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HCBS poised to expand: Wait lists reveal large unmet need
States have some good fiscal opportunities to expand home- and community-based services (HCBS) in the Patient Protection and Affordable Care Act (PPACA), according to Charlene Harrington, RN, PhD, FAAN, director of the University of CaliforniaSan Francisco's National Center for Personal Assistance Services. However, an initial investment is required to set up the programs, says Dr. Harrington, and states face budget shortfalls.
The January 2011 AARP report, Weathering the Storm: The Impact of the Great Recession on Long-Term Services and Supports, showed "a pretty steady trend upward" in HCBS, notes Dr. Harrington. "But there are these huge waiting lists in states," she says. "That is a big concern. It obviously shows there is a lot of unmet need."
Lawsuits putting pressure
The current financial crisis may mean that some states can't take advantage of the opportunities to expand HCBS, says Dr. Harrington. However, there is no question that states face "tremendous pressure" from their constituents to do so, she says.
There are also lawsuits in 34 states currently, says Dr. Harrington, which are putting additional pressure on states, and most court rulings have been in favor of the plaintiffs. In 1999, the Supreme Court ruled that individuals have the right to live at home or in the community if they are able to and choose to do so, rather than to be placed in institutional settings by the government, notes Dr. Harrington. That decision resulted in a number of subsequent lawsuits against states, she explains, which are putting additional pressure on states to "rebalance" their services from institutional to HCBS.
"The lawsuits are primarily for failure of state Medicaid programs to provide adequate HCBS, to prevent individuals from being institutionalized unnecessarily," says Dr. Harrington. Some of the lawsuits are against states that had placed large numbers of individuals into institutions and have failed to help those who want to go to home and community settings, she explains.
In addition, says Dr. Harrington, it's a violation of the Americans with Disabilities Act to keep people in institutions if they can be in the community. "The momentum is on the side of the plaintiffs," she says.
Savings are possible
Expanding HCBS programs isn't necessarily going to cost states more money, according to Dr. Harrington. "In fact, we've shown over time that the states that have expanded the most saved the most money," she says.
States can probably save some money by implementing HCBS programs, says Dr. Harrington, as long as they control the admission to the nursing homes. "The fear is that these new options will be implemented, but the nursing homes will still be filled," she says. "That would cost them more money."
For this reason, many states put some controls on their nursing home admissions, and then try to set up a program so people can stay in the community, says Dr. Harrington.
The PPACA gives some significant financial incentives for states to implement HCBS programs, adds Dr. Harrington. "States can get an increase in federal match, but they still have to come up with the money to get the federal match," she says. "The question is whether the financial crisis will prevent them from doing this."
If states want to take advantage of the new opportunities, she explains, they have to increase the amount they spend in order to get the match, and this may not be possible.
States may in fact, choose to cut HCBS because they are optional programs, says Dr. Harrington. "States may do this when money gets tight, but I don't think they have explored the overall implications," she says.
Cutting HCBS programs costs the state more in terms of ER visits and hospitalizations, Dr. Harrington notes. "States need to take a close look at the consequences before they implement that kind of policy," she says. "That could increase the overall cost of care."
Contact Dr. Harrington at (415) 476-4030 or Charlene.Harrington@ucsf.edu.