www.ohca.com SPRING/SUMMER 2024 The Oregon Caregiver 11 DATA & RESEARCH Home and community-based services (HCBS) are increasingly utilized across the states to provide long term services and supports (LTSS) to older adults and people living with disabilities. This nationwide increase is driven by a focus on improved access to multiple care settings, along with a desire to move away from more costly nursing facility-based care when other care settings are more appropriate. To accomplish this aim, HCBS are often provided through the Medicaid program, which pays for care provided in community-based settings such as assisted living and memory care communities or in a person’s own home, such as working with an in-home care agency or by paying a family member, neighbor, or friend to provide assistance. Since 2013, more Medicaid dollars have been spent on HCBS per year than on nursing facility-based care. According to a 2023 report from the Kaiser Family Foundation, by 2020 (the most recent year that comprehensive data is available), 72% of all Medicaid LTSS enrollees solely used HCBS for their LTSS needs, 4% used both HCBS and institutional care, while 24% received care and support in nursing facilities. During the COVID-19 pandemic, the American Rescue Plan provided additional funding for states to provide HCBS. These data points demonstrate just how important and widespread the use of HCBS have become over the past few decades. Oregon in particular has a long and storied history of using HCBS to provide LTSS. The first Medicaid Waiver to pay for care in settings other than nursing facilities was granted to Oregon in 1981. This allowed for care to be provided in a home-like environment. Today, all states have some type of HCBS Waiver in place. But the extent of the services offered through these waivers as well as the number of waivers in place varies by state. Building on the early innovations in care, Oregon continues to be a national leader in the use of HCBS today. As much as 95% of Oregon’s entire LTSS population receives those services and supports via HCBS. According to an analysis from Mathematica of Federal Fiscal Year 2020 Medicaid expenditures, nearly 84% of all Oregon Medicaid dollars are spent on HCBS annually, which is the highest rate of any state in the country. This high utilization of HCBS ensures that all Oregonians in need of care and support have the option to receive those services in the settings which will best meet their unique needs with dignity, honor, and respect. There are several types of waivers that states can obtain from the Centers for Medicare & Medicaid Services (CMS) to offer Medicaid funded long term care services. Oregon currently has multiple approved waivers in place including a 1915(c), 1915(b)(4), and 1115 Demonstration Waiver, along with innovative Medicaid state plans such as the so-called K Plan which provides an enhanced 6% federal rate to Oregon for The Use of Home and CommunityBased Services: Where Are We Now? By Walt Dawson, D. Phil providing expanded HCBS. The use of multiple waivers along with state plans allows for continued innovation and expanded access to Medicaid services. Oregon continues to innovate with the use of HCBS. Late last year, Oregon’s longstanding program to support non-Medicaid individuals in need of long term care services, Oregon Project Independence (OPI), received approval for expansion as part of a Medicaid 1115 Demonstration Waiver. This waiver allows for Medicaid funds to be used to support OPI participants for the first time in the history of OPI. The continued uptake and enhancement of HCBS across the country is an important evolution of the LTSS system in the United States. HCBS are fundamental to Oregon’s innovative LTSS system. Oregon must continue to be a leader in HCBS in the years ahead, as new opportunities to support the LTSS needs of older adults and people living with disabilities become clearer. Additional information about Oregon’s HCBS Waivers and associated rules can be found online. Walt Dawson is OHCA’s research consultant as well as an assistant professor at Oregon Health & Science University and a senior Atlantic fellow with the Global Brain Health Institute. Building on the early innovations in care, Oregon continues to be a national leader in the use of HCBS today. As much as 95% of Oregon’s entire LTSS population receives those services and supports via HCBS.
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