Medicaid Home and Community Based Services: Proposed Policies to Improve Access, Costs, and Quality

Abstract

The U.S. population is aging, with the number of adults aged 65 and older expected to almost double from 37 million in 2005 to over 70 million in 2030, or from 12 to almost 20 percent of the population (Institute of Medicine, 2008). Because the population is aging, the demand for long term care (LTC), particularly services at home, is increasing. In the U.S., over 13.2 million individuals living at home and in the community receive 21.5 billion hours of help per year from either informal or formal paid help (LaPlante, Harrington, and Kang, 2002). Medicaid is the most critical public program for individuals who are aged and disabled because, according to 2006 data, it pays for almost 46 percent of all nursing home care and 38 percent of home health in the U.S. (Catlin, Cowen, Hartman, Heffler, and the National Health Expenditure Accounts Team, 2008). Medicaid home and community based services (HCBS) have been the focus of widespread efforts by the federal and state governments to expand access for several reasons. First, there is a growing demand by individuals to remain in their homes for as long as possible rather than to live in institutions. Second, the Supreme Court ruled in the Olmstead case in 1999 that individuals have the right to live at home or in the community if they are able to and choose to do so, rather than to be placed in institutional settings by the government. Third, a number of subsequent Olmstead-related lawsuits against states have required states to expand access to HCBS. Finally, in the past decade, the federal government has provided a number of initiatives and resources to assist states in complying with the Olmstead decision and in rebalancing their LTC services from institutional to HCBS (Kitchener, Ng, and Harrington, 2007). Inequities in access to Medicaid HCBS services are widespread, and limited funds have resulted in many unmet needs for HCBS. As HCBS cost issues have been a primary focus of policy makers, access and quality problems have not been sufficiently addressed. As 2009 marks the beginning of a new presidency and Congress, it is important to examine the progress that has been made in providing Medicaid HCBS along with the many current problems. The focus of this article is to examine issues of access, cost, and quality for Medicaid HCBS programs and to suggest policy changes.