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1915(c) Medicaid Waiver Program Total Participants in the United States, 1992-1997
Source publication
The study examined trends and predictors of state Medicaid home and community based waiver participants and expenditures from 1992 to 1997 to identify factors of interest to policy makers and clinicians.
HCFA Form 372 data were collected from state officials for each waiver for each year. Two separate regression analyses were conducted to examine t...
Contexts in source publication
Context 1
... total number of HCBS participants increased from 235,668 in 1992 to 561,510 in 1997, or by 138% (see Table 2). Some states like Alaska were slow to begin their programs (Alaska's started in 1994), whereas many states began waivers early in the 1980s after the federal legislation was passed. ...
Context 2
... top five states in HCBS waiver participants per capita were Oregon (7.91 per 1,000 population), Kansas (5.92 per 1,000 population), Rhode Island (5.79 per 1,000 population), Missouri (4.41 per 1,000), and Vermont (3.84 per 1,000 population; see Table 2). The lowest five states in HCBS waiver par- ticipants per capita in the nation were Indiana, Loui- siana, Tennessee, Maryland, and Mississippi. ...
Similar publications
This article estimates the potential savings to the Medicaid program of using 1915c Home and Community Based Services (HCBS) waivers rather than institutional care. For Medicaid HCBS waiver expenditures of $25 billion in 2006, we estimate the national savings to be over $57 billion, or $57,338 per waiver participant in 2006 compared with the cost o...
Citations
... Traditionally, Democrats tend to be more supportive of social welfare spending while Republicans tend to be more fiscally conservative and less supportive of funding programs in this area (Grogan, 1994). Within LTSS and Medicaid policy specifically, Harrington et al. (2000) find having a Democratic governor is associated with greater HCBS waiver spending. Kitchener et al. (2007) conclude that liberal states are more likely to offer a personal care benefit and have more personal care participants per capita. ...
... Based on this study, states with a higher percentage of Democrats in the state legislature were more likely to pursue BIP. This finding is consistent with literature examining the role of ideology and partisanship in Medicaid HCBS policy (Harrington et al., 2000;Kitchener et al., 2007). However, it is also consistent with the supposition that partisan opposition to the health insurance provisions of the ACA may have discouraged some states from pursuing BIP. ...
Objective:
The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program.
Methods:
Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors were considered representing states' economic, political, and programmatic conditions.
Results:
The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP.
Discussion:
Findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.
... States with more liberal eligibility standards may have greater financial incentive to adopt HCBS policies as cost containment measures due to higher spending. Research suggests that states with more generous Medicaid eligibility may face greater pressure to constrain expenditures (Harrington et al. 2000;E. Miller and Wang 2009 ...
The Patient Protection and Affordable Care Act (ACA) included new optional Medicaid home and community-based (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.
... This variation in state support for HCBS has already received a fair amount of attention in the literature, with a large body of work examining the factors associated with state-level support for HCBS policy decisions and spending. Some of the variation in HCBS supports has been linked to characteristics of the state, including the percent of the population that is comprised of older or disabled persons, minority population, percent rural, income, number of home health agencies, and nursing home beds (Harrington et al., 2000;Kitchener et al., 2007;Miller, 2005;Miller et al., 2006). Political factors, including party leadership and whether the legislature is liberal or conservative, are also associated with HCBS spending (Harrington et al., 2000;Miller & Kirk, 2016;Nattinger & Kaskie, 2017). ...
... Some of the variation in HCBS supports has been linked to characteristics of the state, including the percent of the population that is comprised of older or disabled persons, minority population, percent rural, income, number of home health agencies, and nursing home beds (Harrington et al., 2000;Kitchener et al., 2007;Miller, 2005;Miller et al., 2006). Political factors, including party leadership and whether the legislature is liberal or conservative, are also associated with HCBS spending (Harrington et al., 2000;Miller & Kirk, 2016;Nattinger & Kaskie, 2017). Finally, political and consumer advocacy groups are also important to HCBS policy development (Kitchener & Harrington, 2004). ...
Older adults in need of assistance often prefer to remain at home rather than receive care in an institution. To meet these preferences, Medicaid invited states to apply for the Balancing Incentive Program (BIP), a program intended to “rebalance” Medicaid-financed long-term services and supports to Home- and Community-Based Services (HCBS). However, only about half of eligible states applied. We interviewed Medicaid administrators to explore why some states applied for BIP whereas others did not. Supportive state leadership and the presence of other programs supporting community-based care were positively related to BIP application. Opposing policy priorities and programs competing for similar resources were negatively related to BIP application. Because states most likely to apply already had policy goals and programs supporting HCBS, BIP may inadvertently widen disparities across states, pushing those on the margins ahead and leaving the ones that are worst off in HCBS support to fall even further behind.
... There are other clusters worth mentioning. Cluster #3 focused on the SAGE database and its applications [49,52]. The most active citer to cluster #4 [10,57,61] was Kane [10] who wanted to bring LTC and a good quality of life closer together. ...
Since the early 1960s, long-term care (LTC) has attracted a broad range of attention from public health practitioners and researchers worldwide and produced a large volume of literature. We conducted a comprehensive scientometric review based on 14,019 LTC articles retrieved from the Web of Science Core Collection database from 1963 to 2018, to explore the status and trends of global LTC research. Using CiteSpace software, we conducted collaboration analysis, document co-citation analysis, and keyword co-occurrence analysis. The results showed a rapid increase in annual LTC publications, while the annual citation counts exhibited an inverted U-shaped relationship with years. The most productive LTC research institutions and authors are located primarily in North American and European countries. A simultaneous analysis of both references and keywords revealed that common LTC hot topics include dementia care, quality of care, prevalence and risk factors, mortality, and randomized controlled trial. In addition, LTC research trends have shifted from the demand side to the supply side, and from basic studies to practical applications. The new research frontiers are frailty in elderly people and dementia care. This study provides an in-depth understanding of the current state, popular themes, trends, and future directions of LTC research worldwide.
... According to the World Health Organization (2002), the worldwide need for LTC is growing at a rapid rate, due to increases in the elderly population, injury incidence, and chronic disease prevalence. Indeed, the number of LTC recipients in the United States is projected to increase from 15 million in 2000 to 27 million by 2050 (The Lewin Group, 2004) and spending on LTC is projected to increase from $194 billion in 2000 to more than $340 billion by 2030 (Harrington et al., 2000;Burwell et al., 2008). As public programs are major funding sources for LTC (e.g., Medicaid covered 43% of LTC services in 2002) (Wiener et al., 2004;Kaye et al., 2010), federal and state health policymakers need better decision support in order to make LTC capacity decisions. ...
We study the problem of capacity planning for long-term care services, which is important not only for the elderly and disabled who cannot adequately care for themselves, but also for long-term care providers and health policymakers. Patients with long-term care needs usually have to transfer between different settings such as nursing homes and home- and community-based services. We model patient flows among these settings using an open migration network and formulate the planning of capacity needed for providing long-term care with a newsvendor-type model. We explore the structural properties of the model and identify the most influential factors, such as the penalty cost for capacity shortage and transition rates between different care settings, in making capacity decisions. With the model developed, capacity decisions for long-term care service networks can be made more systematically with full consideration of different patient flow patterns and budget constraints. The research will be especially useful to long-term care policymakers in a state or nationwide given the worsening shortage of care providers and the escalating long-term care needs resulting from population aging.
... Evaluations of the effect of waiver enrollment on service use, expenditures, and outcomes are rare. Studies have examined the characteristics of HCB waiver programs (e.g., cost, accessibility, trends) (Amaral, 2010;Hall-Lande et al., 2011;Harrington et al., 2000;Kitchener et al., 2003;Kitchener, Ng, & Harrington, 2004;Konetzka, Karon, & Potter, 2012;Laudicina & Burwell, 1988;LeBlanc et al., 2000;Rizzolo et al., 2013;Weissert, 1985). Two recent studies (Hall-Lande et al., 2011;Rizzolo et al., 2013) presented the national status of HCB service waivers for people with intellectual and developmental disorders and ASD, respectively. ...
Abstract We examined (a) the associations between Medicaid home and community-based waiver participation and service use and expenditures among children with ASD; and (b) how states' waiver spending moderates these effects. We used 2005 Medicaid claims to identify a sample of children with autism spectrum disorder (ASD). We selected two comparison groups who had no waiver participation: (a) children who were eligible for Medicaid through disability (disability group), and (b) children who had at least one inpatient/long-term care (IP/LT) episode (IP/LT group). Waiver participants were less likely to use IP/LT services and had lower associated expenditures than the disability group. As states' waiver spending increased, waiver participants became increasingly less likely to use IP/LT services. Waiver participants had more outpatient visits and associated expenditures; this difference increased as state waiver spending increased. Compared with the IP/LT group, waiver participants had lower IP/LT expenditures, more outpatient visits, and associated expenditures. Higher state waiver generosity increased this effect on outpatient visits and expenditures.
... For example, in 2002, Medicaid covered 43% of LTC services (Wiener et al. 2004;Kaiser 2009a), and fifty percent of total Medicaid expenditures were for 7.7% of full-benefit enrollees (Wenzlow et al. 2008). Because the population is expected to age dramatically in coming decades (Humes 2005), spendings on LTC for the elderly and disabled is projected to increase from $194 billion in 2000 to more than $340 billion by 2030 (Harrington et al. 2000;Burwell et al. 2008;Stevenson 2008). As a result, federal and state policy makers are seeking more efficient and affordable LTC delivery methods. ...
Long-term care (LTC) provides medical and non-medical services to people with chronic disease or disability, many of whom
are older adults eligible for receiving care through public funding sources. Annual spending on LTC in the United States exceeds
$200 billion per year and is increasing rapidly. As a large portion of the population receives publicly-paid LTC, the public
programs supporting LTC face increasing financial pressures. Although nursing home care has been a viable option, it is three
times more costly than community-based care, which offers a flexible alternative by providing care at home and in the community.
However, little is known on how much infrastructure is needed to provide such care. We showcase the potential of operations
research to support decision making to improve the LTC delivery system. We formulate an optimal control problem to determine
the infrastructure capacity of community-based care from a cost saving viewpoint. This example shows that methodologies of
operations research can provide valuable insights in improving LTC delivery.
... Given public discourse and official party platforms, one would assume states controlled by Democrats would be more likely to adopt regulatory reforms. This expectation is suggested by the extant literature, that ideologically more liberal states with Democratic public officials are more likely to favor government interventions and expenditures to improve quality and increase Medicaid spending than ideologically conservative states with Republican officials (Barrilleaux and Miller 1988; Erikson, Wright, and McIver 1993; Harrington, Mullan, and Carrillo 2004; Harrington, Carrillo, et al. 2000; Miller 2005). But is this always the case? ...
... The political party affiliation of the governor may also influence the likelihood of adoption. As reported earlier, prior studies suggest that ideologically more liberal states with Democratic public officials are more likely to favor government interventions and expenditures to improve quality and increase Medicaid spending (Barrilleaux and Miller 1988; Erikson, Wright, and McIver 1993; Harrington, Mullan, and Carrillo 2004; Harrington, Carrillo, et al. 2000; Miller 2005). Since WPT programs typically operate partly through increases in reimbursement, we expect states with Democratic governors to be more likely to adopt such programs. ...
... This also may be true of states with more generous standards for qualifying for Medicaid nursing home coverage. Indeed, more generous states may experience greater pressure not only to control spending, as prior research demonstrates (Harrington, Carrillo, et al. 2000; Miller 2005 Miller , 2006b), but also to pursue WPT and other initiatives that better enable nursing homes to provide quality care to Medicaid recipients. States with higher reimbursement rates may be more likely to adopt as well. ...
Because states play such a prominent role in the U.S. health care system, they have long grappled with how to best control health care costs while maintaining high quality of care. There are many policy tools available to address efficiency and quality concerns--from pure state regulation to market-oriented competition designs. Given public discourse and official party platforms, one would assume that states controlled by Democrats would be more likely to adopt regulatory reforms. This study examines whether party control, as well as other economic and political factors, is associated with adopting wage pass-through (WPT) policies, which direct a portion of Medicaid reimbursement or its increase toward nursing home staff in an effort to reduce staff turnover, thereby increasing efficiency and the quality of care provided. Contrary to expectations, results indicate that states with Republican governors were against WPT adoption only when for-profit industry pressure increased; otherwise, they were more likely to favor adoption than their Democratic counterparts. This suggests a more complex relationship between partisanship and state-level policy adoption than is typically assumed. Results also indicate that state officials reacted predictably to prevailing political and economic conditions affecting state fiscal-year decisions but required sufficient governing capacity to successfully integrate WPTs into existing reimbursement system arrangements. This suggests that WPTs represent a hybrid between comprehensive and incremental policy change.
... Although fiscal and programmatic concerns are often cited as the underlying reasons for adoption (Coughlin and Zuckerman 2002;Grabowski, et al. 2008), no systematic empirical research has been conducted to examine the comparative influence of state political, economic, and programmatic circumstances on the adoption decision. That these factors may be important is reflected in prior research identifying significant associations between various internal state characteristics and policies affecting Medicaid nursing home reimbursement and other areas (Barrilleaux and Miller 1988;Grogan1999;Harrington, et al. 2000;Miller 2004Miller , 2005Miller , 2006aMiller , 2006bSwan, Harrington, and Pickard 2001). In addition, prior studies indicate that state decisions to adopt may be related to broader, contextual conditions deriving from other states' adoption decisions and changes in federal law and regulation (Allen, Pettus, and Haider-Markel 2004;Cline 2003;Grogan 1999;Miller 2004Miller , 2005Miller , 2006aMiller , 2006b. ...
... The likelihood of provider tax adoption may also be influenced by state long-term care policy and market characteristics. Previous research indicates that states with more generous income, asset, and other standards for qualifying for Medicaid nursing home coverage experience greater pressure to control spending (Harrington, et al. 2000;Miller 2005Miller , 2006bSwan, Harrington, and Pickard 2001). In addition to cost containment, these states may seek to maximize alternative sources of funding with which to support their more generous programs. ...
... In addition to state governing capacity, prior research suggests that ideologically more liberal states should be more likely to favor government interventions and expenditures, such as higher Medicaid spending levels, than ideologically more conservative states (Barrilleaux and Miller 1988;Erikson, Wright, and McIver 1993;Harrington, et al. 2000;Miller 2005;Schneider 1991). Since the immediate goal of provider tax adoption is to draw additional federal Medicaid matching dollars with which to bolster provider reimbursement, we expect states with more liberal electorates and public officials to be more likely to do so than states with more conservative electorates and public officials. ...
Since Medicaid is jointly financed by the federal and state governments, state officials have sought to offset state expenditures by maximizing federal contributions. One such strategy is to adopt a provider tax, which enables states to collect revenues from providers; those revenues are then used to pay for services rendered to Medicaid recipients, thereby leveraging federal matching dollars without concomitant increases in state expenditures. The number of states adopting a nursing home tax increased from thirteen to thirty-one between 2000 and 2004. This study seeks to identify the factors that spurred the rapid increase in nursing home provider taxes following implementation of the Balanced Budget Act of 1997. Results indicate that states with more powerful nursing home lobbies, lower proportions of private pay nursing home residents, worse fiscal health, weaker fiscal capacity, broader Medicaid eligibility, and nursing home supply restrictions were more likely to adopt. This implies that state officials react rationally to prevailing fiscal and programmatic circumstances when formulating policy under Medicaid and that providers seek relief, in part, from the adverse fiscal consequences of federal policy changes by promoting policy change at the state level.
... Note. These variable choices were influenced by Baumgartner & Jones, 1993;Berry & Berry, 1990, 1992Braddock & Fujiura, 1991;Buchanan, Cappellini, & Ohsfeldt, 1991;DiLeo, 2001;Elazar, 1984;Gray, 1973;Harrington, Carrillo, Wellin, Miller, & LeBlanc, 2000;Heclo, 1978;Jacoby & Schneider, 2001;Ka & Teske, 2002;Kingdon, 1995;Lowi, 1964;Mohr, 1969;Mooney & Lee, 1995;Rigby, Brooks-Gunn, & Kagan, 2004;Sapat, 2004;Schneider, 1993;Schneider & Jacoby, 1996;Walker, 1969;Walker, 1983. Region and trends among neighboring states · Percentage of the states in the CMS (Centers for Medicare and Medicaid Services) region offering choice Note. ...
Key Points
· Foundations that work on national public policy issues face challenges in demonstrating impact.
· This case study of how the Robert Wood Johnson Foundation’s initiative to support choice of program provider for developmentally disabled adults uses some advanced statistical techniques to demonstrate the impact of the foundation’s funding.
· This study suggests that to get the greatest impact on policy change, foundations should consider offering modest competitive grants to governmental departments; spending the funds in regional groupings; and focus on jurisdictions that have demonstrated interest in the policy area by spending their own funds.
