The primary argument for the expansion and enhancement of community-based care has increasingly come to be that recipients greatly prefer it, an argument so widely accepted as to be regarded as self-evident. Farmer's (1996) study of nursing home organization was explicitly based, in part, on the assumption that "no one's first choice of residence was a nursing home." A recent AARP survey described by Keenan (2010) found that 86 percent of respondents aged 45 and older, asked where they would like to live as they aged, agreed or strongly agreed with the statement, "What I'd really like to do is stay in my current residence for as long as possible."
Apart from the well-accepted preference of people over age 65 or people with disabilities for community-based care is the strong likelihood of better health outcomes for people who are successfully supported in the community compared to outcomes likely to have occurred under institutional care. Outbreaks of influenza and norovirus, for example, are recognized threats to people living in institutions. Nursing home-acquired pneumonia is a significant cause of mortality and morbidity to residents (Mills et al. 2009). Although evidence sometimes conflicts, several studies have demonstrated that residents in assisted living and HCBS settings have fewer depressive symptoms and better psychological well-being, and more were generally happy (Pruchno and Rose 2000; Franks 2004; Wodchis 2003).
Finally, of course, evidence suggests that providing services in the community may result in cost savings to state Medicaid programs. Several studies (for example, Kitchener et al. 2006; Kaye et al. 2009; Harrington et al. 2011; Kaye 2012) find that replacement of institutional with community LTSS resulted in cost saving for Medicaid programs. These studies provide only incomplete guidance to states, however, for two reasons. First, the term "HCBS" is much less well defined than is institutional care. A nursing home day is commonly understood to mean round-the-clock care and to include room, meals, and other services. In contrast, HCBS care may include quite different services from state to state, possibly with limitations on the number of hours of care allowed. Second, empirical studies can provide information only on the results of re-balancing that has occurred so far. Given that states and providers surely began re-balancing by focusing on those people most easily supported in the community, rather than, say, a random group of people eligible for institutional care, evidence on re-balancing to date provides little or no evidence on the probable effects of further extending efforts to re-balance care for the elderly and people with disabilities.1 That said, the most reasonable policy for states to adopt, given current research, would appear to include gradual expansion of community-based LTSS, at least until evidence suggests that further expansion was more expensive or led to worse outcomes than institutional care. No evidence yet indicates that we have reached that point.
Despite evidence of cost effectiveness, states facing budgetary crises may be less likely to develop and implement new programs, particularly due to evidence that shifts to HCBS may involve initial cost increases at the beginning of these programs before savings are achieved (Kaye et al. 2009). Given ongoing economic constraints in many states, policymakers have questioned how budget concerns have affected progress toward HCBS re-balancing across states, and within states, for subpopulations of enrollees. Initial feedback indicates that many states have continued to pursue the goal of re-balancing during the recent economic downturn (Walls et al. 2011; Cheek et al. 2012), but limited information is available on how progress has varied across states and for subpopulations of enrollees during this period.
1 New Jersey's Rebalancing Workbook, for example, recognizes that "the least frail client in a nursing facility (NF) could be the frailest client in HCBS, and the frailest client in HCBS could be the least frail client if moved to a NF." (New Jersey Department of Health and Senior Services 2009).