The decade between 1998 and 2008 brought a significant expansion of Medicaid-financed long-term services and supports (LTSS) for persons with intellectual and developmental disabilities (ID/DD). During this time, the combined total end of fiscal year (FY) service recipients in the Medicaid intermediate care facility (ICF/MR) and home and community based services (HCBS) programs for persons with intellectual and developmental disabilities increased by 69.6%, from 364,601 to 618,283 (see Table 1). This occurred as ICF/MR residents decreased by 25.0% and HCBS recipients more than doubled, from 240,321 to 525,119, a 118.5% increase. Between FY 1998 and FY 2008, the combined federal and state expenditures for the Medicaid ICF/MR and HCBS programs doubled (increased by 102%), from $16.967 billion to $34.273 billion. This combined increase in Medicaid LTSS expenditures included a 22% increase for ICF/MR programs, from $9.833 billion to $11.963 billion, and a 213% increase in expenditures for Medicaid HCBS programs for persons with intellectual and developmental disabilities, from $7.133 to $22.310 billion. States varied considerably in their contributions to these national trends. One third of all states (17) more than doubled their total Medicaid LTSS recipients during the decade. Forty-eight states decreased or maintained the same number of ICF/MR residents during the decade, but reductions in these states ranged from more than 50% in 10 states to less than 10% in 9 states. In contrast, every state increased HCBS recipients between June 1998 and June 2008, with 31 states more than doubling HCBS recipients (including the District of Columbia, which went from no HCBS recipients to 1,203 during the decade). Although 48 states decreased or maintained the same ICF/MR populations, only 16 states decreased ICF/MR expenditures during the decade. During the same period, all states increased HCBS expenditures, with HCBS expenditures more than doubling in all but 5 states and more than tripling in most (27) states. Controlling for changes in the Consumer Price Index (CPI) between 1998 and 2008, the increases in expenditures between 1998 and 2008 were considerably less. Specifically, when adjusted for the CPI increase of 32%, the $9.833 billion spent for ICF/MR services in FY 1998 would have been worth about $12.933 billion in 2008 inflation-adjusted (“real”) dollars. Similarly, in CPI-adjusted 2008 dollars, the total increases in HCBS expenditures went from $9.382 billion in 1998 (in 2008 dollars) to $22.310 billion in 2008, a 138% increase. Overall, in 2008 dollars, the total expenditures for Medicaid LTSS for persons with intellectual and developmental disabilities increased from $22.314 billion to $34.273 billion in 2008 (53.6%).

Table 1.

Changes in Medicaid ICF/MR and HCBS Programs for Persons With ID/DD: Service Recipients and Expenditures, 1998–2008

Changes in Medicaid ICF/MR and HCBS Programs for Persons With ID/DD: Service Recipients and Expenditures, 1998–2008
Changes in Medicaid ICF/MR and HCBS Programs for Persons With ID/DD: Service Recipients and Expenditures, 1998–2008

Figure 1 presents on a national level the effects of the dynamics noted above on per-person Medicaid LTSS expenditures in CPI-adjusted 2008 dollars. It shows the real-dollar per-person expenditures for Medicaid ICF/MR and HCBS programs and for the two programs combined. As shown, between FY 1998 and 2008, the real-dollar average per-person expenditures for ICF/MR residents increased from $104,087 to $128,406, an increase of 23.4%. HCBS per-person real-dollar expenditures increased slightly during the decade, from $39,039 to $42,486 (an 8.8% increase). The average per-person real-dollar expenditures for ICF/MR and HCBS recipients combined between FY 1998 and FY 2008 actually decreased from $60,401 in FY 1998 to $55,433 in FY 2008, a decrease of 8.2%. The primary factor in the lower average real-dollar expenditure was the decrease of 22% in the number of persons enrolled in the considerably more costly ICF/MR program ($128,406 per person in FY 2008) and the 213% increase in the number of people enrolled in the much less costly HCBS program ($42,486 per person in FY 2008).

Figure 1.

Real dollar (2008) changes in annual Medicaid per-person expenditures between FY 1998 and FY 2008.

Figure 1.

Real dollar (2008) changes in annual Medicaid per-person expenditures between FY 1998 and FY 2008.

(Sources: Research and Training Center on Community Living. (2009). Residential services for persons with developmental disabilities: Status and trends through 2008. Minneapolis, MN: Author; U.S. Bureau of the Census. (2009). Statistical abstract of the United States. Washington, DC: Author.)

Edited by K. Charlie Lakin and David Braddock