Implications of Rhode Island's global consumer choice compact Medicaid waiver for rebalancing long-term care under the affordable care act

Federal approval of the Global Waiver (GW) in 2009 provided Rhode Island (RI) with greater flexibility to modify its Medicaid program. Because 89% of long-term care (LTC) expenditures in RI are directed toward institutional settings, a primary goal was to facilitate the state's efforts to shift the locus of LTC to non-institutional settings. This study draws lessons from RI's experience with the GW for the LTC rebalancing provisions of the Affordable Care Act (ACA). Data derive from 325 archival sources and 26 semi-structured interviews. Results suggest that prospectively documenting home- and community-based services (HCBS) capacity is necessary to ensure that sufficient resources are available to meet the complex care needs of a larger service clientele. Results also suggest that increased reimbursement is especially important for attracting participating providers; so too is maintaining sufficient numbers of state regulators for purposes of monitoring quality. Ultimately, the distribution of LTC spending is likely to remain stagnant given just how difficult it is for laggard states such as RI to make more than marginal progress even with the provision of additional options and incentives that otherwise should promote rebalancing. Nursing home care continues to be a mandatory benefit while HCBS remains an optional benefit states may offer at their discretion. This leaves investments in HCBS especially vulnerable to the vagaries of state budget and political processes, which when combined with the absence of minimum standards and requirements to cover all geographic areas and target populations, suggest persistent unmet need, both within and across states.