State expenditures on home and community based services and use of formal and informal personal assistance: a multilevel analysis

Despite wide state variation in commitment to home and community-based services (HCBS) for functionally impaired older persons, little is known about how such variation affects older adults' strategies to compensate for their functional limitations. This study examines the association of state HCBS expenditures with use of formal and informal personal assistance among non-institutionalized older Americans aged 70 and older with functional limitations. We conducted multilevel multinomial logistic regression analysis using data from the first wave of the Assets and Health Dynamics among the Oldest Old Survey, combined with data on state HCBS expenditures. Controlling for individuals' demographic, socioeconomic, and care needs factors, persons residing in states with higher HCBS expenditures were more likely to use formal personal assistance, but not less likely to use informal assistance. Our study suggests state variation in HCBS expenditures leads to inequitable access to formal personal assistance, especially among those with high functional limitations.