Special guest post by Nicholas J. Diamond
Medicaid is currently facing a timely, although largely underappreciated, challenge: rebalancing Medicaid long-term services and supports (LTSS). For context, LTSS refer to a broad range of paid and unpaid medical and personal care assistance for individuals who experience difficulty completing self-care tasks due to aging, chronic illness, or disability. According to 2013 estimates, there are approximately 12 million individuals in the U.S. who rely on LTSS, mostly paid for through Medicaid, with a projected increase to approximately 27 million individuals by 2050.
Medicaid has a historical structural bias toward institutional care, such as nursing homes, as opposed to home and community-based services (HCBS), such as home health aides, personal care, chore services, supported employment, rent and food for live-in caregiver, and nonmedical transportation, among many others. Medicaid LTSS rebalancing, therefore, shifts spending away from institutional settings and toward HCBS, which is less expensive and generally preferred by beneficiaries. States may provide HCBS through a complex panoply of federal statutory authorities, including waiver authorities, which afford states wide latitude in designing programs. As you might imagine, with flexibility comes significant variations in how states provide HCBS, which specific types of HCBS they provide, and whether, for instance, cost containment strategies available under certain authorities negatively impact access to needed services.
Against this background, what can we learn from global health norms? The true measure of any health intervention is whether it benefits the intended population. The Medicaid HCBS population is low-income, with highly complex care needs, including individuals with physical and intellectual/developmental disabilities, and varies both within and across subpopulations, particularly with regard to age. Consequently, not only are the circumstances under which an individual comes to rely on LTSS impacted by various social, cultural, and economic determinants, but also the conditions under which that individual receives LTSS touch an array of care settings and providers.
Given this amalgam of structural and intermediary health determinants, it makes sense to consider HCBS from the perspective of a social determinants of health (SDH) approach, which is familiar to global health, but less so in U.S. health policymaking. Such an approach suggests a rebalancing of HCBS itself such that authorities and the specific types of HCBS that flow from those authorities more directly address structural determinants that contribute to health inequities, as opposed to disproportionately favoring intermediary determinants of health. An example of a potential adjustment to current authorities would be creating a standardized enrollment cap, or even eliminating enrollment caps altogether, under section 1915(c) because such caps ignore the fact that access is instead a highly complex issue that depends chiefly on an individual‘s placement within hierarchies of power, prestige, and economic status, among other germane structural factors.
What is more, we need to better gather data and evidence, especially around health outcomes, for HCBS, in order to ascertain which specific types of HCBS best serve particular populations. Others have identified the availability of high quality data for all communities as a health equity issue, and the World Health Organization has stressed the need for a better understanding of the underlying causes of health inequities and evidence on which interventions best address those causes. As policymakers look to further advance Medicaid LTSS rebalancing, having better data and evidence on health equity in the HCBS population would help to shepherd adjustments to the existing statutory architecture.
The broader point that I wish to make here, however, is that we need to devote greater attention to bridging the normative divide between global and U.S. health policymaking. Even though the right to health under the International Covenant on Economic, Social and Cultural Rights (ICESCR) and related instruments have little chance of ever being part of U.S. law, this should not preclude us from applying conceptual frameworks like the SDH framework to, and suffusing their norms into analyses of, pressing domestic policy challenges. While this doubtless occurs informally at the agency level, we should endeavor to expand the reach of such insights throughout all levels of policymaking.
Nicholas J. Diamond, JD, MBE trained in both law and bioethics, and is currently a LL.M. candidate in global health law at Georgetown Law. He also leads market strategy in the healthcare and life sciences sectors at a global technology company. You can follow him on Twitter.
