Strengthening home and community-based care through Medicaid waivers

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community- based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.     

Estimating the expense of a mandatory home-and community-based personal assistance services benefit under Medicaid

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability. DESIGN AND METHODS: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS. RESULTS: New expenditures for PAS are estimated to be $1.4-$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA). IMPLICATIONS: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Medicaid physician fees and the quality of medical care of Medicaid patients in the USA

When enacted in 1965, the original Medicaid legislation sought to finance access to mainstream medical care for the poor. I use data on visits to office-based physicians from the National Ambulatory Medical Care Survey in four years—1989, 1993, 1998 and 2003—to test the extent to which this goal has been achieved. Specifically, I test whether this goal has been achieved more in states that pay higher fees to physicians who treat Medicaid patients compared to states that pay lower fees. By comparing the treatment of Medicaid patients to that of privately-insured patients and by using state fixed effects, I am able to estimate the effects of changes in the generosity of Medicaid physician payment within a state on changes in access to care for Medicaid patients, therefore separating Medicaid’s effect on access to health care from any correlation between the Medicaid fee and other attributes of the state in which a patient lives. Using this method, I examine the effect of Medicaid fees on whether or not an office-based physician accepts Medicaid patients, on the fraction of a physician’s practice that is accounted for by Medicaid, and on the length of visit times with physicians. Results imply that higher Medicaid fees increase the number of private physicians, especially in medical and surgical specialties, who see Medicaid patients. Higher fees also lead to visit times with physicians that are more comparable to visit times with private pay patients.

Medicaid home- and community-based services: impact of the affordable care act

The Affordable care Act (ACA) legislation of 2010 has three important voluntary provisions for the expansion of home- and community-based services (HCBS) under Medicaid: A state can choose to (1) offer a community first choice option to provide attendant care services and supports; (2) amend its state plan to provide an optional HCBS benefit; and (3) rebalance its spending on long term services and supports to increase the proportion that is community-based. The first and third provisions offer states enhanced federal matching rates as an incentive. Although the new provisions are valuable, the law does not set minimum standards for access to HCBS, and the new financial incentives are limited especially for the many states facing serious budget problems. Wide variations in access to HCBS can be expected to continue, while HCBS will continue to compete for funding with mandated institutional services.     

The courts and elective abortions under Medicaid.

Although therapeutic or elective abortions are among the most frequently performed medical procedures for women throughout the world, indigent American women are now denied coverage under the Medicaid program because of the Hyde Amendment, which prohibits the use of federal funds for the termination of pregnancies except in narrowly defined cases. The vast majority of states, left free to choose as to the expenditure of their own funds for abortion coverage, have also denied this type of welfare assistance to economically eligible women. The discriminatory effect of the refusal to subsume abortions as part of the Medicaid mandate has been the subject of various legal actions. The constitutionality of that denial is at issue and now awaits Supreme Court determination.     

Medicaid nursing facility reimbursement in flux: effects of federal regulatory changes and prevailing fiscal conditions, 1978-1998

Basic concepts and trends are examined in Medicaid nursing facility reimbursements between 1978 and 1998, because Medicaid payment reform is a common budget reduction strategy pursued by state officials. Non-incremental changes in state rate-setting methods, as well as incremental changes in per diem rates and expenditures per recipient, are analyzed. In addition to substantial cross-state variation, results reveal clear trends in reimbursement policy characteristics over time. Not only do these track closely with changes in the federal regulatory environment, but they also track closely with prevailing fiscal and economic conditions. Given the serious ramifications reimbursement policy changes can have for nursing home residents and providers, it is imperative that the impact of federal disengagement from this policy area be understood.     

State discretion and medicaid program variation in long-term care: when is enough, enough?

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.     

THE POLITICAL ECONOMY OF NEW DEAL FISCAL FEDERALISM

While the introduction of federal matching grants to finance the New Deal relief programs is usually viewed as a mechanism to insure federal control over state relief spending, a careful study of the New Deal reveals that the reverse was the case: matching grants allowed the states to escape close federal control. The standard economic model of inter-governmental grants reveals that the federal government will, if allowed, prefer to use discretionary rather than matching grants. With discretion, however, came power; power that neither the states nor Congress wished to see concentrated in the Executive branch.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

Medicaid Funding for Assisted Living Care: A Five-State Examination

Medicaid waiver programs financing assisted living care are examined in five states to gain insights about program implementation, accomplishments, and challenges. Documents, augmented with stakeholder interviews, are used to describe income eligibility, options for supplementing payments to facilities, risk adjustment payment levels, and participation. Needs determination and waiver-based payments are in place. Eligibility and funding levels are complicated by room and board allocations that are linked to the federal benefit rate for Supplemental Security Income. Provider participation may be diminishing. Many recipients have to accept shared occupancy as program payments are insufficient for single units.     

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect’s existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio’s long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.     

Restrictiveness of Eligibility Determination and Medicaid Enrollment by Low-Income Seniors

Medicaid is an important source of supplemental health care coverage for low-income seniors, yet little is known about the effect of state policy on Medicaid enrollment by eligible elderly. Data from a nationally representative survey were used to examine Medicaid enrollment by elderly, low-income Medicare beneficiaries living in states that liberalize or restrict Medicaid eligibility criteria using the 1986 Omnibus Budget Reconciliation Act or provision 209(b) of the 1972 Social Security Act Amendment, respectively. Controlling for demographics and health status, residence in states applying these laws was significantly, though modestly, associated with Medicaid enrollment. Additionally, 73% of eligible elderly Medicare beneficiaries were not enrolled in Medicaid, and most have serious chronic health problems. These findings suggest that a significant number of eligible elderly are not enrolled in Medicaid and that liberalizing or tightening Medicaid eligibility criteria can have an impact on Medicaid enrollment by low-income elderly patients.     

HOW INEFFICIENT ARE MULTIPLE IN-KIND TRANSFERS?

The inefficiencies from multiple in-kind transfers are smaller than one would guess from studying such programs singly, though Medicaid can give rise to average discounts as large as 60 percent. The benefits from the programs are quite large relative to recipients' incomes. Effective marginal tax rates under in-kind transfers are appreciably lower than they would be if the programs gave cash. Poverty rates among recipients are markedly lowered if one counts the value of in-kind transfers as income; this effect is insensitive to whether one accounts for the discounting of in-kind transfers by recipients.     

When Political Freedom Does Not Offer Travel Freedom: The Varying Determinants of Visa-Free Travel Opportunities

The ease with which a person can travel abroad may greatly impact the possibilities of what they can achieve in life. Previous scholars have found that as a country politically liberalizes and becomes wealthier its nationals can travel to more countries without a visa. After analysing data from Henley and Partners, the World Bank, and Freedom House for 154 countries, I find that this is only true for nationals from countries with above-average incomes. Among the bottom half of countries in the income distribution and the most unequal societies, nationals in politically free countries do not have greater visa-free mobility than nationals in less politically free countries. The higher a country's income per capita, the more travel opportunities its citizens lose because their society is not completely politically free. My findings have implications for how policymakers evaluate the costs of both migration policies and policies that politically and economically liberalize societies.     

Medicaid Beneficiaries' Access to Residential Care Settings

Residential care settings (RCSs) are community-based housing and supportive services providers. Medicaid beneficiaries' access to RCSs is of concern to policymakers and other stakeholders because most people prefer community-based to institutional services and RCSs are generally less expensive than nursing homes. To better understand Medicaid beneficiaries' access to state-licensed RCSs, we examined Medicaid policies in 50 states and the District of Columbia, interviewed seven subject-matter experts, and conducted four state case studies informed by reviews of state policies and interviews with 27 stakeholders. Factors identified as influencing Medicaid beneficiaries' access to RCSs include Medicaid reimbursement rates for RCS services, the supply of Medicaid-certified RCSs and RCS beds, and policies that affect RCS room and board costs for Medicaid beneficiaries. Shifting Medicaid spending toward community-based instead of institutional care may require attention to these interrelated issues of RCS payment, supply, and room and board costs.     

Medicaid State Plan Personal Care Services

Abstract

Policymakers face mounting pressures from consumer demand and the 1999 Olmstead Supreme Court decision to extend formal (paid) programs that deliver personal care to the elderly, chronically ill, and disabled. Despite this, very little is known about the largest program that delivers personal care: the Medicaid State Plan personal care services (PCS) optional benefit. This paper presents the latest available national program (participant and expenditure) trend data (1999–2002) on the Medicaid PCS benefit and findings from a national survey of eligibility and cost control policies in use on the program. The program trends show that, over the study period, the number of states providing the Medicaid PCS benefit grew by four (from 26 to 30), and national program participation, adjusted for population growth, increased by 27%. However, inflation-adjusted program expenditures per participant declined by 3% between 1999 and 2002. Findings from the policy survey reveal that between 1999 and 2002 there was a marked decline in the range of services provided, and by 2004, almost half the programs operated a cap on the hours of services provided.     

The Woodwork Effect in Medicaid Long-Term Services and Supports

This paper examines annual real per capita Medicaid long-term services and supports (LTSS) expenditures (in 2010 $) over the period 1995 to 2010. Medicaid community LTSS expenditures increased substantially. If that trend constituted a woodwork effect, expenditures on institutional services should have declined more slowly than community expenditures increased, resulting in total expenditures increasing over time. Such a woodwork effect is observed for the population with intellectual and developmental disabilities (IDD) but not for the non-IDD population, composed of persons with disabilities other than IDD, including older persons. During this time period, the goals for serving people with IDD changed; institutional and community cost-neutrality rules were relaxed (and with that concerns over a woodwork effect), and instead goals of community involvement and participation were emphasized for all eligible persons. For the non-IDD population, tighter adherence to cost-neutrality rules and controls over nursing home reimbursements may have helped avoid a woodwork effect as community expenditures increased. With the passage of the Americans with Disabilities Act in 1990, goals have changed for people with disabilities of all ages, and the notion of a simple trade-off between institutional and community service costs that constitutes the woodwork effect must be complemented with a much broader idea of cost analysis that values independence and community participation for people with disabilities of all ages.     

DECENTRALIZED INCOME REDISTRIBUTION RECONSIDERED

In theory, a state could redistribute income at a lower cost to its taxpayers than if the national government handled it. Part of the cost is exported out of state when federal tax revenues generated by the state fall as money incomes are reduced by additional redistribution. Simulations combining labor supply and migration responses show that for some reasonable parameter values enough of the cost is exported so that states do face lower costs of redistribution. Hence, the federal tax system provides at least a partial offset to the well-known externalities generated by local redistribution.