Home & Community-Based Services: State-Only Funded Programs.
Martin Kitchener, Alice Wong, Micky Willmott and Charlene Harrington
UCSF National Center for Personal Assistance Services
States may be required to contribute match funding to some federally funded long-term care (LTC) programs and to different extents. In FY 2005 states spent 22.9% of total state expenditure on Medicaid (NASBO, 2006: 45). Total expenditures for HCBS are increasing and totaled $17.1 billion in FY 2003, with states paying 5.1 % and 4.8 % on total health care expenditures on HCBS in FY 2002 and 2003, respectively (Milbank 2005: 13). Medicaid spending grew quickly in the early 2000s, forcing state legislatures and officials to investigate ways to contain Medicaid costs rather than expanding services (Coleman et al 2003).
This paper introduces some of the other, non-waiver public funds that are used to fund HCBS, concentrating on (1) state-only funded HCBS programs, (2) Older Americans Act funds and (3) non-waiver, Medicaid funds. Evidently, like Medicaid programs, some of these have been affected by the budget crises that many states have experienced over the last few years. A table accompanies this paper and selected findings are reported below.
2. State funded LTC programs
State-funded programs vary in size and scope (Summer 2001) and the funding method also varies, with some being funded through general state revenue (taxes) and others using creative methods such as revenue from state lotteries or tobacco settlement monies. A recent report suggested that the advantage of state-funded HCBS is that they are not constrained by federal regulation and can cover people who might not otherwise be eligible for support (Summer 2001). Summer found that although 50 states report having state-funded multi-service programs for HCBS, some of these funds are used to match federal funds provided through the Older Americans Act or block grants. In the table accompanying this paper, we report the state-only funded programs separately from those funded partially by matching federal funds (e.g. the programs included in the accompanying table are those which are exclusively funded by state revenue and do not include OAA programs which are funded by states and the federal government).
Wiener et al found that state-only funded HCBS programs tend to be used to supplement Medicaid funding (2002) but that the use of personal care options (non-waiver Medicaid services, see below) and state-only funds is more financially burdensome for states, therefore leading them to rely mostly on Medicaid waivers. Wiener et al studied the LTC system of 7 states in detail (Alabama, Indiana, Kentucky, Maryland, Michigan, Washington and Wisconsin). Out of these, all had state-only funded programs although only Washington, Indiana and Kentucky's were large programs that serve over 10,000 people (2002). The table we present reflects this finding that most state-only funded programs are relatively small in terms of the amount spent and population served.
Whilst Wiener et al concur with Summer's assertion that state-only funded programs tend to fill the gaps in Medicaid coverage, it found that Washington and Indiana both have "very flexible service structures" although no states ran programs which did not have eligibility requirements and cost containment strategies such as individual expenditures. Some state-only funded programs have waiting lists although, as Wiener et al note, these are caused by limited state funds rather than limits on number of participants ('slots'), as is the case with Medicaid waivers (2002).
3. Key trends
Most States (and the District of Columbia) have state-only funded HCBS programs (n = 48) covering mostly elderly and/or physically disabled adults. The three states where no programs have been found are Missouri, Mississippi and Montana. A total of 157 state-only funded programs have been found, although other authors have found less than this (Summer and Ihara 2004). However, 14 states have programs which have been reported in secondary sources as being state-funded but do receive funding from other sources (Arizona, Alabama, California Connecticut, Delaware, Florida, Indiana, Massachusetts, Minnesota, New York, Oklahoma, Texas, Vermont, Wyoming). The largest participation on a state-only funded HCBS program was the 'Options' Program in Pennsylvania that cost $207 million in 2002 and served almost 230,000 people, devoting state lottery revenue to funding services for seniors. The state with the most state-only funded programs is Delaware with 6 programs.
Coleman, Barbara and Fox-Grage, W (July 2003) State long-Term Care: Recent Development and policy developments 2003 update National Conference of State Legislatures, Washington D.C.
Friss Feinberg, Lynn (2004) State Support for Family Caregivers & Paid Homecare Workers. NGA Center for Best Practices Aging Initiative: Issue Brief June 25 2004. National Governor's Association. http://www.subnet.nga.org/ci/assets/4-caregivers.pdf
Georgetown University (2007) Medicaid and long-term care. Georgetown University Long-Term Care Financing Project. At: http://ltc.georgetown.edu/pdfs/medicaid2006.pdf
Georgetown University (2007) National spending for long-term care. Georgetown University Long-Term Care Financing Project. At: http://ltc.georgetown.edu/pdfs/natspending2007.pdf
Georgetown University (2004) Who pays for long-term care? Georgetown University Long-Term Care Financing Project. At: http://ltc.georgetown.edu/pdfs/whopays2004.pdf
Milbank Memorial Fund (2005) 2002-2003 State Health Care Expenditure Report co-published by the Milbank Memorial Fund, the National Association of State Budget Officers and the Reforming States Group. At: http://www.milbank.org/reports/05NASBO/NASBO2005.pdf
Milbank Memorial Fund (April 2003) 2000-2001 State Health Care Expenditure Report co-published by the Milbank Memorial Fund, the National Association of State Budget Officers and the Reforming States Group. At: http://www.milbank.org/reports/2000shcer/index.html#community
National Association of State Budget Officers (2006) 2005 State Expenditure Report NASBO. At: http://www.nasbo.org/Publications/PDFs/2005%20State%20Expenditure%20Report.pdf
National Association of State Budget Officers (2004) 2003 State Expenditure Report NASBO. At: http://www.nasbo.org/Publications/PDFs/2003ExpendReport.pdf
Summer, Laura (2001) State-funded Home and Community-based Service Programs National Governor's Association. At: http://www.nga.org/cda/files/031901SERVICEPROG.pdf
Summer, Laura (2003) Choices and Consequences: the availability of community-based long-term care services to the low-income population. Georgetown University Long Term Care Financing Project, May 2003. At : http://ltc.georgetown.edu/pdfs/choicesfull.pdf
Summer, L & Ihara, E (2004) State-Funded Home and Community-Based Service Programs for Older People. AARP. At: http://assets.aarp.org/rgcenter/post-import/2004_11_hcbs.pdf
Wiener, Joshua, Jane Tilly & Lisa Maria Alecxih (2002) Home and Community Base Services in Seven States. Health Care Financing Review, Spring 2002. Volume 23, no.4
References for State-only funded HCBS programs table
1 Wiener JM, Tilly J & Alecxih LMB (2002) Home and Community-based Services in Seven States. Healthcare Financing Review Spring 2002, volume 23, number 3.
2. Wiener JM & Goldenson, Susan (2001) HCBS for older people & younger persons with disabilities in Alabama: Final Report The Urban Institute for the US Dept of HHS. http://www.urban.org/url.cfm?ID=410364
3 Friss-Feinberg L, Newman, S, Gray, L, Kolb, K, Fox-Grage, W (2004) The state of the States in Family Caregiver Support: a 50-State Study. Family Caregiver Alliance.
4 Summer, L & Ihara, E (2004) State-Funded Home and Community-Based Service Programs for Older People. AARP.
5 State of Alaska Dept of Health and Social Services, Division of Boards and Commissions: 'Alaska Commission on Aging State Plan for Health Services' June 14 2004-June 13 2004 http://www.hss.state.ak.us/acoa/FINALSTATEPLAN2004-2006.pdf
6 Arizona Health Care Cost Containment System 2005 Overview, Chapter 3 Arizona Long Term Care System. http://www.ahcccs.state.az.us/publications/overview/2005/Chap3_2005.pdf. Arizona Senior Resources. http://www.de.state.az.us/senior/caregivers.asp. State of Arizona Dept of Economic Security Annual Report State Fiscal Year 2003, July 1 2002 – June 30 2003 http://www.de.state.az.us/aaa/pdf/AAA-AR-2003.pdf
7 California Linkages Program http://www.aging.ca.gov/html/programs/linkages.html California Long Term Care County Data Book http://www.caads.org/ltcdata/ltc_data.html
8 Eiken, Steve & Heestand, A (2003) Promising Practices in Long Term Care System Reform: Colorado's Single Entry Point System. Medstat for DHHS. http://www.cms.hhs.gov/PromisingPractices/Downloads/coseps.pdf. Colorado Dept of Health Care Policy and Financing FY04-05 Total Appropriation http://www.chcpf.state.co.us/HCPF/Budget/Budgetindex.asp. Lisa Chevalier 'Promising Practices in Home and Community Based Services: Colorado Simplified Access to Nursing Home Alternatives.' Medstat for CMS. http://www.cms.hhs.gov/PromisingPractices/Downloads/cosa.pdf. Adult Assistance Programs A Fact Sheet. Colorado Dept of Human Services. July 2005. http://www.state.co.us/gov_dir/govnr_dir/ospb/budget/factsheets/ humanservices/dhs-jul2005-adultassist.pdf
9 2-1-1 InfoLine, Connecticut Statewide Respite Care Program http://www.infoline.org/InformationLibrary/Documents/ Statewide%20Respite%20Care%20Program%20fj.asp. Connecticut Elder Law Newsletter May 26, 2004. http://www.ctelderlaw.org/. Connecticut Alzheimer's Association Chapter, Fact Sheet on Respite Care http://www.alzct.org/Resources/alzheimers_respite_care.html
10 Information on Delaware Health and Social Services, Division of Services for Aging and Adults with Physical Disabilities programs from: http://www.dhss.delaware.gov/dhss/dsaapd/index.html Clearinghouse for the Community Living Exchange Collaborative, Delaware NFT II Summary http://www.hcbs.org/htmlFile.php/fid/517/did/164/. Delaware Dept of Health and Social Services, Service Specification # VI Statewide Respite Care, Revised 7/13/06. http://www.dhss.delaware.gov/dhss/dsaapd/files/community_living_companion_respite.pdf, Respite Care in Delaware: a critical need for change. A Report of the Respite Care Task Force of the Family Support Initiative, Center for Disability Studies, University of Delaware. Fall 2003. http://www.udel.edu/cds/reports/respitecarereport.pdf
11 Summer, Laura (2001) State-funded Home and Community-based Service Programs National Governor's Association. http://www.nga.org/Files/pdf/031901SERVICEPROG.pdf
12 Florida Department of Elder Affairs. Community Based Services to Help Elders Remain in their Homes, at: http://elderaffairs.state.fl.us/english/seniorcomp.html Florida Dept of Elder Affairs. 2006 Summary of Programs and Services, at: http://elderaffairs.state.fl.us/english/GLR/sops2006/Entire%20Document.pdf
13 Iowa Dept of Elder Affairs. Senior Living Program. http://www.state.ia.us/elderaffairs/services/srliving.html
14 Illinois Dept on Aging http://www.state.il.us/aging/
15 Tilly, J & Goldenson, S (2001) HCBS for older people & younger persons with disabilities in Indiana. http://www.urban.org/publications/410083.html
16 Kansas Dept on Aging Annual Report 2005. http://www.agingkansas.org/kdoa/legislative/2005_Annual_Report.pdf Kansas Dept on Aging Annual Report 2003. http://www.agingkansas.org/kdoa/legislative/AnnualReport2003.pdf Kansas Dept on Aging, 2000 Kansas Dept on Aging Annual Report FY 2000 Executive Summary http://www.agingkansas.org/kdoa/legislative/annual_fy_2000.htm. Kansas Dept on Aging Program Descriptions http://www.agingkansas.org/kdoa/programs/progdescriptions.htm
17 Kentucky Cabinet for Health Services Olmstead Compliance Plan FY2002 through FY2012. http://chfs.ky.gov/ols/olmstead/. KY Cabinet for Health Services, Division of Aging Services, Personal Care Attendant Program . http://chfs.ky.gov/agencies/os/dail/pcap.htm
18 The Massachusetts Rehabilitation Commission, Agency Programs and Divisions. http://www.mass.gov/?pageID=eohhs2terminal&L=4&L0=Home&L1=Government&L2= Departments+and+Divisions&L3=Massachusetts+Rehabilitation+Commission& sid=Eeohhs2&b=terminalcontent&f=mrc_g_programs&csid=Eeohhs2
19 Mollica, R (2001) Personal Care Services: A comparison of 4 states, AARP. http://assets.aarp.org/rgcenter/health/2001_04_care.pdf
20 Mass.gov, Elders Affairs Dept website, Home Care Program Overview. http://www.mass.gov/?pageID=elderstopic&L=2&L0=Home&L1=Home+Care&sid=Eelders
21 Tilly, J & Kasten J (2001) HCBS for older people & younger persons with disabilities in Maryland. The Urban Institute for Dept of Health and Human Services. http://www.urban.org/publications/410085.html. Community Services Administration (Maryland) Annual Report 2002. http://www.dhr.state.md.us/download/csarpt.pdf. Maryland Dept of Human Resources. Office of Personal Assistance Services, Attendant Care Program. http://www.dhr.state.md.us/how/srvadult/attend.htm Maryland Dept of Human Resources, Office of Adult Services, Adult Care Services. http://www.dhr.state.md.us/how/srvadult/care.htm, Project Home http://www.dhr.state.md.us/oas/projhome.htm, In-Home Aide Services http://www.dhr.state.md.us/oas/aide.htm
22 Dept of Health and Human Services, Bureau of Elder and Adult Services State and Medicaid long term care expenditures FY97-FY01 http://www.maine.gov/dhhs/beas/ltc/ltc_exp_97_01.htm & Dept of Health and Human Services, Bureau of Elder and Adult Services, State Plan on Aging Oct 1 2004 - Sept 30 2008. http://www.maine.gov/dhhs/beas/stateplan/2005/plan_2004_2008.htm
23 Tilly, J & Kasten J (2001) HCBS for older people & younger persons with disabilities in Michigan http://www.urban.org/url.cfm?ID=410092
24 Minnesota Dept of Human Services Aging Initiative (June 2006) The Status of Long Term Care In Minnesota, 2005, Report to the Minnesota Legislature http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased& Rendition=Primary&allowInterrupt=1& noSaveAs=1&dDocName=dhs_id_059536 Minnesota Dept of Human Services Aging Initiative (May 2004) The Status of Long Term Care In Minnesota, 2003, Report to the Minnesota Legislature http://www.dhs.state.mn.us/aging/documents/pub/dhs_id_026183.pdf
25 Governor's Council on Disability. Missouri's Guide to Home and Community Based Services http://www.gcd.oa.mo.gov/pdf/GCDServices.pdf
26 North Dakota Dept of Human Services. Home and Community-Based Services. http://www.nd.gov/humanservices/services/adultsaging/homecare.html
27 Horvath, J & Thompson, R (2003) Promising Practices in Long Term Care System Reform: New Hampshire's Community-based Service System for People with Developmental Disabilities. Medstat for DHHS. http://www.cms.hhs.gov/PromisingPractices/Downloads/nhcbsdd.pdf
28 Reinhard, Susan & Fahey, C (2003) Rebalancing Long Term Care in New Jersey: from institutional toward home and community based care. Milbank Memorial Fund. http://www.milbank.org/reports/030314newjersey/Rebalancing_Mech.pdf, Silberberg, Mina & Caruso, D (2001) New Jersey's Statewide Respite Care Program: a study of program design, implementation, clients and services. Rutgers University. http://www.cshp.rutgers.edu/PDF/Respite_report.pdf & Promising Practices in Home and Community based Services: New Jersey Statewide Respite Care Services. http://www.hcbs.org/files/38/1877/NJStatewideRespite.pdf
29 New Mexico Dept of Health. Developmental Disabilities Supports Division, State General Funded Services. http://www.health.state.nm.us/ddsd/sgfserviceswebsitedev/stategeneralfundedsvcspg01.htm
30 State of Nevada Dept of Human Resources. Strategic Plan for People with Disabilities. October 2002 http://hr.state.nv.us/shcp/documents/Disability_Documents/StrategicPlan-Disability.pdf
31 New York State Office for the Aging. Visitor's Guide. http://aging.state.ny.us/home, NYC Dept for the Aging (DFTA) Annual Plan Summary 2006-07 http://www.nyc.gov/html/dfta/downloads/pdf/public_hearings/publichear_annualplan9-05.pdf
32 Ohio, Franklin County Senior Options http://www.officeonaging.org/fcso/. State of Ohio Long Term Care Consumer Guide. Paying for Long Term Care. http://www.ltcohio.org/consumer/index.asp?html=PayingCare
33 Justice, Diane & Heestand, A (2003) Promising Practices in LTC Systems Reform: Oregon's Home & Community-Based Services System. Medstat for CMS. http://www.cms.hhs.gov/PromisingPractices/Downloads/orhcbss.pdf
34 Pennsylvania Dept of Aging. Programs & Services for older Pennsylvanians At: http://www.aging.state.pa.us/aging/cwp/view.asp?a=3&q=197606.
35 Eiken, Steve & Heestand, A (2003) Promising Practices in LTC Systems Reform: South Carolina's Services for older people and people with physical disabilities. Medstat for CMS. http://www.cms.hhs.gov/PromisingPractices/Downloads/scsop.pdf
36 Tennessee Commission on Aging and Disability, State Plan on Aging FY 2006-2009. http://www.state.tn.us/comaging/State%20Plan%20pdf.pdf HCBS Options for Community Living FY02 Annual Performance Report.
37 Utah State Division of Aging & Adult Services Annual Report 2005. http://hsdaas.utah.gov/pdf/2005_DAAS_Annual_Report.pdf Utah State Division of Aging & Adult Services Annual Report 2003. http://hsdaas.utah.gov/pdf/2003_DAAS_Annual_Report_Revised.pdf
38 Justice, Diane (2003) Promising Practices in LTC Systems Reform: Vermont's Home & Community-based System. Medstat for CMS. http://www.cms.hhs.gov/PromisingPractices/Downloads/vthcbss.pdf
39 Wiener, JM & Lutzky, S HCBS for older people & younger persons with disabilities in Washington: final report The Urban Institute for the US Dept of HHS. At: http://www.urban.org/url.cfm?ID=410355
40 HCBS for older people & younger persons with disabilities in Wisconsin: final report Urban Institute for the US Dept of HHS. http://www.urban.org/publications/410355.html Family Support Program http://dhfs.wisconsin.gov/bdds/fsp.htm
41 West Virginia Bureau for Behavioral Health and Health Facilities. Divison for Developmental Disabilities. http://www.wvdhhr.org/bhhf/mrdd.asp
42 Wyoming Developmental Disabilities Division. Respite Services Page. http://ddd.state.wy.us/Documents/heather1.htm
43 Alabama Department of Rehabilitation Services Annual Report 2003. http://www.rehab.state.al.us/Home/ADRS%20News/Annual%20Reports/2003%20Annual%20Report.pdf
44 State of Alaska Department of Health and Social Services Fiscal Year 2006 Budget Overview. http://www.hss.state.ak.us/das/budget/pdfs/overview.pdf
45 California Department of Aging 2006/07 Aging Services Data Report. http://www.aging.ca.gov/html/whatsnew/Aging_Services_Data_Report.pdf
46 Colorado Department of Health Care Policy and Financing FY 07-08 Budget Request, Schedule 3, By Long Bill Group and Line Item, Table F, Other Medical Services. http://www.chcpf.state.co.us/HCPF/Budget/07-08Reqests/Sch%203%20OMS.pdf
47 Report to the Twenty-Third Legislature, State of Hawaii, Regular Session of 2006, Executive Office on Aging. http://www4.hawaii.gov/eoa/pdf/2005_Annual_Report.pdf
48 Community and Home Options to Institutional Care (CHOICE) for the Elderly and Disabled, Annual Report SFY 2006, Family and Social Services Administration, State of Indiana. http://www.state.in.us/fssa/elderly/options/pdf/CHOICE-2006%20Annual%20Report.pdf
49 Health Care Resource Book, 2006, Colorado Legislative Council. http://www.state.co.us/gov_dir/leg_dir/lcsstaff/2006/research/06HealthCareResourceBook.pdf