Press Release

For Immediate Release Contact


Sue Ducat
Director of Communications
(301) 841-9962

Rebalancing Medicaid Long-Term Services And Supports

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation examines the changed landscape of Medicaid long-term services and support (LTSS) spending twenty-five years after the passage of the Americans with Disabilities Act (ADA). In the past, most of that funding was earmarked for institutional care. That has now shifted to home and community-based settings (HCBS) -- and the Centers for Medicare and Medicaid Services (CMS) projects that by 2020, 63 percent of all Medicaid LTSS spending will be outside of institutional settings, although Medicaid's statute continues to promote an "institutional bias." As the brief notes, Congress has provided options and incentives for states to develop noninstitutional service care for nonelderly Medicaid beneficiaries, most significantly through the Affordable Care Act (ACA); however, state progress in this area has been uneven, ranging from 25.5 percent of total LTSS spending in Mississippi to 78.9 percent in Oregon. The brief outlines the elements within the Medicaid programs that will enable future reform and support consumer-centered services.


Topics covered by this brief include:


  • What's the background? The brief traces the legal decisions that have cleared the way for HCBS programs, beginning with the landmark 1999 Supreme Court Olmstead v. L.C. In that decision, the Court ruled that unnecessary institutionalization of individuals with disabilities violated Title II of the ADA, thus obligating states to provide integrated community-based services to people with disabilities.
  • What's the debate? While there is a strong national trend toward community-based services, systematic and policy questions have arisen such as whether systems should vary by state, by age, or by other population characteristics. The brief outlines the lower demand for HCBS by older adults, whose needs may be more temporary, versus those of younger permanently disabled adults.

  • What's next? CMS has recently published new regulations and a HCBS toolkit, to help state Medicaid programs implement plans that fully comply with the new national standards. As states move forward, the role of Medicaid LTSS is recognized as an important resource, supporting effective community integration for people living with chronic and disabling conditions.