A few respondents stated that many of the counties did not want to use public funding in residential care settings, because they subscribed to a philosophy that favored homecare. One stated that many counties thought some CBRFs, particularly larger ones, were more like institutions. Given that the COP and waiver program are intended to provide alternatives to institutions, they do not want to use limited funds in what they see as quasi-institutional settings.
The state gives counties tremendous power -- even when there is pressure for counties to fund assisted living, some won't fund it. Some of the resistance comes from the COP philosophy of providing services at home. But if someone lives in an assisted living facility, it is their home.
There has been a bias towards providing services to people in their homes and in small facilities (eight beds or smaller). It took years to get the state to allow waiver funds to be used in facilities with up to 20 beds. You need special authorization to provide waiver services in facilities with 20+ beds. But some places have 160 beds and they have waiting lists because that's where people want to be.