Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers
Key Findings on Select Indicators and Public Policy Actions to Improve Performance
The Scorecard is a tool to help states improve their LTSS systems. The key findings that follow illustrate areas in which there is a large range in state performance and examples of how public policy action can lead to improvement.
Medicaid safety net
The Scorecard finds great variation in the percentage of the low- and moderate-income population with a disability in activities of daily living (ADLs) that is covered by the Medicaid LTSS safety net. In a typical month, the top five states provide Medicaid LTSS to 63 percent of this population. By contrast, in the bottom five states, coverage averages just 20 percent—less than a third of the rate in the top states. The national average is 37 percent.
Policy action: States have substantial control over establishing financial eligibility standards for Medicaid coverage. States also have great flexibility to determine the level of disability needed to qualify for services.
The five highest performing states on the proportion of Medicaid and state general revenue LTSS spending for older people and adults with physical disabilities going toward HCBS spend, on average, 60 percent of their dollars on HCBS. The average proportion of spending across the United States is 37 percent, and the five lowest performing states devote just 13 percent of Medicaid LTSS spending (for older people and adults with physical disabilities) to HCBS. Relatively few states "balance" spending, that is, spend more than half of their LTSS dollars for HCBS. The extent of such balancing in the top states is nearly five times as high as in the bottom states.
Policy action: This is an area over which state governments have tremendous control and, through their public policies, can make considerable strides in ensuring that people who need LTSS can choose non-institutional options for care. States that have improved the balance of services away from institutions and toward HCBS have taken advantage of Medicaid "optional" services such as HCBS "waivers" and the Personal Care Services option. States also can pursue new opportunities offered by the Patient Protection and Affordable Care Act to improve the balance of their LTSS systems.