A female doctor of Latin descent consults a senior woman in a nursing home. The doctor is using a tablet to show her results from her most recent test.

An analysis of state Medicaid waiver programs over the past two decades found the array of home-and-community-based services (HCBS) provided to older adults has grown substantially. 

The analysis featured in Health Affairs looked at trends in Medicaid home- and community-based services Section 1915 [c] and Section 1115 demonstration waivers targeting seniors between 1998 and 2020. All but one state offered home-based services, and 47 offered day services, caregiver support and equipment, technology and modifications. Nearly one-third of state Medicaid programs offered home-delivered meals and round-the-clock services. Only one state covered expenses for live-in caregivers.

The researchers also found that spending climbed substantially across all services, suggesting a possible uptick in access to HCBS programs.

“We could not distinguish whether these increases were a result of increases in participation or spending per participant (or both) in our data,” the report said. “Analyzing trends in participation and spending per beneficiary is an important avenue for future work using Medicaid claims data.” 

Expanding HCBS has been a priority of the Biden administration. The American Rescue Plan provided $12.7 billion for states to invest in community-based programs through a temporary 10 percentage point increase in the Federal Medical Assistance Program (FMAP). North Carolina, long a hold-out in expanding its Medicaid program, is close to passing legislation that would extend access to hundreds of thousands of adults because of increased federal funding.

The president’s Build Back Better initiative initially earmarked an additional $400 billion for home-based services. That amount was later scaled back to $150 billion, but the bill stalled in the U.S. Senate late last year.