By Terence Ng, Charlene Harrington, and Martin Kitchener

doi: 10.1377/hlthaff.2009.0494

Medicare And Medicaid In Long-

HEALTH AFFAIRS 29,
NO. 1 (2010): 22–28
©2010 Project HOPE—
The People-to-People Health
Foundation, Inc.

Term Care

Terence Ng is a senior
research analyst in the ABSTRACT Medicare and Medicaid, two publicly funded health programs,
Department of Social and both cover populations in need of long-term care, but they are poorly
Behavioral Sciences,
University of California, San coordinated. Gaps often exist in some services while there is overlap in
Francisco. others. This can lead to inefficient delivery of services and confusion
Charlene Harrington (charlene among program recipients and providers alike. Spending on postacute
.harrington@ucsf.edu) is
services in Medicare and long-term care services in Medicaid has grown
professor emeritus of
sociology and nursing in the more rapidly than enrollment in either program since 1999. Although
Department of Social and
Behavioral Sciences,
growing numbers of people receive home and community-based services
University of California, paid for by the two programs, there are wide variations across states and
San Francisco.
among target groups. The system of long-term care is in need of
Martin Kitchener is a structural reform.
professor of public sector
management and policy,
Cardiff Business School,
Cardiff University, in Cardiff,
Wales.

L
ong-term care refers to a broad range Medicare paid for 25 percent, Medicaid and
of services and supports for people other public funds paid for 42 percent, out-
who need assistance for ninety days of-pocket funds paid for 22 percent, and pri-
or more, including those with vate insurance and other sources paid for 11 per-
chronic illnesses and a variety of dis- cent (excluding hospital-based nursing home
abilities. The need for long-term care spans the spending).3
age range from children to older people.1 Growth Medicare and Medicaid together pay for the
in the aged population, especially those age majority of long-term care.Yet the programs had
eighty-five and older, has contributed to a grow- different origins, and covered populations were
ing need for long-term care. At the same time, added at different times and for different rea-
older people may have lower disability levels sons. Medicare operates at the federal level only;
than those in previous generations and may in contrast, Medicaid has both federal and state
use fewer institutional services than elders used components. The resulting variation among
in the past.2 states’ budgets and coverage decisions adds to
Most long-term care services are provided by the overall complexity of public programs’ ser-
informal (unpaid) family caregivers: such people vices and spending within and across states. The
provided assistance to 10–11 million people liv- system of providing and paying for long-term
ing at home in 2007.1 Formal long-term care in- care in the United States reflects this piecemeal
volves two main types of services: (1) home and developmental history and shared federal-state
community-based services, such as personal responsibility. The result can be confusion
care; and (2) institutional care in nursing homes among patients and providers, amid seemingly
and intermediate care facilities for the develop- illogical patterns of insurance coverage and
mentally disabled. available services.
Most formal long-term care services are paid In this paper we explore the patterns in ser-
for by government sources. In 2007, of the total vices and spending under each program for in-
$190.4 billion in estimated spending for nursing stitutional, home care, and other long-term care
home and home health care in the United States, services. We examine the rise in home and com-

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munity-based services, the existence of waivers
from federal and state coverage requirements,
and the changing population groups who use
long-term care services. We conclude with a dis-
cussion that points toward the need to reduce the
fragmentation and lack of coordination in long-
term care services by removing the divide be-
tween Medicare and Medicaid programs in favor
of a structurally different system of providing
long-term care.
Medicare Long-Term Care Trends
POSTACUTE CARE AND HOSPICE SERVICES Medicare
provides short-term postacute care (after hospi-
talization) to beneficiaries who are aged and dis-
abled.4 To be eligible for Medicare postacute nur-
sing home and home health services, people
must require skilled care or therapy services
for short periods.4 In addition to postacute care,
the Medicare hospice benefit covers hospice care
at the end of life, in nursing homes, at home, or
in residential settings. Many nursing homes and
home health agencies provide both short-term
postacute care as well as long-term care.
After Medicare benefits are exhausted, some
individuals need long-term care services that
must be paid for out of pocket, by private insur-
ance, or by the Medicaid program for those with
low incomes and assets. Medicare also provides
acute care, medical care, and other services to
people with chronic care or long-term care
needs, or both. Examining these services is be-
yond the scope of this paper.
An estimated 4.9 million (15 percent) Medi-
care beneficiaries received short-term postacute
services, out of a total of 32 million beneficiaries
who used Medicare services in 2007 (Exhibit 1).5
During 1999–2007, the total number of Medi-
care beneficiaries grew by 10 percent, but total
Medicare spending growth grew by 39 percent.
The total number of Medicare postacute benefi-
ciaries grew by 21 percent, while their expendi-
tures increased by 75 percent. For details, see
Appendix Exhibit 1.6
From 1999 to 2007, the number of Medicare
nursing facility users increased by 32 percent,
home health users by 15 percent, and hospice
users by 110 percent, compared to spending
growth rates of 88 percent, 59 percent, and
229 percent, respectively (Exhibit 1). For these
three services, Medicare cost increases were
more than double the increases in beneficiary
use during the period.
Medicare is paying for a growing portion of
total public nursing home spending. Medicare
nursing home spending increased from 23 per-
cent in 1999 of total nursing home spending to
32 percent in 2007, while the Medicare portion
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
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of public spending for home health remained
about 80 percent during the same period (data
not shown). Home health users made up 63 per-
cent of beneficiaries and 41 percent of expendi-
tures of total Medicare postacute services in
2007 (Exhibit 1), which was about the same dur-
ing the 1999–2007 period.
Medicaid Long-Term Care Trends
MEDICAID LONG - TERM CARE SPENDING AND PARTICIPA-
TION Medicaid, as a joint federal and state pro-
gram managed by the states, is the primary payer
for long-term care services for individuals with
low incomes and assets.7 Eligibility is generally
automatic for the categorically needy (those re-
ceiving Supplemental Security Income federal
cash benefits), although eleven states have more
restrictive standards.7,8 In addition, thirty-five
states plus the District of Columbia have so-
called medically needy programs, which cover
those who spend down their assets by incurring
medical expenses and meet the state’s income
and asset requirements.8 Nursing home care and
home health are mandatory benefits, while other
long-term care services are optional.
Overall Medicaid spending grew by 48 percent,
while total long-term care spending grew by
39 percent between 1999 and 2007 (Exhibit 2).9,10
Long-term care represented about one-third of
total Medicaid spending in 2007, which was
about the same as in 1999. For details, see Ap-
pendix Exhibit 2.6
There was no change in the number of Medic-
aid institutional participants (residents), while
◀
39
institutional spending increased by 15 percent
between 1999 and 2007 (Exhibit 2). The stagna-
tion in the number of participants reflects a re- %
duction in the use of intermediate care facilities
Medicaid Long-Term
for the developmentally disabled balanced by
Care Spending
small growth in nursing facility participants
39 percent of institutional
(see Appendix Exhibit 3).6 Nursing home use recipients used 61 percent
has not kept pace with growth in the aged popu- of total Medicaid long-
lation over the period (about 17 percent among term care spending
in 2006.
those age sixty-five and older and 30 percent
among those age seventy-five and older between
2000 and 2007).11 In spite of the constraints on
Medicaid institutional participants and spend-
ing, 39 percent of institutional recipients used
61 percent of total Medicaid long-term care
spending in 2006.
MEDICAID HOME AND COMMUNITY - BASED SERVICES
Three major state Medicaid home and commu-
nity-based services programs are as follows:
(1) waivers, (2) home health, and (3) personal
care services. The waiver program (under Sec-
tion 1915[c] of the Social Security Act) allows
states to waive Medicaid requirements in order
to target specific population groups, limit the
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 EXHIBIT 1

National Medicare Postacute And Hospice Care Spending And Beneficiaries, Adjusted For Inflation, Selected Years
1999–2007
Percent change,
Program/measure 1999 2003 2007 1999–2007
Total Medicare beneficiaries (thousands) 29,363a 32,587 32,223 10%
Total Medicare spending (millions of dollars) $207,408 $262,360 $288,504 39
Total Medicare postacuteb beneficiaries (thousands) 4,074 4,347 4,924 21
Total Medicare postacuteb spending (millions of dollars) $21,626 $28,255 $37,829 75
Nursing facility beneficiaries (thousands) 1,390 1,662 1,828 32
Nursing facility spending (millions of dollars) $11,785 $16,818 $22,152 88
Home health beneficiaries (thousands) 2,684 2,685 3,096 15
Home health spending (millions of dollars) $9,840 $11,437 $15,677 59
Home health beneficiaries as percent of Medicare 66% 62% 63% −5
postacute beneficiaries
Home health spending as percent of Medicare 46% 40% 41% −9
postacute spending
Hospice beneficiaries (thousands) 474 729 996 110
Hospice spending (millions of dollars) $3,142 $6,346 $10,345 229

SOURCE Centers for Medicare and Medicaid Services. Medicare data compendium, 2008. Baltimore (MD): CMS; 2008 [cited 2009
Nov 16]. Available from: http://www.cms.hhs.gov/DataCompendium/. NOTES Consumer Price Index (CPI)–adjusted spending reported
in constant 2007 dollars. See Technical Appendix 1 for full details (Note 6 in text). aEstimated data. bIncludes nursing facilities
and home health. See Technical Appendix 1.

number of waiver slots, limit geographical areas,
limit services, and provide services otherwise not
covered by the state Medicaid plan.12 Home and
community-based services waivers are limited to
people who meet the state eligibility require-
ments for institutional care, and program costs
cannot be higher than costs for institutional ser-
vices (that is, must be cost-neutral). The waiver
programs give states greater control over the
number of participants and spending than the
personal care program allows, and they provide
wide flexibility in the benefits offered.12
Personal care services, actively offered by
thirty-one states, provide assistance with activ-
ities of daily living (such as eating, bathing, and
using the toilet) and must be offered statewide to
all age and population groups who meet the state
need criteria.13 These programs are less costly per
participant than the waiver programs because
benefits are more limited and individuals do
not need to meet the institutional-need crite-
ria required for waiver programs. Many states
have other home and community-based services
waiver demonstrations and state-funded home
and community-based services programs.14
TRENDS IN MEDICAID HOME AND COMMUNITY - BASED
SERVICES In 2006, almost 2.9 million people re-
ceived Medicaid home and community-based
services, including waivers, home health, and
personal care (Exhibit 2). (Data for 2006 are
the most recently available for such partici-
pants.) Between 1999 and 2006, the number
of participants grew steadily by an average of
6 percent annually. In 2007, total Medicaid
spending on home and community-based ser-
vices had risen to $41.8 billion, representing
an increase of about 95 percent over 1999 levels.
The number of Medicaid hospice participants
rose by three times to 187,000 over the study
period, and hospice spending climbed from
$393 million in 1999 to $1.9 billion in 2007.
For details, see Appendix Exhibits 2 and 3.6
The large growth in Medicaid home and com-
munity-based services has occurred for several
reasons. First, there is growing demand by in-
dividuals to remain in their homes rather than to
live in institutions.12 Second, the Supreme Court
ruled in the Olmstead case in 1999 that indivi-
duals 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 set-
tings by the government.15 The court ruling, a
number of subsequent lawsuits against states
for failure to provide adequate home and com-
munity-based services, and advocacy organiza-
tions have encouraged states to expand access to
such services.12 Finally, in the past decade, the
federal government has provided a number of
initiatives and resources to assist states in com-
plying with Olmstead to increase access to home
and community-based services.16
VARIATIONS IN ACCESS FOR WAIVER TARGET
GROUPS Although the Medicaid personal care
and home health programs are required to cover
all age and population groups, home and com-
munity-based services waiver programs are re-

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 EXHIBIT 2

National Medicaid Long-Term Care (LTC) And Hospice Care Spending And Participants, Adjusted For Inflation, Selected Years
1999–2007
Percent change,
Program/measure 1999 2003 2007 1999–2007
Total Medicaid participants (thousands)a 40,300 51,971 56,825b 41%
Total Medicaid spending (millions of dollars)a $211,156 $275,566 $311,848 48
Total Medicaid LTCc participants (thousands) 3,641 4,359 –d 29e
Total Medicaid LTCc spending (millions of dollars) $72,079 $89,603 $100,118 39
Institutionalf participants (thousands)a 1,745 1,805 1,747b 0.1
Institutionalf spending (millions of dollars)g $50,684 $57,744 $58,301 15
Home and community-based servicesh participants 1,896 2,554 d
51e
(thousands)i
Home and community-based servicesh spending (millions of $21,395 $31,859 $41,817g 95
dollars)i
d
Medicaid home and community-based services participants 53% 59% 15f
as percent of Medicaid LTC participants
Medicaid home and community-based services spending as 30% 36% 42% 40
percent of Medicaid LTC spending
Hospice participants (thousands)a 60 125 187b 212
Hospice spending (millions of dollars)a $393 $1,005 $1,901b 384

SOURCES See below. NOTES Consumer Price Index (CPI)–adjusted spending reported in constant 2007 dollars. Medicaid LTC includes
institutional care, hospice, and home and community-based services. aCenters for Medicare and Medicaid Services MSIS data.
Available from: http://msis.cms.hhs.gov/ bEstimated data for Hawaii, North Dakota, Maine, Ohio, and Utah. cLTC includes
institutional care and home and community-based services. dNot available. ePercentage change, 1999–2006. fInstitutional data
include intermediate care facilities for the developmentally disabled and nursing facilities. gBurwell B, Sredl K, Eiken S. Medicaid
LTC expenditures in FY 2007. Eagan (MN): Thomson Medstat; 2008 Sep. hIncludes waivers, home health, and personal care services
(PCS) state plan. iUniversity of California, San Francisco (UCSF), Annual Waiver Program Survey; and UCSF Annual Survey of State
Medicaid Home Health and PCS state plan programs.

quired to establish target groups for each waiver.
In 2006, 90 percent of waiver participants either
were in the aged or combination aged and dis-
abled waiver groups, or were individuals with
mental retardation/developmental disabilities
(Exhibit 3). Spending per participant for mental
retardation or developmental disability waivers
was $40,952, compared to $9,644 for the com-
bination aged and disabled waivers in 2006.10
VARIATIONS IN ACCESS AND SPENDING ACROSS
STATES Rates of participation in Medicaid home
and community-based services vary widely
across states. In 2006, the average number of
participants was 9.59 per 1,000 U.S. population
(see Appendix Exhibits 3 and 4 for details).6 Iowa
had the highest participation rate of 16.8 per
1,000 state population, while Virginia had the
lowest rate of 3.21 per 1,000. Average home
and community-based services spending per ca-
pita was $128 in 2006: New York State had the
highest per capita spending ($384), while Ver-
mont spent only $42 per capita (Appendix Ex-
hibit 4).6 Average spending per participant was
$13,320 in 2006, although this ranged from
$4,336 in Vermont to $33,862 in Rhode Island
(data not shown).
States use a range of cost containment strate-
gies in home and community-based services,
which account, in part, for state variations in
participants and spending, especially for the
waiver programs to meet the cost-neutrality re-
quirements. For example, 5 percent of waivers
used more restrictive functional eligibility criter-
ia than for institutional care, and 32 percent used
more restrictive financial eligibility standards
than for nursing facilities.10 Many states used a
combination of fixed expenditure ceilings, ser-
vice limits, hourly limits, and geographic limits
for waivers.10 Overall, state spending for home
and community-based services depends on an-
nual state budget allocations, which are then
matched by the federal government.
UNMET NEED FOR HOME AND COMMUNITY - BASED
SERVICES In spite of the growth in Medicaid home
and community-based services and new federal
initiatives, there is unmet need for such services,
even in states that have expanded their pro-
grams. State officials have reported a variety of
program needs for specially targeted groups that
are not met by existing programs, especially pro-
grams for children, the mentally ill, and those
with traumatic brain injuries. In 2008, thirty-
eight states reported that 122 waiver programs
had waiting lists of 393,096 people.10 The num-
ber of people on waiting lists increased by more
than 30 percent between 2007 and 2008. In

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 EXHIBIT 3

Section 1915(c) Waiver Participants And Spending, By Target Group, 2006

Participants (1,107,358) Spending ($25 billion)

Disabled Disabled
6% 4% Aged and
Others Others
3% aged/disabled
4%
21%

Aged and
aged/disabled
Mentally retarded/ 51% Mentally retarded/
developmentally
developmentally
disabled
disabled
40%
72%

SOURCE Authors’ analysis of data from Centers for Medicare and Medicaid Services, Form 372. NOTES Other waivers include those
serving children, and people with traumatic brain injuries, mental disabilities, and HIV/AIDS.

2008, the average length of time spent on a wait-
ing list ranged from nine months for aged waiv-
ers to thirty-two months for mental retardation/
developmental disability waivers.10
COMPLEXITY AND FRAGMENTATION OF HOME AND
COMMUNITY - BASED SERVICES PROGRAMS During
the past decade, there have been many federal
initiatives to expand home and community-
based services in the states. These programs in
states include the following: (1) Real Choice Sys-
tems Change grants, (2) Medicaid Section 1115
research and demonstration projects, (3) Man-
aged Care/Freedom of Choice Waivers (1915(b)
waivers), (4) Money Follows the Person grants,
(5) Program of All-Inclusive Care for the Elderly
(PACE) programs, and (5) Cash and Counseling
demonstration projects.16 In addition, the Deficit
Reduction Act (DRA) of 2005 gave states in-
creased flexibility in delivering LTC services in
community-based settings.17
The new initiatives, along with the Medicaid
home and community-based services programs,
are frequently located in multiple departments
within states and are closely related to other state
programs such as aging, social services, mental
health, developmental disabilities, housing, and
vocational rehabilitation. Some states have more
than ten home and community-based services
waivers; when all Medicaid waivers were con-
sidered, some states reported twenty-four to
twenty-seven total waivers in 2008.9,10 Home
and community-based services programs often
have different administrative structures, finan-
cial eligibility criteria, need criteria, screening
and assessment procedures, provider recruit-
ment and management, reimbursement struc-
tures, and quality oversight procedures. The
many state home and community-based services
programs are administratively costly and confus-
ing to consumers and providers.
Improving Coordination Between
Medicare And Medicaid
IMBALANCE IN SPENDING BETWEEN INSTITUTIONAL
AND COMMUNITY PROGRAMS Overall home and
community-based services spending per partici-
pant was about $13,300 in 2006, compared with
the average of about $33,000 for institutional
participants in 2006 (spending divided by parti-
cipants in Exhibit 2; also see Technical Appen-
dix 2).6 Institutional spending includes room
and board, whereas home and community-based
services spending does not. Nursing home par-
ticipants often spend down their income (such as
that from Social Security benefits), and Medicaid
pays the remainder of costs. The average Medic-
aid nursing home rate was estimated to be $151
per day, or about $55,000 annually in 2006.18
The disproportional spending on Medicaid in-
stitutional services compared to home and com-
munity-based services has been the focus of state
and federal policymakers’ efforts to shift institu-
tional to home and community-based services
spending (called “rebalancing” long-term care).
In spite of the steady growth in home and com-
munity-based services, participants made up
61 percent of the total long-term care population

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but accounted for only 39 percent of total long-
term care spending in 2006 (see Appendix Ex-
hibit 4).6 Variations in states’ home and commu-
nity-based services spending were wide, ranging
from Oregon, which spent 32 percent on institu-
tional long-term care and 68 percent on home
and community-based services, to Mississippi,
which spent 88 percent on institutional long-
term care and only 12 percent on home and com-
munity-based services in 2006. For details, see
Technical Appendix 5.6
COORDINATION OF MEDICARE AND MEDICAID FUND-
ING Although Medicare and Medicaid pay for
67 percent of nursing home and home care in
the United States,3 these programs are generally
not coordinated or integrated (the PACE pro-
gram and some managed care waiver demonstra-
tions are the exception). Hospitals, with an in-
centive to discharge patients as soon as possible
to reduce costs, often discharge them before ap-
propriate postacute or long-term care services
can be arranged. They may encourage nursing
home placement if home and community-based
services are not available.19 High rates of expen-
sive rehospitalization are now recognized as a
serious problem for Medicare.20 The problems
after hospital discharge have been the subject
of various intervention studies, but a review of
clinical trials found little improvement, which
indicates a need for greater efforts to design ef-
fective discharge planning and posthospitaliza-
tion follow-up programs.21
Discussion
Medicare postacute spending grew more rapidly
than the number of users between 1999 and
2007. Moreover, Medicare is paying for a grow-
ing portion of total public spending on nursing
home care. The growth in Medicare short-term
postacute service use, in part, reflects short
hospital stays and a growing demand for reha-
bilitation services. Many nursing home, home
health, and hospice providers prefer the higher
rates from Medicare for postacute services than
those received for Medicaid long-term care
services.20,21
Medicaid institutional participants and spend-
ing had much lower growth rates than Medicare
postacute care and Medicaid home and commu-
nity-based services spending over the study per-
iod. Medicaid has made rapid progress during
the past decade in expanding home and commu-
nity-based services programs to a growing num-
ber of target groups and participants. These
trends probably reflect a combination of changes
in consumers’ preferences,12 state policies to re-
duce institutional use,22 state limitations on
Medicaid reimbursement rates,18 provider pre-
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ferences for Medicare short-stay patients,23 and
growth in home and community-based services
options12 and providers.21
Although Medicaid home and community-
based services have expanded rapidly, wide var-
iations in participants and spending are evident
across states, and large waiting lists for services
hint at inequities across states and limited access
in many states. Variations in participants and
spending rates for different target groups also
suggest that inequities in access exist within and
across states. Of greater concern is that the pro-
portion of total state home and community-
based services spending continues to be well be-
low institutional spending. States vary greatly in
their efforts to shift spending from institutional
to home and community-based services, which
may reflect differences in state resources, state
policies, and commitments to rebalancing.
In spite of the state savings reported on home
and community-based services waivers over in-
stitutional care,24 policymakers are concerned
that Medicaid participants who use waiver ser-
vices may not have been willing to use institu-
tional services. The result is a “woodwork effect”
of higher overall state costs as previously un-
cared-for people seek care—in effect, coming
“out of the woodwork.”25 On the other hand,
a recent study found that states with well-
established home and community-based services
programs had less overall long-term care spend-
ing growth than did those with low home and
community-based services spending, because
these states were able to reduce institutional
spending over time.25 Most demonstration stud-
ies, however, have found that new home and
community-based services programs were asso-
ciated with increased costs, along with greater
satisfaction among both clients and caregivers.26
The current financial crises at the national and
state levels threaten the continued access to and
spending on Medicaid home and community-
based services, while Medicaid enrollment has
been increasing.27 These financial issues pose
serious challenges to the future expansion of
home and community-based services programs.
In this paper we have emphasized the com-
plexity and multiplicity of state Medicaid long-
term care programs and Medicare postacute ser-
vices. Consolidation or improved coordination
of Medicaid long-term care programs within
states may be one approach to improving effi-
ciency and access while controlling costs.
Although Medicare postacute and Medicaid
long-term care services are intricately related,
they are poorly coordinated and have competing
incentives. Medicare focuses on limiting hospi-
tal and postacute use and costs, resulting in
shifts in care to the Medicaid long-term care
JA N UA RY 2 0 1 0 2 9 :1 HE A LT H A FFA IR S 27
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 program. That program, in turn, has little incen-
tive to reduce Medicare hospital and emergency
room use. Policy changes are needed to align the
This research was supported by the
Kaiser Commission on Medicaid and the
Uninsured, Grant no. 09-1018-400, and
NOTES
1 Kaye HS, Harrington C, LaPlante
MP. Long-term care in the United
States: who gets it, who provides it,
who pays, and how much does it
cost? Health Aff (Millwood).
2010;29(1):11–21.
2 Vladeck BC. Economic and policy
implications of improving longevity.
J Am Geriatr Soc. 2005;53(9):
S304–7.
3 Hartman M, Martin A, McDonnell
P, Catlin A, National Health Expen-
diture Accounts Team. National
health spending in 2007: slower
drug spending contributes to lowest
rate of overall growth since 1998.
Health Aff (Millwood). 2009;28
(1):246–61.
4 Davis K, Collins SR. Medicare at
forty. Health Care Financ Rev. 2005–
06;27(2):53–62.
5 Centers for Medicare and Medicaid
Services. Medicare data compen-
dium, 2008 ed. [Internet]. Balti-
more (MD): CMS; 2008 [cited 2009
Jun 25]. Available from: http://
www.cms.hhs.gov/
DataCompendium/
6 This document is available as an
online supplement at http://
content.healthaffairs.org/cgi/
content/full/29/1/
hlthaff.2009.0494/DC1
7 U.S. Department of Health and Hu-
man Services, Office of the Assistant
Secretary for Planning and Evalua-
tion. Understanding Medicaid home
and community services: a primer
[Internet]. Washington (DC): ASPE;
2000 Oct [cited 2009 Jun 24].
Available from: http://aspe.hhs
.gov/daltcp/reports/primer.pdf
8 Crowley J. Medicaid medically needy
programs: an important source of
Medicaid coverage [Internet]. Issue
Paper. p. 1–23. Washington (DC):
Kaiser Commission on Medicaid and
the Uninsured; 2003 Jan [cited
2009 Jun 21]. Available from:
http://www.kff.org/medicaid/
loader.cfm?url=/commonspot/
security/getfile.cfm&PageID=14325
9 Burwell B, Sredl K, Eiken S.
Medicaid LTC expenditures in FY
2007. Eagan (MN): Thomson Med-
stat; 2008 Sep.
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incentives for the two programs. These findings
suggest the need for structural reform of the
long-term care system. ▪
by the National Institute on Disability
and Rehabilitation Research (U.S.
Department of Education), Grant no.
10 Ng T, Harrington C, O’Malley M.
Unpublished data update for Medic-
aid home and community based
service programs. Washington (DC):
Kaiser Commission on Medicaid and
the Uninsured; 2009.
11 U.S. Census Bureau. Growth in aged
population: 2000 to 2007 [Inter-
net]. Washington (DC): Census Bu-
reau; [cited 2009 Jun 22]. Available
from: http://factfinder.census.gov/
servlet/DatasetMainPageServlet?_
program=DEC&_submenuId=&_
lang=en&_ts= (create a custom ta-
ble for “Sex by Age” to obtain data
for U.S. residents ages sixty-five-
plus and seventy-five-plus).
12 Kitchener M, Ng T, Miller N,
Harrington C. Medicaid home and
community-based services: national
program trends. Health Aff (Mill-
wood). 2005;24(1):206–12.
13 Kitchener M, Ng T, Harrington C.
Medicaid state plan personal care
services: trends in programs and
policies. J Health Soc Pol. 2007;19
(3):9–26.
14 Mollica RL, Simms-Kastelein K,
Kassner E. State-funded home and
community-based services programs
for older adults [Internet].
Washington (DC): AARP Public
Policy Institute and National Acad-
emy for State Health Policy; 2009
Apr [cited 2009 Dec 7]. Available
from: http://assets.aarp.org/
rgcenter/il/2009_06_hcbs.pdf
15 U.S. Supreme Court. Olmstead v.
L.C. (98-536). 527 U.S. 581 (1999).
[cited 2009 Jun 21]. Available from:
http://supct.law.cornell.edu/supct/
html/98-536.ZS.html
16 Centers for Medicare and Medicaid
Services. Medicaid state waiver
program demonstration projects—
general information. Baltimore
(MD): CMS; 2005 Dec 14 [cited
2009 Jun 22]. Available from:
http://www.cms.hhs.gov/
MedicaidStWaivProgDemoPGI/
17 Centers for Medicare and Medicaid
Services. Overview of the Deficit
Reduction Act of 2005 (S. 1932 and
H. Con. Res. 95). Baltimore (MD):
CMS; 2009 Sep 21 [cited 2009
Jun 21]. Available from: http://
H133B080002.
www.cms.hhs.gov/
DeficitReductionAct/
18 Swan JH. State Medicaid reimburse-
ment per diem rates, 2002–2007.
Unpublished statistics from state
surveys. Denton (TX): University of
North Texas; 2008.
19 Shepperd S, Parks J, McClaran JJM,
Phillips C. Discharge planning from
hospital to home. Cochrane Data-
base Syst Rev. 2004;1:CD000313.
20 Jencks SF, Williams MV, Coleman
EA. Rehospitalizations among pa-
tients in the Medicare fee-
for-service program. N Engl J Med.
2009;360:1418–28.
21 Kaye HS, Chapman S, Newcomer RJ,
Harrington C. The personal assis-
tance workforce: trends in supply
and demand. Health Aff (Millwood).
2006;25(4):1113–20.
22 Miller NA, Ramsland S, Goldstein E,
Harrington C. Use of Medicaid 1915c
home and community cased care
waivers to reconfigure state LTC
systems. Med Care Res Rev. 2001;58
(1):100–19.
23 Medicare Payment Advisory Com-
mission. A data book: healthcare
spending and the Medicare pro-
gram. p. 125–46. Washington (DC):
MedPAC; 2009Jun [cited 2009
Jun 24]. Available from: http://
www.medpac.gov/documents/
Jun09DataBookEntireReport.pdf
24 Kitchener M, Ng T, Miller N,
Harrington C. Institutional and
community-based long-term care: a
comparative estimate of public
costs. J Health Soc Pol. 2006;22
(2):31–50.
25 Kaye HS, LaPlante MP, Harrington
C. Do noninstitutional long-term
care services reduce Medicaid
spending? Health Aff (Millwood).
2009;28(1):262–72.
26 Grabowski DC. The cost-effective-
ness of noninstitutional long-term
care services: review and synthesis
of the most recent evidence. Med
Care Res Rev. 2006;63(1):3–28.
27 McNichol EC, Lav IJ. State budget
troubles worsen. Washington (DC):
Center on Budget and Policy Priori-
ties; 2008 Oct 24.