A Comparative Analysis of State Adoption of the Community First Choice Program

• In Event: Population Aging and Public Policy

Abstract

People in need of long-term services and supports (LTSS) and their families prefer to remain at home and in the community rather than receive care in a nursing home or other institutional setting. Despite this preference and federal and state government programs to increase access to non-institutional care, progress rebalancing Medicaid-funded LTSS toward home and community-based services (HCBS) for the elderly and people with disabilities has been slow. The Patient Protection and Affordable Care Act (ACA) included the opportunity for states to expand Medicaid funded HCBS through the Community First Choice (CFC) program. States that pursue CFC provide personal care and attendant services to Medicaid eligible elders or persons with disabilities, and, in return, receive a higher federal Medicaid match rate for CFC spending. By 2015, eight states had elected to add CFC as a Medicaid HCBS benefit. The purpose of this study is to identify the factors that influenced states’ adoption of CFC.

This research utilized comparative case studies to examine states’ adoption of CFC. The case study states were selected utilizing “most similar” and “most different” approaches. In the former, two cases that are similar in many respects but different on the dependent variable (i.e. CFC adoption) are examined while in the latter two cases states that are different in many respects but perform the same on the dependent variable are explored. Texas and Oklahoma were selected as the most similar cases because Texas adopted CFC while Oklahoma has not. While Maryland and Texas were selected as the most different states because both states adopted CFC but differed with respect to demographics; political and economic climate; existing long-term services and supports; and Medicaid policies. Data was collected through interviews with state and national level bureaucrats, consumer advocates, provider representatives, and policy experts, as well as a comprehensive review of pertinent documents.

Findings indicate a key factor in pursuing CFC was leadership from the state Medicaid office. Influential leaders in both Maryland and Texas were able to convince the governor and legislature of the benefits of adopting CFC. In addition, officials in both states realized that they could obtain additional federal revenue for existing Medicaid services, and the new revenue could address issues with which the state had been grappling. A key reason why states such as Oklahoma have not elected this option is that CFC is an entitlement benefit, and states were concerned with the budgetary implications of making a new Medicaid benefit available statewide without the option of a waiting list.

In conclusion, the specific features of CFC as well as internal state factors influenced states’ pursuit of this option. The enhanced match associated with CFC made it attractive for states already providing similar benefits. However, the inability to implement a waiting list was concerning for some states which contributed to decisions not to adopt CFC. These findings suggest that future federal initiatives to change state HCBS systems should consider the use of financial incentives to spur state adoption, while providing states with desired mechanisms to manage costs, such as waiting lists or enrollment caps. Findings also highlight the important role of bureaucratic leadership within the state Medicaid agency in state adoption decisions. They suggest that a key factor promoting HCBS expansion is state agency leaders being willing and able to act as policy entrepreneurs who couple HCBS policy opportunities with the problem of HCBS rebalancing within their states.

Authors

• Lisa Beauregard, University of Massachusetts Boston

• Edward Alan Miller, University of Massachusetts, Boston