Interviewer: Dignity Digest
Guest: Peter Tiernan
Note: For more details on this issue, visit DignityMA Campaign to Restore Elder Care Services.
Dignity Digest: Peter, let’s start with the problem. What’s happening with the Enhanced Community Options Program (ECOP) in Massachusetts right now?
Peter Tiernan: The situation is deeply concerning. Over the past year, ECOP—Massachusetts’ enhanced home care program for low-income older adults who qualify for nursing home–level care—has been significantly reduced. The program census dropped by roughly 40%, and nearly 1,000 eligible elders have been placed on a waitlist.
These are individuals who, until recently, would have received services. Instead, they’re waiting—often with worsening health—despite being clinically eligible for higher levels of care.
Dignity Digest: You’ve proposed a “Limited Frail Elder Waiver” as a solution. What is that, in simple terms?
Peter Tiernan: It’s a smart restructuring of an existing program. The idea is to convert ECOP into a Medicaid-funded 1915(c) Home and Community-Based Services waiver, which I call the Limited Frail Elder Waiver.
This would allow Massachusetts to draw down federal Medicaid matching funds—what we call Federal Financial Participation (FFP) for services the state is already providing.
In short: the same people, similar services—but now partially paid for by the federal government.
Dignity Digest: And what would that mean financially for the state?
Peter Tiernan: It’s a rare win-win. The proposal is projected to generate $50–$55 million annually in new federal funding, while still fully serving everyone currently eligible—including those on the waitlist.
Even after expanding access, the state would see a net General Fund savings of about $38 million per year. That’s because federal dollars would replace a significant portion of current state spending.
Dignity Digest: So, this could actually eliminate the waitlist?
Peter Tiernan: Yes—completely. Financial modeling assumes full enrollment of all currently eligible individuals, including those wait-listed.
And importantly, it does so while still reducing overall state costs. That’s what makes this proposal so compelling—it’s not about choosing between fiscal responsibility and access to care. We can achieve both.
Dignity Digest: How is this different from the existing Frail Elder Waiver?
Peter Tiernan: The key difference is accessibility. The traditional Frail Elder Waiver has stricter financial eligibility rules, especially around assets.
The Limited Frail Elder Waiver would: use less restrictive asset rules (potentially up to $130,000 or no asset test), maintain similar clinical eligibility, include a cost cap per participant to ensure fiscal discipline, and limit total enrollment to align with current ECOP demand. This design makes it easier for low-income seniors, especially those living alone—to access services without unnecessary administrative barriers.
Dignity Digest: You mention federal policy changes that make this possible. What changed?
Peter Tiernan: A key development is a 2021 federal guidance (CMS SMD #21-004) that allows states to apply more flexible financial eligibility rules specifically for home and community-based services.
Massachusetts hasn’t yet taken advantage of this flexibility. My proposal essentially says: we should.
Dignity Digest: Some policymakers worry about unintended consequences—like the “woodwork effect.” How does your proposal address that?
Peter Tiernan: That concern often comes up – the idea that expanding eligibility will suddenly bring in a large number of new applicants.
This proposal includes built-in safeguards: a cap on individual service costs, a limit on total program enrollment, and initial targeting of current ECOP participants and those already waitlisted These features tightly control program growth while still addressing the immediate need.
Dignity Digest: Beyond eliminating the waitlist, what broader impact could this have?
Peter Tiernan: It reinforces a fundamental principle: people should receive care in their homes whenever possible. This approach: prevents unnecessary nursing home placements, supports independence and dignity, and strengthens the overall home care system Importantly, it frees up resources that could be reinvested in other priorities—like basic home care services or public guardianship.
Dignity Digest: If you could leave policymakers with one message, what would it be?
Peter Tiernan: Massachusetts has already built a strong home care system. This proposal simply modernizes how we fund it. We have an opportunity to: eliminate waitlists, expand access, draw down significant federal funding, and reduce state costs. It’s not often that public policy offers that kind of alignment. We should act on it.