Institutional Arrangements in State Medicaid Governance and their Relationship to Medicaid Long-Term Service and Support Policy Development
Open AccessState Medicaid programs finance institutional long-term care arrangements, such as nursing facilities or intermediate care facilities, as well as a range of home- and community-based services (HCBS). HCBS are an alternative to more-common institutional services and allow individuals to remain in their homes or communities. Because HCBS may be more targeted than institutional services, they can also be less costly as a result. While state Medicaid spending for long-term care has historically heavily been dominated by institutional care, both states and the federal government recognize the potential fiscal benefit offered by more cost-effective delivery of long-term services and supports (LTSS) and both levels of government have made incremental and systematic shifts in systems of long-term care to work toward the goal of greater access to and use of HCBS. This shift is typically referred to as “rebalancing” long-term care systems. While states face the same federal regulatory environment and the same financial incentives, Medicaid LTSS systems range broadly in the services offered, reimbursement mechanisms, and covered populations. This may stem from different political, fiscal, demographic, or ideological environments within states, but it can also differ from the institutional arrangements within states’ Medicaid policymaking structures. These institutional arrangements can result in different state approaches to the same policy goal, and can be linked to progress toward even a widely-shared policy goal.The perceived and potential influences of such organizational and institutional features within states’ Medicaid LTSS systems were explored here through a case study approach. Primarily, the research sought to identify which institutional features within states and their Medicaid long-term care systems might hinder or facilitate adoption of expansions in HCBS and thus, progress towards more rebalanced Medicaid LTSS systems. This was investigated through comprehensive case studies conducted among two Medicaid programs in Maryland and North Carolina. These case studies revealed key features that are cited by respondents as important features of their policymaking environment, such as complex, networked governance arrangements; positive relationships among participants in the policymaking process; widespread agreement about policy goals; and equitable participation from stakeholders in Medicaid policy development. In particular, the relationships between and among state agencies and their staffs and among the larger stakeholder community were cited repeatedly as key to states’ abilities to move forward reforms. While the experience of these two states is unlikely to translate directly to other states, this offers guidance to state Medicaid agencies, and can provide some input for other states desiring to expand their HCBS programs or simply enhance the functioning of their LTSS governance arrangement. This research also provides direction for additional research regarding LTSS policy development and administration of Medicaid LTSS systems.
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