Josephine C Jacobs1,2,3, Todd H Wagner1,2,4, Ranak Trivedi2,5, Karl Lorenz2,6, Courtney H Van Houtven7,8,9. 1. Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA. 2. Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA. 3. Division of Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA. 4. Departments of Surgery, Stanford University School of Medicine, Stanford, California, USA. 5. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA. 6. Section of Palliative Care, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA. 7. Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA. 8. Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA. 9. Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.
Abstract
OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts. DATA SOURCES: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012. STUDY DESIGN: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator. DATA COLLECTION/EXTRACTION METHODS: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services. PRINCIPAL FINDINGS: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health. CONCLUSIONS: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.
OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts. DATA SOURCES: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012. STUDY DESIGN: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator. DATA COLLECTION/EXTRACTION METHODS: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services. PRINCIPAL FINDINGS: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health. CONCLUSIONS: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.
Entities:
Keywords:
Veterans Health Administration; home- and community-based services; institutional care; long-term care; unpaid caregiving
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