Voices: Miki Kapoor, CEO, PPL – Image for illustrative purposes only (Image credits: Pixabay)
States across the country face mounting pressure to deliver long-term care amid an aging population and persistent shortages of traditional caregivers. Self-directed care programs, which let individuals choose and manage their own support at home, are drawing renewed interest as a practical response. Miki Kapoor, chief executive of PPL, argues that these models combine personal choice with stronger accountability and lower overall costs for Medicaid programs.
Shifting Away From Institutional Models
For decades, long-term care in the United States centered on large agencies and institutional settings that handled most services through standardized contracts. This structure often left little room for individual preferences and created high expenses for states. Kapoor notes that self-directed care reverses that pattern by placing the person receiving care at the center of decisions about who provides support and how it is delivered.
The change requires updated technology and clearer rules to prevent misuse of funds. Earlier versions of the model sometimes lacked real-time tracking or consistent oversight, which slowed wider use. Modern tools now allow electronic timekeeping, visit verification, and immediate visibility into spending, giving states the confidence to expand programs without increasing fraud risks.
Expanding the Caregiver Workforce
Traditional home care agencies continue to struggle with recruitment and retention because they rely on a limited pool of paid staff. Self-directed programs address the shortage by recognizing family members and close friends who already provide unpaid support. These individuals can receive compensation, benefits such as health coverage and paid time off, and formal training while remaining in compliance with program rules.
The result is both a larger supply of caregivers and better continuity for the person receiving care. Relationships built on existing trust tend to last longer than those arranged through rotating agency staff. Kapoor points out that this consistency improves daily outcomes and reduces the need for more expensive interventions later.
Key Requirements for Responsible Growth
Successful expansion depends on several practical safeguards that balance flexibility with program integrity. States must establish clear guidelines that keep consumers in charge of approving care plans while requiring documented oversight at every step.
- Standardized electronic systems for timekeeping and visit confirmation
- Real-time data access for program administrators
- Multilingual training and customer support for participants and caregivers
- Consistent rules that prevent waste while preserving individual choice
When these elements operate together, self-directed care can grow without compromising accountability or increasing taxpayer costs.
Outlook for 2026 and Beyond
Kapoor expects self-directed care to move from a supplementary option to a central part of long-term care delivery. Demographic trends make the shift unavoidable: more older adults prefer to remain at home, yet traditional workforce numbers cannot keep pace. Programs that demonstrate measurable improvements in satisfaction, health outcomes, and spending efficiency are already influencing state policy decisions.
The focus for the coming year centers on scaling these programs with built-in transparency and support structures. Kapoor describes the priority as “scale with accountability,” meaning growth that preserves dignity and choice while protecting public resources. As more states document positive results, the model is positioned to reshape how Medicaid delivers home-based services nationwide.
