As noted earlier, LTSS systems have increasingly emphasized and relied on HCBS (Doty 2010; KFF 2012). However, studies have shown substantial interstate and intrastate variations in this progress. Some states -- for example, Alaska, New Mexico, Oregon, and Washington -- have been identified as making these transitions successfully, whereas others have traditionally received low rankings (Wenzlow et al. 2011). Within states, performance indicators suggest that HCBS use is more common among working-age Medicaid enrollees with disabilities than among aged LTSS recipients (Wenzlow et al. 2011). Moreover, the predecessor to this study found that, within the population of individuals under65 with disabilities, those individuals with ID/DD had particularly high rates of HCBS use, higher than rates for individuals under 65 with other disabilities (Wenzlow et al. 2011).
Factors that might be related to balanced LTSS systems include single-access points; availability of person-centered services; participant involvement; precipitating events or crises; and effective state leadership, planning, and processes (Eiken 2004). In their review of the literature, Mollica and Reinhard (2005) also identified as critical components the availability of broad HCBS, single global LTSS budgeting, standardized assessment tools, transition programs, and quality improvement. In a study of MFP grantees, Irvin and Ballou(2010) found two additional features -- the depth of HCBS experience and coverage of optional state plan personal care -- among systems that were more balanced in terms of LTSS spending. Ruttner and Irvin (2013) found that states offering personal care services through state plans, as opposed to through waivers alone, spend a higher median share of their LTSS expenditures on HCBS. A survey of state programs confirmed many of these factors as facilitating re-balancing and also highlighted the broad fiscal challenges states face in maintaining and improving LTSS systems in hard economic times (Rose et al. 2010). In this study's predecessor, two factors over which states have little control -- poor weather conditions and the size of the workforce needed to provide adequate HCBS -- were associated with systems that were less balanced toward HCBS. Conversely, three factors that states can alter -- availability of Medicaid consumer-directed services, state plan personal care coverage, and availability of state SSI supplements for people living in the community -- were positively associated with systems that were more balanced toward HCBS (Wenzlow et al. 2011). Finally, the importance of state characteristics associated with rates of re-balancing toward HCBS may vary across different age groups of LTSS users (Miller 2011). Greater state investment in HCBS and reduced nursing home capacity were associated with re-balancing for aged individuals, but rates of institutionalization of working-age adults were more closely associated with state sociodemographiccharacteristics and chronic disease prevalence.
Many important questions about LTSS system performance remain unanswered. Are states identified as successes providing HCBS to more people, or are they providing more services? Who remains without access to appropriate HCBS? Can successful policies implemented in some states work for others? How do fiscal constraints and other state characteristics hinder or facilitate system transformation? For example, we would expect that rural states, in which the distance between service providers and recipients is large, may find it more challenging to provide their clients with LTSS in home and community-based settings; hence, the lessons learned in more urban states may not apply. Finally, what effect have a weakened economy and constrained state budgets had on progress toward re-balancing in recent years? Insights into these questions would be particularly helpful to states as they face budget crises and as some consider cuts to Medicaid rather than expansions of it.