HCBS spending as a percentage of LTSS spending is the most commonly used measure of LTSS system transformation. As in the previous study, however, we found differences across states and subgroups for this measure and other measures that included a utilization-based measure (percentage of LTSS users who used HCBS) and a relative per-user expenditure ratio (per-user HCBS spending to per-user institutional care spending). Both the previous and current analyses underscored how different indicators of LTSS systems provide different insights into the level and nature of HCBS spending and use in a state. Specifically, some states are achieving higher rates of HCBS spending by providing a more limited set of HCBS to a large number of enrollees, whereas others are providing more extensive HCBS to fewer enrollees or are targeting specific subpopulations of enrollees. These analyses emphasize the need to continue using varied measures to evaluate HCBS programs and system transformation.
Our previous assessment of LTSS balance measures by subgroup indicated that differences in rates of HCBS use between enrollees who are aged and those with disabilities, as well as people with ID/DD, were widespread across the states (Wenzlow et al. 2011). As in 2006, we identified the largest differences in measures of LTSS systems by population age group and service delivery system. In the current analysis, we monitored the populations being reached by HCBS and the progress states have made since 2006 on using HCBS to serve different populations of enrollees. As we found in 2006, several states achieved overall balance by serving a relatively large number of aged people, whereas others did so by providing more HCBS to people with disabilities and ranked relatively low on balance for the aged. Finally, assessing performance on multiple measures and for multiple populations enabled us to identify a small group of states (Alaska, California, Colorado, Vermont, and Washington) that appear to have high rates of HCBS use and expenditures for diverse populations of Medicaid enrollees.
For the 35 states with reliable LTSS data in both 2006 and 2009, performance on two key indicators -- the percentage of Medicaid LTSS expenditures that were for HCBS and the percentage of LTSS users receiving HCBS -- reveals slight but notable progress in many states in re-balancing toward HCBS. We found, however, that progress by states during this time period on some measures was not always matched by corresponding progress on other measures or for all populations.
We updated our exploratory analysis of the bivariate association between state factors and policies and indicators of LTSS system balance. Our results suggest that several state factors are associated with system balance toward HCBS: (1) personal and home care aides per 1,000 elderly or individuals with a disability; (2) rates of consumer-direction; (3) percentage of out-of-home placements in facilities with six or fewer residents; and (4) availability of assisted living and residential care units, which were all positively associated with HCBS spending. Conversely, only the percentage of potential Medicaid eligibles age 75 or older was negatively associated with HCBS use and spending. We also found that higher rates of consumer-direction, availability of home health aides, and the availability of assisted living and residential care units were positively associated with HCBS use and expenditures for enrollees who were aged or had physical disabilities, but not for those enrollees with ID/DD. Other factors appear to be related to the progress in re-balancing LTSS for this population, most notably the availability of resources, shorter waiting lists for ID/DD waivers, and availability of small-facility placements for out-of-home care. We cannot infer causal relationships from these findings, but rather note that they point the way toward possibly fruitful work in the future.