Our findings indicate that alternative system performance indicators provide a more nuanced understanding of LTC system transformation and potentially could lead to different conclusions about program effectiveness and re-balancing efforts across states and subgroups than those based on one or two aggregate measures, such as total Medicaid spending on non-institutional compared to institutional LTC or total numbers of Medicaid beneficiaries receiving HCBS compared to those residing in nursing homes, long-term hospitals, or ICFs/IID. It will be important for future studies to assess state LTC systems on multiple dimensions for distinct target populations. As Medicaid continues to serve more enrollees in the community, it also will be important to monitor the breadth and type of LTC services low-income people need and receive.
Several promising policy options -- including Medicaid and non-Medicaid policies -- are associated with LTC system performance, but longitudinal studies will be needed to assess impacts. Of particular interest are which approaches are most cost effective and their applicability to different Medicaid subgroups. As state budgets change over time, also of interest is the extent to which fiscal constraints will limit states' ability to support or maintain HCBS expansions into the future.