How States Support Older Adults and Persons with Disabilities During COVID-19

• In Event: Population Aging and COVID-19

Abstract

COVID-19 has presented challenges for older adults and persons with disabilities who receive Medicaid home and community-based services (HCBS). Many of these individuals are at high risk for serious illness because of their age or chronic conditions. In response to the challenges of COVID-19, some states have sought to expand or sustain Medicaid HCBS programs. At the federal level, the Centers for Medicare and Medicaid Services (CMS) has allowed states certain flexibilities to promote this objective should they wish to adopt them. With CMS’s approval, state actions have included increasing provider payment rates, allowing family members to be caregivers, and allowing case management entities to provide direct services. These policies are designed to sustain home and community-based options for at risk populations by maintain and increasing provider capacity. The number of states adopting these options ranges from 23 (allowing case management entities to provide services) to 41 (increasing provider payment rates). The purpose of this study is to identify the factors that are associated with state adoption of these flexibilities.

This study uses cross-sectional data to identify factors associated with states’ adopting Medicaid HCBS flexibilities in response to COVID-19 using multivariate methods. The dependent variables were binary variables indicating whether a state adopted each specific Medicaid HCBS flexibility option. Data for the dependent variable derived from the Kaiser Family Foundation’s Medicaid Emergency Authority Tracker. The explanatory variables were factors posited to be associated with state policymaking based on the literature. These include measures of state government ideology and control (percentage of legislature Democratic, unified government), governing capacity (bureaucratic capacity), demand and supply of HCBS programs, fiscal capacity and health, and existing public policies (spending levels and policies). Data derived the U.S. Census Bureau, CMS, and Kaiser Family Foundation, among other sources. Logistic regression with robust standard errors was used to conduct the analyses.

Findings indicate that the factors associated with state adoption varied depending on the flexibility. States that increased provider payment rates spent more per capita on Medicaid HCBS (b=.01, p<.05) and had a higher rate of COVID-19 cases on April 1st (b=.05, p<.05). In contrast, states that allowed family members to be paid caregivers had a higher percentage of Democrats in the state legislature (b=.22, p<.01), had a higher percentage of the population aged 85 years and older (b=5.64, p <.01), were less likely to offer paid sick leave (b=-7.93, p<.001), and spent less per capita on Medicaid HCBS (b=-.02, p<.001). Lastly, states that allowed case management entities to provide services were less likely to have a unified government controlled by the same political party (b=-3.02, p<.01), had a lower per capita gross domestic product (b=-.12, p<.05), and had fewer home health agencies per 100,000 population (b= -.78, p<.05).

This research provides insight into what factors are associated with state adoption of flexibilities to sustain Medicaid HCBS programs during COVID-19. The findings indicate that states increased provider payment rates partly in response to prevalence of COVID-19 within their state. As cases increase, states may come under pressure to increase provider rates further which may not be feasible because of budget constraints. The results also suggest that demand for and supply of services may be a factor in whether states allowed family members to be paid caregivers. States with a higher proportion of individuals aged 85 years and older were more likely to permit caregivers to be paid which may suggest that these states may not have enough providers to care for the population. Lastly, the results suggest that provider supply was associated with whether a state allowed case management entities to provide direct care services. States with fewer home health agencies were more likely to allow this flexibility. Based on these results, states may be pursuing available Medicaid HCBS flexibilities to address provider and workforce shortages which existed prior to COVID-19 but have been exacerbated by the pandemic.

Authors

• Lisa Beauregard, University of Massachusetts Boston

• Edward Alan Miller, University of Massachusetts, Boston

• Michael K. Gusmano, Lehigh University

• Pamela Nadash, University of Massachusetts, Boston

• Liz Simpson