People with Disabilities Need More Access to HCBS, Researchers Say

McKnight’s Home Care / By Liza Berger
Long-term care reform in the post-COVID-19 era must include an expansion of home- and community-based services (HCBS) for people with disabilities, two Harvard University researchers said in an article in The New England Journal of Medicine.
“Although the public may think of nursing home placement as the inevitable result of impairment, it is frequently driven by social rather than clinical factors,” authors David Grabowski, PhD, and Ari Ne’eman, wrote. “Many people with disabilities end up in nursing homes because of inadequate services or housing. This problem is particularly acute for persons with serious mental illness (SMI), who account for one third of long-stay residents under 65 years of age.”
There is an inherent bias toward institutional care for people with disabilities, they said. While Medicaid, the primary payer of HCBS, requires states to cover nursing home care without a waiting list, it permits states to maintain long waiting lists for HCBS.
“Long waits exacerbate unmet care needs by denying people access to services until they face a crisis — such as a medical emergency or the death of a family member — that may drive them into a nursing home or other institution,” they said.
HCBS rebalancing tweaks
While there has been a gradual rebalancing toward Medicaid HCBS versus nursing home care, people with disabilities still tend to end up in nursing homes, Ne’eman told McKnight’s Home Care Daily Pulse. Generally, state long-term services and supports systems tend to distinguish between people with developmental disabilities, and older adults and non-elderly with physical disabilities, he said.
“The aggregate numbers are a little misleading because the developmental disability system has a much higher percentage of HCBS funding than the aging and physical disability system,” he said.
A new BIP
Some possible avenues to grow HCBS for people with disabilities include establishing a successor to the Affordable Care Act’s Balancing Incentive Program (BIP). This initiative provided additional funding to states with low HCBS spending in exchange for meeting specific benchmarks.
A new BIP program would allow for targeting of specific subgroups in a state so a state would have to meet HCBS thresholds for both the developmental disability system and aging and physical disability system, Ne’eman said.
Legislators also could reform the Preadmission Screening and Resident Review program, the federally mandated screening system designed to divert people with SMI or intellectual disability from nursing home placement. The Section 1115 Medicaid waiver program could be yet another way for the Centers for the Medicare & Medicaid Services to allow states to pay for ongoing rental systems for people at greatest risk of institutionalization, Ne’eman said.
“There remains more work to be done in order to broaden the scope of individuals who can access support in their homes and communities in order to divert people from nursing homes and support some people currently residing within them to transition back to the community,” Ne’eman said.