If you are impoverished and unable to care for yourself, Medicaid is required by law to provide long-term services–in a nursing home. Although the frail elderly and younger people with disabilities overwhelmingly prefer to stay at home, states are under no obligation to offer care in the community.

So here is an idea: Why doesn’t Medicaid make home care the default option for assistance? The joint state/federal program would still pay for care in nursing facilities when this assistance is appropriate, but the first option would be help at home. This idea is included in a bill called the Community Choice Act, introduced by Senator Tom Harkin (D-IA) and Representative Danny Davis (D-Il).   

Most state Medicaid programs do provide some limited home care, under a complex set of Medicaid “waiver” rules. But benefits vary widely among the states, and in many jurisidictions, seniors must wait years before a home care slot becomes available for them.

Recently, Medicaid has slowly expanded its home care benefit, but progress has been very slow. According to a recent study by AARP, three-quarters of Medicaid long-term care spending for older people and younger adults with disabilities still goes to nursing facilities. In 2007, only five states spent more than half of their Medicaid long-term care dollars on home care. Nine states spent less than 10 percent .

Amazingly, Medicaid home care is expanding at this glacial pace even though it has been more than a decade since the U.S. Supreme Court ordered states to provide community assistance to all who need it.

So why have states been so slow to embrace the home care option? Mostly because they worry it will be too popular. Many state officials are driven by the fear of what is known as “the woodwork effect.” The idea: If you make Medicaid benefits too attractive, more families will apply for them and state costs will explode.

Remember, today most of us are caring for our parents and other relatives with disabilities  without any government help. And states like it that way. As long as the choice is between helping mom at home without any support or putting her in a nursing home, many families will make huge sacrifices to keep her at home. And when it comes to Medicaid-eligible families, that choice can save government a lot of money.

To be sure, many people with disabilities require institutional care. They may not have the family support they need to stay at home, or the nature of their illness may mean a skilled nursing facility is the best setting for them. And they should have access to an institutional benefit. But for most of the frail elderly and disabled, home care is the best option. Government should do its part to make it work.