Barriers and Facilitators to Implementing the ACA's Balancing Incentive Program

• In Event: Politics of Aging: A Global Perspective

Abstract

Older adults and their families prefer to receive long-term services and supports (LTSS) at home and in the community rather than in a nursing home. However, slow progress has been made rebalancing Medicaid-funded LTSS toward home and community-based services (HCBS) for the elderly and people with disabilities despite federal and state government efforts to improve access to non-institutional care. The Patient Protection and Affordable Care Act (ACA) included the opportunity for states to increase spending on HCBS through the Balancing Incentive Program (BIP). As part of BIP, participating states needed to achieve changes to their HCBS systems and meet specific spending thresholds for Medicaid HCBS. In return, states received additional federal revenue based on their HCBS spending. Over twenty states participated in BIP and were required to meet the program requirements by 2015. The purpose of this study is to identify the factors that facilitated or impeded states’ implementation of BIP.

This research utilized comparative case studies to examine states’ implementation of the Balancing Incentive Program. The case study states were selected utilizing a “most different approach” whereby the cases varied in many respects but performed the same on the dependent variable of interest, i.e., the adoption of BIP. Data was collected through interviews with state and national level bureaucrats, consumer advocates, provider representatives, and policy experts. Maryland and Texas were the case study states. These states were selected because both states participated in BIP beginning in 2012 but differed with respect to demographics; political and economic climate; existing long-term services and supports; and Medicaid policies.

Findings indicate that factors that facilitated Maryland and Texas’ implementation of BIP were regular communication with the Centers for Medicare and Medicaid Services and their consultants, Mission Analytics Group, and merging BIP with existing HCBS programs. In addition, leadership within state government and the substantial amount of funding associated with BIP helped the implementation process. On the other hand, the short duration of BIP presented a challenge for states because they needed to enact multiple changes within a limited period of time. In addition, state procurement and contracting processes impeded the speed with which the BIP requirements could be met. Key stakeholders, including consumer advocacy and provider organizations, often felt as though their state implemented BIP with minimal input from interested groups. Determining how to spend the enhanced BIP Federal Matching Assistance Percentage also posed a challenge for some states.

In conclusion, the structure of the Balancing Incentive Program as well as internal state factors influenced the program’s implementation. The short duration and substantial amount of funding associated with the BIP, as well as frequent communication between the federal government and participating states impacted the implementation process. State procurement processes, level of provider and consumer group involvement, and existing HCBS policies also played a role in implementation. The implications for federal initiatives to change state HCBS systems as well as state efforts to rebalance HCBS programs are severalfold. At the federal level, findings suggest that federal initiatives with short durations can pose challenges especially given state procurement timeframes. They also suggest that federal agencies and contractors regularly engage with participating states to facilitate implementation. At the state level, greater engagement with consumer advocates, provider representatives, and other stakeholders can generate buy-in which facilitates implementation. Leveraging existing HCBS initiatives can facilitate implementation of new initiatives as well.

Authors

• Lisa Beauregard, University of Massachusetts Boston

• Edward A. Miller, University of Massachusetts, Boston