[Editors' Note: This special supplement is based on information collected by NASDDDS as part of a 1993 survey of specialized, Medicaid-funded home and community-based waiver programs for people with developmental disabilities. The Association is preparing an in-depth report summarizing the results of this survey, which should be available for public distribution during the Spring of 1994.]

In recent years, the Medicaid home and community-based (HCB) waiver program has played a rapidly expanding role in underwriting the costs of community services and supports for people with developmental disabilities. Based on the result of NASDDDS' latest HCB Waiver Survey, it appears that MR/DD waiver programs, nationwide, will continue to experience a vigorous rate of growth during 1994.

Nationwide Trends in Program Utilization

As of March 1, 49 states were operating more than 80 HCB waiver programs that furnished specialized community services and supports for people with developmental disabilities. During the 1994 program year, officials in these states estimate that 134,717 individuals will participate in their programs, a new high in the number of waiver participants, nation-wide. Based on past utilization patterns, final figures for the year are likely to be in the range of 130,000 - 135,000 persons receiving services, or a gain of 25,000 - 30,000 individuals over the 104,521 individuals who participated in such programs during 1993.

Chart A shows MR/DD HCB waiver utilization for the thirteen-year period between 1982 and 1994. The following observations can be made concerning waiver utilization trends over this period:

・ 1994 will mark the fourth year in a row in which the number of individuals with developmental disabilities participating in the HCB waiver program has grown by 23,000 or more.

・ Since 1990, the number of waiver participants will have nearly tripled. The annual compounded rate of growth in the number of program participants over this five year period has been 31.4 percent.

・ If current trends continue, the number of HCB waiver participants will exceed the number of persons served in ICFs/MR by 1995. This year, only about 8 percent more individuals are being served in ICFs/MR than in the HCB waiver program. In 1990, there were roughly four times as many ICF/MR residents as HCB waiver participants.

A variety of factors are contributing to this rapid growth in the number of HCB waiver participants, including:

・ Over the past three years, larger states have begun to use the HCB waiver program far more extensively than in the past. In particular, between 1991 and 1994, the number of individuals participating in the HCB waiver programs of California, Florida and New York will have grown from just over 5,000 persons to more than 44,000.

・ The programs in operation in other states also have continued to expand rapidly. About one-half the states have at least doubled the number of waiver participants in their programs since 1990.

・ Institutional downsizing and facility closures continue to be an ongoing source of program growth. In 1992 and 1993, nearly 6,000 institutional residents moved into community living arrangements paid for by HCB waiver dollars. This year, states expect over 4,000 more institutional residents to move to the community via their HCB waiver programs.

・ In addition, through specially -targeted OBRA waiver programs, roughly 2,500 inappropriately placed nursing facility residents with developmental disabilities have moved to community settings since 1989. Approximately 2,000 ICF/MR beds, nationwide, also have been converted to HCB waiver funding over the past two years. In 1994, states expect that another 1,000 ICF/MR beds will be converted to HCB waiver funding.

Given present unused waiver capacity and the growth in utilization caps already approved by HCFA, the number of program participants almost certainly will continue to expand at a brisk pace over at least he next few years.

Nationwide Trends in Program Outlays

In 1994, state-federal Medicaid outlays for HCB waiver services are expected to reach $3.5 billion, 45 percent above the 1993 expenditure total of $2.4 billion and more than triple the $1.1 billion spent in 1991. The growth in program spending between 1982 and 1994 is depicted in Chart B.

The following observations may be made concerning MR/DD HCB waiver spending:

・ Since 1990, MR/DD HCB waiver spending has been growing at an annual compounded rate of 41.3 percent. Estimated 1994 spending is roughly four times the level recorded in 1990.

・ The rate of increase in spending continues to exceed the participant growth rate due to the continuing annualization of service costs for newly added program participants from previous years.

・ In 1994, the nationwide average per capita cost of HCB waiver services is expected to reach $26,124, or 12.2 percent above the 1993 figure ($23,278). Since 1990, HCB waiver per capita costs have been increasing at an average annual compounded rate of 7.5 percent.

While HCB waiver spending continues to grow at a very rapid pace, it still is only roughly one-third of the estimated $ 10 billion plus that will be spent on ICF/MR services this year. On an average per capita basis, HCB waiver costs remain roughly 35-40 percent of ICF/MR costs.

The ongoing growth in the number of individuals participating in the waiver program coupled with the annualization of the costs of supporting the roughly 30,000 individuals who are expected to enter the program this year will lead to a continued rapid growth in program outlays through 1995.

State-by-State Results
The following summary information on state-by-state trends can be gleened from the survey results:

・ The five top-ranking states (CA, NY, AZ, FL, MA) in terms of the number of program participants account for 41 percent of all participants, nationwide. The top ten-ranking states serve 58 percent of all participants, nationwide.

・ Nationwide, an average of 52.9 individuals with developmental disabilities per 100,000 in the general population are expected to participate in the HCB waiver program during 1994. The median participation rate among all states is roughly 10 percent higher (58.16 individuals per 100,000 general population). Fourteen states are expected to have participation rates of 50 percent or more above the nationwide average. Nine states (ND, AZ, SD, RI, WY, VT, NH, MN, NY) expect to serve 100 or more participants per 100,000 population. However, a nearly equal number of states are expected to have participation rates 50 percent or more below the nationwide average.

・ Turning to federal-state outlays, the top five ranking states (NY, CA, PA, MN, MA) are expected to account for roughly 37 percent of nationwide program expenditures during 1994. Waiver outlays are expected to reach $ 100 million or more in 13 states this year. In 1992, only four states had outlays that topped $ 100 million.

・ The states continue to exhibit wide variations in per capita spending for HCB waiver services. Seven states (OR, VT, PA, CT, NH, WY, DE) have estimated per capita outlays of more than 50 percent above the nationwide average. On the other hand, estimated per capita costs in eleven other states are more than 50 percent below the national average.

・ This wide variation in per capita costs has been an on going characteristic of MR/DD HCB waiver programs for several year.

Along nearly all lines, there continue to be wide variations among the states in the extent to which they employ the HCB waiver program to meet the needs of people with developmental disabilities.

Conclusion

Based on NASDDDS survey results, it is clear that the states are continuing to aggressively expand their HCB waiver programs for people with developmental disabilities. Over the past five years, both the number of participants and spending for HCB waiver services have increased very quickly. Certainly, 1994 is shaping up as another year of major program expansions nationwide. States are relying more heavily than ever on the program to pay for he community placement of institutionalized persons as well as to respond to the needs of people living in the community for services and supports. At the same time, there remain marked variations among the states in the role that the program plays in paying for community services.

HERE AND THERE

Over 1,000 people with developmental disabilities now are participating in Florida's supported living program, including 570 individuals who receive Medicaid-reimbursable supports through the State's Community Supported Living Arrangements (CSLA) program and an additional 107 home and community-based (HCB) waiver participants. Recently, the State added the coverage of personal assistance services and environmental modifications to its CSLA program. Other changes are being made in the State's HCB waiver program for people with developmental disabilities to increase the role the program plays in paylng for supported living.

Wisconsin's Birth to Three early intervention program is the recipient of the Wisconsin Family Based Services Association's first statewide "In Search of Excellence Award" because the program has "demonstrated the family based services philosophy in its practice and service delivery to families in an exemplary manner. "January 1, 1994 marked the first anniversary of full implementation of early intervention service in all Wisconsin countries. Wisconsin was one of only 18 states/jurisdictions to fully implement its Part H early intervention program under the original timetables contained in the 1986 amendments to the Individuals with Disabilities Education Act. The program provides eligibility evaluations, furnishes service coordination to eligible children and their families, and arranges for services identified in the family's Individualized Family Support Plan. FMI: Sue Robbins, Birth to Three Program Coordinator, Division on Community Services Department of Health and Social Services, P.O.Box 7851, Madison, WI 53707 (tel 608/266-8276).

In 1993, 3,645 persons, with mental retrdation participated in the Texas In-Home and Family Support (IHFS) Program, suppoted by $9.5 million in state dollars. Under this program, individuals and families receive up to $3,600 per year to assist them in living in the community. Participants, not professionals, "decide how money will be spent." FMI: Ora Houston, Director of IHFS, MR Services, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, TX 78711-2668 (tel 512/323-3254).

Texas officials also report that the number of individuals residing in large, publicly-operated state schools has declined to about 6,250. Since 1991, roughly 660 individuals have moved into community living arrangements. There has been significant progress in downsizing both Fort Worth (slated to close in 1995) and Travis (expected to close in 1999) State Schools as a result of the settlement agreement in the Lelsz v. Kavanaugh class action lawsuit.

The New York State Office of Mental Retardation and Developmental Disabilities (OMRDD) has issued an update to its Comprehensive Developmental Center Closure Plan. New York plans to close all of its developmental centers (DCs) by the Year 2000. This update describes closure and post-closure activities at eight DCs that have ceased operation as well as the status of closures at four additional centers. Also included is information concerning: (a) the impacts on the OMRDD workforce stemming from facility closures; (b) the develop of specialized services to meet the needs of DC residents with complex health needs and behavioral problems; and, (c) alternative uses for DCs. This update furnishes a wealth of information concerning NYS DC closure activities. To obtain a copy, please write: OMRDD, 44 Holland Avenue, Albany, NY 12229.

The Administration on Developmental Disabilities has awarded Training in Aging Projects (TIPs) to eleven Universiry Affiliated Programs. These project grants span a three year period and are aimed at improving services and supports for older adults with developmental disabilities. Over the next three years, UAPs in FL, GA, IL, IN, MA, MS, MO, MT, NY, ND, and WI will conduct such projects.

Colorado State Senator Claire Traylor has announced her retirement. Senator Traylor was instrumental in securing the passage of the State's famiiy support legislation in 1991.