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)

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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

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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

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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)

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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

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6. Medicaid Long Term Care

• Resource demands of institutional provision (e.g., nursing homes) and
• Mounting pressures to extend HCBS:
  1. Poor quality of Nursing Home care & increasing costs (IOM 2001)
  2. Consumer preferences for HCBS, especially by disabled
  3. Legal pressures including Americans with Disability Act (1990) & the Olmstead decision (1999). Litigation against states & settlement agreements

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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%

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18. "Caps" on Waiver Expenditures, 2002

"Cap"	Percentage
Maximum amount limit	37%
Average limit	15%
Others	29%
Unknown	15%

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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%

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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

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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

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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

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23. Conclusions

I. Participation and Expenditure Trends

1. Persistence of large inter-state variation in HCBS program provision and growth
2. Differential and sometimes negative participation growth

II. Data

1. Continue tracking HCBS program trends
2. Expand data gathering to include Home Health & Personal Care policies

III. Policy

1. Medicaid LTC expenditure growth likely/necessary
2. Distribution Choice 1: Medicaid vs tax cuts, military spending etc
3. Distribution Choice 2: Institutional vs HCBS
4. HCBS: cost controls, provider supply, regulation, quality
5. Large waiting list (e.g. Texas) and long wait times for waiver services

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