Understanding Home and Community-Based Long-Term Services and Supports

An Evaluation of Medicaid's Balancing Incentive Program

by Yan Wang

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Home and community-based services (HCBS) have now become a mainstay of publicly-funded long-term services and supports (LTSS) in the United States, as the reliance on institutional long-term care is decreasing. Much of this national trend is driven by a process known as Medicaid LTSS delivery system rebalancing. The objective of my dissertation is to explore and better understand HCBS as a way to curb LTSS spending growth through an evaluation of Medicaid's most recent rebalancing effort — the Balancing Incentive Program (BIP).

The study consists of three sections. The introductory chapter gives a general overview of background information and research context. The next chapter reviews Section 1915 (c) Waivers as the standard bearer of HCBS to present a snapshot of service provision and use across states. It involves a detailed inspection and classification of HCBS to address heterogeneous definitions and scopes. Chapter 3 has two subsections which perform quantitative data analyses. The first part assesses the effectiveness of the BIP in terms of its impact on health care utilization, expenditures, and health among older adults; and the second part investigates whether the program contributes to survival benefits for the elderly population.

My dissertation illustrates the evolving landscape of LTSS; and it suggests that federal and state policies aimed at expanding HCBS as alternatives to institutional long-term care seem to be a promising practice, without driving up the utilization of and expenditures on other health care services or negatively impacting health outcomes. Under the pressure of population aging and government budget crisis, the study could make a timely contribution to the development of a more efficient and effective long-term care system in the United States.

Table of Contents

  • Chapter One

    Introduction and Background

  • Chapter Two

    Provision and Utilization of HCBS: A Comprehensive Review of Medicaid Section 1915 (c) HCBS Waivers

  • Chapter Three

    Medicaid Long-Term Services and Supports Rebalancing: Evidence from the Balancing Incentive Program

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This document was submitted as a dissertation in May 2019 in partial fulfillment of the requirements of the doctoral degree in public policy analysis at the Pardee RAND Graduate School. The faculty committee that supervised and approved the dissertation consisted of Jeanne S. Ringel (Chair), Rosalie Liccardo Pacula, and Regina A. Shih.

This report is part of the RAND Corporation dissertation series. Pardee RAND dissertations are produced by graduate fellows of the Pardee RAND Graduate School, the world's leading producer of Ph.D.'s in policy analysis. The dissertations are supervised, reviewed, and approved by a Pardee RAND faculty committee overseeing each dissertation.

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