Evaluating the Affordable Care Act's Long-Term Services and Supports Rebalancing Programs.

Objective: To understand the impact of the Balancing Incentive Program (BIP) and Community First Choice State Plan Option (CFC) on LTSS rebalancing as measured by the size of and balance between the community and institutional LTSS workforces.

Study setting and design: Using a stacked difference-in-difference design, this paper evaluates the impact of BIP and CFC on the number of LTSS workers per 1000 persons 65+, the number of community LTSS workers per 1000 persons 65+, the number of institutional LTSS workers per 1000 persons 65+, and the proportion of all LTSS workers employed in community-based settings. We also test the impact of BIP's performance targets by separately estimating program effects for states that had yet to meet BIP rebalancing targets upon entering the program.

Data sources and analytical sample: Workforce and population data from the American Community Survey from 2005 to 2021.

Principal findings: This study finds that BIP resulted in a 13.24% (95% CI: 1.14%, 25.34%) increase in the size of the HCBS workforce in participating states, while finding no statistically significant effect for CFC (1.51%, 95% CI: -12.77%, 15.79%). The point estimate for growth in the HCBS workforce caused by BIP is twice as large in states bound by performance targets embedded within the BIP program (16.18%, 95% CI: 4.01%, 28.35%) as it is in states that are not (8.25%, 95% CI: -9.77%, 26.27%), suggesting that additional federal funding may be more effective when tied to performance targets for states. Neither program had a statistically significant effect on the size of the institutional workforce (BIP: 5.04%, 95% CI: -2.38%, 12.44%; CFC: 0.24%, 95% CI: -6.52%, 7.00%).

Conclusion: Federal policymakers seeking to increase investment in HCBS should ensure that additional funds are tied to measurable performance targets, incentivizing states to undertake expansions in HCBS that would not otherwise have taken place.