Grey Matters: Political-Economic Analyses of Long-Term Care

Abstract

This dissertation includes two quantitative studies on Medicaid long-term care (LTC) coverage in the United States, and one qualitative study that draws lessons from Germany’s LTC system for Canada. Chapter one is a political analysis of Medicaid LTC expenditures. Historically, public financing of Medicaid LTC has favored institutional over home- and community-based services (HCBS). However, as states face political, fiscal and social pressures to provide more care in people’s home and communities, this paper provides a longitudinal, political analysis of interstate variation in spending on different HCBS programs. Fixed effects regression models are used to examine state HCBS expenditures per capita and as a share of total state LTC spending for the period 2001-2010. Generally, a Democratic governorship has a relatively strong and positive effect on HCBS spending, while a socially liberal electorate has a strong but negative effect. Chapter two estimates the impact of HCBS waiver spending on different types of LTC spending. In 1981, Congress introduced the 1915(c) waiver program to assist state Medicaid programs with expanding their provision of HCBS. Given that a waiver for HCBS may only be extended to beneficiaries who meet their state’s eligibility criteria for institutional care, policymakers have long considered the waiver program to be one that lowers Medicaid LTC spending. However, targeting of social services is imperfect, and little is known about the financial impact of the waiver program. Accordingly, this chapter analyzes different Medicaid LTC expenditure categories using variations in waiver program spending across states and time. The results suggest that no cost savings are occurring. Chapter three examines the German LTC system with the intent of drawing applicable lessons for Canada. In 1995, Germany implemented a national, universal social LTC insurance (LTCI) system. In contrast, the exclusion of LTC from the Canada Health Act has led to a patchwork system whereby the scope of care, and its access, varies by region. The German experience, however, can provide useful lessons for Canada. This chapter analyzes the German system’s experience in both financing and providing user-directed care. The goal is to better understand the groundwork that helped establish and sustain Germany’s LTCI system as it is designed, and whether Canadian policymakers can replicate some of this work in pursuing their own social LTCI system.