The parent caregiver ‘savings’ Arizona is chasing don’t exist — unless care disappears

Want to save hundreds of millions of dollars on care for children with significant disabilities? There’s a remarkably effective way: just don’t provide all of the necessary care. 

We wouldn’t call it that, of course. 

We’d call it “savings.” 

That distinction is at the heart of Arizona’s increasingly contentious debate over Parents as Paid Caregivers. 

The confusion starts with the name. 

Parents as Paid Caregivers, or PPCG, sounds like a program that pays parents simply for taking care of their children. It isn’t. 

First, PPCG isn’t a separate “program” or disability service at all. Even the July Arizona Auditor General report at the center of the recent controversy calls PPCG a “service delivery model.” In plain English, PPCG does not create a new service or authorize additional care. Instead, it expands the existing direct-care workforce by allowing qualified, trained and certified parents to provide services already assessed and authorized for their children.

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Second, these are not simply ordinary parenting responsibilities. Parents are expected to feed, dress and supervise a child. But specialized tube feeding, transferring a growing teenager who cannot move independently or providing intensive disability-related care long after a child would ordinarily be independent is something different. Arizona recognizes that difference, too: extraordinary care, beyond what would ordinarily be expected of a parent of a child without a disability. 

Those distinctions must be clarified when we talk about cost. 

The service existed before the parent caregiver did 

If a qualified non-parent caregiver provides an authorized hour of care, Medicaid pays for that service. If a qualified parent provides that same authorized hour, Medicaid pays the same. 

The child’s need didn’t change. The work didn’t change. Only the worker did. 

The Arizona Health Care Cost Containment System, our state’s Medicaid agency, made the same point in its formal response to the recent audit: “The State’s obligation to cover the authorized service does not disappear.” 

So, if Arizona removed parents from the paid workforce tomorrow and other qualified caregivers filled every shift, where would the savings come from? 

They wouldn’t. 

There is, however, a very effective way to make the expenditure disappear: No one provides the necessary service. 

Arizona knows what that looks like. 

The ‘cheaper’ alternative has a cost 

For years, Arizona struggled with a serious direct-care workforce shortage. People could qualify for long-term care services and have necessary care authorized without enough workers available to provide it. When Arizona sought permanent federal authority for paid parent caregiving, AHCCCS specifically identified the historical workforce shortage and access-to-care challenges as reasons for the model. 

An unfilled shift generates no Medicaid claim. 

It also generates no care. 

Calling that lower spending a success is like celebrating an understaffed fire department for coming in under budget when it couldn’t answer every call. No one would call that efficiency. We would ask why the calls went unanswered. 

Research on Medicaid home and community based services has also found that receiving Home and Community Based Services can reduce reliance on costly emergency and inpatient care. The cost of an unfilled shift may simply move elsewhere in the healthcare system, like costly emergency services, crisis care, and institutionalization. 

We have already seen what the cheaper model looks like in Arizona. We called it a direct-care workforce crisis. 

What the audit actually tells us 

That history matters when we return to the recent state audit fueling much of the controversy over PPCG spending. 

The report criticized aspects of the state’s implementation and oversight, although AHCCCS formally disagreed with all four findings directed to the agency. One thing the audit did not find was evidence of widespread fraud by parent caregivers.

Importantly, its largest projected reduction in spending came from decreasing actual services to children with disabilities. The audit estimated Arizona could have reduced fiscal-year 2026 spending by $133 million to $493 million had a new age-based standardized assessment approach to total services for disabled children remained in effect last fall. 

That approach lasted only 16 days for a reason. 

AHCCCS implemented the Home and Community Based Services Needs Tool on Oct. 1, 2025, then paused it in mid-October amid serious legal and operational concerns and fully reversed decisions made under it. The agency subsequently revised its approach, including developing an Extraordinary Care Review process, with revised implementation planned for December. 

Those projected hundreds of millions of dollars in “savings” aren’t money auditors discovered being stolen or misused by parents — they were estimates of reduced spending on underlying disability services when the assessment approach resulted in less authorized care for children. 

That is a separate issue entirely from who is allowed to provide services once they are authorized. 

Again, the care costs the same, regardless of the caregiver’s last name. 

So, what are we actually saving? 

Arizona should scrutinize every Medicaid dollar. It should enforce its rules and maintain strong oversight. But policymakers and journalists warning about the “exploding cost” of PPCG must answer the question their own argument raises: What care, exactly, should Arizona stop paying for?

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If the answer is parent-provided care, replacing the parent with another worker does not produce the savings. Arizona still pays for the service. 

The savings appear only when less necessary care is paid for or delivered. 

If that is what we mean by controlling the “exploding cost” of PPCG, we should all be willing to say so plainly. 

There is a profound difference between efficiency and unmet need. Real efficiency reduces unnecessary costs without reducing access to necessary care or destabilizing the workforce that provides it. 

But if Arizona spends less because necessary care doesn’t reach the child, that is not efficiency. It is unmet need. 

The cheapest Medicaid service will always be the one someone does not receive.

We should stop calling that savings and start looking at its true cost.