In 2009, about 45 percent of LTSS expenditures were for HCBS, and nearly 67 percent of LTSS users received HCBS. Medicaid spent about $19,500 per user for HCBS, or about 48 cents for every dollar for persons using institutional care. Most states reported modest progress on re-balancing toward HCBS from 2006 to 2009.
Taken together, two measures (the percentage of LTSS expenditures for HCBS and the percentage of LTSS users receiving HCBS) identify a few states that appear to have the highest levels of balance in the breadth and depth of their LTSS. These states, which include Alaska, California, Colorado, Vermont, and Washington, ranked highly on both measures for most or all subpopulations of enrollees. Throughout the rankings, however, a number of states achieved a notably higher ranking on one measure than on the other. For these states, alternative measures of the LTSS system provide different perspectives on LTSS utilization and expenditures. For example, for two states with the same percentage of expenditures allocated to HCBS, one may provide limited HCBS to a broad range of users, and the other may provide more expansive services to a small number of HCBS recipients. Thus, assessing multiple measures continues to provide a more complete picture of the role of HCBS in state Medicaid programs than any single measure alone.
Subgroup analyses by state suggest that differences in HCBS use and expenditures between aged enrollees and those eligible on the basis of disability remained widespread across the states. As we found in the previous study, several states achieved overall balance by serving a relatively large number of aged people, but most did so by providing more HCBS to younger enrollees with disabilities, particularly people with ID/DD, and ranked relatively low for the aged. This suggests that, even in states that rank near the top on overall balance toward HCBS, there may be room for further re-balancing for some services or subpopulations.
Subgroup analyses also suggest that HCBS use continues to be most common within the Medicaid ID/DD service system, compared to systems designed for the aged or people with physical disabilities. This differential emphasizes the importance of measuring system performance in multiple dimensions and within different service systems. The underlying cause for the higher rates of HCBS use and expenditures among those with ID/DD are likely to be complex but could result from a variety of factors, such as more states pursuing goals of achieving balance in this population, greater success in providing the services these individuals need in the community, and greater demand for community-based services among this population and their advocates.