A NEW PROGRAM designed to give frail Medicaid recipients more control over the type of services they receive in their homes shows a great deal of potential. The governor and officials at the state Department of Health and Human Services are to be commended for developing and pushing for federal approval for SC Choice, which is starting in a few Upstate counties this year and will expand statewide next year.

Under this program, Medicaid recipients who are unable to take care of themselves entirely would have some say over who the person is who cooks their meals or even performs more intimate tasks such as bathing them or helping them use the bathroom. They could decide that they wouldn’t even need someone to prepare or deliver meals for them, but could do it themselves, if they only had a microwave. They could decide they don’t need their regular attendant to come by on a week when family is visiting from out of town — and bank that time for a week when they need it more. And the list goes on.

While having these new choices will be a godsend to many people — not to mention likely saving the state money — the program only nibbles around the edges of a larger problem. That is because, ultimately, it is only the Legislature that can provide what is for many seniors the most important choice of all when they can no longer care for themselves — whether to stay at home or move to a nursing home.

Seniors must meet the same medical criteria to receive in-home care or nursing home care under the state’s Medicaid program. In theory, the choice is theirs. In reality, it is not. The Legislature determines how many slots will be available for in-home care and how many for nursing home care. At the end of August, there were 264 people on the waiting list for nursing home care; there were 3,573 on the waiting list for community long-term care, as home care is called.

As the Legislative Audit Council noted in a review of the Medicaid program last year, many patients who would rather stay at home feel that they have no choice but to move into a nursing home because they need some sort of care as soon as possible.

It’s not just a matter of preference, although anyone with an infirm parent — or anyone who is infirm themselves — can tell you how important it is to be able to stay at home if you prefer that. It’s also a matter of money. Medicaid spends an average of $32,000 a year for every one of its 11,000 patients in nursing homes; it spends an average of $13,000 a year for each of its 11,000 patients who receive the type of assistance that allows them to stay at home. In other words, we are forcing some people to choose a treatment option that costs far more than twice as much as the option they would prefer to choose.

Of course, there are some people whose health is such that there is no choice other than nursing home care. And with a waiting list for that care — and an aging population that will only demand more services — it’s not at all clear that the problem is that we’re overfunding nursing home care. It is clear, though, that we are underfunding home care. And that is the looming senior-care issue that the state must face up to.