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

 正式或有偿长期服务和支持（LTSS）估计美国每年的费用为2110亿至3060亿美元，预计这些支出将随着婴儿潮一代的年龄而增加。人口趋势，包括较小的家庭规模，增加女性劳动力的参与，和更长的寿命将减少家庭照顾者的可用性，对正式的LTSS系统，特别是对医疗补助，国家最大的单一支付正式LTSS的进一步负担。医疗补助一直处于政策努力的最前沿，以“重新平衡”LTSS从机构到家庭和社区为基础的设置。这些重新平衡的努力反映了个人对接受家庭和社区服务的偏好，这些转变也显示出在10年内节省了约15%的人均长期社会服务支出。尽管这一重点增加，这些再平衡政策的评估在很大程度上忽视了健康和死亡率的结果，结果的差异，以及对老年人的影响与特定的健康状况，如痴呆症，谁可能有高于平均医疗补助支出。最近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50%的LTSS支出的州获得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：自测健康，功能，长期机构化和死亡率。有理由怀疑，这些结果的差异也可能受到实施BIP后的影响，因为白人和少数民族往往采用非常不同的LTSS战略，并有不同程度的护理。同样，生活在农村地区的人比城市居民更可能有很少或距离较远的医疗服务提供者，而且护理协调分散，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。该提案采用混合方法来（1）进行定性分析，以确定各州的BIP实施阶段和挑战;（2）使用差异中的差异方法来测试BIP实施对四种健康结果的影响，该方法利用准实验框架来比较实施和未实施BIP（但有资格）的州;（3）评估种族/民族和农村/城市 BIP对健康影响的差异;（4）检查健康状况和获得非正式护理（通常由家庭提供的无偿护理）以及县或州一级获得正式护理的机会是否进一步修改了BIP对健康结果和差异的影响。将合并2008-2017年的多个行政和调查数据库，以检查居住在BIP和非BIP州的65岁及以上双重资格成年人的健康结果。这项研究的目的是为决策者提供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，但结果对更普遍的HCBS以及了解再平衡政策如何影响老年人的健康和健康差异具有影响。

 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.