An Investigation of Interstate Variation in Medicaid Long-Term Care Use and Expenditures Across 40 States in 2006. I. Background and Objectives


Efforts to transform Medicaid long-term care (LTC) from a predominantly institution-based system to one with more community-based services appear, from a national perspective, to have made substantial progress, particularly over the past decade. Since the Supreme Court's 1999 Olmstead v. L.C. decision affirmed the right of persons with disabilities to receive services in the most integrated setting appropriate for their needs (US Supreme Court 1999), Medicaid home and community-based services (HCBS) use and expenditures have more than doubled (Ng et al. 2009) and the use of nursing homes and intermediate care facilities for people with intellectual disabilities (ICFs/IID) has declined substantially (Alecxih 2006; Wiener et al. 2009; Lakin et al. 2009).1

This overall success, however, masks wide variation in the levels of success across states and different subgroups. Efforts to re-balance LTC systems from their traditional reliance on institutional care to HCBS have been achieved more widely for some populations (young enrollees with disabilities) than others (people over 65) (Wenzlow et al. 2008) and have varied widely across states (Howes 2010; Kassner et al. 2008; Ng et al. 2009). In this report, we explore what factors are linked to successful state outcomes to help identify where new solutions for the remaining institutionalized populations may lie.2

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