The exploratory findings presented here suggest several directions for future research.
Level of Need and the Distribution of Care Received. The utilization and spending per-user patterns reported here suggest substantial differences across states in the populations served and/or service levels provided. Looking at the distribution of spending for both HCBS and institutional care services would provide insight into whether low-spending (or high-spending) states are providing the same level of care to all of their enrollees or serving a wide range of needs. To further our understanding of whether LTC systems are meeting the requirements set forth by Olmstead even further, LTC balance analyses should move toward examining the needs of enrollees, appropriate settings that can support those needs, and whether services received are indeed provided in the most integrated appropriate settings.
Addressing the Continuum of Care in Measures of Long-Term Care Balance. As in past studies, we differentiated HCBS from institutional care to study LTC balance. However, HCBS includes a range of residential settings, such as assisted living, and institutional care can include smaller ICFs/IID more similar to group homes than traditional state institutions. Future research will need to address the true continuum of LTC settings to better understand Medicaid LTC system transformation.
Environmental Barriers to HCBS Use and System Transformation. Although our analyses were exploratory, we identified significant associations between LTC balance and winter precipitation and availability of care providers. This suggests that environmental barriers may need to be taken into account when measuring progress toward system transformation.
Constraints as Mediators of Long-Term Care Policy. Our preliminary analysis identified significant bivariate relationships between state-level contextual factors, such as constraints and policies, and LTC system performance. These cross-sectional comparisons could be supplemented usefully with a more extensive study of the multivariate relationships across measures. Of particular interest is how the association between policies and balance may differ across groups of states experiencing similar fiscal, environmental, and demographic characteristics. A longitudinal study assessing the effects of select policies would be an important extension of this work.