A perfect storm is brewing. An additional consequence of the law is that it adds yet another layer of bureaucracy to programs and recipients and includes privacy rights infringement for workers to each state’s already overburdened Medicaid agencies. Both of these elements are time consuming, invasive and pushing away qualified workers and further exacerbates the existing crisis in recruiting and keeping good personal care services workers nationally. Most states that administer the consumer directed personal care services program either through HCBS, MCO or some other method are already experiencing a serious worker shortage that negatively impacts disabled clients and elders who rely on these workers to live in the community outside of institutions like nursing homes. In several states, disabled and elder personal care services consumers have defaulted to emergency rooms and short term nursing home stays because they can’t find adequate and appropriate workers.