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Data Note: Data Do Not Support Relationship Between States’ Medicaid Expansion Status and Home and Community-Based Services Waiver Waiting Lists

States have broad flexibility around many aspects of their Medicaid programs today.  Among the many options states can select is whether to offer most Medicaid home and community-based services (HCBS).  HCBS waiver authority has existed since the 1980s, and all states offer at least one Medicaid HCBS waiver for seniors and people with disabilities today.  States choose how many people to serve under these waivers, and their ability to limit enrollment can result in waiting lists when the number of people seeking these services exceeds the number of program slots.  More recently, one of the major choices available to states is whether to adopt the Affordable Care Act’s (ACA) Medicaid expansion to nearly all non-elderly adults with income up to 138% of the federal poverty level ($16,643 per year for an individual in 2017); the expansion has been implemented by 32 states as of January, 2017.  Some policymakers have been discussing whether state choices to adopt the ACA’s Medicaid expansion come at the expense of providing Medicaid HCBS to seniors and people with disabilities.  Since 2002, the Kaiser Family Foundation has surveyed states about their Medicaid HCBS program policies, including waiver waiting lists.  This data note analyzes Medicaid HCBS waiver waiting list data for 2014 and 2015 and concludes that there does not appear to be a relationship between a state’s Medicaid expansion status and changes in its HCBS waiver waiting list.

Medicaid HCBS waiver waiting lists pre-date the ACA’s Medicaid expansion (Figure 1).  Nearly 641,000 people in 35 states were on waiting lists in 2015.  They include people with intellectual and developmental disabilities (I/DD), seniors, people with physical disabilities, people with HIV/AIDS, people with mental health needs, people with traumatic brain or spinal cord injuries, and children who are medically frail.  Not all people on waiting lists may be eligible for Medicaid waiver coverage, as some states do not determine eligibility until a waiver slot becomes available.  For example, as of 2015, 61% of waiting lists for HCBS waivers targeted to people with I/DD screen for eligibility at the time of waiting list enrollment.  In addition, while on a waiting list, people may receive other Medicaid services.  For example, 93% of people with I/DD on HCBS waiver waiting lists were receiving non-waiver Medicaid services in 2015.

Figure 1: HCBS waiver waiting lists pre-date the ACA’s Medicaid expansion.

Figure 1: HCBS waiver waiting lists pre-date the ACA’s Medicaid expansion.

Most expansion states (67%, or 20 of 30) either had no HCBS waiver waiting list or had a decrease in their waiting list from 2014 to 2015 (Figure 2).1  Eleven expansion states (AZ, DC, DE, HI, MA, ND, NH, NY, OR, RI, & VT) had no HCBS waiver waiting list in 2014 and 2015.  Nine expansion states (AK, AR, CA, IA, IN, MI, NM, PA & WA) experienced a decrease in their HCBS waiver waiting list from 2014 to 2015.2  Two of these states expanded Medicaid in 2014, and completely cleared their HCBS waiver waiting lists between 2014 and 2015 (MI, 14,040 people, & WA, 1,350 people).  Indiana expanded Medicaid in 2015 and experienced a double-digit percent decrease (64%, or 3,381 people) in its HCBS waiver waiting list between 2014 and 2015.

Figure 2: Most expansion states had no HCBS waiver waiting list or a decrease from 2014 to 2015, while most non-expansion states had a waiting list increase.

Figure 2: Most expansion states had no HCBS waiver waiting list or a decrease from 2014 to 2015, while most non-expansion states had a waiting list increase.

Slightly more non-expansion states (13) than expansion states (10) experienced an HCBS waiver waiting list increase between 2014 and 2015, and the average increase was over 2.5 times greater in non-expansion states compared to expansion states (Figure 3).  Among the 13 non-expansion states (AL, FL, GA, NE, LA, MT, OK, SD, TN, TX, UT, VA, & WI),3 the average number by which their HCBS waiver waiting list increased from 2014 to 2015 was 6,214. Among the 10 expansion states (CO, CT, IL, KY, MD, MN, NJ, NV, OH, & WV), the average number by which their HCBS waiver waiting list increased from 2014 to 2015 was 2,422.

Figure 3: The average Medicaid HCBS waiver waiting list increase from 2014 to 2015 was over 2.5 times greater in non-expansion states than expansion states.

Figure 3: The average Medicaid HCBS waiver waiting list increase from 2014 to 2015 was over 2.5 times greater in non-expansion states than expansion states.

The two states with the largest total HCBS waiver waiting lists in 2015 were non-expansion states.  Both of these states experienced increases in their waiting lists between 2014 and 2015.  Texas reported a waiting list of 163,146 in 2014, and 204,550 in 2015.4  Florida reported a waiting list of 76,750 in 2014, and 83,365 in 2015.

Figure 4: Texas and Florida have the largest total HCBS waiver waiting lists as of 2015.

Figure 4: Texas and Florida have the largest total HCBS waiver waiting lists as of 2015.

Endnotes
  1. LA and MT expanded in 2016, and are counted as non-expansion states in 2014 and 2015.  Data include waiting lists for § 1915 (c) HCBS waivers.  Two expansion states and one non-expansion state separately reported 2015 HCBS waiting lists for § 1115 waivers – these data were not collected for 2014.

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  2. Data include waiting lists for § 1915 (c) HCBS waivers.  CA and NM separately report HCBS waiting lists in 2015 for their § 1115 waivers.  These data were not collected for 2014.

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  3. LA and MT expanded in 2016, and are counted as non-expansion states in 2014 and 2015.

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  4. Texas also reports a 2015 HCBS waiting list for its Section 1115 waiver.  These data were not collected for 2014.

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