Let's do the math. Imagine a person has been assessed and authorized for 72 hours of personal assistance each week.

Those 72 hours represent actual needs. Bathing. Dressing. Toileting. Transfers. Meals. Mobility. Getting out of bed. Getting back into bed. The ordinary things that allow someone to live safely in their own home.

Now apply a 56-hour limit to the attendant providing that care.

72 authorized hours
– 56 attendant hours
= 16 hours

The person still has 72 hours of assessed need. The attendant reaches 56. And 16 hours of care are left sitting on the table.

That is where this comment begins. This is different from the question of Virginia's 56-hour soft cap and whether an individual can qualify to receive services above that threshold. Even if every one of those 72 hours remains authorized, Virginia still has another problem to solve:

Someone has to work them. An authorization cannot give a bath. On paper, everything might look fine. The individual still has 72 authorized hours. No services have technically been eliminated. The spreadsheet balances. But the person receiving care does not live on the spreadsheet. An authorization cannot get someone out of bed. It cannot perform a transfer. It cannot prepare dinner. It cannot help someone use the bathroom at 9:00 at night. A human being has to do those things.

If the attendant who has historically provided that care stops at 56 hours, another person must somehow appear to provide the remaining 16. And that is where the math gets considerably more complicated.

The Invisible Second Shift

Someone now has to find another attendant. That means recruiting, enrollment, paperwork, scheduling, training, coordination, and introducing another person into what can be some of the most private moments of an individual's life. That work does not happen by itself.

The family becomes the scheduler.
The individual becomes the recruiter.
The home becomes the workplace coordinator.
The caregiver becomes the trainer.

None of those responsibilities appear in the equation. Yet somebody carries them. And there is no guarantee that after doing all of that work, another attendant will actually be available to take the remaining hours. Then 72 minus 56 stops being a math problem. It becomes a care gap.

The Live-In Reality

That gap becomes even harder to ignore for live-in caregivers. A live-in attendant does not disappear from the home when compensated hours end. More importantly, neither does the person's disability or need for assistance. The caregiver may still be standing in the same kitchen. The person may still need help getting into bed. The bathroom may still require assistance. A transfer may still need to happen. The need is physically present, the person who has historically provided the assistance may be physically present, and yet the compensated hours have ended. That creates a dangerous expectation that should be confronted directly:

Who is expected to provide the care when paid time and human need no longer line up?

Live-in consumer-directed attendants currently do not receive overtime compensation. A policy that further restricts the hours one attendant can provide therefore cannot be evaluated only by looking at what Medicaid pays.   We also have to look at what Medicaid stops paying for but someone still ends up doing.

The Cost Didn't Vanish. Suppose another worker cannot be found for those 16 hours. Maybe a mother fills them. Maybe a sister changes her work schedule. Maybe the live-in attendant keeps helping because leaving someone in bed, without toileting assistance, without a meal, or without a necessary transfer is not a realistic choice. Nothing about that is free. The labor still occurred. The time was still spent. The person's needs were still met. The only thing that changed was who absorbed the cost.

That is cost shifting.

A program can make an expenditure disappear from one side of a ledger while the actual cost reappears somewhere else in lost wages, unpaid caregiving, reduced family employment, caregiver exhaustion, or unmet care.

The spreadsheet may show savings while the household shows the bill.

Follow the 16 Hours: That is the measurement Virginia should undertake. Not simply how many hours were authorized. Not simply how many exceptions were approved. Follow the hours that can no longer be worked by the original attendant. If another paid attendant picks them up, document that. If they remain vacant, document that. If the family provides them without compensation, document that. If the live-in caregiver continues providing assistance without being paid, document that. If the individual goes without care, document that too. Because only then will we know what actually happened. Those 16 hours cannot simply disappear from the state's accounting. Care doesn't disappear because payment does.

Hour 57

That brings us back to hour 57. At hour 56, a policy threshold may have been reached. At hour 57, a person may still need to use the bathroom. That is the difference between administering hours and providing care. If Virginia intends to change how those hours can be provided, then the Commonwealth must account for what happens after the threshold not merely what the authorization says before it.

Take the original equation:

72 hours of need – 56 hours provided = 16 hours remaining.

Those 16 hours have to land somewhere.

On another worker.
On a family.
On a caregiver without pay.
Or on a person who goes without care.

There is no fifth place where they magically disappear.

So when Virginia calculates the impact of this policy, show us all of the math! Because if the Commonwealth counts the dollars it no longer spends but does not count the labor families and caregivers absorb, the equation is incomplete.

Someone always carries the load.