Evaluating disparities in older adult health, institutionalization, and mortality after implementation of Medicaid's Balancing Incentives Program

 描述(由申请人提供)：在美国，正式的或有偿的长期服务和支持(LTSS)每年的成本估计在211至3060亿美元之间，随着婴儿潮一代的年龄增长，这些支出预计会上升。人口趋势，包括家庭规模变小，女性劳动力参与率增加，以及寿命延长，将减少家庭照顾者的可获得性，给正式的LTSS系统带来进一步的负担，特别是对医疗补助计划，它是全国最大的正式LTSS的单一支付者。医疗补助一直处于政策努力的前沿，目的是将LTS从机构环境重新平衡到以家庭和社区为基础的环境。这些再平衡努力反映了个人接受以家庭和社区为基础的服务(HCBS)的偏好，这些过渡也被证明在10年内节省了约15%的人均LTSS支出。尽管这种关注有所增加，但对这些再平衡政策的评估在很大程度上忽略了健康和死亡结果、结果的差异以及对患有特定健康状况(如痴呆症)的老年人的影响，这些老年人的医疗补助支出可能高于平均水平。最新实施的再平衡政策是平衡激励计划(BIP)，该计划向各州提供额外资金，以增加那些在HCBS上花费不到LTSS支出的50%的州获得LTSS的机会。我们将对BIP对四种健康结果的影响进行首次正式评估：自我评估健康、功能、长期住院和死亡率。有理由怀疑，在BIP实施后，这些结果的差异可能也会受到影响，因为白人和少数族裔往往采用非常不同的LTSS战略，并获得不同程度的护理。同样，与城市居民相比，居住在农村地区的个人更有可能拥有很少或遥远的医疗提供者，以及零散的护理协调，所有这些都限制了他们获得必要护理的能力，并对个人和人口的健康结果产生不利影响。该提案使用混合方法来(1)进行定性分析以确定各州实施BIP的阶段和挑战；(2)使用差异法测试BIP实施对四个健康结果的影响，该方法利用准实验框架来比较已经实施和没有(但有资格)实施BIP的州；(3)评估种族/民族和农村/城市 (4)审查健康状况和获得非正规护理(一般由家庭提供的无偿护理)以及县或州一级获得正规护理的机会是否进一步改变了综合保健计划对健康结果和差异的影响。跨越2008-2017年的多个管理和调查数据库将被合并，以检查居住在BIP州和非BIP州的符合双重条件的65岁及以上成年人的健康结果。这项研究的目的是为政策制定者提供对BIP对健康和健康差距的影响的严格分析。虽然这些分析侧重于BIP，但其结果对HCBS有更广泛的影响，并有助于理解再平衡政策如何影响老年人的健康和健康差距。

 DESCRIPTION (provided by applicant): Formal, or paid long term service and support (LTSS) have estimated annual costs of $211 to $306 billion in the U.S. and these expenditures are expected to rise as Baby Boomers age. Demographic trends including smaller family sizes, increased female workforce participation, and longer lifespans will reduce the availability of family caregivers, placing further burden on the formal LTSS system and especially on Medicaid, the nation's largest single payer of formal LTSS. Medicaid has been at the forefront of policy efforts to "rebalance" LTSS from institutional to home-and community-based settings. These rebalancing efforts reflect individuals' preferences to receive home- and community-based services (HCBS) and these transitions have also been shown to save about 15% in per capita LTSS spending over 10 years. In spite of this increased focus, evaluations of these rebalancing policies have largely neglected health and mortality outcomes, disparities in outcomes, and effects on older adults with specific health conditions such as dementia, who may have higher than average Medicaid expenditures. The most recently implemented rebalancing policy is the Balancing Incentive Program (BIP), which offers additional funding to states to increase access to LTSS in states that were spending less than 50% of LTSS expenditures on HCBS. We will conduct the first formal evaluation of BIP's effects on four health outcomes: self-rated health, functioning, long-term institutionalization, and mortality. There is reason to suspect that disparities in these outcomes may also be affected after BIP's implementation, as whites and minorities tend to employ very different LTSS strategies and have different levels of access to care. Similarly, individuals living in rural areas are more likey than their urban counterparts to have few or distant medical providers and fragmented care coordination, all of which limit their ability to obtain necessary care and adversely affect individual and population health outcomes. This proposal employs a mixed-method approach to (1) conduct qualitative analyses to identify states' BIP implementation stages and challenges; (2) test the effect of BIP implementation on the four health outcomes using a difference-in- difference approach that capitalizes on the quasi-experimental framework to compare states that did and did not (but were eligible to) implement BIP; (3) assess racial/ethnic and rural/urban differences in BIP's effects on health; and (4) examine whether health conditions and access to informal care (unpaid care generally provided by family), and county- or state-level access to formal care further modify the effects of BIP on health outcomes and disparities. Multiple administrative and survey databases spanning 2008-2017 will be merged to examine health outcomes for dual-eligible adults 65 years and older who live in BIP and non-BIP states. The goal of this study is to provide policymakers with rigorous analyses of BIP's effects on health and health disparities. While these analyses focus on BIP, the results have implications for HCBS more generally and for understanding how rebalancing policies influence health and health disparities in older adults.