adequate baseline reimbursement for workforce costs, supervision, travel, documentation, technology and necessary service intensity.
A poorly funded outcome contract may encourage providers to reduce staffing or avoid people with greater needs. A well-designed arrangement can instead create room for investment in coaching, rehabilitation, assistive technology and coordinated support.
The distinction is especially important for smaller HCBS providers. Organizations with limited reserves may be unable to absorb delayed incentive payments, uncertain attribution or losses associated with unpredictable participant needs.
Payment reform becomes credible when financial incentives are proportionate to the outcomes providers can influence, the underlying service rates are sustainable and the contract does not reward inappropriate reductions in support.
5. Operational Scenario: Independence Gains Reduce a Provider's Revenue
Consider an illustrative adult with an intellectual disability who receives Medicaid-funded supported living services under a state-approved HCBS arrangement. Their personal goal is to travel independently to a community employment program and manage more of their weekly shopping.
The provider develops a structured learning plan involving travel training, practical budgeting, supported decision-making and regular review. Direct support professionals initially provide intensive assistance, but over several months the person becomes more confident and begins completing some activities with less direct support.
The service coordinator reassesses the person's needs and preferences. The individual wants to retain support for unfamiliar journeys and complex financial decisions but no longer requires the same level of assistance for familiar shopping trips.
Under the existing unit-based reimbursement model, fewer delivered support hours mean reduced provider revenue. The provider has invested substantial staff time in skill development but receives no additional recognition for the sustained improvement.
An illustrative alternative payment arrangement could retain reimbursement for necessary support while offering a carefully designed outcome incentive for demonstrable progress toward person-defined goals. Evidence would include the person's own account, observed competence, continuity of participation and reassessment of ongoing support needs.
The arrangement would need safeguards. The provider should not receive a reward simply because authorized hours decline, and the person should not lose the ability to request reassessment if circumstances change.
For the state or payer, the lesson is that independence-focused payment may be most defensible when it rewards verified capability and choice, rather than reductions in expenditure alone.
6. Managed Care Could Accelerate Reform, but Also Concentrate Risk
Some states operate managed long-term services and supports arrangements in which Medicaid managed care organizations administer covered services under state contracts. Other states retain fee-for-service delivery or use mixed arrangements. Managed care therefore offers one potential route for outcome-based funding, not a universal national mechanism.
Managed care organizations may have access to information about assessments, service authorizations, claims, encounter data, hospital utilization and provider performance. This creates opportunities to examine whether different combinations of support improve outcomes over time.
However, a capitated health plan also has financial incentives to control expenditure. Without strong oversight, independence-focused measures could be interpreted as justification for reducing authorized services or increasing utilization-management restrictions.
The operational safeguard lies in separating outcome measurement from decisions about individual entitlement. Service authorization must continue to reflect assessed need and applicable Medicaid requirements, while any payment incentive should reward meaningful progress without undermining rights.
For MCOs, authorization and utilization management need to remain transparent, consistent and subject to appropriate review and appeal. Member grievances, service reductions and provider disputes should be examined alongside reported outcome improvements.
Network adequacy is another concern. If outcome incentives favor providers serving people with relatively straightforward needs, organizations supporting high-acuity participants may become financially disadvantaged. Risk adjustment, fair attribution and monitoring of referral acceptance are therefore essential.
States remain accountable for oversight of their Medicaid programs, including delegated functions. MCOs remain responsible for the performance of contracted arrangements within applicable requirements, while providers retain direct responsibility for safe and appropriate delivery.
A mature outcome-based contract should establish who verifies results, who investigates disputed data, how participants challenge decisions and what happens when the model produces unintended consequences.
7. The Workforce Must Be Rewarded for Enabling Progress, Not Just Delivering Hours
Payment reform will have limited value unless it changes what providers can invest in and what frontline workers are supported to achieve. Direct support professionals, personal care attendants, rehabilitation workers, peer specialists and other community staff often influence independence through everyday practice.
Developing capability requires time, patience and professional judgment. A worker supporting someone to prepare a meal may initially need to provide extensive assistance, then gradually shift toward prompting, observation and confidence-building. This can take longer than completing the task on the person's behalf.
Traditional productivity measures may inadvertently discourage this approach. Supervisors focused on visit completion, documentation volume and scheduling efficiency may struggle to recognize the value of slower, developmental support.
Outcome-based models should therefore connect payment incentives with workforce capability and appropriate skill mix. Staff need practical competence in person-centered planning, communication, coaching, positive risk-taking and recognizing when additional professional input is required.
Training completion alone is insufficient. Providers should examine observed practice, supervision records, participant feedback and evidence that workers can adapt support as needs and abilities change.
Workforce sustainability also matters. Providers cannot build consistent relationships when staff turnover is high, schedules are unstable or workers lack access to supervision. Payment arrangements that reward long-term outcomes should recognize the employment infrastructure needed to achieve them.
There is a potential tension between rewarding reduced service intensity and maintaining a stable workforce. If successful providers lose revenue without compensating outcome payments or opportunities to redeploy staff, they may have little financial capacity to sustain developmental practice.
The stronger model rewards high-quality support and measurable progress while allowing providers to reinvest in supervision, specialist competence and continuity.
8. Operational Scenario: A Restorative Care Model Improves Independence Without Guaranteeing Savings
An illustrative 76-year-old Medicaid beneficiary returns home after hospitalization and receives community-based assistance under a state program that includes appropriate restorative support. Before the hospitalization, the person managed most daily activities independently but now requires help with mobility, dressing and meal preparation.
The provider works with the service coordinator and relevant rehabilitation professionals to establish a time-limited support plan. The beneficiary identifies returning to familiar daily routines as the principal goal, rather than simply reducing service hours.
Staff provide practical assistance while encouraging safe participation in activities. Progress is reviewed through functional observations, the person's own feedback and changes in the level of help required.
After several weeks, the person regains some abilities but continues to need support with bathing and transportation. A conventional productivity measure might record the number of completed visits. A more meaningful outcome assessment would recognize improved mobility, greater confidence and the remaining need for assistance.
Suppose the intervention reduces the number of weekly support hours. This does not automatically establish net savings. The program has incurred rehabilitation costs, additional supervision and potentially higher short-term service intensity. The person's future health needs may also change.
An outcome-based payment model could recognize functional improvement and participant experience without assuming that every reduction in hours produces a financial return. It would also allow continued services where reassessment demonstrates ongoing need.
The lesson is that independence-focused funding requires credible evaluation of both human outcomes and total costs, rather than treating reduced service utilization as proof of success.
9. Measurement Is the Foundation of Financial Credibility
Outcome-based payment depends on data that can withstand scrutiny from providers, Medicaid agencies, MCOs, auditors and people receiving services. This is a higher evidentiary standard than simply recording that a goal was included in a care plan.
Measures should be sufficiently reliable to support payment decisions, sensitive to meaningful change and appropriate for the population concerned. They also need to distinguish outcomes influenced by providers from those shaped by housing, employment markets, family circumstances or broader healthcare access.
For example, employment outcomes may depend on local job availability, transportation and employer accessibility. Hospital utilization may reflect underlying medical complexity. Community participation may be constrained by geography or the availability of accessible activities.
Effective data quality arrangements should therefore examine completeness, consistency, timeliness and the possibility of selective reporting.
A balanced payment evidence framework could include:
- Participant-defined goals and baseline circumstances.
- Validated functional or quality-of-life measures where appropriate.
- Evidence of actual support delivered and professional practice.
- Participant-reported experience, choice and control.
- Service continuity, safeguarding and complaint indicators.
- Financial information sufficient to assess sustainability and unintended incentives.
These measures should be reviewed together. A provider reporting strong goal attainment but rising complaints about service withdrawal should trigger further investigation. Similarly, an organization supporting people with substantial lifelong needs should not be penalized simply because functional improvement is limited.
The Quality Dashboard Builder can support the organization of outcome, quality and performance indicators for management and governance review. Its outputs require validation against source records and participant experience before being relied upon for contractual or financial decisions.
Measurement maturity is demonstrated not by the number of indicators collected, but by whether organizations can explain what changed, why it changed and whether the improvement was meaningful to the person concerned.
10. Risk Adjustment and Equity Determine Whether Payment Reform Is Fair
Outcome-based funding can unintentionally create incentives to select participants who are more likely to achieve measurable improvement. This is particularly problematic in Medicaid programs serving people with complex disabilities, progressive conditions or significant social disadvantage.
Providers working with people who have stable housing, reliable transportation and strong informal support may find it easier to demonstrate certain outcomes than those supporting individuals experiencing homelessness, rural isolation or multiple health conditions.
Risk adjustment can help account for differences in participant characteristics, but it cannot resolve every fairness problem. Poorly designed adjustments may obscure disparities or rely on incomplete information about disability, functional need and social circumstances.
States and payers should examine equity and access barriers alongside performance outcomes. This includes monitoring referral acceptance, service availability, participant characteristics, appeals and whether providers are withdrawing from higher-cost populations.
Outcome measures should also recognize maintenance, prevention and stability. For someone with a progressive neurological condition, maintaining community participation or preventing avoidable deterioration may represent excellent support even when functional independence does not increase.
Financial incentives should not encourage providers to redefine success around what is easiest to measure. Nor should they transfer disproportionate risk to organizations serving people with the greatest needs.
A fair payment model needs a clear explanation of which outcomes are rewarded, how differences in need are considered, what happens when circumstances change and how people can challenge decisions affecting their support.
11. Operational Scenario: A Provider Network Faces Unintended Selection Incentives
An illustrative state Medicaid program introduces a limited outcome incentive for participating HCBS providers. The incentive rewards improvements in selected functional measures and community participation outcomes while maintaining ordinary reimbursement for authorized services.
During the first year, aggregate results appear encouraging. Several providers report substantial progress, and the state considers expanding the arrangement.
However, a quality review identifies an unexpected pattern. Providers achieving the highest incentive payments have increasingly accepted participants with relatively stable support needs, while referrals involving complex behavioral support or progressive conditions are taking longer to place.
The state examines referral records, participant characteristics, provider acceptance rates and service authorization data. It also consults people receiving services, advocacy organizations and providers supporting high-acuity populations.
The review finds that the payment methodology has not adequately recognized maintenance outcomes or the additional resources needed for complex support. Although no single provider has necessarily breached its contract, the collective incentive structure may be influencing network behavior.
The state revises the evaluation approach before wider implementation. It considers population-specific measures, stronger access safeguards and differentiated performance expectations. Providers receive clearer guidance on documenting meaningful outcomes for people whose principal goal is stability rather than measurable functional improvement.
Future monitoring includes changes in referral acceptance, unmet need, participant experience and financial sustainability, not simply the proportion of people meeting incentive targets.
This scenario illustrates why outcome-based funding requires active system oversight. A payment model can generate apparently positive performance results while creating barriers for the people who most need reliable community support.
12. Rights, Appeals and Safeguarding Cannot Become Secondary to Payment Outcomes
Independence-focused payment must preserve the distinction between encouraging capability and restricting necessary services. A person should not be pressured to accept fewer hours, unsuitable technology or an unwanted living arrangement because a provider or payer has a financial interest in demonstrating reduced dependence.
Person-centered planning should establish the individual's goals, communication preferences and decision-making arrangements. Where guardians or legally authorized representatives are involved, their authority must be understood within applicable state law and the person's retained rights.
Positive risk-taking may be appropriate when a person chooses greater independence despite some uncertainty. However, this requires proportionate assessment, informed choice and appropriate safeguards. It does not justify ignoring serious risks or withdrawing essential support.
Providers examining these decisions can use the Positive Risk Enablement Planner to structure discussion of autonomy, proportionality and support arrangements. It does not replace legal capacity assessment, clinical judgment or applicable reporting requirements.
Where service reductions or denials occur, beneficiaries must retain applicable notice, hearing and appeal protections. Managed care grievance and appeal processes operate within relevant Medicaid requirements, while state procedures and program structures determine the precise route.
Safeguarding oversight must remain independent of financial performance incentives. Suspected abuse, neglect, exploitation or coercion may require external reporting to Adult Protective Services, other state authorities or law enforcement under applicable rules.
For boards and payer oversight committees, the warning signs include rising service-reduction appeals, complaints about pressure to accept less support, unexplained changes in authorization patterns and deterioration in participant experience.
The credibility of independence-focused payment will depend on whether people retain genuine control over their lives, including the right to receive continuing assistance when it remains necessary.
13. Governance Must Connect Financial Incentives With Human Outcomes
Outcome-based payment introduces new governance responsibilities because organizations are no longer assessed solely on whether services were authorized, delivered and billed correctly. They may also be financially rewarded for reported changes in people's lives.
This increases the importance of clear accountability for measure selection, data validation, payment decisions, participant rights and corrective action.
State Medicaid agencies need to understand whether payment arrangements remain consistent with approved authorities and whether the resulting incentives support program objectives. Managed care organizations, where involved, need oversight of delegated functions, provider performance and unintended restrictions on access.
Provider executives and boards should examine the relationship between outcome achievement, workforce conditions, service continuity and financial performance. An increase in incentive revenue is not sufficient assurance if it coincides with higher staff turnover, rising complaints or reduced access for people with complex needs.
Strong risk ownership and assurance arrangements should establish who investigates anomalous performance, who can suspend or revise an incentive arrangement and how concerns are escalated beyond individual contracts.
For example, a provider reporting unusually rapid reductions in service intensity may warrant review of assessment quality, participant feedback and authorization records. Conversely, a provider achieving strong quality-of-life outcomes without reducing service hours may demonstrate valuable practice that conventional financial measures overlook.
The Governance Maturity Assessment offers a structured way to examine leadership accountability, assurance arrangements and organizational readiness for more complex performance expectations.
Corrective action should address the underlying cause of poor performance rather than merely improving reporting. If incentives lead to inappropriate service reductions, remediation may require contract changes, staff retraining, revised authorization controls and direct engagement with affected participants.
Improvement should be verified through subsequent practice and outcome evidence. Closing an action because a policy has been rewritten does not establish that people are receiving better support.
14. Technology Could Support More Personalized Payment, but Creates New Risks
Digital systems may eventually make independence-focused payment more feasible by improving the availability of timely outcome information. Care management platforms, electronic records, assistive technology and secure information exchange can support longitudinal understanding of individual progress.
For example, a provider may combine structured goal reviews with service delivery records and participant-reported experience. A payer may examine whether improvements remain stable over time rather than relying on a single annual assessment.
However, data integration is not straightforward. HCBS providers often operate with different technology systems, varying levels of digital maturity and limited resources for interoperability. Information may also be held by healthcare organizations, housing providers or community partners operating under different legal and contractual arrangements.
Effective interoperability and data exchange require clear information governance, appropriate access controls, consent management where applicable and accountability for data accuracy.
Artificial intelligence may support future analysis of patterns in service utilization, functional change or workforce capacity. Yet predictive models can reproduce existing inequities if historical data reflects unequal access or incomplete documentation.
Automated recommendations should not replace individual assessment, professional judgment or beneficiary rights. Organizations need human review, transparent decision processes and mechanisms for challenging inaccurate or biased information.
There is also a risk that technology becomes a proxy for independence. A remote monitoring device may improve safety for one person but create unwanted surveillance for another. Digital support should be evaluated against personal choice, accessibility and the quality of human relationships.
The strongest technology strategy would support more reliable evidence and individualized decision-making without allowing algorithms or administrative convenience to determine what independence should mean.
15. What a Credible Transition Toward Independence-Focused Payment Could Look Like
A national shift from service-based reimbursement to independence-focused payment is neither established nor inevitable. Medicaid's federal-state structure, the diversity of covered populations and the importance of continuing support make a single replacement model unlikely to be appropriate.
A more credible direction would involve carefully evaluated arrangements that combine reliable baseline payment with targeted incentives for person-centered outcomes. These could be developed within applicable state authorities and approved arrangements, with implementation adapted to the population and service model.
For time-limited restorative interventions, a defined episode of support may offer opportunities to recognize functional improvement and sustained independence. For lifelong disability services, incentives may be better linked to choice, participation, continuity and personally meaningful achievement. For complex LTSS, maintaining stability and preventing avoidable disruption may represent the most appropriate outcome.
State agencies and health plans considering pilot evaluation and learning should establish baseline measures, comparison approaches where feasible, participant involvement and explicit safeguards before expanding financial incentives.
Early implementation should test whether the payment arrangement changes provider behavior in beneficial ways. Does it encourage investment in staff competence? Does it improve access to community activities? Are people more involved in decisions? Are providers accepting participants with complex needs? Do outcomes persist after the incentive period?
Financial evaluation should examine the full cost of the model, including administration, data collection, workforce development and any additional services required. Savings should not be assumed simply because one category of service expenditure falls.
Over time, successful approaches may contribute to more personalized Medicaid purchasing, better alignment between payment and quality, and stronger recognition of the value created by community-based support.
However, the most promising development may not be a complete replacement of fee-for-service reimbursement. It may be a balanced model in which necessary support remains adequately funded while additional incentives recognize autonomy, continuity and outcomes that matter to individuals.
Conclusion
Medicaid could move further toward paying for independence, but only if independence is understood as greater choice, capability and control rather than simply reduced reliance on paid services. That distinction is fundamental to the future of outcome-based Home- and Community-Based Services.
Traditional reimbursement provides important accountability for authorized and delivered support, yet it can undervalue the work involved in developing skills, sustaining community participation and helping people exercise greater autonomy. Carefully designed outcome incentives could recognize these achievements and encourage providers to invest in person-centered practice.
The risks are equally significant. Poorly constructed payment arrangements could reward service withdrawal, disadvantage people with complex or progressive conditions, create incentives for selective enrollment and shift financial uncertainty onto already pressured community providers.
Federal Medicaid requirements establish essential boundaries, while state program design determines how alternative arrangements can be developed and implemented. Managed care may provide additional opportunities for coordination and measurement, but it does not remove the need for strong oversight, fair reimbursement and beneficiary protections.
For providers, the strongest opportunity lies in demonstrating meaningful outcomes alongside reliable service delivery. For Medicaid agencies and health plans, it lies in creating payment structures that reward genuine improvements without weakening access. For governance leaders, it requires credible evidence that financial incentives remain aligned with individual rights and long-term system sustainability.
The future of Medicaid payment should not be framed as a choice between funding services and funding independence. The more ambitious objective is to fund the right support, at the right intensity, in ways that help people live the lives they choose. Independence should be the outcome of better support, not a justification for providing less of it.