PRIDE and Funding

The major source of public funding for long-term services and supports provided in home and community settings is the Medicaid program. When first enacted, Federal Medicaid funding for meeting the long-term service needs of people with disabilities and chronic conditions was available mainly when the person was placed in an institutional setting, with few avenues for securing Medicaid dollars to support individuals in their homes and communities. In the 35 years since its enactment, Medicaid’s “institutional bias” has been progressively reduced through numerous amendments to Federal laws and policy. These amendments have offered new options for states to fund comprehensive home and community long-term services. At one time, only a small portion of Medicaid long-term care spending was directed to home and community services. Today, 28 percent of long-term care spending is for such services, and these outlays are one of the fastest growing components of total Medicaid spending, according to the U.S. Department of Health and Human Services.

It is not possible to estimate an average per person cost of Medicaid Waiver services nationwide because the scope and duration of services varies widely depending on the eligibility criteria applied in each State. For example, in New Hampshire only individuals with acquired brain injuries who need 24-hour access to care are served under the State’s waiver program. Consequently, the per-person cost is significantly higher than in States where the primary TBI Medicaid Waiver service may be case management. Since Medicaid Waivers are jointly funded Federal /State programs, the Federal share of total expenditures varies from 50 to 83 percent depending on the State. 31 States serve individuals with TBI under Developmental Disabilities Waivers; 26 States serve individuals under Aging and Disabled Waivers; 10 States serve individuals with brain injuries under Elderly Waivers; and 11 States serve individuals using Physical Disabilities Waivers. In the State of Georgia, 30 slots are set aside for persons with TBI in the State’s Independent Care Waiver. Montana reports that a set of services appropriate to persons with TBI are included in its Aging and Physical Disabilities Waiver.
What we do know from a 2009 report from Thompson Reuters looking at long term care expenditures, for Federal Fiscal Year 2008 total Medicaid long-term care expenditures equaled $106.4 billion. Medicaid nursing home expenditures increased 4.1 percent in FY 2008, from $47.1 billion to $49.0 billion. Expenditures for services provided in ICF/MR decreased 1.8 percent, from $12.2 billion to $12.0 billion.  

Total home and community based services (HCBS) increased by 4.9 percent to $45.4 billion.  From various sources of data, the consensus seems to be that between 1% and 2% of the HCBS budgets are spent on Traumatic Brain Injury waiver programs, between $450 million and $900 million.  What is also obvious is the cost savings of home and community service programs.