The associations between LTSS balance measures and state factors and policy variables presented in this chapter indicate several relationships that appear relevant for understanding variations in HCBS use and expenditures across states. Of the several measures selected to capture exogenous state characteristics, only two were significantly correlated with measures reflecting HCBS penetration in state LTSS systems overall: (1) personal and home care aides per 1,000 elderly and or persons with a disability, which was positively associated with HCBS spending and use; and (2) percentage of potential Medicaid eligibles age 75 or older, which was negatively associated with HCBS spending and use. We hypothesize that the relationship between home care workers and HCBS may be the result of several factors. HCBS may expand when there are home care workers available to serve more people in residential settings. Conversely, communities with very high levels of demand for these services may find that there are insufficient community resources, including care workers, available to serve everyone in the community, or the increased demand for these workers may drive an increase in their supply. The three policy variables most consistently related to LTSS systems with higher rates of HCBS use were consumer-direction, percentage of out-of-home placements in facilities with six or fewer residents, and availability of assisted living and residential care units. These factors may be important contextual variables to consider when assessing LTSS balance.
Some of the relationships we identified in this chapter were only significant for some subpopulations of enrollees. Three factors -- total taxable resources, percentage of potential aged Medicaid eligibles, and size of the waiver waiting list for ID/DD HCBS waivers -- were only associated with increased HCBS use for individuals with ID/DD. Other factors -- availability of home health aides, rates of consumer-direction, and availability of assisted living and residential care units -- were only significantly related to HCBS use for individuals who were aged or had physical disabilities. These findings underscore the importance of assessing drivers of variation in HCBS use and expenditures for subpopulations separately, as different factors appear to be relevant for each group.
Given the complex and dynamic environment across and within states for LTSS delivery, it is not feasible to isolate and determine the precise nature of the relationship between a single state policy constraint or factor and HCBS balance in a descriptive analysis. The interaction of different factors and the difficulty of measuring many relevant social and environmental aspects within states mean that the relationships identified in this analysis can only be exploratory. Moreover, the measures we are able to assess may reflect other types of characteristics about the state or environment that we cannot measure. Thus, the relationships we see may be the result of rates of HCBS use being correlated with our measures, and there may be other factors we cannot measure driving the relationships that we identify. Finally, the inconsistencies in our results from 2006 to 2009 and the differences in results across balance measures highlight the limitations of such analyses. Despite these limitations, the associations that we identify point to topics warranting further research that uses more sophisticated quantitative and qualitative techniques.