Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. Key Findings on Variation in Medicaid Long-Term Care System Performance in 2006

03/18/2014

  • Across the 38 study states in 2009, about 45 percent of Medicaid LTC spending was for HCBS in 2009, while almost 67 percent of Medicaid LTC users used HCBS. Medicaid spent about $19,500 per user for HCBS, or 48 cents per user of HCBS for every dollar on people in institutional care. However, there is considerable variation, across states and population subgroups.

  • Most states reported modest progress on re-balancing toward HCBS from 2006 to 2009.

  • Taken together, two measures (the percentage of long-term services and supports (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 (e.g., the District of Columbia and New York), but most did so by providing more HCBS to younger enrollees with disabilities (e.g., New Hampshire, Vermont, and Wyoming), 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 on multiple dimensions and within different service systems.

  • Looking at population subgroups, about 65 percent of their HCBS LTC spending went for those with ID/DD, compared with 49 percent adults under age 65 with other disabilities, and 30 percent for LTC recipients over 65. About 86 percent of Medicaid enrollees using LTC services for ID/DD received HCBS, compared with 78 percent of those with other disabilities under age 65, and 55 percent for users over 65.

  • Several states that have achieved much better than average HCBS coverage for one or more population groups deserve further study so that other states may learn from their experience. Specifically:

    • Overall, Washington, Alaska, Vermont, California, and Colorado had the highest percent of Medicaid LTSS expenditures going for HCBS (75 percent to 58 percent, in declining order). Alaska, California, Washington, Idaho and Iowa had the highest percent of Medicaid LTSS users receiving HCBS (90 percent to 75 percent). New Hampshire, Washington, Indiana, Utah, and Wyoming had the highest per-user spending for HCBS, relative to per-user spending for institutional care (102 percent to 74 percent).
    • In terms of serving the aged, Washington, Alaska, California, New York and the District of Columbia had the highest percent of Medicaid LTSS expenditures going for HCBS (59 percent to 38 percent, in declining order). Alaska, California, Washington, Idaho and Iowa had the highest percent of Medicaid LTSS users receiving HCBS (86 percent to 63 percent). Louisiana, New York, Washington, Indiana, and New Hampshire had the highest per-user spending for HCBS, relative to per-user spending for institutional care (77 percent to 56 percent).
    • In terms of serving those under age 65 with disabilities other than ID/DD, Kansas, Alaska, Colorado, North Carolina, and California had the highest percent of Medicaid LTSS expenditures going for HCBS (75 percent to 63 percent, in declining order). California, North Carolina, Virginia, and Alabama had the highest percent of Medicaid LTSS users receiving HCBS (90 percent to 88 percent). Kansas, Indiana, Ohio, and Texas had the highest per-user spending for HCBS, relative to per-user spending for institutional care (64 percent to 58 percent).
    • In terms of serving those under age 65 with ID/DD, New Hampshire, Alaska, Maryland, Colorado, and Wyoming had the highest percent of Medicaid LTSS expenditures going for HCBS (99 percent to 91 percent, in declining order). New Hampshire, Alaska, Colorado, Maryland, and Kansas had the highest percent of Medicaid LTSS users receiving HCBS (100 percent to 98 percent). New Hampshire, Alaska, Oklahoma, Indiana, and Utah had the highest per-user spending for HCBS, relative to per-user spending for institutional care (144 percent to 57 percent).
  • If small ICFs/IID (having fewer than six beds) were considered to provide HCBS rather than institutional services, then the percent of Medicaid LTSS expenditures for ID/DD that went towards HCBS would increase from 65 percent to 68 percent, the percent of users would increase from 86 percent to 89 percent, and the per-user expenditure of HCBS relative to institutional care would increase from 33 percent to 36 percent.

  • States with relatively high rates of HCBS spending overall did not always have consistently high rates of HCBS spending for all subgroups of enrollees. For example, the relatively high overall rankings for New Hampshire, Vermont, and Wyoming on the expenditure share measure appear to be driven primarily by higher rates of expenditures on enrollees under age 65 with disabilities and lower spending on aged enrollees. In comparison, the high ranks of the District of Columbia and New York appear driven by high rates of HCBS use and per-user spending among the aged.

View full report

Preview
Download

"ProgBal.pdf" (pdf, 1.6Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®