Some have said that state choices about whether to adopt the ACA’s Medicaid expansion come at the expense of providing Medicaid home and community-based services (HCBS). Since 2002, the Kaiser Family Foundation has surveyed states about their HCBS waiver waiting lists. All states offer at least one 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 services exceeds the number of waiver slots. This analysis examines the most recent data available, including HCBS waiver waiting list data for 2015 and 2016. The data do not support a relationship between a state’s Medicaid expansion status, which is primarily financed with federal funds, and changes in its HCBS waiver waiting list.
Waiting List Changes and Adoption of Medicaid Expansion
Among the 21 states that experienced an HCBS waiver waiting list increase from 2015 to 2016, the average increase was lower in expansion states compared to non-expansion states (Figure 1). The average waiting list increase across 13 expansion states (Arkansas, California, Connecticut, Iowa, Kentucky, Louisiana, Michigan, North Dakota, New Hampshire, New Mexico, Nevada, Ohio, and Oregon) was 1,756 people and ranged from 3 people in North Dakota to 11,101 in Louisiana. The average waiting list increase across eight non-expansion states (Alabama, Maine, Mississippi, Nebraska, Oklahoma, South Carolina, Texas, and Utah) was 3,502 people and ranged from 302 people in Utah to 11,806 people in Texas. Table 1 contains waiting list data by waiver population and state for 2016. In addition, the Medicaid expansion has enabled some people who were not previously eligible for coverage to access needed HCBS, such as home health or personal care state plan services.
Most ACA expansion states (56%, or 18 of 32) either have no HCBS waiver waiting list or had a decrease in their waiting list from 2015 to 2016 (Figure 2). Eight expansion states (Arizona, DC, Delaware, Hawaii, Massachusetts, Rhode Island, Vermont, and Washington) had no HCBS waiver waiting list in 2015 or 2016; seven of these states (all except Washington) also had no waiting list in 2014, the year that they implemented the expansion. Ten expansion states (Alaska, Colorado, Illinois, Indiana, Maryland, Minnesota, Montana, New Jersey, Pennsylvania, and West Virginia) experienced a decrease in their HCBS waiver waiting lists from 2015 to 2016. New Jersey completely cleared its waiting list between 2015 and 2016, and the other nine states experienced double digit percent decreases, ranging from -15% in Montana to -97% in Minnesota. Three of these states (Alaska, Indiana, and Pennsylvania) also experienced waiting list decreases from 2014 to 2015.
Medicaid HCBS waiver waiting lists pre-date the ACA’s Medicaid expansion, which became effective in most states in 2014. Over 656,000 people in 39 states were on HCBS waiver waiting lists in 2016 (Figure 3); 35% of total HCBS waiver waiting list enrollment (232,000 people) are in Texas, a non-expansion state. Not all people on waiting lists may be eligible for Medicaid waiver coverage, as many states do not determine eligibility until a waiver slot becomes available. As of 2016, just over half (53%) of waivers with waiting lists screened individuals for eligibility before being placed or while on a waiting list. However, most people on HCBS waiver waiting lists are receiving other Medicaid services. Nearly 90 percent of waivers with waiting lists provided non-waiver services (i.e., Medicaid state plan services, such as personal care) to people who were waiting for waiver services.
|Phys. Dis.||Children||HIV/AIDS||Mental Health||TBI/SCI||Total|
|Total No. of Waiting Lists||55||3||17||11||19||1||3||9||118|
|Total No. of Enrollees||423,735||25,347||147,693||9,389||47,145||70||1,319||1,497||656,195|
|Avg. Waiting Period (in months)||48||31||21||18||27||5||15||17||23|
|NOTES: Data may not sum to total due to rounding. I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. “Unknown” indicates there was a waiting list but number of persons is unknown. A dash indicates that there was no operational § 1915(c) waiver for the target enrollment group or waiting list. AZ, RI, and VT do not have § 1915(c) waivers but provide similar HCBS in §1115. *NM and TX reported waiting lists for seniors/physical disabilities in their §1115 waivers. SOURCE: KFF analysis of Medicaid HCBS Program survey.|