Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. C. LTSS System Performance Indicators by System Type (Aged, ID/DD, Non-ID/DD)

03/18/2014

As found in the 2006 analysis, HCBS use and expenditures were greater among younger enrollees with disabilities than among enrollees age 65 or older. HCBS accounted for an average of 30 percent of LTSS spending among all enrollees age 65 and older, compared with 59 percent for those under 65. Breaking down these age groups, the percentage of total LTSS spending for HCBS peaked at 72 percent for people under age 21, dropped to 50 percent for people between ages 45 and 64, and fell to a low of 22 percent for those age 85 and older (Table II.3).

High rates of HCBS use among individuals with ID/DD account for some of the differences in HCBS use between enrollees who are aged and those under age 65. People with ID/DD are primarily under age 65 and make up a sizable portion of enrollees under age 65 with disabilities. More than 86 percent of these enrollees used HCBS (compared to 67 percent overall and 78 percent of those with other disabilities). HCBS accounted for 65 percent of Medicaid LTSS spending for these enrollees (compared to 45 percent overall and 49 percent for those with physical disabilities). Per-user spending on HCBS for people with ID/DD was more than $45,000 in 2009, higher than for any other subgroup shown in Table II.3. However, Medicaid spent only 36 cents per user on HCBS for every dollar spent for people using costly ICF/IID care.


TABLE II.3. Expenditure and Utilization-Based Measures of the Balance of LTSS Among Enrollees Who Were Aged or Had Disabilities and Were Eligible for Full Medicaid Benefits in 2009, by Population Subgroup

Subgroup Total LTSS $ % of Medicaid
  LTSS $ Allocated  
to HCBS
Total LTSS Users % of LTSS
  Users Receiving HCBS  
  Per-User $  
on HCBS
  Ratio of Per-User  
$ on HCBS
Relative to ILTC
Total 90,014,728,763 45.3 3,130,010 66.6 19,547 0.609
Enrolled all year 82,020,013,747 47.7 2,573,776 71.5 21,259 0.534
Aged
(65 and older)
43,542,067,317 30.2 1,699,811 54.5 14,184 0.493
Enrollees with disabilities (under 65) 46,472,661,446 59.4 1,430,199 81.0 23,840 0.506
Under age 21 6,000,339,459 72.1 217,772 88.6 22,418 0.523
21-44 years 17,805,713,908 66.5 441,201 86.3 31,105 0.427
45-64 years 23,240,331,758 50.1 791,221 75.4 19,518 0.508
65-74 years 11,050,527,050 39.8 481,843 67.7 13,483 0.439
75-84 years 15,682,873,911 31.9 638,191 57.1 13,731 0.478
85 years and older 16,211,595,916 21.7 556,311 39.7 15,963 0.560
Enrollees under 65, excluding people with ID/DDa 17,073,802,672 49.0 920,598 78.0 11,638 0.326
Enrollees Under 65 with ID/DDa 27,890,359,407 64.5 458,937 86.1 45,550 0.363
Non-Hispanic White 57,500,212,184 41.8 1,826,107 59.3 22,170 0.690
Black 18,314,102,656 44.5 665,797 70.1 17,466 0.530
Hispanic 7,849,081,287 58.2 352,288 82.1 15,806 0.471
Other or missing race 6,351,332,636 63.2 285,818 86.0 16,337 0.435
Female 51,462,981,612 42.7 1,927,997 65.2 17,474 0.600
Male 38,550,764,690 48.7 1,201,964 68.8 22,699 0.608
Not a dual-eligible 23,153,664,455 58.6 831,187 82.1 19,899 0.506
Sometimes a dual-eligible 2,897,172,775 39.0 167,810 61.1 11,026 0.647
Always a dual-eligible 63,963,891,533 40.7 2,131,013 61.0 20,035 0.558

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.

  1. Excludes data from District of Columbia, Vermont, and Washington (people with ID/DD could not be distinguished from other enrollees in these states).

TABLE II.4. Percentage of LTSS Expenditures Allocated to HCBS in 2009, by Age and System Type

State Aged
(65+)
Enrollees with Disabilities Under Age 65
Total Enrollees with
Physical Disabilities
Enrollees with ID/DD Enrollees with ID/DD
Including Small ICF
%
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank  
All 38 (or 35) States   30.2 --- 59.4 --- 49.0 --- 64.5 --- 67.7 ---
Washington 58.5 1 89.1 2 NA --- NA --- NA ---
Alaska 58.5 2 85.0 4 73.2 2 97.4 2 99.0 2
Vermont 24.6 17 92.2 1 NA --- NA --- NA ---
California 50.8 3 70.8 9 62.6 5 79.0 14 87.1 7
Colorado 27.2 10 82.0 6 68.1 3 93.8 4 94.2 3
Wyoming 16.5 27 83.8 5 55.8 10 91.1 5 91.1 5
Kansas 26.4 11 79.4 7 75.4 1 82.1 8 84.0 10
New Hampshire 19.7 22 87.2 3 62.5 6 99.0 1 99.0 1
District of Columbia 38.4 5 60.7 18 NA --- NA --- NA ---
New York 41.9 4 56.9 27 46.4 16 60.8 24 61.4 28
Virginia 25.5 12 69.7 10 48.7 13 83.2 7 84.1 9
North Carolina 31.7 6 59.2 20 67.8 4 52.6 28 64.4 25
Maryland 17.6 26 71.8 8 42.6 19 93.8 3 93.8 4
Nevada 27.5 9 62.1 16 42.3 20 82.0 9 86.0 8
Missouri 22.5 20 65.7 12 49.8 12 79.7 11 79.8 12
Oklahoma 24.7 16 60.5 19 43.9 18 70.7 20 71.7 21
Utah 9.5 35 56.4 28 14.2 35 72.9 18 72.9 19
Idaho 25.0 15 57.7 26 57.6 8 57.8 26 67.9 22
Iowa 29.1 7 51.7 32 53.0 11 51.3 30 56.0 30
Nebraska 18.2 24 63.2 14 38.9 23 77.3 15 77.9 15
Texas 28.4 8 53.6 30 61.4 7 47.9 33 55.0 31
South Carolina 20.5 21 62.8 15 57.0 9 65.6 22 65.6 24
West Virginia 16.0 28 68.0 11 44.8 17 80.6 10 83.3 11
Ohio 24.5 18 54.9 29 47.1 15 60.4 25 62.3 26
South Dakota 10.3 32 63.8 13 19.1 33 79.3 13 79.3 14
Louisiana 25.4 14 46.3 34 41.4 21 48.7 32 60.5 29
Connecticut 17.7 25 58.5 22 27.4 31 71.3 19 77.8 16
Indiana 11.9 30 58.0 24 47.3 14 63.2 23 72.8 20
Delaware 12.8 29 58.0 23 27.9 30 77.3 16 77.3 17
Illinois 25.4 13 42.1 36 35.5 25 47.9 34 48.6 34
New Jersey 24.4 19 44.5 35 36.2 24 49.4 31 49.4 33
Georgia 10.4 31 61.7 17 39.3 22 79.6 12 79.6 13
Florida 7.2 37 57.8 25 32.3 26 73.5 17 75.1 18
Alabama 10.2 33 58.9 21 26.8 32 88.7 6 88.7 6
North Dakota 8.6 36 49.3 33 28.3 29 54.7 27 62.2 27
Arkansas 18.8 23 37.8 37 18.0 34 51.4 29 51.4 32
Kentucky 6.4 38 51.9 31 31.2 27 67.4 21 67.4 23
Mississippi 10.1 34 20.7 38 28.5 28 14.6 35 14.7 35

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).
NOTE: 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.

NA = not available (in this state, people with ID/DD could not be distinguished from other enrollees).


TABLE II.5. Percentage of LTSS Users Receiving HCBS in 2009, by Age and System Type

State Aged
(65+)
Enrollees with Disabilities Under Age 65
Total Enrollees with
Physical Disabilities
Enrollees with ID/DD Enrollees with ID/DD
Including Small ICF
%
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank   %
  HCBS  
  Rank  
All 38 (or 35) states   54.5 --- 81.0 --- 78.0 --- 86.1 --- 88.5 ---
Alaska 85.5 1 92.7 1 90.0 3 99.2 2 99.8 1
California 80.2 2 90.9 4 90.4 1 92.0 12 96.3 10
Washington 74.5 3 89.7 8 NA --- NA --- NA ---
Idaho 69.9 4 87.7 11 88.3 6 86.0 22 92.7 14
Iowa 62.8 5 86.7 13 87.6 7 85.6 23 87.4 22
North Carolina 61.5 6 87.1 12 90.4 2 72.9 31 81.5 27
Vermont 54.3 12 92.3 2 NA --- NA --- NA ---
Colorado 55.4 11 90.4 5 86.5 8 98.5 3 98.8 3
Virginia 58.5 9 91.4 3 88.6 4 96.8 6 97.0 6
Missouri 57.7 10 83.9 15 81.7 11 94.0 11 94.0 12
District of Columbia 59.1 7 77.5 23 NA --- NA --- NA ---
Kansas 44.8 20 89.6 10 84.8 9 97.5 5 97.6 5
Nevada 58.8 8 78.7 21 72.5 20 94.2 10 96.6 9
Alabama 38.1 24 89.6 9 88.4 5 96.6 8 96.6 8
Wyoming 37.6 25 89.8 6 80.8 12 96.7 7 96.7 7
New York 51.0 16 81.7 17 74.6 17 90.8 15 91.2 18
South Carolina 44.1 21 84.9 14 84.8 10 85.1 24 85.1 24
Oklahoma 52.2 13 75.4 26 74.7 16 77.2 29 78.4 31
Texas 52.1 14 73.3 30 75.9 15 67.2 33 74.3 33
West Virginia 40.7 23 81.2 18 76.9 14 90.6 16 91.9 16
New Jersey 51.9 15 75.4 27 72.8 19 80.5 26 80.5 29
Maryland 32.3 29 83.1 16 73.1 18 98.3 4 98.3 4
Ohio 50.6 17 71.0 31 65.9 27 78.9 28 80.1 30
Illinois 48.9 18 66.7 35 57.7 32 89.2 19 89.2 20
Connecticut 42.3 22 78.5 22 71.9 21 89.3 18 93.0 13
New Hampshire 32.4 28 89.8 7 79.9 13 99.6 1 99.6 2
Nebraska 37.4 26 76.6 24 66.8 25 89.7 17 90.0 19
Florida 27.2 33 78.8 20 67.9 23 91.6 13 92.2 15
Arkansas 45.1 19 61.3 37 57.0 33 69.9 32 69.9 34
South Dakota 25.7 34 81.0 19 53.6 34 95.3 9 95.3 11
Utah 20.4 37 68.4 34 42.1 35 83.7 25 83.7 25
Louisiana 31.2 30 63.6 36 62.1 31 66.4 34 77.1 32
Delaware 27.3 32 75.6 25 70.6 22 87.2 21 87.2 23
Mississippi 37.3 27 60.0 38 66.4 26 42.5 35 42.5 35
North Dakota 27.6 31 74.4 29 67.3 24 79.5 27 83.3 26
Georgia 24.3 35 75.2 28 63.9 29 91.2 14 91.2 17
Kentucky 23.4 36 69.8 32 64.1 28 89.2 20 89.2 21
Indiana 19.9 38 69.0 33 63.4 30 74.8 30 80.9 28

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).
NOTE: 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.

NA = not available (in this state, people with ID/DD could not be distinguished from other enrollees).


TABLE II.6. Ratio of Per-User Expenditures on HCBS Relative to Per-User Expenditures on Institutional Care in 2009, by Age and System Type

State Aged (65+) Enrollees with Disabilities Under Age 65
Total Enrollees with
Physical Disabilities
Enrollees
with ID/DD
  Ratio     Rank     Ratio     Rank     Ratio     Rank     Ratio     Rank  
All 38 (or 35) states   0.408 --- 0.418 --- 0.326 --- 0.363 ---
New Hampshire 0.563 5 1.108 3 0.582 3 1.443 1
Washington 0.610 3 1.296 2 NA --- NA ---
Indiana 0.564 4 0.702 5 0.606 2 0.620 4
Utah 0.423 9 0.649 6 0.248 24 0.568 5
Wyoming 0.359 17 0.725 4 0.377 12 0.404 18
Vermont 0.343 22 1.451 1 NA --- NA ---
Nebraska 0.421 10 0.630 7 0.379 11 0.471 12
Kansas 0.480 7 0.594 13 0.639 1 0.349 26
Louisiana 0.771 1 0.561 16 0.499 6 0.519 7
South Dakota 0.353 18 0.507 22 0.235 27 0.300 29
Delaware 0.419 11 0.506 23 0.185 33 0.543 6
New York 0.770 2 0.371 30 0.362 13 0.212 35
Virginia 0.363 16 0.620 10 0.352 14 0.430 15
Maryland 0.464 8 0.578 14 0.300 16 0.382 23
Georgia 0.372 15 0.576 15 0.396 10 0.411 17
Colorado 0.344 21 0.628 8 0.421 8 0.422 16
Ohio 0.408 12 0.603 11 0.578 4 0.452 13
District of Columbia 0.484 6 0.529 19 NA --- NA ---
Connecticut 0.341 23 0.518 20 0.200 32 0.371 24
Oklahoma 0.329 25 0.553 17 0.298 18 0.755 3
Texas 0.395 13 0.466 26 0.575 5 0.472 11
North Dakota 0.268 33 0.392 29 0.234 29 0.346 27
West Virginia 0.294 30 0.601 12 0.299 17 0.515 8
Kentucky 0.231 34 0.532 18 0.287 20 0.327 28
Illinois 0.393 14 0.474 25 0.437 7 0.386 21
Missouri 0.279 32 0.488 24 0.284 21 0.499 9
South Carolina 0.347 20 0.332 31 0.266 23 0.362 25
Alaska 0.312 28 0.625 9 0.407 9 0.910 2
Nevada 0.286 31 0.511 21 0.315 15 0.387 20
Florida 0.212 36 0.393 28 0.241 25 0.271 31
Arkansas 0.308 29 0.409 27 0.176 34 0.489 10
New Jersey 0.322 26 0.293 33 0.240 26 0.254 32
Iowa 0.352 19 0.218 37 0.225 30 0.220 34
North Carolina 0.331 24 0.261 35 0.296 19 0.433 14
California 0.314 27 0.313 32 0.235 28 0.384 22
Idaho 0.198 37 0.284 34 0.282 22 0.288 30
Alabama 0.213 35 0.241 36 0.069 35 0.392 19
Mississippi 0.197 38 0.185 38 0.219 31 0.238 33

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).
NOTE: 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.

NA = not available (in this state, people with ID/DD could not be distinguished from other enrollees).


Medicaid LTSS users typically are regarded as belonging to one of three distinct subpopulations: (1) elderly people who are frail or have dementia; (2) non-elderly adults with physical disabilities; and (3) people with ID/DD.11 In general, individuals in these groups are likely to have different service needs and preferences. Older adults are more likely to have multiple chronic diseases, needing prescription medications and durable medical equipment, as well as services that address physical and cognitive limitations (Prohaska et al. 2012; Muramatsu et al. 2012). Individuals with ID/DD frequently use services such as case management, residential services, day supports, employment supports, personal care, respite, transportation, and clinical services. In addition, people with ID/DD may be more likely to live with family members who provide unpaid care (Smith et al. 2007). Table II.4, Table II.5 and Table II.6 show state performance scores and ranks for each of these subgroups for each of the three measures. In the District of Columbia, Vermont, and Washington, people with ID/DD could not be distinguished from those with physical disabilities; therefore, in these states, rates are shown only for the total population of enrollees with disabilities. The states in each table are ordered by the ranking on that measure for the total population of enrollees who are aged or have disabilities (as shown in Table II.2). (See Appendix Tables D.2-D.6 for a summary of performance indicators by state by subpopulation of enrollee.)

States with relatively high rates of HCBS spending overall did not always have consistently high rates of HCBS spending for all subgroups of enrollees. For example, the relatively high overall rankings for New Hampshire, Vermont, and Wyoming on the expenditure share measure (as shown by the ordering of states on Table II.4) appear to be driven primarily by high rates of expenditures among enrollees with disabilities and lower performance among aged enrollees. In comparison, the high ranks of the District of Columbia and New York appear driven by high rates of HCBS use among the aged.

Figure II.3 compares expenditures for HCBS for the aged and individuals with disabilities, highlighting the consistency with which expenditures for HCBS for individuals with disabilities exceed those in the aged population. The figure also highlights how the difference in rates of expenditures for HCBS by subpopulation varied across states. In Alaska and Washington, for example, both groups of enrollees had high rates of expenditures for HCBS. In other states, such as New Hampshire and Vermont, the differential between the two subpopulations is quite large.

Table II.5 highlights the diversity in rankings on rates of HCBS use by subpopulation. The almost uniformly high rates of HCBS use among enrollees with disabilities across states are particularly notable (81 percent of LTSS users with disabilities received HCBS across all 38 states). Within the population of enrollees with disabilities, individuals with ID/DD have consistently high rates of HCBS use nationwide (86 percent of LTSS users, with only Mississippi reporting a rate under 66 percent of enrollees). These results indicate that, nationally, rates of HCBS use and expenditures, compared to rates of institutional care use, continue to be greater for people with ID/DD than for those who are aged or have physical disabilities. This phenomenon may be partly the cause and partly the result of the closure of many ICFs/IID. In addition, states began using HCBS waivers because of the flexible services and supports available that can accommodate individuals with an array of care needs in a targeted fashion without resorting to institutionalization (Smith et al. 2000).


FIGURE II.3. Percentage of Medicaid LTSS Expenditures for HCBS in 2009, by Eligibility Group

FIGURE II.3. Percentage of Medicaid LTSS Expenditures for HCBS in 2009, by Eligibility Group

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. States in figure are sorted based on percentage of Medicaid LTSS expenditures overall for aged and enrollees with disabilities.

ALT TEXT for FIGURE II.3, Line Chart: Shows the relationship between the percentage of Medicaid LTC Expenditures for HCBS in 2009 (measured on the Y-axis as a function of the state (displayed on the X-axis). There is one line on the graph for each eligibility group--total, aged, and disabled enrollees. The line for total enrollees rises from left to right across the graph, since the states are sorted from the lowest value for total percentage (in Mississippi) to the highest value (in Washington). The lines for aged and disabled also tend to rise from left to right, but since the states are not sorted according to these values, the pattern is irregular. See Table D.13 for data.


Given the consistently high rates of HCBS use among enrollees with disabilities, it appears that the top overall rankings for this measure were driven largely by the percentage of aged enrollees in each state receiving HCBS. For example, the top six states overall were the six states with the highest percentages of aged enrollees receiving HCBS. Similarly, Figure II.4 highlights how, for states with the highest rankings on this measure, the gap between the percentage of aged and enrollees with disabilities receiving HCBS is much narrower than for the states ranking near the bottom of this measure. In Alaska, the top-ranked state, the gap between aged and enrollees with disabilities receiving HCBS was only 7 percentage points (with 86 percent of aged LTSS users receiving HCBS and 93 percent of enrollees with disabilities). In comparison, in Indiana, the bottom-ranked state, the gap was 49 percentage points (with only 20 percent of aged LTSS users receiving HCBS and 69 percent of enrollees with disabilities using these services).


FIGURE II.4. Percentage of LTSS Users Receiving HCBS in 2009, by Eligibility Group

FIGURE II.4. Percentage of LTSS Users Receiving HCBS in 2009, by Eligibility Group

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. States in figure are sorted based on percentage of Medicaid LTSS users receiving HCBS among all aged and enrollees with disabilities.

ALT TEXT for FIGURE II.4, Line Chart: Shows the relationship between the percentage of Medicaid LTC Users Receiving HCBS in 2009 (measured on the Y-axis as a function of the state (displayed on the X-axis). There is one line on the graph for each eligibility group--total, aged, and disabled enrollees. The line for total enrollees rises from left to right across the graph, since the states are sorted from the lowest value for total percentage (in Indiana) to the highest value (in Arkansas). The lines for aged and disabled also tend to rise from left to right, but since the states are not sorted according to these values, the pattern is irregular. See Table D.14 for data.


As Table II.4 and Table II.5 show, in most states, aged enrollees have the lowest HCBS spending and user shares, and individuals using ID/DD services have the highest rates. In some states, this discrepancy was extreme. In Utah, for example, 73 percent of LTSS expenditures for individuals with ID/DD were for HCBS, compared to only 14 percent for individuals with other disabilities and 10 percent for aged individuals. Similarly, in New Hampshire, more than 99 percent of individuals with ID/DD used HCBS, compared to 32 percent of aged enrollees. In New Hampshire as well, the notably high ratio of almost $1.45 in expenditures on HCBS to every dollar in expenditures for institutional care for individuals with ID/DD is in marked contrast to the state's ratio of spending less than 60 cents for every dollar for institutional care for enrollees who are aged or have physical disabilities (Table II.6).

Intrastate differences in HCBS expenditures and use across subpopulations of enrollees, particularly the distinctly higher rates among individuals with ID/DD, illustrate how some states have, by design or accident, achieved higher levels of balance for some populations than for others. In New Hampshire, for example, the uniquely high rate of HCBS use and expenditure for individuals with ID/DD may be the result of a historical emphasis on providing HCBS over institutional care to this subpopulation, including closures of large institutional facilities for these populations, which has not been achieved to the same extent for other populations of LTSS users (Smith et al. 2000).

The varying balance between HCBS and institutional care within states may also reflect variation in state LTSS programs that serve these subpopulations, with programs for individuals with ID/DD nearly always operating separately from those for individuals who are aged or have physical disabilities. California, Idaho, Iowa, and North Carolina, for example, rank very high on the percentages of aged and enrollees with physical disabilities using HCBS, but lower on rates of HCBS use among individuals with ID/DD. Conversely, South Dakota and Utah had low rates of HCBS use among enrollees who are aged or have disabilities but report high rates of HCBS use among individuals with ID/DD. Such differences may result from distinct programs and policies or from different levels of interest and access to HCBS across subpopulations of enrollees.

The rightmost two columns of Table II.4 and Table II.5 expand the definition of "community care" for enrollees with ID/DD to include either receipt of HCBS or residence in any ICF/IID with six or fewer beds.12 For most states, the expanded definition results in higher shares of expenditure for or users or community care, although, in most states, the increase is modest. In eight states (California, Connecticut, Idaho, Indiana, Louisiana, North Carolina, North Dakota, and Texas) the share of LTSS expenditure devoted to community care increased by more than five percentage points.

Finally, Table II.6 shows per-user expenditures on HCBS relative to per-user expenditures on ILTC by subpopulation. For all subpopulations, average HCBS expenditures were notably lower than rates of institutional care expenditures. HCBS expenditures for aged enrollees were slightly more similar to expenditures for institutional care users than they were for either group of younger enrollees with disabilities, but this pattern is not consistent in all states. Varying rates of HCBS and institutional care use and expenditures by subpopulation across states limit interstate comparisons based on these ratios. Instead, within states, these ratios highlight, but do not explain, differences in per-user spending by subpopulation.

A potential problem affecting state-level comparisons of the locus of LTSS is the absence of any adjustment for risk or casemix. States with generous eligibility for LTSS will probably have more enrollees who have relatively mild limitations receiving services. This, in turn, will tend to inflate both the share of expenditures accounted for by HCBS and the share of enrollees receiving HCBS, perhaps pushing them higher in the rankings seen in earlier tables. Those rankings, however, do not compare shares of spending or enrollees in LTSS spending for enrollees with similar degrees of limitation or frailty.

Although risk adjustment of Tables II.2-II.6 would help ensure a more accurate comparison of LTSS balance across states, the data available to us contain little or no information describing functional or cognitive limitations, ruling out the computation of standard LTC adjusters. We therefore adopted two fairly crude alternative comparisons, each relying on age as an adjuster, to assess the robustness of state rankings. The comparisons are carried out only on the 65+ population because the relationship of age to care needs is not well established among the disabled.

The first approach is simply to compare shares of LTSS expenditures for HCBS and shares of LTSS recipients who receive HCBS only in the 85+ population. Although the care needs for those 85 and older vary markedly, it is surely the case that this population is more homogeneous than the entire 65+ population. If state rankings for the two primary measures of balance differ sharply for the 65+ and 85+ populations, then at least some of the variation observed in Tables II.2-II.6 is probably accounted for by differences across states in the characteristics of people who receive LTSS rather than the underlying balance between community and institutional care. If the ranking is largely the same, say, with few states changing ten or more places in rank, then perhaps the absence of risk adjustment is not a serious drawback to existing comparisons.

The second approach attempts to gauge the extent to which a state's system of community care continues to meet the needs of LTSS recipients as their needs increase (on average) by comparing the ratio of the share of LTSS expenditures (or users) among the 85+ population to the corresponding share among the population aged 65-74. A high ratio suggests that as enrollees age, the state's HCBS system continues to address needs in the community. A low ratio suggests that a state needs to rely increasingly on institutional care as enrollees age. It is crucially important to recognize that this measure takes as given the share of LTSS care accounted for by HCBS among those aged 65-74. The measure indicates the degree to which a state is able to maintain community care for the 85+ population at the level that it provides it for the population aged 65-74, whatever that level happens to be. For lack of any better term, we refer to this ability as HCBS "persistence."

Results of these alternative rankings are shown in Table II.7, for the share of expenditures, and Table II.8, for the share of enrollees. Comparison of columns 2 and 3 in each of the tables indicates that rankings based on HCBS expenditures or users among the 85+ population were quite similar to those among the total aged (65+) population. In Table II.7, only Kansas shifted by ten or more places in rank. In Table II.8, none did. In both tables, there is a barely discernible tendency for southern states to rise slightly in the rankings. For the most part, however, this crude method of risk adjustment may indicate that state differences in casemixdo not strongly affect rankings for these measures.


TABLE II.7. LTSS Expenditures Allocated to HCBS in 2009: Percentage Among Aged 65+, Percentage Among Those Aged 85+, and Ratio of Percentage Among Those Aged 85+ to Percentage Among Those Aged 65-74

State Aged 65+ Aged 85+ Ratio: % Among 85+/
% Among 65-74
  % HCBS     Rank     % HCBS     Rank     % HCBS     Rank  
All 38 states 30.2 --- 21.7 --- 0.55 ---
Washington 58.5 1 44.9 2 0.63 5
Alaska 58.5 2 49.6 1 0.80 1
California 50.8 3 39.3 3 0.67 4
New York 41.9 4 34.2 4 0.69 3
District of Columbia   38.4 5 28.7 5 0.63 6
North Carolina 31.7 6 24.0 6 0.59 10
Iowa 29.1 7 20.0 10 0.46 16
Texas 28.4 8 20.5 9 0.58 11
Nevada 27.5 9 17.9 11 0.49 15
Colorado 27.2 10 15.0 17 0.33 27
Kansas 26.4 11 13.5 21 0.29 29
Virginia 25.5 12 20.7 8 0.62 7
Illinois 25.4 13 14.7 19 0.42 20
Louisiana 25.4 14 21.4 7 0.72 2
Idaho 25.0 15 17.9 12 0.49 14
Oklahoma 24.7 16 14.3 20 0.40 21
Vermont 24.6 17 16.1 14 0.38 23
Ohio 24.5 18 17.6 13 0.51 13
New Jersey 24.4 19 15.5 15 0.44 18
Missouri 22.5 20 15.1 16 0.45 17
South Carolina 20.5 21 12.7 23 0.38 24
New Hampshire 19.7 22 9.2 26 0.23 33
Arkansas 18.8 23 14.7 18 0.61 8
Nebraska 18.2 24 13.3 22 0.52 12
Connecticut 17.7 25 9.3 25 0.29 28
Maryland 17.6 26 10.8 24 0.39 22
Wyoming 16.5 27 6.6 30 0.18 36
West Virginia 16.0 28 7.7 28 0.25 31
Delaware 12.8 29 6.2 32 0.28 30
Indiana 11.9 30 5.1 34 0.22 35
Georgia 10.4 31 7.0 29 0.43 19
South Dakota 10.3 32 5.4 33 0.22 34
Alabama 10.2 33 6.3 31 0.34 26
Mississippi 10.1 34 7.7 27 0.59 9
Utah 9.5 35 4.0 36 0.24 32
North Dakota 8.6 36 2.9 37 0.16 37
Florida 7.2 37 4.6 35 0.37 25
Kentucky 6.4 38 2.2 38 0.15 38

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).
NOTE: 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.


Columns 2 and 4 of Table II.7 and Table II.8 point to two overall results concerning HCBS persistence as defined just above. First, those states that rank highest in HCBS balance, measured using either expenditures or user, also tend to rank highest on the HCBS persistence measure. For expenditures (Table II.7), six of the ten states ranked in the top 10 among the 65+ population also ranked in the top 10 in persistence. For percentage of enrollees, eight of the ten states ranked in the top 10 for the 65+ population also ranked in the top 10 in persistence. High performance in overall measures of community care appears to predict high performance in persistence. Second, there was greater overall divergence between persistence rankings and rankings on spending and use in the 65+ population. Nine states had rankings on the persistence measure that differed by ten or more places from their ranking on share of LTSS expenditures allocated to HCBS (Table II.7). Twelve states' rankings differed by ten or more places on share of HCBS users among LTSS users (Table II.8).


TABLE II.8. Users Receiving HCBS in 2009: Percentage Among Those Aged 65+, Percentage Among Those Aged 85+, and Ratio of Percentage Among Those Aged 85+ to Percentage Among Those Aged 65-74

State Aged 65+ Aged 85+ Ratio: % Among 85+/
% Among 65-74
  % HCBS     Rank     % HCBS     Rank     % HCBS     Rank  
All 38 states 38.0 --- 39.7 --- 0.59 ---
Alaska 85.5 1 79.9 1 0.91 1
California 80.2 2 67.9 2 0.79 2
Washington 74.5 3 64.3 3 0.77 3
Idaho 69.9 4 58.3 4 0.70 5
Iowa 62.8 5 48.6 7 0.62 14
North Carolina 61.5 6 48.8 6 0.66 8
District of Columbia   59.1 7 46.6 8 0.69 6
Nevada 58.8 8 46.4 9 0.68 7
Virginia 58.5 9 50.4 5 0.72 4
Missouri 57.7 10 44.6 10 0.64 11
Colorado 55.4 11 39.1 13 0.54 20
Vermont 54.3 12 42.6 11 0.63 13
Oklahoma 52.2 13 34.8 17 0.53 21
Texas 52.1 14 36.8 15 0.57 18
New Jersey 51.9 15 35.3 16 0.51 24
New York 51.0 16 37.2 14 0.58 17
Ohio 50.6 17 40.2 12 0.64 10
Illinois 48.9 18 28.9 22 0.45 29
Arkansas 45.1 19 34.3 18 0.60 16
Kansas 44.8 20 27.8 23 0.42 32
South Carolina 44.1 21 33.1 19 0.66 8
Connecticut 42.3 22 25.6 25 0.41 33
West Virginia 40.7 23 23.4 27 0.38 34
Alabama 38.1 24 26.8 24 0.49 25
Wyoming 37.6 25 20.9 29 0.35 35
Nebraska 37.4 26 30.1 20 0.63 12
Mississippi 37.3 27 29.7 21 0.65 9
New Hampshire 32.4 28 18.9 31 0.34 36
Maryland 32.3 29 21.2 28 0.47 27
Louisiana 31.2 30 24.0 26 0.62 15
North Dakota 27.6 31 18.7 33 0.43 31
Delaware 27.3 32 17.7 34 0.45 30
Florida 27.2 33 20.1 30 0.51 22
South Dakota 25.7 34 18.9 32 0.46 28
Georgia 24.3 35 17.4 35 0.51 23
Kentucky 23.4 36 11.7 37 0.30 38
Utah 20.4 37 13.5 36 0.48 26
Indiana 19.9 38 10.4 38 0.30 37

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).
NOTE: 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.


States in the South had generally higher rankings on the persistence measure than on other measures of overall balance. Of the six states whose persistence rankings were ten or more places higher than budget-share rankings in the 65+ population in Table II.7, five were southern states. Of seven states whose persistence rankings were similarly higher in Table II.8, five were southern states. Despite generally low rankings on overall balance, southern states, especially Louisiana, appear to rank substantially higher in terms of persistence.13 We have been unable to identify factors common to southern states that could account for this pattern.

As should be clear, this discussion of the factor we term "persistence" is highly speculative. It does suggest that future work might usefully examine state differences in community care versus institutional care across groups of people that differ in severity of impairment or need for care.


11 Medicaid programs and services also are available for people with mental illness. However, many people with mental illness use health care services for short durations rather than for LTC, and we were unable to identify long-term mental health care in MAX uniquely. In this study, we thus group people with mental illness by age with enrollees who are aged or have physical disabilities.

12 Due to limitations in MAX facility identifiers, we were unable to ascertain the correct size of facility for enrollees who resided in facilities outside their own state.

13 What is notable about this result is the not the preponderance of low-ranking states, among those whose persistence rankings were substantially higher than their overall rankings, but rather the preponderance of southern states. In fact, low-ranking states outside the Deep South, including Delaware, Indiana, Kentucky, North Dakota, South Dakota, and West Virginia, do not exhibit this pattern.

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