A Comparison of Medicaid Institutional versus Community Expenditures: FY 2008 Aged/Disabled Compared to Developmental Disabilities

by Steve Gold

In the previous two Information Bulletins, we reviewed how well your State has done at ending discrimination against the elderly and people with physical disabilities (#296) and ending discrimination against people with developmental disabilities (#297) with regards to Medicaid Long Term Care expenditures and services.

In this Information Bulletin, we will focus on how your State has done at ending discrimination by comparing the two CMS categories of people with disabilities, each with a separate budget line: on one hand, elderly/people with physical disabilities, and, on the other hand, people with developmental disabilities. Again, this comparison is with regards to how your State allocates its Medicaid Long Term Care expenditures between its institutional versus community-based services.

This separation into two caategories is because historically CMS has not encouraged States to combine different disabilities into one Medicaid Waiver and because the federal Medicaid statute requires cost comparisons based on the type of institution a person would enter: elderly/people with physical disabilities go into nursing facilities, and people with developmental disabilities go into Intermediate Care Facilities.

If one looked at "all disabilities, " that is, combined the two categories in FY 2008, then 57.3% of all Medicaid LTC expenditures went for institutional services and 42.7% went for community services. However, when Medicaid expenditures in an "all disabilities" category are broken down and separated into MR/DD and Aged/PD categories, there is a dramatic difference.

For persons receiving Medicaid funded MR/DD services in FY 2008, nationally 35.5% went for institutions (ICFs) and 64.51% was spent for community-based (waiver) services. Thus, significantly less Medicaid funds went to provide services for persons with MR/DD in institutions than in the community. In dollars, $12 billion was spent on institutions but $22 billion was spent for community-based services.

In contrast, for the aged and persons with physical disabilities, 68.4% of Medicaid funds was spent on institutional services and 31.6% on community-based services. In dollars, nursing facilities received $49 billion but only $22.6 billion was spent for community-based services.

Why the lopsided distribution based on type of disability? Better DD advocates? More expensitve? More DD advocates? More organized DD community? Flukes?

Let's compare some specific States in FY 2008:

ND spent 90.6% for A/PD on NH institutions (one of the worst in the country), but it spent only 45.8% of its DD expenditures on institutions.

SD is similar - it spent 87.7% of A/PD on NH institutions but only 20.3% on DD institutions.

IN spent 88.1% of its A/PD on NH institutions but only 39.5% of its DD on institutions.

PA spent 86.4% of it's A/PD on NH institutions but only 30.5% on DD institutions. FL spent 82.9% of it's A/PD on institutions but only 32.5% on DD institutions.

The following States in FY 2008 totally flipped when one compares people in the A/PD category and people in the DD category:

RI was one of the worst States in A/PD expenditures with 86.8% to institutions, but was third best in DD with only 3.8% on institutions.

AL was one of the worst States in A/PD expenditures with 84.3% to institutions, but was one of the best States in DD expenditures with only 12.2% to institutions.

MD - one of the worse with A/PD with 84.1% to institutions, but one of the best with DD with only 9.5% to institutions.

Certainly States know how to serve some people with disabilities primarily in the community b they do it for people with developmental disabilities. Why don't States treat all people with disabilities the same opportunities?

Obviously, some States are treat the two categories the same:

OR and. NM are equal opportunity States with virtually no institutional expenditures for either A/PD and DD.

On the other hand, MS has virtually only institutional expenditures for both A/PD and DD.

Let's compare some specific States with a decrease of at least 5% in institutional expenditures between FY 2006 and FY 2008:

LA reduced its DD institutional expenditures 14.2% and also reduced it's A/PD expenditures 12.4%.

TX reduced its DD institutional expenditures 7.3% but kept it's A/PD institutional expenditures at virtually the same.

DC decreased its DD institutional expenditures 30.7% and decreased it's A/PD institutional expenditures 14.2%.

MO decreased its DD institutional expenditures 18.5% but kept it's A/PD virtually the same.

NC decreased DD institutional expenditures 7.3% but kept its A/PD about the same.

SC decreased DD institutional 10.0% but reduced it's A/PD by only 4.1%.

KY decreased DD 7.4% but had virtually no change in A/PD.

NV decreased DD 7.8% but kept it's A/PD about the same.

CT decreased DD by 7.6% but had virtually no change in A/PD.

TN decreased 10.7% in DD institutionalization but had virtually no change in A/PD.

MA increased its DD 7.5% but kept it's A/PD about the same.

NJ increased its DD institutional expenditures by 9.1% but kept it's A/PD institutional expenditures the same.

Why are there such dramatic differences between the two categories? We always thought the ADA meant all Americans with all Disabilities Act - not Americans with some or preferential Disabilities Act. Obviously, some States and the disability advocates successfully treat all disabilities equally. Why don't all States?

Steve Gold, The Disability Odyssey continues

Related articles by Zemanta

• Nursing Homes Get Old for Many With Disabilities (thehealthcareblog.com)