Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. 1. State Constraints


Policymakers have always known that states face unique circumstances that make it important to allow for state differences in implementing health care programs. Re-balancing also faces regional challenges, which may result in slow development of HCBS in some areas. Previous studies have cited fiscal constraints (Howes 2010; Smith et al. 2009) and lack of adequate housing (Denny-Brown and Lipson 2009; Siebenaler et al. 2005) as challenges states face in their efforts to shift their LTSS systems from heavy reliance on institutional care to community settings.

To understand how some of these factors may continue to be related to a state's success in re-balancing the LTSS system, we re-investigated the following factors examined in our previous study:

  • Cost of Living in the Community. High costs may make it difficult for the elderly poor and those with disabilities to maintain their residence, whereas admission to a nursing home can relieve those financial burdens. In 2006, however, average housing costs were found to actually have a positive relationship with HCBS balance among aged enrollees, possibly indicating that we were capturing the effects of living in wealthier states with more available resources rather than simply the resources a person needs to remain in the community.

  • State Financial Resources. A high level of local financial resources may make it feasible for a state to support programs that subsidize utility bills and other living costs, making it less expensive for an individual to remain in the community. In 2006, higher per-capita income at the state level was associated with higher levels of HCBS balance among enrollees with ID/DD.

  • Environmental Factors. Extreme weather conditions may make it unsafe to live alone or difficult to travel, encouraging more nursing home placements. In 2006, higher rates of winter precipitation were associated with lower overall rates of HCBS balance.

  • High Demand for Services. States with a high proportion of elderly residents may be more likely to be at the forefront of HCBS because meeting the needs of those individuals is likely to be a high priority. In 2006, we found no relationship between the percentage of low-income individuals age 75 or older and rates of HCBS balance.16

  • Ability to Provide Care. In 2006, greater availability of personal and home care aides was associated with higher levels of HCBS balance for all subpopulations. In this association, the relationship may be that states with relatively few home care workers or labor shortages may be reluctant to introduce programs that might strain already overtaxed labor markets when nursing homes can serve more residents with fewer workers. Or, conversely, higher rates of HCBS use and demand may drive greater supply of care workers.

Table III.1 lists the factors we measured for this study, including the specific measures we used as indicators of constraints, their sources, and their hypothesized relationships with the degree of HCBS provision in a state.

16 Low-income individuals include those whose income, as reported in the American Community Survey (ACS), is broadly consistent with income eligibility requirements for Medicaid-financed LTC. Individuals identified as low-income, and potentially eligible for Medicaid, include individuals who reported receipt of SSI or who had income levels under 300 percent of SSI in 2009.

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