Medicaid Home & Community-Based Services Under Fiscal Crisis
Text-Only Outline
1. Medicaid Home & Community-Based Services Under Fiscal Crisis
GSA ANNUAL MEETING, SAN DIEGO
Sunday 23 November, 2003
Martin Kitchener PhD MBA*
Charlene Harrington PhD*
Terence Ng MA*
Risa Elias MPP (Kaiser Family Foundation)
*Department of Social and Behavioral Sciences
University of California, San Francisco
Tel: (415) 502-7364
Funded by: Kaiser Commission on Medicaid & the Uninsured, and National Institute for Disability & Rehabilitation Research (NIDRR)
2. Total US Expenditure for LTC in 2001 - $132 billion
| Funding Source | % of Total Expenditure |
|---|---|
| Medicare | 16% |
| Medicaid/gov | 45% |
| Out-of-pocket | 25% |
| Private Insurance and other | 14% |
Source: Levit et all 2003
3. Medicaid Long Term Care
Medicaid - joint federal-state program for poor
2001 total Medicaid LTC participants: 4 million
2001 total Medicaid LTC expenditures: $75 billion
43 states report budget deficits in 2003
4. Medicaid LTC Participants by Provision Type, 2001
Total Participants: Est. 4 million
| Provision Type | % of Medicaid LTC Participants |
|---|---|
| Home and Community-Based Services | 52% |
| Institutional Services | 48% |
Source: HCBS (Kitchener et al 2003); Institutional (MSIS 2000 Data)
5. Medicaid LTC Expenditures by Provision Type, 2001
Total Expenditures: $75 billion
| Provision Type | % of Medicaid LTC Expenditures |
|---|---|
| Home and Community-Based Services | 28% |
| Institutional Services | 72% |
Source: CMS Form 64 Data, Medstat 2003
6. Medicaid Long Term Care
- Resource demands of institutional provision (e.g., nursing homes) and
- Mounting pressures to extend HCBS:
- Poor quality of Nursing Home care & increasing costs (IOM 2001)
- Consumer preferences for HCBS, especially by disabled
- Legal pressures including Americans with Disability Act (1990) & the Olmstead decision (1999). Litigation against states & settlement agreements
7. Study Aims & Method
Aims
- Examine trends in participation and expenditure on HCBS programs under fiscal crises.
- Track states' responses to financial crisis and legal challenges
- Examine the impact of policy changes to access.
Method
- CMS Form 372 reports for waivers (data collected since 1992, n = 229 in 2001)
- CMS Form 64 Data for Personal Care and Home Health, expenditure data available since 1992.
- Survey of Personal Care (n = 28) and Home Health Programs (n = 51), ongoing since 1999.
- Survey of Waiver Policy (2002), 91% response rate
8. Medicaid HCBS Programs
- Home Health care
- Required in all states for those eligible for Medicaid institutional care
- State Plan Personal Care optional benefit
- Available in only 28 states
- Must be statewide, available to Medicaid categorically eligible groups
- HCBS waivers
- Must be nursing home eligible, selective recipient groups
- Slots & expenditures can be preset and limited
- Financial and medical eligibility vary across states
- Waiting lists can be established
- Can be restricted geographically
- Since 2002, can have community transition grants
9. Medicaid HCBS Participants by Program, 1999 - 2001
Number of participants (in thousands)
| Home Health | Personal Care | Waivers | |
|---|---|---|---|
| 1999 | 744 | 508 | 698 |
| 2000 | 710 | 556 | 768 |
| 2001 | 728 | 557 | 833 |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
10. Medicaid HCBS Participants by Program, 2001
Total 2,117,948
| Program | % of Medicaid HCBS Participants |
|---|---|
| Waivers | 40% |
| Home Health | 34% |
| Personal Care | 26% |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
11. Medicaid HCBS Expenditures by Program, 1999 - 2001
Expenditures (in billions of dollars)
| Home Health | Personal Care | Waivers | |
|---|---|---|---|
| 1999 | 2.4 | 4.0 | 11.4 |
| 2000 | 2.5 | 4.5 | 12.6 |
| 2001 | 2.8 | 5.0 | 14.2 |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
12. Medicaid HCBS Expenditures by Program, 2001
Total: $22 billion
| Program | % of Medicaid HCBS Expenditures |
|---|---|
| Waivers | 64% |
| Home Health | 13% |
| Personal Care | 23% |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
13. HCBS Participants and Expenditures by Program, 2001
| Waivers | Personal Care | Home Health | |
|---|---|---|---|
| Participants | 40% | 26% | 34% |
| Expenditure | 64% | 23% | 13% |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
14. Waiver Expenditures by Recipient Type, 2001
Total: $14 billion
| Recipient Type | % of Waiver Expenditures |
|---|---|
| MR/DD | 74.4% |
| Aged/Disabled | 23.5% |
| TBI/Head Injury | 1.0% |
| Children | 0.6% |
| AIDS | 0.4% |
| Mental Health | 0.1% |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
15. Waiver Expenditures and Expenditures per Participant, 1992 - 2001
($17,070 per participant, 2001)
Line graph showing waiver expenditures and $ per participant from 1992 - 2001.
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
16. Waiver Cost Control Policies
- Limits on waiver financial and medical eligibility for those who are otherwise eligible for institutional care
- Ceilings or caps on services and expenditures per recipient
- Geographical limits within states
- Limits on waiver slots
- Establishment of waiting lists
17. Waiver Financial Eligibility Limits As a % of SSI or Poverty Level, 2002 N=209 Waivers (91%)
| SSI/FPL | waivers |
|---|---|
| 100% | 25% |
| 101-299% | 8% |
| 300% | 67% |
18. "Caps" on Waiver Expenditures, 2002
| "Cap" | Percentage |
|---|---|
| Maximum amount limit | 37% |
| Average limit | 15% |
| Others | 29% |
| Unknown | 15% |
19. Waiver Waiting Lists by Recipient Types, 2002
Total - 155,884
| Recipient Type | % of Waiver Waiting Lists |
|---|---|
| Elderly/Disabled | 44.8% |
| MR/DD | 43.6% |
| Children | 4.5% |
| Disabled | 3.8% |
| TBI/Head Injury | 2.3% |
| Elderly | 0.9% |
20. Waiting Lists for HCBS Waivers in Selected States, 2002
Georgia - 9,404 on 4 wait lists
Ave. wait time 31 months
Mississippi - 4,800 on 1 wait list
Ave. wait time unknown
Indiana - 7,343 on 3 wait lists
Ave. wait time 20 months
New Mexico - 6,271 on 3 wait lists
Ave. wait time 28 months
N. Carolina - 7,146 on 2 wait lists
Ave. wait time 6 months
Texas - 74,244 on 4 wait lists
Ave. wait time 18 months
Louisiana - 9,817 on 5 wait lists
Ave. wait time unknown
Wisconsin - 8,734 on 4 wait lists
Ave. wait time 12 months
21. State Variation in Medicaid HCBS, 2001
| Program/Measure | Three Lowest States |
US Ave. | Three Highest States |
|---|---|---|---|
| Waivers | |||
| Participants per 1,000 population |
DC-0.50 IN-0.85 TN-0.87 |
2.92 | OR-10.79 KS-7.30 WA-6.64 |
| Expenditures per participant |
MS-$5,089 DC-$5,930 AR-$7,589 |
$17,070 | TN-$39,740 ME-$39,355 NM-$38,159 |
| Home Health | |||
| Participants per 1,000 population |
TN-0.09 NV-0.19 OR-0.26 |
2.56 | MN-12.16 KS-8.91 CT-7.77 |
| Expenditures per participant |
NM-$178 OK-$278 NH-$557 |
$3,893 | NE-$13,104 NJ-$10,806 CO-$9,587 |
| State Plan PCS | |||
| Participants per 1,000 population |
NH-0.10 UT-0.14 NV-0.38 |
1.96 | AR-7.97 MO-7.30 CA-5.89 |
| Expenditures per participant |
OR-$806 SD-$1,177 UT-$1,827 |
$9,018 | NH-$27,730 MA-$20,568 NY-$17,785 |
| Medicaid HCBS | |||
| Participants per 1,000 population |
TN-0.96 NV-1.87 IN-2.19 |
7.44 | MN-19.91 KS-16.21 AR-15.27 |
| Expenditures per participant |
MS-$3,283 DC-$3,609 AR-$3,899 |
$10,423 | TN-$36,806 PA-$23,674 RI-$20,536 |
Source: Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF
22. Unmet Need for Medicaid HCBS
- Large & long waiting lists for HCBS in many states
- Cost of unmet need for Medicaid HCBS: $1.9bn for those living alone & $4.7bn for those living with others.
- State officials report many groups not served (e.g., TBI, mentally ill).
- Only 28 states offer State Plan Personal Care Option
- Fiscal crises may impede HCBS program growth
LaPlante et al, (in press); Kitchener et al, 2003
23. Conclusions
I. Participation and Expenditure Trends
- Persistence of large inter-state variation in HCBS program provision and growth
- Differential and sometimes negative participation growth
II. Data
- Continue tracking HCBS program trends
- Expand data gathering to include Home Health & Personal Care policies
III. Policy
- Medicaid LTC expenditure growth likely/necessary
- Distribution Choice 1: Medicaid vs tax cuts, military spending etc
- Distribution Choice 2: Institutional vs HCBS
- HCBS: cost controls, provider supply, regulation, quality
- Large waiting list (e.g. Texas) and long wait times for waiver services