# Examining State Policies and Administrative Factors as Determinants of Consumer-Reported Unmet Service Needs in Publicly Funded Home- and Community-Based Services in the United States

## TL;DR

This study explores how state policies and administrative factors affect unmet service needs for home- and community-based services in the U.S.

## Contribution

The study identifies specific state-level factors that influence consumer-reported unmet service needs in publicly funded HCBS.

## Key findings

- Higher Medicaid managed care enrollment and Medicaid expansion were linked to lower odds of unmet service needs.
- Greater HCBS spending relative to institutional care spending was associated with higher odds of unmet service needs.
- Consumers in PACE and Managed Long-Term Services had significantly lower odds of unmet service needs compared to Medicaid waiver programs.

## Abstract

Access to home- and community-based services (HCBSs) varies substantially between states. Yet, it is unknown how state-level policies and administrative factors impact consumer-reported unmet service needs, an important indicator of HCBS access and quality. Using the National Core Indicators—Aging and Disability Adult Consumer Survey (2016–2019; n = 13,654 community-dwelling older adults, 13 states), we examined associations between unmet HCBS needs with four state-level factors: HCBS spending relative to institutional care spending, HCBS spending per client, percentage of Medicaid beneficiaries in managed care, and Medicaid expansion; and funding program. In the adjusted logistic regression model, the odds of overall unmet HCBS needs were lower with higher percentage Medicaid beneficiaries in managed care (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.89–0.96) and Medicaid expansion (aOR, 0.80; 95% CI, 0.73–0.87) but greater with higher HCBS spending relative to institutional care spending (aOR, 1.19; 95% CI, 1.11–1.28). Compared to Medicaid waiver, odds of unmet HCBS needs were significantly lower among consumers in Managed Long-Term Services and Supports (aOR, 0.67; 95% CI, 0.61–0.74) and Program of All-Inclusive Care for the Elderly (PACE; aOR, 0.39; 95% CI, 0.31–0.49). State policies and administrative factors are important place-based determinants of HCBS consumers’ unmet HCBS needs/access; and warrant consideration in HCBS quality assurance and improvement.