Medicaid Home and Community-Based Services Initiation and Acute Services Use

TL;DR

This study finds that starting Medicaid home and community-based services reduces older adults' use of emergency departments and hospital stays.

Contribution

The study provides new evidence linking Medicaid HCBS initiation to reduced acute care use among low-income older adults.

Findings

Medicaid HCBS initiation was associated with a 24% decrease in emergency department use.

There was a 32% decrease in inpatient discharge probability after HCBS initiation.

The reduction in acute services use persisted for 6 months after HCBS initiation.

Abstract

This cohort study reports on the association of initiation of Medicaid home and community-based services with use of acute services.

Is initiation of Medicaid home and community-based services (HCBS) associated with changes in acute services use?

In this cohort study among 1218 older adults across 11 states, Medicaid HCBS initiation was associated with a 24% decrease in within-person probability of emergency department use and a 32% decrease in inpatient discharge.

Results of this study suggest that, among older adults with unmet need for Medicaid-funded long-term services and supports, initiation of Medicaid HCBS may reduce reliance on costly acute care services.

For more than a decade, Medicaid has funded the majority of long-term services and supports through home and community-based services (HCBS). Whether access to Medicaid HCBS may affect dual-eligible beneficiaries’ use of Medicare-covered medical services is not well understood.

To determine whether Medicaid HCBS initiation is associated with changes in acute services use and medication fills.

This cohort study used Southern Community Cohort Study data linked to Medicare and Medicaid claims to identify a cohort of older adults residing across 11 southeastern states, largely recruited from community health centers between 2002 and 2009. The sample included older adults with 12 months of continuous traditional Medicare or Medicare Advantage enrollment centered on first month of Medicaid HCBS initiation. All analyses were conducted from spring 2023 to fall 2025.

Initiation of Medicaid HCBS between 2006 and 2018. HCBS was identified by presence of a Medicaid personal care claim or 1915(c) waiver enrollment or claim.

Inpatient discharges, emergency department (ED) use, and unique prescription drugs filled estimated using linear regressions with an event study structure. Event study models with person and year fixed-effects estimated changes in person-month probability of ED use and inpatient discharge and unique drugs filled in the 6 months before and after initiation of HCBS. Subanalyses estimated differences by pre-HCBS Medicaid enrollment status, Medicaid waiver vs state plan HCBS use, Alzheimer disease and related dementia, and diabetes diagnosis.

In a sample of 1218 new HCBS users (75% female, 77% Black; mean [SD] age, 70.5 [7.5] years), Medicaid HCBS initiation was associated with a decrease in probability of ED use (−2.70 percentage points; 95% CI, −4.18 to −1.22 percentage points) and a decrease in probability of inpatient discharge (−2.63 percentage points; 95% CI, −3.75 to −1.51 percentage points). These differences represent a 24% decrease in the within-person probability of any ED use and a 32% decrease in inpatient discharge down from adjusted pre-HCBS probabilities of 11.4% and 8.1%. Event-month trends demonstrated discontinuity at HCBS initiation and reduced the probability of acute services use that was maintained 6 months thereafter. The number of unique drugs filled steadily increased before and after HCBS, with no discontinuity observed at HCBS initiation.

In this study among a large cohort of older adults with low income across the southeastern US, Medicaid HCBS was associated with a persistent decrease in acute services use. Future research should explore additional outcomes to better inform policies that can improve HCBS outcomes and an understanding of its tradeoffs with acute services use.

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