Why Do States Pursue Medicaid Home Care Opportunities? Explaining State Adoption of the Patient Protection and Affordable Care Act's Home and Community-Based Services Initiatives

Abstract

The Patient Protection and Affordable Care Act (ACA) included new optional Medicaid home and communitybased (HCBS) initiatives: the Balancing Incentive Program, the 1915(k) Community First Choice personal care benefit, and the revised 1915(i) state plan benefit. This study identifies political, economic, programmatic, and intergovernmental factors that facilitated or impeded state participation in these ACA programs. Longitudinal and cross-sectional regression analyses were used to model state adoption from 2011 to 2015. Findings indicate that political ideology, economic factors, and existing HCBS policies were the most important determinants of whether a state adopted the ACA's HCBS opportunities. This research has implications for federal officials interested in spurring states to achieve greater rebalancing of Medicaid long-term services and supports toward HCBS.

An Engine of Change? The Affordable Care Act and the Shifting Politics of Demonstration Projects

“…The analysis here suggests that greater bureaucratic discretion and fiscal authority have been insufficient conditions for the development of autonomous programmatic innovation (Carpenter 2001). In contrast to the work of Lisa Beauregard and Edward Miller (2020) on state Medicaid waivers, we show that partisan ideology and weak institutional capacity are not the only barriers to policy innovation. Instead, our analysis shows that the ACA's actuarial certification requirements--which require the CMS actuary to provide a probing analysis of demonstrations--may place new limits on the scope of innovations that CMMI undertakes and is able to expand.…”

“…By contrast, in states with a large number of ongoing demonstration models, the initiative was a way of coordinating and consolidating existing delivery-system reforms (Rocco, Kelly, and Keller 2018). This is to some extent consistent with Beauregard and Miller's (2020) findings on the importance of institutional capacity in states' adoption of 1915(c) waivers within Medicaid.…”

“…Infrastructural gaps constituted barriers to the expansion of several demonstration projects we observed. As Beauregard and Miller (2020) show, gaps in infrastructure or capacity are not unique to CMMI demonstration projects. Yet, in several instances, the implementation of CMMI models was contingent on the adoption of significant changes in data systems, such as those that facilitate patient identification for care management.…”

“…In sum, although the ACA may have removed some of the barriers to the expansion of demonstration projects--among them the challenge of convincing Congress to expand successful demonstrations--it may have left other barriers in place and generated a new set of challenges for programmatic innovation. Using demonstration projects to facilitate policy learning requires surmounting not only the challenges of weak institutional capacity and political opposition (Beauregard and Miller 2020), but also technical challenges in commensurating the effectiveness of policy innovation.…”

The Affordable Care Act's “community first choice” option: Effect on long‐term care expenditures

“…Examining the relationship between CFC adoption and HCBS spending is the first step to exploring the impact of such programs on individual‐ and caregiver‐level outcomes. While some ACA initiatives (Balancing Incentives Program [BIP] 8 , 9 , 10 , 11 and the Money Follows the Person [MFP] demonstration 12 , 13 ) have been previously studied, there exists no empirical evidence of CFC adoption on state‐level Medicaid HCBS expenditures.…”