While Medicaid’s support for home and community-based care has been growing, nursing homes still absorb the bulk of Medicaid’s long-term care spending in most states. Medicaid’s emphasis on institutions flies in the face of the desire expressed by people of all ages who need long-term care: They would far prefer to remain at home or in the community. Research also suggests that investing resources in home and community-based care not only can provide services that people prefer but over time actually slow the growth in total long-term care spending by reducing reliance on costly institutional care.
Different approaches would expand the availability of home and community-based services in Medicaid in different ways. For example, the Community Choice Act, S. 799, introduced in the 110th Congress, would require all states to make home and community-based personal attendant services available as an option to people eligible for Medicaid nursing home services. States would receive enhanced federal matching rate for attendant care services during an initial period, as they developed these programs.
Another approach, proposed in the Empowered at Home Act, S.3327, in the 110th Congress, would allow states to extend income eligibility standards for home and community-based care to nursing home and home and community-based services waiver levels—that is, income up to 300 percent of the supplemental security income, or SSI, benefit level—and allow people to retain more assets, so they could actually afford to stay in their homes. States could also extend disability-based eligibility for home and community-based care to people whose conditions have not yet deteriorated to a nursing-home-equivalent level of need so they are actually able to manage in their homes.
These changes would overcome restrictions that have limited states’ interest in amending their state Medicaid plans—as allowed under the Deficit Reduction Act of 2005—to broaden long-term care services in the community. For states that choose to expand in these ways, the bill would also eliminate states’ ability to cap enrollment and waive state-wideness requirements. If states take up the option, these changes could assure far broader availability of home and community-based care in many states. If made mandatory, or funded more extensively by the federal government, people in need of long-term care could be better and more efficiently served in all states.
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