A working group is recommending that the state shave $32 million a year from a $1.7 billion personal care attendant program that is placing strain on the state budget.
The group’s new report lays out targeted cost containment measures for the PCA program, one of the fastest growing line items in the budget due to the state’s aging population and demand for in-home care.
The group’s proposals would tighten overtime rules for personal care attendants and limit how much time the state will pay for meal preparation. Supporters say the changes are carefully calibrated to avoid harming vulnerable residents while addressing a program whose costs have more than doubled in less than a decade.
Charlie Carr, legislative liaison for the Disability Policy Consortium and a working group member, said the proposed savings reflect an effort to make limited reductions without undermining the core of the program.
“I’m hoping, between our relationship over the many years with the Legislature, their willingness to support us in keeping the program whole, that with these savings, even though they’re very modest in terms of the overall budget, we’re hoping hoping hoping, they’re going to accept it,” Carr said.
The recommendations follow three months of negotiations among advocates, labor representatives and state officials.
The PCA program, administered by MassHealth, pays workers to assist seniors and people with disabilities with daily tasks such as bathing, dressing, eating and grocery shopping, allowing many to live independently rather than in nursing homes. Enrollment and costs have surged as the state’s 65-and-older population grows and as wages for home care workers have risen under a 2023 labor contract.
According to data reviewed by the working group, PCA spending rose from about $841 million in 2015 to $1.75 billion in 2024 — a 108% increase. Over the same period, the number of members receiving PCA services climbed from roughly 40,000 to 56,000, while average hourly wages increased from $13.68 to $19.50.
The group’s most significant recommendation would cap paid meal preparation assistance at seven hours per week, a change projected to save roughly $28 million annually. The report emphasizes that the policy would include a medical exception for individuals who require specialized meals, as documented by a physician.
Carr said meal preparation has long been a flashpoint in debates over PCA spending and the group concluded it was an area where limited cuts were unavoidable.
“This time around, we talked about and discussed it, and we felt like if somebody needed special meals to be prepared, if they got a note from their doctor that would be considered,” Carr said. “But we felt that if we had to cut anywhere, that would be the area for a slight cut.”
The group also recommended limiting how much overtime PCAs can work, from 26 hours per week to 20, a change aimed at cutting overtime pay costs and saving the state an estimated $3.9 million. Overtime has been a persistent cost driver in the program.
Beyond the cuts, the working group endorsed the idea of establishing a cost-growth benchmark for the PCA program, though it stopped short of recommending a specific hard spending cap. Instead, members coalesced around a “composite benchmark” that would account for multiple factors, including growth in the state’s older adult population, shifts in patient acuity, wage growth and state revenue trends.
The report says the many members said they did not not want the benchmark to function as an automatic trigger for cuts. If spending exceeds expectations, the issue would be sent back to the working group for further analysis and recommendations. Ultimately, funding decisions are up to the Legislature.
The PCA program has become a tender spot in recent budget cycles.
Last spring, lawmakers rejected Gov. Maura Healey’s attempt to rein in PCA spending by tying it to the Health Policy Commission’s health care cost growth benchmark, set at 3.6% for 2025. Legislative leaders stripped the proposal from their budgets and instead boosted PCA funding, drawing praise from labor unions and disability advocates who warned that a hard cap could reduce access to essential services.
At the time, the House and Senate pointed to the PCA working group as the appropriate venue to hash out more acceptable ways to slow spending growth.
The group’s first report, released earlier this year, identified about $7.4 million in savings by enforcing the existing overtime cap, addressing fraud and eliminating certain administrative payments. But even as those changes were discussed, PCA spending grew by roughly $86 million over the past year.
The report shows how far PCA spending has outpaced cost-growth benchmarks. Using a model recommended by MIT economist Jon Gruber — inflation plus growth in the 65-and-older population — the group found that PCA costs exceeded that benchmark by hundreds of millions of dollars over the past decade. Average annual growth in the program from 2017 to 2024 was nearly 9.8%, compared with about 6.9% under the inflation-plus-aging model.
The working group considered a range of more aggressive cost-saving ideas, including deeper overtime reductions, eliminating overtime pay entirely, capping all instrumental activities of daily living, or removing certain services for members with live-in aides. Some of those options carried projected savings of $50 million or more — and in one case nearly $90 million — but failed to gain consensus.
Union leaders and advocates have long argued that the PCA program saves the state money as about 50% of the costs are reimbursed by the federal government, and the program allows people to stay in their homes compared with costly institutional care. They also note that many PCAs still struggle financially despite recent wage increases, and warn against balancing the budget “on the backs of workers.”
Administration officials have repeatedly described the program’s growth as unsustainable, particularly as it consumes a growing share of the MassHealth budget.
Carr said the relatively small size of the proposed savings, compared with the overall program, remains a concern.
“I worry, yes I worry, because of the federal situation we find ourselves in,” he said. “But we hope that this is going to satisfy [the Legislature], because they like [the program] very much… They don’t want to see protests going on. So we’ve got our fingers crossed.”
He added that the group was aware of the risks of failing to propose any savings at all.
“If you’re not at the table, you’re on the menu. We didn’t want to be in that position,” Carr said.
“Do I feel good about making cuts to the program? No. But if we don’t take some modest cuts and demonstrate to the Legislature that we are serious about working with them to save money, that would be much more damaging.”
The fate of the savings recommendations will be determined in the fiscal 2027 state budget cycle, which kicks off in January when Gov. Healey plans to release her annual budget blueprint.
