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8 St. Louis University Journal of Health Law & Policy 61 (2014)
Reprinted with permission of the Saint Louis University Journal of Health Law & Policy ©2014 St. Louis University School of Law, St. Louis, Missouri.


This article examines efforts states are making to expand access to community-based services for elderly and disabled Medicaid beneficiaries and suggests several options that might improve such access nationally. Like much of Medicaid, Medicaid long term services and supports (LTSS) have developed through a complex process of accretion. Policymakers appear only rarely to have considered an overarching view of such services and the needs of those who require them. Rationalizing Medicaid LTSS will accordingly require not only additions but also substantial pruning, and may even warrant a reconsideration of who should have ultimate authority to develop and direct such services. The article first provides a brief history of public programmatic support for LTSS over the last forty-five years. It then details changes to programs offering home and community-based services under the Affordable Care Act and institutions of new ones. Finally, it discusses challenges facing Medicaid home and community-based service programs and provides a number of options that may help improve service access and satisfaction.