Towards Equitable Home and Community Based Services Policy: Examining State Generosity and Disparities in Use and Health Outcomes

Abstract

Home and community-based services (HCBS) are a crucial aspect of long-term services and supports (LTSS), supporting over 7 million older adults and people with disabilities to remain in their homes and communities. Medicaid is the primary payer of HCBS, leading to significant state-level variation in investment and services design. These inequitable distributions of HCBS contribute to geographic disparities in service access and health outcomes and may exacerbate existing racial inequities in LTSS. However, the decentralized nature of HCBS design poses challenges for evaluating HCBS. Understanding how state HCBS policy decisions impact service use and health outcomes across racial and ethnic groups is critical for informing policy efforts to reduce systemic inequities. To address this, I examined one key aspect of state Medicaid HCBS design, HCBS generosity, and how it impacts HCBS use and health outcomes among older adults across racial and ethnic groups. First, I employed a mixed-methods analysis of publicly available 1915(c) Medicaid waivers serving older adults active in 2024 to characterize variation in HCBS generosity (Paper 1). Second, I assessed the relationship between four measures of Medicaid HCBS generosity and the use of any HCBS, home-based care, and case management among dual-eligible older adults across racial and ethnic groups using 2019 Medicaid administrative claims (Paper 2). Finally, I examined associations between Medicaid HCBS generosity and hospitalization and mortality among dual eligible older adults with both Alzheimer’s disease and related dementia and diabetes, a group with particularly complex care and LTSS needs, and how these relationships vary by race and ethnicity using 2018-2019 Medicare fee-for-service claims. (Paper 3). In paper 1, I found that 1915(c) waivers serving older adults varied substantially across all measured aspects, with differences in eligibility criteria and service prioritization raising concerns for inequitable access to HCBS across waivers. Qualitative findings identified concepts related to HCBS generosity that warrant further measurement consideration, such as person-centered care. Findings from paper 2 showed that greater HCBS generosity, particularly in spending share and breadth of coverage, was associated with higher HCBS and home-based care use, but not case management. Associations also varied by race and ethnicity and the different operationalizations of generosity. Non-Hispanic white and Black beneficiaries generally had higher probabilities of use than Hispanic and Asian beneficiaries, with some exceptions. Finally, findings from paper 3 indicated that higher HCBS spending share and greater HCBS breadth were associated with reduced hospitalization across racial and ethnic groups, with the strongest effects for non-Hispanic white and Asian beneficiaries; effects on mortality were smaller. Overall, these findings provide evidence for HCBS generosity as a multidimensional construct, with substantial variation across both spending and non-spending measures. Additionally, policies that expand not only spending but also the scope and accessibility of HCBS may be necessary to promote equitable utilization and health outcomes among dual-eligible older adults. Finally, further efforts are needed that not only prioritize increasing HCBS spending and coverage to support use but also ensure the quality and relevance of services to meet the needs of marginalized communities.