Challenges, Opportunities, and Advocacy

Research shows that home- and community- based services are cost effective over the long-term. Additionally, individuals prefer care in the community to institutional care. With regard to expanding home- and community-based services in Medicaid, several challenges confront advocates.

State Budget Crises and Optional Service Cuts
State budget crises put optional Medicaid benefits at risk. Most home- and community- based long term services are optional in Medicaid. Therefore, these services have been and will continue to be a target for state cuts. However, cutting home- and community-based services can be short-sighted in terms of service costs over the long-run and in terms of constituent satisfaction.

To get increased federal Medicaid matching funds under the American Recovery and Reinvestment Act (the stimulus package, ARRA), states must maintain Medicaid eligibility. They do not need to maintain services, leaving cuts to optional services open for states. Advocating for states to maintain optional services is a key challenge for advocates. Advocates need to remind elected officials that recipients of Medicaid optional services are voting constituents or relatives of voting constituents and most would prefer care in the community, that community based care is less costly in the long-run, and that the need for long-term services is only increasing—building capacity for community-services is important to meeting long-term need.

Advocacy Opportunities and Health Reform
Health reform presents opportunities for advocates to make the case for states to provide more home- and community-based services. It includes two new programs that provide added federal matching funds for home- and community-based services.

• The Community First Choice Option gives states a 6 percentage point increase in federal matching funds for costs associated with a new personal attendant benefit in Medicaid.
• The State Balancing Incentives Payment Program is available to states that spent less than 50 percent of their Medicaid long-term services budget on HCBS in 2009. Qualifying states can apply for a 2 or 5 percentage point increase in federal matching dollars for Medicaid HCBS. In return, states must implement administrative changes designed to increase use of HCBS in Medicaid.

Both programs are outlined in Helping People with Long-Term Health Care Needs: Improving Access to Home- and Community- Based Services in Medicaid and Long-Term Services: Overview of Health Reform Provisions.

Advocates can push states to take up these optional programs. If successful, these programs can be a platform for broader, sustained expansion of home- and community-based services in Medicaid.

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