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August 24, 2021

Report Highlights Medicaid Home and Community-Based Services’ Struggles with Worker Shortages, Closures

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum
JAMA Health Forum. 2021;2(8):e213157. doi:10.1001/jamahealthforum.2021.3157

Shortages of direct care workers for state Medicaid home and community-based services for older adults and nonelderly people with disabilities worsened in many states during the COVID-19 pandemic, hampering the efforts of entities such as group homes and adult day health programs, according to a new report from the Kaiser Family Foundation (KFF).

“The COVID-19 pandemic … brought new focus to the long-standing unmet need for home and community-based services (HCBS) among seniors and people with disabilities and direct care workforce shortages,” the authors wrote. This shortage “has been driven by low wages, high turnover, and limited opportunities for career advancement,” they note.

Medicaid is a primary payer for HCBS, and the new KFF report provides findings from the organization’s most recent survey of Medicaid HCBS programs in all 50 states and the District of Columbia. A total of 41 states responded to the survey by mid-July 2021, although response rates for individual questions varied.

The pandemic affected all settings in which Medicaid home and community-based services are delivered, in ways that varied to some degree by the type of setting. States most often pointed to pandemic-related workforce shortages as having the greatest effect on HCBS provided in group homes or in an enrollee’s home, whereas closures stemming from social distancing measures were the factor that most frequently affected adult day health programs. States also reported that some HCBS enrollees and their families declined to have workers in their homes because they feared coronavirus exposure during in-person services, particularly before COVID-19 vaccines became available.

Two-thirds (25) of the 41 responding states reported permanent closure of at least 1 HCBS provider, and 16 states reported that more than 1 closed permanently. Hardest hit were adult day health programs, with 25 states citing permanent closures of such programs. In addition, 12 states reported closures of entities providing in-home services, 11 reported closures of supported employment providers, and 8 reported closures of group homes.

Several states said that workforce shortages already existed before the pandemic and worsened after COVID-19 was declared a public health emergency. Other challenges that affect the ability of HCBS facilities and programs to remain financially viable or reopen after closure include their ability to maintain leased space and retain trained staff.

The authors note that “important data gaps remain,” with fewer than half of responding states tracking COVID-19 vaccination rates among Medicaid HCBS enrollees. “At the same time, state HCBS programs are playing a role in facilitating vaccine access for HCBS enrollees, with most responding states adopting multiple policies in this area,” they wrote.

The report also presents findings on policies adopted by states in response to other challenges posed by the COVID-19 pandemic, as well as states’ early plans made possible by temporary funds for HCBS from the American Rescue Plan Act (ARPA).

All 41 of the responding states said they had adopted at least 1 policy to help Medicaid HCBS enrollees and providers get COVID-19 vaccines, and most had more than 1 such policy in place. Many cited policies that included partnering with public health agencies in vaccine outreach and education efforts or providing enrollees with access to vaccination appointments by leveraging Medicaid’s nonemergency transportation benefit. Some states reported using Medicaid emergency authorities to provide HCBS via telehealth to enrollees at home and in adult day health programs.

About three-quarters of responding states reported providing retainer payments, under authority from the Centers for Medicaid & Medicare Services, to financially support Medicaid HCBS providers during the pandemic. The retainers are intended to help providers of HCBS maintain capacity when circumstances (such as temporary closures of adult health centers because of mandated social distancing orders) prevent enrollees from actually receiving those services.

Nearly 6 in 10 of responding states reported initial plans for an ARPA-directed temporary 10 percentage–point boost in federal Medicaid matching funds for HCBS. Increasing provider payment rates and workforce recruitment were the 2 initiatives that states cited most often as potential uses for the new funds.

Recent experience confirms that these 2 areas “are crucial to sustaining and expanding access to long-term care services at home and in the community,” the report says.

The enhanced funding through ARPA is due to expire on March 31, 2022. The report notes that the budget reconciliation package proposed by Democratic leaders included additional funding for HCBS—although Congressional committees will work out the details—and that President Biden proposed a $400 billion federal investment in Medicaid HCBS earlier in the year.

However, the report notes, “it is unclear how much of that funding increase will be approved by Congress as it considers competing priorities in the budget package this year.”

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Article Information

Published: August 24, 2021. doi:10.1001/jamahealthforum.2021.3157

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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