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Older adults are not “drawn out of the woodwork” to try to qualify for Medicaid benefits when a state expands home- and community-based services, according to the findings of a new study. 

The results counter concerns from the nursing home industry and state policymakers that long-term services and supports spending will increase if state Medicaid programs are rebalanced to enable more people aged 65 or more years to age in place, according to authors Brian E. McGarry, PT, PhD, an assistant professor of geriatrics and aging at the University of Rochester, and David C. Grabowski, PhD, a professor of health care policy at Harvard Medical School.

“Our article suggests this concern is unfounded and that expansion of HCBS leads to less nursing home spending and more individuals receiving HCBS,” they wrote earlier this month in the Journal of the American Geriatrics Society.

McGarry and Grabowski’s analysis included data for 1999-2017 from various sources for 45 states (all but Arizona, California, New Mexico, Oregon and Rhode Island) and Washington, DC.

“One of the really interesting results from our study is that when a state expands [HCBS] spending by a dollar, you’re actually getting a 26-cent offset in terms of nursing home spending. A dollar put into home- and community-based care goes further,” Grabowski told McKnight’s Senior Living. “A dollar spent on nursing home care is just a dollar, but a dollar spent on home- and community-based care generates some savings, and I think that’s a really important story or lesson for state policymakers. No, it’s not free. You’re going to have to spend more, but your money’s going to go further, by both expanding benefits for the setting where most of us want care — and that’s in the community — but also shrinking the number of folks who are in a nursing home.”

On a per-person basis, the study results suggest that state Medicaid programs can fund almost three HCBS waiver slots for the cost of one nursing home bed, McGarry and Grabowski said. 

Although the study did not look specifically at assisted living providers who offer HCBS to residents through state waivers, 18% of assisted living residents rely on Medicaid to pay for daily services (assisted living room and board is not covered), and 61% of assisted living communities are Medicaid-certified, according to the National Center for Assisted Living.

“Certainly assisted living, although it’s a small part of this story, is a big part of what’s happened in nursing homes over the last 25 to 30 years,” Grabowski said.

HCBS, private-pay assisted living and some Medicaid assisted living are reducing the number of individuals who are living in nursing homes, he added. “A lot of data suggest that we have lower occupancy, but we also have increased acuity in nursing homes, because a lot of individuals who previously would have been there today are in the community or in assisted living.”

“Strong” evidence exists that some family caregivers of LTSS recipients who are living with dementia prefer that their loved one not age in place in their homes, however, according to the researchers.

“There’s always going to be a group for whom nursing homes … and assisted living are probably the preferred settings,” Grabowski said. “That sounds backwards to a lot of people, but I’ve argued this. We’re always going to need nursing homes, and we should be expanding home- and community-based care, and I think those aren’t opposing views or conflicting forces.”

Previous research by Grabowski (see here and here) has shown that “when you expand private-pay assisted living, you’re largely taking out private-paying nursing home residents and shifting them to assisted living,” he said. “And then the other effect we saw was acuity. …The higher-acuity residents are left in nursing homes. The expansion of assisted living, at least in private-pay, has really meant fewer private-paying residents in nursing homes, and those that are there are higher acuity.”

An “interesting” follow-up study to the one recently published in JAGS would be “to think more narrowly about what it means in those states or markets that are fully invested in Medicaid assisted living … to determine what impact that has had on Medicaid use in nursing homes,” Grabowski said.