The Senate and House will soon move forward on landmark Medicaid legislation. One critically important piece of Congress’s reconciliation package is the proposed investment in chronically underfunded Medicaid home and community-based services (HCBS) for people with disabilities and older adults. Such an investment could help reverse decades of under-resourcing HCBS and fix structural biases that incentivize institutional care rather than community-based services.
However, as the proposal moves forward, it must contain sufficient funding to meaningfully expand access to services, improve the workforce, and make significant strides towards eliminating the institutional bias.
A robustly-funded HCBS investment could:
- Give states a much-needed infusion of federal funds for HCBS via a permanent increase to states’ federal medical assistance percentage (FMAP) for these services. When states spend more on HCBS, they will receive more Federal money in return. While specific estimates regarding how much the proposal would increase federal funding to states are not yet available, a different bill that provided just a one-year 10% FMAP bump for HCBS was estimated to provide $12.6 billion in new federal funding.
- Turn current short-term investments in HCBS into more meaningful, long-term opportunities to build and sustain a better functioning HCBS system. Thanks to the American Rescue Plan Act (APRA), states received a 10% FMAP bump for HCBS expenditures to help with the immediate fallout from COVID-19. As it stands, this increase ends in March 2022, and thus will primarily help states respond to the most immediate needs for people with disabilities receiving these services. An investment now could build upon ARPA, extending the FMAP bump, and provide a stable framework for states to address longer term goals.
- Invest in the direct care workforce by addressing insufficient payment rates and requiring that rate increases are passed on to direct care workers. For example, direct support professionals, like most direct care professionals, are disproportionately women of color, and are paid a median hourly wage of only $12 an hour, with an average national turnover rate of 42% for the year 2019. Low wages and high turnover, taken together, creates gaps in available services and supports, leaving individuals with an entitlement to services, but no one to provide it.
- Improve funding for and access to behavioral health services for individuals with psychiatric disabilities. The definition of HCBS in proposals to date have rightfully included behavioral health services, instead of limiting the definition of HCBS to special waiver-funded services that primarily assist individuals with physical, intellectual, or developmental disabilities. This approach breaks down disability-specific silos that exist between Medicaid services funded via different authorities, and dismantles barriers to cross-disability reform efforts.
- Potentially make more than three million new individuals eligible for HCBS by expanding the financial eligibility for the services. If the package requires states to raise the income limits for HCBS waivers to the maximum allowable, as has been discussed, economists estimate this would make up to 3.2 million new individuals eligible for HCBS.
- Increase the availability of personal care services. Medicaid-funded Personal care services (PCS) provide assistance to help individuals complete the activities that they need to get through their day and continue living in the community. This includes help with things like bathing, eating, or dressing, cooking, light chores, or transportation. Seventeen states limit PCS to Medicaid enrollees who qualify for special waiver programs. These waiver programs often have years-long waiting lists. Expanding state plan PCS in these states could address immediate needs of those who need PCS but cannot access or are not eligible for these waivers.
- Require states to maintain or increase HCBS services and eligibility in exchange for increased funding. If the proposal contains a strong “maintenance of effort” (MOE) provision, this will protect enrollees from future cuts in the services or programs they rely on, and help ensure that HCBS services remain available for those who need them.
Additional Resources related to Home and Community-Based Care
Keep Essential Care: Home and Community-Based Care
Elizabeth Edwards, April 8, 2020 | Link
Keep Essential Care: Direct Service Professionals
Jennifer Lav, April 13, 2020 | Link
Disability, Race, and Structural Inequity: COVID-19 and the Long-Term Care Workforce
Dave Machledt, April 29, 2020 | Link
COVID-19 Crisis: Unspoken Impacts on Older Adults and Persons with Disabilities
Miriam Delaney Heard, May 12, 2020 | Link
Health Disparities Facing Older Adults of Color amid COVID-19: Guest Blog by Justice in Aging
Gelila Selassie, August 24, 2020 | Link
Health Equity Blog Series Summary
Zamir M. Brown, October 5, 2020 | Link
The American Rescue Plan Act: What’s it do for Health?
Mara Youdelman, March 12, 2021 | Link
The American Rescue Plan: Major Relief for People with Disabilities
Dave Machledt, March 12, 2021 | Link
The Time is Now to Vaccinate High-Risk People with Disabilities
Hannah Eichner, March 15, 2021 | Link
A Change Worth Investing In – Medicaid Home and Community Based Services
Jennifer Lav, March 16, 2021 | Link