Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. Key Findings on Associations between State Constraints, Policies, and Long-Term Care System Performance


We examined the correlations between LTSS balance measures and state characteristics and policy variables. The associations found indicate several relationships that appear relevant for understanding variations in HCBS use and expenditures across states.

  • Of the several measures selected to capture exogenous state characteristics, only two were significantly correlated with measures reflecting HCBS penetration in state LTSS systems overall: (1) personal and home care aides per 1,000 elderly and younger persons reporting disability, which was positively associated with HCBS spending and use; and (2) percentage of potential Medicaid eligibles age 75 or older, which was negatively associated with HCBS spending and use.

  • We hypothesize that the relationship between home care workers and HCBS may be the result of several factors. HCBS may expand when there are home care workers available to serve more people in residential settings. Conversely, communities with very high levels of demand for these services may find that there are insufficient community resources, including care workers, available to serve everyone in the community, or the increased demand for these workers may drive an increase in their supply.

  • The three policy variables most consistently related to LTSS systems with higher rates of HCBS use were consumer-direction, percentage of out-of-home placements in facilities with six or fewer residents, and availability of assisted living and residential care units. These factors may be important contextual variables to consider when assessing LTSS balance.

  • Some of the relationships were only significant for some subpopulations of enrollees. Three factors -- total taxable resources, percentage of potential aged Medicaid eligibles, and size of the waiver waiting list for ID/DD HCBS waivers -- were only associated with increased HCBS use for individuals with ID/DD. Other factors -- availability of home health aides, rates of consumer-direction, and availability of assisted living and residential care units -- were only significantly related to HCBS use for individuals who were aged or had physical disabilities. These findings underscore the importance of assessing drivers of variation in HCBS use and expenditures for subpopulations separately, as different factors appear to be relevant for each group.

Given the complex and dynamic environment across and within states for LTSS delivery, it is not feasible to isolate and determine the precise nature of the relationship between a single state policy constraint or factor and HCBS balance in a descriptive analysis. Further analysis is needed to understand the interaction of different factors underlying the relationships identified in this analysis.

Our exploratory analysis of the associations between system performance, state policies, and other factors that might facilitate or hinder Medicaid HCBS expansions suggests that:

  • Two factors over which states have little control -- poor weather conditions and size of the workforce needed to provide adequate HCBS -- are associated with systems less balanced toward HCBS.

  • Three factors that states could alter -- availability of Medicaid consumer-directed services, state plan personal care coverage, and availability of state Supplemental Security Income supplements for people living in the community -- are positively associated with systems more balanced toward HCBS. Note that consumer-direction may promote HCBS use because it has the potential to enlarge the workforce insofar as self-directing program participants are not limited to receiving services from workers recruited into home care agency employment but are permitted to choose to hire other individuals who may be motivated to become paid helpers because of pre-existing personal relationships, as relatives, friends, and neighbors.

  • State policies and constraints are likely to function differently for different subgroups of Medicaid enrollees. Consumer-direction, for example, was significantly associated with HCBS spending for the aged and people with physical disabilities, but not for enrollees with ID/DD. Other factors appear to be related to progress in re-balancing LTC for people with ID/DD, most notably financial resources.

We cannot infer causal relationships from these findings, but rather note that they point the way to possibly fruitful work in the future.

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