Allocating Home Care: Assessing Deservingness Perceptions for In-Kind Services

• In Event: Public Perceptions and Health Communication

Abstract

Political scientists have long examined public perceptions of those seeking government assistance and how those perceptions may shape the programs that serve them. Although a sizable literature has examined the social construction of target populations in the context of cash assistance, relatively little research has explored how the public perceives those seeking help in the form of in-kind service-provision. In this paper, I will use data from a nationally representative conjoint experiment to examine public perceptions of deservingness for home and community-based services (HCBS) designed to assist people with disabilities and older adults remain in the community and avoid institutionalization. To my knowledge, this will be the first use of conjoint experimental methods to examine public opinion on the allocation of HCBS.

State Medicaid agencies are the United States’ primary payer for long-term care. While Medicaid programs are required to pay for nursing homes and other forms of institutionalization immediately, they are permitted to maintain waiting lists for people to access community-based help in the form of HCBS. Thirty-seven states had waiting lists for HCBS in 2021, encompassing 656,000 people. Many wait years to access services (Burns, Watts & Ammula, 2022).

In this experiment, I will conduct a conjoint experiment using a Lucid sample weighted to be nationally representative to assess the impact of demographic and clinical traits on public support for the allocation of scarce HCBS. Respondents will be presented with two randomly generated applicants for services currently on a waiting list for HCBS and asked to select one to receive support. Respondents will be informed that not all applicants are able to receive publicly funded services and that those who do not receive HCBS will be at greater risk of institutionalization or serious health consequences (including risk of death). I will randomize applicant’s disability diagnoses, functional needs, age, race/ethnicity, gender/gender identity, degree of family support, and employment status. In addition to which applicant is selected to receive services, I will also use as dependent variables respondent ratings of each applicant’s profile on a seven point scale indicating: a) how deserving each applicant under consideration is to receive services, b) how at risk they are for institutionalization if they do not receive services, and c) how at risk they are for serious health consequences if they do not receive services. These three questions will provide me with useful insights as to the mechanisms through which respondents select particular applicants and/or rationalize their selection.

Consistent with prior work on disability and deservingness (Geiger, 2021), I hypothesize the existence of a “hierarchy of disability”, in which applicants with more stigmatized diagnoses (such as schizophrenia and HIV/AIDS) will be less likely to receive and be perceived as deserving for HCBS. I also anticipate that applicants with congenital disabilities (i.e: present from birth) will be perceived as more deserving and be more likely to be allocated services, based on prior work regarding perceptions of personal control as a factor in public perceptions of deservingness (van Oorschot, 2006; Schneider & Ingram, 1993). I also expect that applicants from racial and ethnic minority groups, transgender applicants and unemployed applicants will be less likely to receive services or be perceived as deserving, and that a greater negative effect will exist where these categories intersect with stigmatized disability diagnoses consistent with intersectionality theory articulated by Crenshaw (1989). I also hypothesize that persons with greater family support will be less likely to receive services, as they will be perceived as less likely to face institutionalization or serious health consequences if they go without assistance. Finally, I anticipate that older adults will more likely to receive services than younger applicants, as respondents may perceive themselves as more likely to face long-term care needs in old age than to acquire a disability earlier in life.

References
Burns, A., Watts, M. & Ammula, M. A Look at Waiting lists for Home and Community-Based Services from 2016 to 2021. Kaiser Family Foundation. November 2022.

Crenshaw K. Demarginalizing the intersection of race and sex: a Black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. U Chi Legal F. 1989;1:139–67.

Geiger BB. Disabled but not deserving? The perceived deservingness of disability welfare benefit claimants. Journal of European Social Policy. 2021 Jul;31(3):337-51.

Schneider A, Ingram H. Social construction of target populations: implications for politics and policy. Am Polit Sci Rev. 1993;87(2):334–47.

van Oorschot W. Making the difference in social Europe: deservingness perceptions among citizens of European welfare states. J Eur Soc Policy. 2006;16(1):23–42.

Author

• Ari Neeman, Harvard University