Macpac: Medicaid Home- And Community-based Services Users Reach 2.5 Million As Institutional Care Declines

The number of Medicaid beneficiaries using home- and community-based services (HCBS) has increased in recent years, reaching over 2.5 million individuals – while the number of beneficiaries utilizing institutional long-term services and supports (LTSS) declined.

HCBS use increased by 2.6% of all Medicaid beneficiaries from 2019 to 2021, according to the Medicaid and CHIP Payment Advisory Commission’s (MACPAC) July brief. The number of beneficiaries using institutional long-term services and Supports (LTSS), meanwhile, declined from 1.8 million in 2019 to 1.5 million in 2021.

To draw its conclusions, MACPAC analyzed HCBS use and spending patterns for Medicaid fee-for-service HCBS users from 2010 to 2013, identifying trends in HCBS within specific demographics.

“Through previous MACPAC work, state and federal officials, as well as national experts, shared the need to identify potential differences in utilization and spending among LTSS subpopulation groupings, but data are lacking,” the report read. “Stakeholders emphasized the importance of stratifying data by, for example, race and ethnicity or geographic location to identify differences. One expert noted that these data would allow policymakers to monitor and ensure all populations are adequately served.”

The report found that home-based services were the second most used HCBS category, making up 24.4% of all HCBS services. 

Researchers also identified that the demographics of HCBS users differed from those of the overall Medicaid population.

Over 40% of HCBS users were 65 years or older, compared to more than 9% of the overall Medicaid population. HCBS users were also more likely to be blind or disabled, more likely to be eligible for both Medicaid and Medicare and less likely to identify as Hispanic, according to the report.

Medicaid spending on HCBS has increased in recent history, and in 2021 Medicaid spending on HCBS reached $82.5 billion compared to $66.6 billion on institutional care. Per-user spending was lower for HCBS, however. Total spending on HCBS per user in 2021 was over $32,000, while total spending on institutional LTSS per user reached over $45,000.

Medicaid’s budget for HCBS is now in question, with the One Big Beautiful Bill Act (OBBA) containing Medicaid cuts totalling $1 trillion over the next decade. 

The Centers for Medicare and Medicaid Services (CMS) has also recently announced that it will no longer approve funding for new Medicaid workforce initiatives focused on home- and community-based services. 

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