Twenty-five years after the passage of the Americans with Disabilities Act(ADA), the Medicaid program is also marking an important milestone in system transformation in 2015. The national profile of Medicaid long-term services and supports (LTSS) expenditures has shifted away from primary dependence on institutional care. In 2013 the majority of Medicaid LTSS spending was for the first time focused on home and community-based settings instead of institutional care, and the Centers for Medicare and Medicaid Services (CMS) projects that community-based spending will reach 63 percent of all Medicaid LTSS spending by 2020. However, the fundamental structure of the Medicaid statute continues to promote an “institutional bias” that strongly limits the potential for true balance for beneficiaries.
Since enactment of the ADA on July 26, 1990, there has been a concerted effort at the state, federal, and community levels to transform one of the Medicaid program’s primary roles as an institutional care-focused financing mechanism into a comprehensive and flexible community-based long-term services and supports program. The most obvious testament to this shift is the strong upward trend in Medicaid spending on community-based care options–between 1995 and 2013, Medicaid home and community-based services (HCBS) expenditures increased from 18.0 percent of total Medicaid LTSS spending to 51.3 percent (see Exhibit 1). Medicaid spending on LTSS totaled $146 billion in 2013, representing a 7.6 percent increase in spending on HCBS and a 0.7 percent decrease in spending for institutional services since 2012.
– Health Affairs
