CoChat
Sign Up
Cited by 26Healthcare Policy and ManagementGeriatric Care and Nursing HomesHealthcare innovation and challenges

Medicaid home and community‐based services spending for older adults: Is there a “woodwork” effect?

Open access
McGarry, Brian E., Grabowski, David C.·2023·Journal of the American Geriatrics Society
DOI 10.1111/jgs.18478
Open this paper in CoChat — free accountOpen PDF

Abstract

Background: Although older adults prefer to age at home, Medicaid has a longstanding institutional bias in funding long‐term services and supports (LTSS). Some states have resisted expanding Medicaid funding for home‐ and community‐based services (HCBS) due to budgetary concerns related to the so‐called “woodwork” effect whereby individuals enroll on Medicaid to access HCBS. Methods: To examine the implications associated with state Medicaid HCBS expansion, we obtained state‐year data for 1999–2017 from various sources. We estimated difference‐in‐differences regressions comparing outcomes in states that expanded Medicaid HCBS aggressively versus those that expanded less aggressively, controlling for several covariates. We examined a range of outcomes including Medicaid enrollment, nursing home census, Medicaid institutional LTSS spending, total Medicaid LTSS spending, and Medicaid HCBS waiver enrollment. We measured HCBS expansion by the total share of state Medicaid LTSS spending for aged and disabled persons devoted to HCBS. Results: HCBS expansion was not associated with increased Medicaid enrollment among individuals ages 65 and older. A 1% increase in HCBS spending was associated with reductions in the state nursing home population of 47.1 residents (95% confidence interval [CI]: −80.5, −13.8) and institutional Medicaid LTSS spending of $7.3 million (95% CI: −$12.1M, −$2.4M). A $1 increase in HCBS spending was associated with $0.74 increase (95% CI: $0.57, $0.91) in total LTSS spending, suggesting each dollar directed to HCBS was offset by $0.26 savings from decreased nursing home use. Increased HCBS waiver spending was associated with more older adults receiving LTSS at a lower cost per beneficiary served relative to the nursing home setting. Conclusions: We did not find evidence of a woodwork effect in those states that expanded Medicaid HCBS more aggressively, as measured by age 65 and older Medicaid enrollment. However, they did experience Medicaid savings from reduced nursing home use, suggesting states that expand Medicaid HCBS are able to use these additional dollars to serve more LTSS recipients.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1111/jgs.18478

Cites

18 of 18 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • There is substantial variation across states in spending on home- and community-based services, ranging from 32% of total Medicaid long-term care services and supports in Mississippi to 84% in Oregon.

    “However, there is substantial variation across states in spending on home‐ and community‐based services, ranging from 32% of total Medicaid long‐term care services and supports in Mississippi to 84% of long‐term care services and supports spending in Oregon”

    From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [897]

    The Introduction and Results describe substantial variation among states in HCBS spending shares. But our copy does not give the claimed 32% figure for Mississippi or 84% figure for Oregon; the Results say Oregon was excluded from the analysis because of data-quality issues. No page numbers are available in our copy. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Evidence demonstrates that Medicaid spending on home- and community-based services reduces costs.

    “despite evidence demonstrating that Medicaid spending on these services reduces costs. 897”

    From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [897]

    The Results report that increased Medicaid HCBS spending is associated with lower nursing-home spending, supporting a cost offset. But they also estimate that each additional $1 spent on HCBS increases total Medicaid long-term services and supports spending by $0.74. The unqualified claim that HCBS spending reduces costs therefore overstates the finding. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Cited by

Sorted by citations

Related

Authors
McGarry, B. E., & Grabowski, D. C.
Affiliations
  • University of Rochester Medicine (US)
  • Harvard University (US)
Corresponding author
Grabowski, David C.
ORCID
Venue
Journal of the American Geriatrics Society
Publisher
Wiley
Published
2023-06-16
Volume
71
Issue
10
Pages
3143-3151
ISSN
  • 0002-8614 (ISSN-L)
  • 1532-5415
DOI
10.1111/jgs.18478
OpenAlex
W4380870797
Cited by
26
References
18
Citations by year
2026: 5 · 2025: 10 · 2024: 7 · 2023: 4
FWCI
5.28
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Journal of the American Geriatrics Society (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
  • Social Sciences › Education › Healthcare innovation and challenges
Keywords
Medicaid, home and community-based services, long-term services and supports, nursing homes, institutional bias, Medicaid waiver programs, older adults, Medicaid expenditures, state Medicaid policy
MeSH terms
Aged, Community Health Services, Health Expenditures, Home Care Services, Humans, Long-Term Care, Medicaid, Nursing Homes, United States

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review