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The Association Between State Medicaid Programs’ Investments in Home and Community-Based Services and Characteristics of Nursing Home Residents Open Access

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Over the past several decades, the federal government and state Medicaid programs have made investments with the intent to serve more individuals in home and community-based settings and fewer in institutions. Although the majority of national Medicaid spending on long-term services and supports (LTSS) is currently on home and community-based services (HCBS), state spending on and investment in HCBS varies widely. This dissertation explored the relationship between Medicaid programs’ HCBS investments and nursing facility residents’ characteristics. The primary dataset was from Brown University’s Shaping Long Term Care in America Project and includes nursing facility characteristics and aggregate resident acuity data. Fixed effects models at the facility level were used to examine whether HCBS investments were associated with the prevalence of clinical characteristics in nursing facility residents that indicate they could have potentially been served through HCBS.These outcomes were measured using variables that specify (1) the percent of facility residents with low care needs, (2) residents’ limitations in activities of daily living, (3) the percent of residents with a low score on a cognitive impairment scale, and (4) the percent of residents who are under age 65. The policies examined include participation in HCBS-promoting initiatives and the presence of waiting lists for HCBS, a proxy for potential unmet need for HCBS. The dissertation hypothesized that HCBS investments would be associated with fewer residents with needs implying they could be taken care of in the community, and fewer residents under age 65. Furthermore, it was expected that the presence of a waiting list for 1915(c) waivers would be associated with the opposite as evidence of unmet need for HCBS.The results of the fixed effects models showed that, in general, participation in HCBS-promoting initiatives in the states where facilities were located did not correlate with a lower percent of residents with low care needs, and were in many cases associated with a higher percentage of residents with low care needs. Increasing the ratio of waiting list length to the number of individuals receiving waiver services was associated with increased nursing facility acuity. The results suggest the presence of a woodwork effect from increased Medicaid investments in HCBS that also draws lower-acuity beneficiaries into institutions. Other significant effects were found for state nursing facility payment policies and facility characteristics, suggesting that these play a bigger role than participation in HCBS investments in influencing nursing facility resident characteristics.This dissertation contributes to the body of literature evaluating the effects of policy interventions on HCBS use, which may be of particular interest as policy makers consider renewing or building upon certain HCBS programs.

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