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

03/18/2014

Across the 38 study states, about 45 million enrollees were eligible for full Medicaid services in 2009, with about 10.5 million eligible on the basis of age or disability. About 7 percent of all full-benefit enrollees and almost 30 percent of enrollees who were aged or disabled used any FFS LTSS -- with higher rates of HCBS than of ILTC use (Table II.1). (See Appendix Table D.1 for state-level detail.) Medicaid-financed LTSS included in these estimates include HCBS (including 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing), as well as institutional services (including services provided in nursing homes and ICFs/IID). The list of states differs slightly from those appearing in Wenzlow et al. (2011), but LTSS utilization rates are consistent with findings in that report, which showed that just over 7 percent of all full-benefit enrollees used LTSS, and almost 5 percent used HCBS.

TABLE II.1. Number of Enrollees Who Were Aged or Eligible on the Basis of Disability Using Medicaid FFS LTSS Compared to the Total Number of Full-Benefit Enrollees in 2009

MeasureAll Full-Benefit
  Medicaid Enrollees  
Full-Benefit Aged
  or Medicaid Enrollees  
with Disabilities
Aged or Disabled
  with Any FFS LTSS  
Aged or Disabled
  with Any FFS HCBS  
Aged or Disabled
  with Any FFS ILTC  
Number, in thousands45,08110,5153,1302,0851,205
Percentage of all full-benefit Medicaid enrollees100.023.36.94.62.7
Percentage of full-benefit aged or Medicaid enrollees with disabilities---100.029.819.811.5

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data (excludes data from Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, and Wisconsin).
NOTES: Enrollees in managed LTSS and those eligible for only restricted Medicaid benefits are excluded. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21

TABLE II.2. Expenditure and Utilization-Based Measures of LTSS System Performance Among Enrollees Who Were Aged or Had Disabilities and Were Eligible for Full Medicaid Benefits in 2009, Ranked by HCBS Share

State RankStates Ranked by Percentage of
LTSS $ for HCBS
States Ranked by Percentage of
LTSS Users Receiving HCBS
States Ranked by the Ratio of Per-User $
on HCBS Relative to Per-User $ on ILTC
$#  Ratio  StateTotal LTSS $% of Medicaid
  LTSS $ Allocated  
to HCBS
StateTotal LTSS Users% of LTSS
  Users Receiving HCBS  
State  Per-User $  
on HCBS
  HCBS $ Per-User/  
ILTC $ Per-User
   All 38 States    90,014,728,763  45.3All 38 States    3,130,010  66.6All 38 States  19,5470.478
132Washington1,930,549,58774.8Alaska7,76489.6New Hampshire31,6641.018
2128Alaska344,563,44773.8California664,24984.9Washington21,2840.857
376Vermont298,904,02361.2Washington82,97181.7Indiana28,9280.829
4235California12,064,245,82960.8Idaho19,70380.0Utah28,5050.771
5816Colorado1,300,230,15957.6Iowa55,29974.5Wyoming26,7360.738
6  15  5Wyoming206,001,29556.4North Carolina149,37173.8Vermont23,2430.726
7128Kansas1,006,566,45856.2Vermont10,70173.6Nebraska21,9320.695
8261New Hampshire463,202,43853.6Colorado46,66573.3Kansas20,0870.683
91118District of Columbia590,462,73350.5Virginia59,02872.6Louisiana21,5690.664
10  1612New York20,116,573,29250.0Missouri96,06870.0South Dakota20,2850.663
11913Virginia1,775,061,68348.7District of Columbia11,12168.5Delaware37,7580.653
12634North Carolina3,182,180,36645.8Kansas41,45767.9New York45,1500.630
132214Maryland1,996,568,84945.7Nevada13,40367.9Virginia20,1810.602
141329Nevada339,047,04245.6Alabama63,91867.7Maryland28,4230.599
151026Missouri1,836,511,96445.0Wyoming6,56166.3Georgia17,9870.594
161820Oklahoma1,151,255,03343.7New York345,39864.5Colorado21,8870.578
17314Utah369,135,85542.7South Carolina45,07263.1Ohio21,4920.567
18436Idaho461,085,97042.5Oklahoma53,60462.5District of Columbia39,1420.536
19533Iowa1,355,006,85842.2Texas246,81461.1Connecticut27,9610.525
20277Nebraska612,132,76642.1West Virginia28,75061.1Oklahoma15,0300.513
211921Texas5,505,748,86442.1New Jersey102,38960.2Texas15,3560.503
221727South Carolina1,075,756,27641.4Maryland53,82259.6North Dakota23,2230.496
232023West Virginia902,596,72841.2Ohio168,01159.3West Virginia21,1420.489
242317Ohio5,415,944,20639.6Illinois155,28757.7Kentucky16,9140.478
253010South Dakota286,371,34538.2Connecticut57,37256.3Illinois13,9740.474
26329Louisiana2,035,834,50238.0New Hampshire13,94156.2Missouri12,2890.461
272519Connecticut2,498,041,84736.2Nebraska21,54954.5South Carolina15,6580.442
28383Indiana2,160,937,79636.0Florida140,19851.9Alaska36,5470.438
293311Delaware340,623,57935.9Arkansas41,00051.2Nevada16,9900.435
302425Illinois3,540,342,81835.4South Dakota10,68050.5Florida17,1640.411
312132New Jersey3,835,410,40233.6Utah10,97550.4Arkansas12,8670.388
323615Georgia1,683,701,04533.0Louisiana72,17449.7New Jersey20,8970.362
332830Florida4,155,577,85830.0Delaware6,71048.2Iowa13,8820.354
341437Alabama1,332,176,14629.7Mississippi40,50646.6North Carolina13,2040.346
353522North Dakota338,845,93928.1North Dakota8,84646.4California12,9930.343
362931Arkansas989,454,10327.3Georgia66,75546.2Idaho12,4250.261
373724Kentucky1,342,891,91627.2Kentucky47,68145.3Alabama9,1540.244
383438Mississippi1,175,187,74614.7Indiana64,19741.9Mississippi9,1720.208
img for Expenditure and Utilization-Based Measures of LTSS System Performance Among


State:Total LTSS $ :Total LTSS Users

StateTotal LTSS $Total LTSS Users
Alabama1,332,176,14663,918
Alaska344,563,4477,764
Arkansas989,454,10341,000
California12,064,245,829664,249
Colorado1,300,230,15946,665
Connecticut2,498,041,84757,372
Delaware340,623,5796,710
District of Columbia590,462,73311,121
Florida4,155,577,858140,198
Georgia1,683,701,04566,755
Idaho461,085,97019,703
Illinois3,540,342,818155,287
Indiana2,160,937,79664,197
Iowa1,355,006,85855,299
Kansas1,006,566,45841,457
Kentucky1,342,891,91647,681
Louisiana2,035,834,50272,174
Maryland1,996,568,84953,822
Mississippi1,175,187,74640,506
Missouri18,365,119,64196,068
Nebraska612,132,76621,549
Nevada339,047,04213,403
New Hampshire463,202,43813,941
New Jersey3,835,410,402102,389
New York20,116,573,292345,398
North Carolina3,182,180,366149,371
North Dakota338,845,9398,846
Ohio5,415,944,206168,011
Oklahoma1,151,255,03353,604
South Carolina1,075,756,27645,072
South Dakota286,371,34510,680
Texas5,505,748,864246,814
Utah369,135,85510,975
Vermont298,904,02310,701
Virginia177,506,168359,028
Washington1,930,549,58782,971
West Virginia902,596,72828,750
Wyoming206,001,2956,561

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data (excludes data from Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, and Wisconsin).
NOTES: Excludes enrollees in managed care and those eligible for only restricted Medicaid benefits. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21.

Medicaid spent $90 billion on LTSS in 2009 in the 38 states in this study (Table II.2). These expenditures represented about 55 percent of total Medicaid expenditures for aged and enrollees with disabilities in these states. (See Appendix Table D.2 for state-level detail, presented alphabetically by state.) Nationwide, about 45 percent of Medicaid LTSS expenditures were allocated to HCBS, from about 15 percent in Mississippi to 75 percent in Washington.


FIGURE II.1. Percentage of LTSS Expenditures for HCBS in 2009

FIGURE II.1. Percentage of LTSS Expenditures for HCBS in 2009

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data (excludes data from Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, and Wisconsin).

ALT TEXT for FIGURE II.1, State Map:

  • Data Not Available--Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, Wisconsin.
  • 14% to 35%--Alabama, Arkansas, Florida, Georgia, Illinois, Kentucky, Mississippi, New Jersey, North Dakota.
  • 36% to 42%--Connecticut, Delaware, Indiana, Iowa, Louisiana, Nebraska, Ohio, South Carolina, South Dakota, Texas, West Virginia.
  • 43% to 50%--Idaho, Maryland, Missouri, Nevada, New York, North Carolina, Oklahoma, Utah, Virginia.
  • 51% to 75%--Alaska, California, Colorado, District of Columbia, Kansas, New Hampshire, Vermont, Washington, Wyoming.

As reported in previous studies, the percentage of LTSS recipients using HCBS exceeded the percentage of expenditures for HCBS (Table II.2). Overall, about 45 percent of LTSS expenditures in the 38 states were for HCBS, whereas more than 66 percent of LTSS users received HCBS. We found wide variation in rates of HCBS use across the states -- almost 90 percent of LTSS recipients in Alaska used HCBS, compared to just 42 percent in Indiana. Figure II.1 and Figure II.2 show the range of state variation in these measures in 2009. The figures display the ranges of HCBS spending and use across states and highlight regional variations in HCBS patterns. A broad consistency in ranking is evident in the figures. Although performance rankings for a number of states move them one group higher or lower across the two figures, rankings for only two states, Alabama and New Hampshire, shifted by two categories across figures.


FIGURE II.2. Percentage of LTSS Users Receiving HCBS in 2009

FIGURE II.2. Percentage of LTSS Users Receiving HCBS in 2009

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data (excludes data from Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, and Wisconsin).

ALT TEXT for FIGURE II.2, State Map:

  • Data Not Available--Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, Wisconsin.
  • 42% to 51%--Arkansas, Delaware, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Dakota, South Dakota, Utah.
  • 52% to 61%--Connecticut, Illinois, Maryland, Nebraska, New Hampshire, New Jersey, Ohio, Texas, West Virginia.
  • 62% to 71%-- Alabama, District of Columbia, Florida, Kansas, Missouri, Nevada, New York, Oklahoma, South Carolina, Wyoming.
  • 72% to 90%--Alaska, California, Colorado, Idaho, Iowa, North Carolina, Vermont, Virginia, Washington.

These data also demonstrate how the two measures (the percentage of LTSS expenditures for HCBS and the percentage of LTSS users receiving HCBS) can be used together to identify states that emphasize HCBS the most in their LTSS systems, as well as states that rely least on these services. Although there are a few states for which the rankings on these measures differ considerably, for most states, particularly those performing at the top and bottom of the rankings, performance on the two measures is generally comparable. Alaska, California, Colorado, Vermont, and Washington all rank near the top for both measures, and the consistency of the rankings for these states indicates that they cover broad populations of LTSS users and provide an array of services in the community. Arkansas, Kentucky, Mississippi, and North Dakota all fall near the bottom for both measures, suggesting that HCBS in these states reach fewer LTSS users and may include fewer services.

Among states for which relative performance on the measures varied, these differences may suggest different strategies for balancing institutional and community LTSS. New Hampshire, for example, ranks high for percentage of expenditures allocated to HCBS and relatively low for percentage of LTSS enrollees receiving HCBS. These rankings indicate that the state provided comparatively high levels of HCBS, either in terms of volume or cost of services, to a relatively narrow population of LTSS users. In contrast, Alabama ranks near the bottom in expenditures for HCBS but relatively high for percentage of LTSS users receiving HCBS. In this state, HCBS appear to be reaching a broader population of LTSS users, but these services may be more limited or more poorly compensated than those provided in other states.

State rankings were less consistent for the third measure we assessed: the ratio of per-user expenditures on HCBS relative to per-user expenditures on ILTC. As indicated above, this measure indicates less about the reach or depth of HCBS in a state and more about the relative costs of providing HCBS and institutional care. Nationwide, per-user expenditures for HCBS ($19,547) averaged about half of per-user expenditures for institutional care. (For every dollar spent on institutional care, 48 cents were spent on HCBS.) This ratio also varied substantially by state, with New Hampshire spending about the same amount per user on HCBS as on institutional care ($1.02 for every dollar spent per user of institutional care). At the other extreme, Mississippi spent only 21 cents on HCBS for every dollar spent per user of institutional care. Such discrepancies indicate that states either provide very different levels and types of HCBS to their recipients or pay substantially different rates for services, compared to institutional care rates.

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