Advancing Equitable Long-Term Care: Medicaid Home and Community-Based Services Policy and Service Use Among Dual-Eligible Older Adults

Background: Older adults overwhelmingly report wanting to age in their homes and communities. Home and Community Based Services (HCBS), which include services such as personal care, adult day programs, respite, caregiver supports, etc., provide crucial supportive services that help older adults in need of long-term care to remain in their homes. Medicaid is the largest payer of HCBS, making it a particularly important long-term care mechanism. Medicaid HCBS design is largely at the discretion of states, which has contributed to administrative complexity that has made it exceedingly difficult for participants to navigate and access services. Research on racial and ethnic disparities on HCBS use has been mixed and limited, with most focusing on differences between non-Hispanic white and Black and Hispanic beneficiaries. Largely missing from this literature is the impact of state-level policy on HCBS use, which could be particularly informative given the significant differences in state service design.

Methods: This retrospective observational study linked publicly available state-level HCBS information with the 2019 Transformed Medicaid Statistical Information System Analytical File. The primary outcome was use of any HCBS. HCBS generosity was measured using three state-level indicators capturing different dimensions, spending share of HCBS, breadth of HCBS coverage, and HCBS intensity. States were categorized into quartiles for each measure. Multivariate logistic regression models assessed the association between the measures of generosity and HCBS use. Stratified models examined how associations varied across non-Hispanic white, Hispanic, Black, and Asian beneficiaries.

Results: The study included 3,278,266 dual-eligible beneficiaries age 65+ across 34 states. Nearly half of beneficiaries (48.5%) reported any HCBS use. In fully adjusted models, higher generosity was associated with increased probabilities of HCBS use. Stratified analyses indicated that associations varied by race and ethnicity and by the different operationalizations of generosity. Increased spending share of HCBS was associated with a greater predicted probability of HCBS for all four racial and ethnic groups. Hispanic and Asian beneficiaries generally had lower probabilities of use across the four spending quartiles compared to non-Hispanic white and Black beneficiaries. Thus, while higher HCBS spending may support service use, disparities in utilization persist. Conversely, greater breadth of HCBS coverage was associated with higher use of HCBS for all racial and ethnic groups, and in the most generous states the probabilities of use were similar for all four groups.

Conclusion and Implications: Overall, findings suggest that more generous HCBS policy environments, particularly broader coverage, may not only increase overall utilization but also attenuate, and in some cases reverse, racial and ethnic disparities in HCBS use. The results highlight that state policy design can meaningfully shape utilization, underscoring the importance of building equitable and responsive HCBS systems, where social workers play key roles in access and navigation. Since broader coverage of HCBS coverage corresponded with increased use and reduced disparities in utilization, subsequent work should investigate pathways to HCBS entry, including awareness of programs, the application process, and authorization of services. Targeted expansion of coverage and eligibility pathways may be particularly important for improving access among Hispanic and Asian beneficiaries.