Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. III. Correlates of Long-term Services and Supports System Performance

03/18/2014

Chapter II documented ongoing and substantial differences in LTSS system balance across states and for subpopulations of enrollees. An important question for policymakers remains: Why do such differences persist? If the differences are due to factors beyond a state's control, this suggests either that states must develop individualized new approaches to achieve greater balance or that the extent of re-balancing will, under the best of circumstances, be limited in some areas or populations. If, however, differences are related to factors that states can affect through policy and program changes, they could indicate how low-scoring states may focus future efforts to improve their systems. In this chapter, we expand upon our analysis of state factors in the previous study to explore whether there are continued relationships between factors previously associated with HCBS use and expenditures, as well as to examine new factors that may be related to LTSS system performance.

This cross-sectional analysis is exploratory and has limited ability to explain broad differences across states. The environments in which states provide LTSS are complex, and the services that a Medicaid enrollee receives are likely influenced by a diverse range of factors that interact to influence that individual's access to services, knowledge of available services, and interest in and ability to use available services. Moreover, many of these factors may operate at smaller levels of the community than the state, and the variation we identify at the state level is likely more nuanced when community-level factors are considered. Finally, in our analysis, we examine associations between factors and the balance of LTSS systems, but we are unable to determine the direction of causality in these associations or whether the relationships we see are the result of additional factors that we cannot measure directly. Some of the factors that we identify as being associated with higher levels of balance may be outcomes or alternative indicators of balance, rather than drivers of variation in state LTSS systems. Thus, our results do not indicate whether there are any causal relationships between the state factors we assess and balance of LTSS. Instead, we expect that our results may point to directions for future, more sophisticated quantitative and qualitative analysis, by identifying relationships between broad patterns in LTSS systems and characteristics of states that are worthy of further investigation.

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