Home and community-based services: public policies to improve access, costs, and quality

Description

The population of the US is aging with the number of adults aged 65 and older almost doublingfrom 12 percent in 2005 to almost 20 percent of the population by 2030. With the population aging,the demand for long term care (LTC), particularly services at home, is increasing. Of thoseindividuals receiving LTC services in the US, most paid services were funded by the government.In 2006, of the total $177.6 billion in estimated spending for LTC nationally, $124.9 billion was fornursing homes (excluding hospital-based LTC) and $52.7 billion was spent on home care.Medicaid is the primary payer for LTC services for individuals with low incomes, paying for 45.8percent of nursing home care and 37.6 percent of home health in the US in 2006. Medicaid is ajoint federal and state program, which covers individuals who are on Supplemental Security Incomeand those who meet each state’s income and asset requirements (the categorically needy). In somestates, it also pays for individuals who spend down their incomes to each state Medicaid levelbecause of medical costs (the medically needy).Medicaid home and community based services (HCBS) has been the focus of widespread efforts bythe federal and state government to expand access for several reasons. First, there is a growingdemand by individuals to remain in their homes for as long as possible rather than to live ininstitutions. Second, the Supreme Court ruled in the Olmstead case in 1999 that individuals havethe right to live at home or in the community if they are able to and choose to do so, rather than tobe placed in institutional settings by the government. Third, a number of subsequent lawsuitsagainst states have encouraged states to expand access to HCBS. Finally, in the past decade, thefederal government has provided a number of initiatives and resources to assist states in complyingwith the Olmstead decision and in rebalancing their services from institutional to HCBS. In spite ofthese efforts, there are inequities in access to services and many individuals have unmet needs forHCBS.The focus of this report is to examine issues of access, cost, and quality for Medicaid HCBSprograms. The trends in state Medicaid HCBS programs, target groups, participants, andexpenditures are summarized. The paper shows the progress in providing Medicaid HCBS but alsoidentifies many current problems and policies. Inequities in access to services and limited fundsresult in unmet needs for HCBS. HCBS cost issues have been a primary focus of policy makers andquality problems are largely not addressed. Policy recommendations are made to improve access,costs and quality at the federal and state levels in the future.