Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. B. Directions for Future Research


The exploratory findings presented here suggest some directions for future research.

  • Documenting Ongoing Patterns in LTSS Systems. This study, combined with previous reviews, provides baseline data on trends in Medicaid-financed HCBS and institutional care use and expenditures over the previous decade. As the ACA is fully implemented and other initiatives to encourage HCBS use mature, it will be important to continue to identify and document trends in different measures of HCBS use and expenditures and in a context of overall Medicaid expansions in many states.

  • Constraints as Mediators of LTSS Policy. Our preliminary analysis identified significant bivariate relationships between state-level contextual factors and LTSS system performance. These cross-sectional comparisons could be supplemented usefully with a more extensive study of the multivariate relationships using regression analysis across measures. Of particular interest is how the association between policies and balance may differ across groups of states experiencing similar fiscal, environmental, and demographic characteristics. A longitudinal study assessing the effects of select policies would be an important extension of this work.

  • Balance at the Community Level. Our analysis examines balance and relationships with policies and programs at the state level. However, many factors relevant to balance in LTSS may be more potent and predictive at the local or community levels. To the extent possible, research that assesses balance and relationships with local factors would provide valuable insights into differences in LTSS balance.

  • Level of Need and the Distribution of Care Received. The patterns in utilization and spending per user reported here suggest sustained and substantial differences across states in the populations served and/or service levels provided. With additional data resources, we could further our understanding of whether LTSS systems are meeting the requirements set forth by Olmstead and examine whether the types of services individuals received are appropriate and provided in the most integrated setting possible. This type of research could be conducted following the implementation of uniform assessment tools for community care (similar to the Minimum Data Set in nursing home care). Such analyses could also potentially be feasible using qualitative data on a smaller scale in select communities.

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