This study expands on earlier work in Wenzlowet al. (2011), using MAX 2009 to assess patterns of both interstate and intrastate variations in LTSS system performance. The study has two broad aims: (1) to update information on differences in LTSS systems within and across states that were identified in the previous report; and (2) to explore how state constraints and policies are related to the balance of LTSS systems.
To characterize the performance of LTSS systems in each state, we summarize HCBS and institutional care service use and expenditures to determine whether some states are achieving more balanced systems either by serving more people or spending more per person covered compared to other states. We also explore how balance varies for important Medicaid subgroups -- aged enrollees over 65, enrollees under 65 and eligible for Medicaid on the basis of disability, and two subgroups of enrollees with disabilities -- those with physical disabilities and those with ID/DD.7 (See Appendix A for a glossary of terms, including the basis of eligibility [BOE] groups.) These subgroups of enrollees tend to have different demographic characteristics and service needs and often are served by different Medicaid programs. Finally, we compare state-level results from 2009 with results on these same measures in 2006 to assess progress toward re-balancing during this period of budget constraints in many states.
The second set of analyses explores how state constraints and policies are associated with the LTSS system performance indicators assessed in the first portion of the study. Specifically, we examine how factors that may challenge system transformation -- for example, cost of living, fiscal constraints, and state demographics -- and state policies are linked with LTSS balance. Finally, we examine how the association between state constraints, policies, and system performance varies across three enrollee subgroups: the aged, enrollees with physical disabilities, and enrollees with ID/DD. In this analysis, we examine the continued relationship between factors that Wenzlowet al. (2011) found to be relevant, as well as new measures of state policy and program features for which data have become available since the previous study was conducted.
Because we could not assess differences in need for care or its appropriateness, we do not assume that a more balanced system always will reflect state success in providing HCBS to populations that need them. Although we rank states by the characteristics of their systems, our aim is to gain insight into how policies and state factors are related to LTSS system performance indicators so as to better understand "high" scores.
Our analyses of state constraints, policies, and LTSS system characteristics should be viewed as exploratory. We were unable to assess causal impacts.
7 Some Medicaid enrollees (an unknown number) have disabilities but are not identified as eligible on the basis of disability. We expect this number to be small. However, to the degree that such individuals exist in our study states and differ from persons in our sample, the results presented here will be biased.