Addressing Problems with Medicaid Home & Community-Based Services in the Age of Rebalancing

For nearly a half-century, Congress has created various legal authorities from among which states may select to provide Medicaid beneficiaries with long-term services and supports (LTSS) in home and community-based settings, instead of in institutions. This article describes these legal authorities and their genesis and contends that a simpler architecture would better serve program goals. In theory, state-level variation could shine a light on how Medicaid can best meet beneficiaries’ needs. Instead, a maze of federal legal authorities has resulted in inconsistent and inequitable access to care among beneficiaries and across geographies. The many programs are difficult to understand, even for researchers and regulators trying to measure outcomes. This opacity obscures the most effective paths forward as the demand for Medicaid LTSS grows. Simplifying Medicaid LTSS legal authorities could ease burdens for states and better serve beneficiaries.