Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers
Wide variation exists within dimensions and indicators
Wide variation exists within all dimensions, with low-performing states being markedly different from those that score high. In many cases, low-performing states have not adopted public policies that increase access to services or that enable consumers to exercise choice and control. Substantial variations also are found in the quality of service delivery and in measures of support for family caregivers.
State Medicaid policies dramatically affect consumer choice and affordability
Medicaid is the primary source of public funding for LTSS. It plays a leading role in determining the extent to which low-income older people, people with disabilities, and their families receive support through home- and community-based services (HCBS). It also affects the extent to which people with LTSS needs who want to avoid entering nursing homes are able to do so, by facilitating or hindering the choice of alternative settings, such as assisted living and supportive services in the home.
This is an area over which states have direct control, and some states have led the way to improve access and choice in Medicaid. These policy decisions are reflected in the proportion of Medicaid LTSS spending that states devote to HCBS and their success in supporting new program participants' choice of HCBS, as opposed to nursing homes.
Support for family caregivers goes hand in hand with other dimensions of high performance
The Scorecard reports on assistance for family caregivers by assessing whether they are receiving needed support and by examining state laws that can aid caregivers. But the most meaningful support for caregivers is a better overall system that makes LTSS more affordable, accessible, and higher quality, with more choices. Thus, high state scores on access, affordability, and choice may reflect states' recognition that caregivers are essential and policies that aid them include building a strong overall system. Very few states that score highly on support for family caregivers score poorly on other dimensions, and few states that score poorly on the caregiving dimension are ranked in the top quartile overall.
States can improve their performance by exceeding the federal requirements for the Family and Medical Leave Act and mandating paid sick leave to help working family caregivers, as well as preventing impoverishment of the spouses of Medicaid beneficiaries who receive HCBS. States also can implement programs to assess the needs of family caregivers and provide respite care and other services to help support their ongoing efforts.