Over the past 15 years, Medicaid

1915(c) home and community-based waivers have made a substantial contribu-tion to States ’ ef forts to transform their long-term care (LTC) systems from largely institutional to community-based systems. By 1997, every State had implemented a waiver program for at least some subgroups of individuals with disabilities, and expen-ditures increased from $3.8 million in 1982 to more than $8.1 billion in 1997. Emerging, as well as long-standing, policy issues related to the waiver program include concerns with access, variation in availability by disability group, State deci-sions related to the provision of community-based LTC, and evidence on ef fectiveness