Chair Amabile, Vice Chair Brown, and members of the Commission:
Thank you for the opportunity to provide public comment.
I am a parent and family caregiver from Western Colorado. I have followed the work of this Commission because the questions before you—Medicaid sustainability, administrative efficiency, long-term services and supports, workforce capacity and program integrity—eventually leave the hearing room and arrive at someone's kitchen table.
I ask the Commission to keep one principle at the center of its work:
Follow the Medicaid dollar all the way to the person.
Colorado unquestionably has difficult fiscal decisions ahead. The Commission was created specifically to identify and evaluate options for sustaining Medicaid while responding to significant federal and state policy changes.
But expenditure growth alone cannot tell us which services are inefficient, which administrative structures add value, or which reductions may simply move costs somewhere else.
That distinction is especially important in long-term services and supports.
Authorization is not the same thing as access
Colorado's Medicaid system contains numerous administrative layers between the Department and the person receiving services.
Case Management Agencies perform essential functions: assessing individuals, developing person-centered plans, coordinating services, processing authorizations, monitoring supports and helping members navigate changes.
Those functions deserve appropriate investment.
They also deserve meaningful measurement.
The Commission should ask:
How long does it take from identified need to authorization?
How long from authorization to actual service delivery?
How frequently must an authorization be corrected or reconsidered?
How often does a member experience a reduction or interruption while an administrative issue is resolved?
How many decisions produce appeals?
How long do those appeals remain unresolved?
And, most importantly:
What happened to the person while the system was deciding?
A completed assessment is not an outcome.
An authorization is not an outcome.
A case-management contact is not an outcome.
The outcome is whether the person received the support necessary to remain healthy, safe, independent and connected to their community.
Appeals should be treated as system data
The Commission's LTSS discussion presents an opportunity to examine appeals not merely as individual disputes but as indicators of system performance.
When large numbers of Medicaid members challenge service decisions, the Commission should examine why.
Was the policy misunderstood?
Was an assessment inaccurate?
Was documentation inadequate?
Was notice unclear?
Was the underlying standard too rigid?
Was the member unable to obtain appropriate assistance before services changed?
Appeals data should become part of Colorado's quality-improvement system.
That means reporting not simply how many appeals were filed, but:
- what service was involved;
- what triggered the dispute;
- how long resolution took;
- whether services continued during the dispute;
- how frequently the original decision changed;
- and whether particular policies, regions, populations or contractors generate disproportionate numbers of disputes.
The purpose should not be to assign blame. It should be to identify where the system repeatedly requires families to use due process to obtain the correct result.
The 56-hour caregiver policy deserves continued examination
Colorado's weekly caregiver limit and exception process provide a useful example.
An exception process can be an important protection.
But the Commission should look beyond the existence of the exception and evaluate what the exception data are telling us about the underlying policy.
If a substantial percentage of people requesting exceptions ultimately qualify, policymakers should ask whether those are truly unusual circumstances or whether the policy is encountering predictable characteristics of Colorado's long-term-care system.
That question is particularly important in rural Colorado.
In Denver or another large population center, policymakers may reasonably imagine that another worker can sometimes be recruited when hours are limited.
That assumption cannot automatically be applied to the Western Slope or other rural communities.
Sometimes the replacement caregiver does not exist.
A policy cannot create a workforce merely by requiring a family to find one.
Before concluding that restricting family-caregiver hours creates sustainable savings, Colorado needs to know what actually happens afterward.
Does another worker take those hours?
Does the member lose services?
Does a parent or spouse provide the same care without compensation?
Does the member become less independent?
Does the person experience a medical crisis?
Does institutional care become more likely?
Without those measurements, Colorado may record a reduction in Medicaid expenditure without knowing whether it actually reduced the underlying cost of care.
Paid family caregivers must be measured before policies affecting them are judged
Family caregiving has become an increasingly important part of Colorado's home- and community-based service system.
Yet one of the most important questions for policymakers is also one of the simplest:
Who is actually providing the care?
Colorado should develop reliable statewide information about paid family caregivers, including the number of caregivers, relationship to the member, geographic distribution, services provided, average hours, vacancy conditions and the availability of non-family workers.
That information matters before major conclusions are drawn about the financial effect of family caregiving.
Family members are not simply interchangeable with an imaginary workforce.
For many people with significant disabilities, family caregivers carry specialized knowledge developed over years: communication systems, behavior support, seizure response, medication routines, accessible technology, mobility support and recognition of subtle changes in health.
That does not mean every family-caregiver arrangement should automatically be preserved without oversight.
It means the state should measure the actual alternative before assuming one exists.
Colorado's new assessment system needs accountability from the beginning
Colorado is also undertaking significant work around assessment and person-centered planning.
Standardization can improve consistency.
It can also magnify an error if a flawed assumption becomes embedded across the entire state.
For that reason, accountability should be designed before statewide reliance on a new assessment methodology rather than added after families begin discovering problems through appeals.
At minimum, Colorado should track:
- reliability and validity of assessment results;
- differences across disability groups;
- geographic and racial disparities;
- frequency of manual corrections;
- disagreement between professional judgment and automated or standardized outputs;
- appeals resulting from assessment-derived service changes;
- service reductions following reassessment;
- unmet need after reductions;
- caregiver loss;
- hospitalization or emergency-department utilization;
- institutional placement;
- and member and family experience.
Automation and standardization should support professional judgment and person-centered planning.
They should not substitute for them.
Administrative spending must demonstrate administrative value
This Commission has spent considerable time asking where Medicaid dollars go.
I encourage you to continue that inquiry through every administrative layer.
For each major administrative structure, ask:
What measurable value does this purchase for the Medicaid member and the taxpayer?
If Colorado spends money on case management, demonstrate that case management improves access and continuity.
If Colorado spends money on utilization review, demonstrate that decisions are timely and accurate.
If Colorado pays contractors to administer benefits, measure whether they reduce complexity rather than create additional layers.
If Colorado establishes an exception process, measure whether people can actually use it before care is disrupted.
And if administrative activity does not measurably improve access, outcomes, integrity or efficiency, then administrative spending deserves the same scrutiny being applied to direct services.
Savings and cost shifting are not the same thing
This is the distinction I most hope the Commission carries forward.
Reducing a Medicaid expenditure is not necessarily the same thing as reducing a Medicaid cost.
If Colorado removes a paid hour of care and a parent supplies that hour without compensation, the underlying need did not disappear.
The cost moved.
If a service reduction produces an appeal, the cost moved into an administrative proceeding.
If inadequate home support contributes to an emergency-room visit, the cost moved into acute care.
If insufficient community support eventually contributes to institutional placement, the cost moved—and may have grown substantially.
If a parent leaves the workforce to provide unpaid care, some of the cost has simply moved outside the Medicaid ledger entirely.
Those consequences are easy to miss because Medicaid accounting can only show what Medicaid paid.
A sustainable system must look beyond the ledger.
My request to the Commission
As you develop recommendations, I respectfully ask the Commission to incorporate the following principles:
Follow the Medicaid dollar all the way to the member.
Measure actual access, not merely authorization.
Treat appeals and exceptions as system-performance data.
Measure the paid and unpaid caregiver workforce before restructuring it.
Account for rural workforce realities.
Build transparency and human review into standardized assessment systems.
Measure downstream consequences of service reductions.
And require administrative structures to demonstrate measurable value just as rigorously as direct-care services.
Colorado should absolutely pursue Medicaid sustainability.
But sustainability cannot mean transferring essential care from a Medicaid line item to an unpaid family, an emergency department, an appeals system or an institution and declaring the original expenditure solved.
If a policy saves money in one column while creating larger costs somewhere else, we have not necessarily reduced the cost.
We may simply have stopped counting it.
Thank you for your work and for considering the perspectives of the people who live with the consequences of these decisions.
Submission record and related materials
Source: Rob Harris’s sent written public comment to the Colorado Commission on Medicaid on September 17, 2026, at 2:47 a.m. Mountain Daylight Time. The sent record verifies transmission; it does not independently establish that the statement was read aloud or adopted by the commission.
Colorado Commission on Medicaid: official meeting schedule and materials
Read the November 10 prepared testimony and its policy sources