Transcript Medicaid & Supporting People with Developmental Disabilities

Medicaid & Supporting
People with
Developmental
Disabilities
Trends, Challenges, and
Opportunities
Gary Smith
HSRI
May 21, 2003
Medicaid is the linchpin
Underwrites primary health care for
at least 1.4 million individuals with
mental retardation and other
developmental disabilities
EPSDT is very important in
supporting children with disabilities
in low-income households
Adults – Rely on Medicaid for
primary health care
Underwrites long-term services and
supports for about 500,000 people
with developmental disabilities
Long-term Services and Supports
Medicaid accounts for 75%+ of state
expenditures on long-term services and
supports for people with developmental
disabilities
Key benefits: HCBS waiver, ICF/MR, and
Targeted Case Management
2002 Spending = $24.1 Billion+
HCBS waiver program: now the primary
program in virtually all states
DD LTS Medicaid Beneficiary
Growth – 1990 to 2002
Growth Rate =
8.2%/year
People with Developmental Disabilities Receiving
HCBS or ICF/MR Services
500,000
1999 – 2002
Increase:
400,000
110,000 (29%)
300,000
2002:
HCBS= 379,000
200,000
100,000
ICF/MR= 111,000
0
90
92
94
96
ICF/MR
98
HCBS
00
02
Expenditure Trends – 1990 to 2002
HCBS and ICF/MR Expenditures
Annual Total
Expenditure
Growth: 6.1%
(inflation
adjusted)
($=2002)
$25.0
$20.0
HCBS=$13.3 B
ICF/MR= +$10.8 B
$ billions
2002
$15.0
$10.0
$5.0
$0.0
90
92
94
96
ICF/MR
HCBS
98
00
02
Principal trends
ICF/MR: Slow fade
– Downsizing/closure public institutions
– Limited development of non-state facilities
HCBS Waiver Program
– States’ main vehicle for underwriting community
services
– Expenditures and number of participants have
grown very rapidly
– States have leveraged old and new dollars
through the waiver program to acquire more
federal dollars
– Outcome: HCBS waiver program fueled
expansion of community services
Shift to waiver program has –
Lowered state per capita costs
Decoupled funding from location
Aided in reducing/containing
waiting lists
Infused dollars into services for
people who live with their families
Substantially boosted dollars for
integrated employment services
Given states an enormously
flexible, agile funding stream
Dialing for dollars …
Waiverization – Unmatched state dollars
Family support – leveraging existing
dollars
In-home supports
Local match
Opportunities vary state-to-state
Going Forward
Critical Issue: State Financial Health
State budget crash
– Cuts in Medicaid: physical health; eligibility
– States throwing on the brakes on system
expansion
– Result: waiting lists are climbing fast
– Payment freezes and cuts
Prognosis – Little or no growth over the midterm
Problems:
– Most states have emptied their unmatched
dollars piggy-banks
– Going forward, slow growth in state
revenues
Outgrowth: future funding will hinge on
recovery of overall state budget
Critical Issue: Litigation
Lawsuits in 23 states over wait
listing individuals with
developmental disabilities for
Medicaid services
Other lawsuits concerning
payments, including worker wages
Aim – put home and community
services on equal footing with
entitled institutional services
Outcome and impact uncertain
Federal Focus Areas
Administrative policy changes to address
barriers to HCS across full spectrum of
people with disabilities
System change grants: aid states to
strengthen community infrastructure and
systems; pave the way for change
Consumer-direction
Quality
Consumer-direction
Movement for individual-direction of
services and supports cuts across
individuals with all types of disabilities
CMS: Independence Plus Initiative
Individual/family-directed Medicaid home
and community services are the “next big
thing” and will lead to substantial changes
in public systems (eventually)
Quality
CMS: Major focus on HCBS waiver quality
management and improvement
– Technical assistance/tool development
– Oversight
– Going forward: requirement for states to spell out fullfeatured HCBS waiver quality management/
improvement systems
States: engaged in high volume of system
enhancement/development activities
Going forward: appreciably higher quality
management expectations
State Management
The scale of HCBS waiver
programs has increased
enormously
Waiver = Community System
States are revamping program
management
Revising/rationalizing
payments/fund allocation
Reconfiguring systems and
“business model” around the
waiver program
Wrap-up
Developmental disabilities services and
Medicaid are wedded at the hip
Medicaid has fueled system growth
HCBS waiver program is a powerful
tool to expand community supports
Going forward: future hinges on
financial health of the states
Focus areas:
– Consumer-direction
– System and quality management
For more information about Medicaid
Home and Community Services
Understanding Medicaid Home and
Community Services: A Primer – available
at: http://aspe.hhs.gov/daltcp/reportsu.shtml#Smith1
Also go to: http://www.hcbs.org/index.htm
for information about a wide variety of
topics