Medicaid Home- and Community-Based Long-Term Care Services in the Age of Olmstead

Medicaid home- and community-based services (HCBS) provide formal long-term care to people who would otherwise be served in institutions. HCBS include home health, personal care, and waiver services. The 1999 Olmstead vs L.C. ruling mandates states to serve Medicaid long-term care recipients in the least restrictive setting possible. The three studies in this mixed-methods dissertation seek to understand the political, socio-demographic, economic, policy, and supply influences on HCBS, the effect of greater HCBS spending on institutional expenditures, and challenges to HCBS expansion since the Olmstead ruling. HCBS spending and utilization are related to several key variables. Economic and supply factors have a robust relationship with HCBS expansion. Socio-demographic factors, notably state populations of racial and ethnic minorities, affect HCBS. However, these effects differ among home- and community-based programs. There is no consistent partisan influence on state HCBS spending and utilization. Greater state investment in 1915(c) waiver programs appears to have, at best, a neutral relationship or, at worst, a weak positive relationship with state institutional Medicaid long-term care spending. Thus, the results do not support prior work indicating that HCBS programs reduce institutional spending. In addition, supply and policy factors both have a robust relationship with institutional spending. Drawing on interviews with state Medicaid officials, this study identifies both barriers and catalysts to HCBS growth since Olmstead. Barriers to HCBS expansion include both financial, such as funding crises, as well as non-financial factors, such as administrative burdens. However, informants said that HCBS programs enjoy broad, bipartisan support from state policy makers as well as support from advocacy groups. This study provides a new contribution to understanding influences on state HCBS spending, the effects of HCBS on institutional care, and the barriers and catalysts to HCBS expansion since Olmstead. Given the implementation of the 2010 Patient Protection and Affordable Care Act, the population aging, and ongoing state fiscal crises, these findings will help guide future research in Medicaid HCBS.Doctor of Philosoph