DOI

10.17077/etd.nebcf36o

Document Type

Dissertation

Date of Degree

Fall 2016

Degree Name

PhD (Doctor of Philosophy)

Degree In

Health Management and Policy

First Advisor

Brian P. Kaskie

First Committee Member

Brian Kaskie

Second Committee Member

Keith Mueller

Third Committee Member

Padmaja Ayyagari

Fourth Committee Member

Brad Wright

Fifth Committee Member

Fred Boehmke

Abstract

Older individuals overwhelmingly prefer to receive long-term services and supports (LTSS) in home and community-based settings. Medicaid elderly 1915(c) waivers have become the primary mechanism that states use to provide home and community-based services (HCBS) to older individuals. Given the positive effects elderly waivers have on the quality of life of older individuals, I examined why states adopt elderly waivers; the extent of the substantive differences in program quality across elderly waivers; and the factors associated with elderly waiver program quality, contrasted with the factors associated with elderly waiver program size (i.e., number of participants and expenditures).

I examined how state contextual, institutional, and political factors, as well as factors external to the states, including neighboring state and federal policy activity, influenced state policy decisions pertaining to elderly waiver adoptions and program quality and size. First, I performed a retrospective analysis using state-level longitudinal data from 1992-2010 to conduct a discrete time-series repeated event history analysis (EHA) to identify the variables associated with state adoptions of elderly waivers. Second, I created a measure of elderly waiver program quality consisting of four equally weighted components of waivers thought to be associated with the provision of higher quality HCBS to older individuals, including: eligibility criteria, self-determination supports, range of services provided, and participant protections. Using correlational analyses, I examined the relationships between program quality and size. Third, I performed retrospective ordinary least squares (OLS) analyses using waiver program-level data from 2015 to examine elderly waiver program quality and size and fixed-effects OLS using data from 1993-2010 to examine elderly waiver program size.

I identified 63 elderly waiver adoptions across 35 states between 1992 and 2010, which were significantly associated with state contextual and external factors. Consistent with previous research, I found that contextual factors, including the number of older individuals, the supply of long-term care facilities and whether the state already had an elderly waiver program, affected state decisions to adopt elderly waivers. There was significant variation in each of the four component and overall quality scores and weak associations between program quality and size. I found that state contextual factors, including market and Medicaid program characteristics, influenced elderly waiver program quality and size. In addition, program quality was shaped by the capacity of state policymaking institutions (e.g., governorships and legislatures), while program size was shaped by neighboring state and federal policy activity.

The findings from this research suggest that elderly waiver adoptions and program quality and size are shaped through different policymaking pathways. Efforts to improve the quality of elderly waiver programs should consider the capacity of state executive officials in addition to contextual determinants and focus on improving existing elderly waiver programs. Given that most waivers scored well on eligibility and participant protections, efforts to improve the quality of elderly waiver programs should focus on expanding self-direction supports opportunities, the types of waiver services, and eliminating restrictions placed on service delivery (e.g., waiting lists).

Public Abstract

Older individuals prefer to receive long-term services and supports in home and community-based settings. Primarily, states provide home and community-based services (HCBS) to older individuals through Medicaid elderly 1915(c) waivers. Because elderly waivers improve the quality of life of older individuals, I examined why states choose to have elderly waivers, the extent of the differences in program quality across elderly waivers, and the factors associated with elderly waiver program quality and size.

I measured elderly waiver program quality related to program eligibility, consumer-direction of services, the range of services provided, and participant safety; and program size by the number of program participants and spending. I examined how state contextual factors (e.g., older adult population size), policymaking capacity (e.g., administrative resources), political ideology, and neighboring state and federal waiver policy activity influenced state decisions to have elderly waivers and program quality and size.

I found significant variation in program quality. State contextual factors, including the size of the older adult population and nursing home industry, influenced state decisions to have elderly waiver programs and program quality and size. In addition, program quality was shaped by the policymaking capacity of state officials, while program size was shaped by neighboring state and federal policy activity.

Efforts to improve the provision of HCBS through elderly waivers should target state officials and focus on improving existing elderly waiver programs by expanding consumer-directed care opportunities, the types of services offered, and eliminating service restrictions (e.g., waiting lists).

Keywords

1915(c) Waiver, Adoption, HCBS, Medicaid, Policy, Program Quality

Pages

xi, 165 pages

Bibliography

Includes bibliographical references (pages 147-165).

Copyright

Copyright © 2016 Matthew C. Nattinger

Share

COinS