Medicaid Community-Based Programs: A Longitudinal Analysis of State Variation in Expenditures and Utilization

Abstract

As states face challenges posed by budget crises and pressures to develop Medicaid home and community-based services (HCBS), this paper provides a longitudinal analysis of state variation in expenditures and utilization for three HCBS programs (waivers, home health and personal care), and for total Medicaid HCBS. The first part of the analysis describes the nature and scope of state variation for each program in 1999, using such measures as participants per 1,000 population and expenditures per capita. The second part of the analysis presents time-series regression models that estimate sociodemographic, state policy, and market factors associated with intra-state variation in waiver participants and expenditures, and home health, personal care and total HCBS expenditures for the period 1992-99. Among the results, positive state-level factors related to HCBS participants and expenditures include: higher percentages of aged people, greater incomes per capita, and a larger supply of home health agencies.

Developing Personal Care Programs: National Trends and Interstate Variation, 1992–2002

“…While findings on ethnicity have been mixed, a higher percentage of the nonwhite population has been shown to positively influence the provision of formal LTC programs, possibly as a result of higher rates of disability and poverty (Wallace et al 1998). Although there is some evidence that urban (metropolitan) residents are more likely to use (and therefore be provided with) formal HCBS compared with rural residents (Nyman et al 1991;Kenney 1993), recent work has found mixed effects (Kitchener, Carrillo, and Harrington 2003). Thus, this study included this variable without a hypothesis.…”

“…Studies show the negative influence on Medicaid HCBS policy development of fiscally conservative state political climates as measured by the voting records of the states' U.S. senators Kitchener, Carrillo, and Harrington 2003). Thus, this study used the voting record of U.S. senators as a measure of state political climate with the expectation that stronger liberal records would be associated with personal care program adoption and expansion (Miller 2005).…”

“…The extent and mix of LTC providers in a state have been shown to influence HCBS program use and expenditures (Ladd and Associates 1997;Wiener and Stevenson 1998;Kitchener, Carrillo, and Harrington 2003). As residential care beds per population and home health agencies constitute HCBS supply, in contrast to institutional (nursing home) supply, they may be associated positively with personal care use and spending (Harrington et al 2000;Kitchener, Willmott, and Harrington 2004).…”

“…The regulation of institutional bed supply is a cost containment strategy that has been associated with the adoption and expansion of HCBS programs (Coleman, Kassner, and Pack 1996). Some work has found a positive relationship between use of a certificate of need (CON) and/or moratorium for nursing facilities and Medicaid HCBS program development , although the effect has not been consistent across studies (Kitchener, Carrillo, and Harrington 2003). We included nursing home bed regulation (i.e., use of CON and/or moratorium) and hypothesized a positive association with PC program development.…”

“…LTC policy studies show that the age of a state population is a strong positive predictor of the expansion of Medicaid HCBS programs (e.g., Kitchener, Carrillo, and Harrington 2003;Miller 2005). While findings on ethnicity have been mixed, a higher percentage of the nonwhite population has been shown to positively influence the provision of formal LTC programs, possibly as a result of higher rates of disability and poverty (Wallace et al 1998).…”