Home & Community-based Services (HCBS): Background; Need in Miami-Dade County; & Federal Opportunity
What is HCBS?
Medicaid home and community-based services (HCBS) programs provide services that are not typically available through Medicare or standard medical insurance, such as personal care aides, home-delivered meals, and private duty nursing to low-income individuals who require significant assistance with basic activities of daily living. Well over half of the funding comes from the federal government. 
Who receives HCBS in Florida?
Most of Florida’s HCBS are provided through either the Medicaid iBudget Waiver for people with developmental disabilities or the Medicaid Long-Term Care (LTC) Waiver for seniors and adults with significant disabilities. These HCBS services are provided as an alternative to institutionalization.  Unlike all other Medicaid services, including institutionalized care, both of these programs have long wait lists. 
Why is HCBS important?
Not only do most people prefer receiving long term services and support at home and in their community, HCBS is also much less expensive than institutionalization.  health outcomes are also adversely affected by institutionalization, as the COVID-19 pandemic dramatically demonstrated.  For example, as of May 2021, (the last month of publicly available data), more than 11,000 residents of long-term care facilities in Florida died from COVID. 
What are workforce issues?
The 2022 Florida Legislature should be commended for their efforts to increase the minimum wage for direct care employees of Medicaid providers to $15 per hour.  However, direct care workers are still very much underpaid, most do not have benefits, and shortages continue.  Thus, getting off the waitlist and enrolling in an HCBS waiver program does not guarantee receipt of needed care, as our underfunded and understaffed workforce cannot meet the needs of all enrollees. 
How does Florida compare?
Florida is ranked 43rd on the most recent AARP Long-Term Services and Supports Scorecard. 
Why is Increased HCBS Funding Especially Critical for Miami-Dade County?
HCBS programs cost far less than nursing facility care. In Miami-Dade County HCBS programs are approximately 3.5 times cheaper than the alternative nursing facility care. 
Rapidly Increasing Senior Population:
More than 20% of the county’s population is over the age of 60 , and the Miami-Dade population eligible for Older Americans Act services, including Medicaid HCBS, is projected to grow by 30% over the next 10 years. 
Additionally, the number of seniors expected to survive past age 85 is increasing rapidly. For example, between 2020 and 2025, the 85+ population will increase by over 13,000 (a 19% increase) and by 2045 this population will more than double. Many in this age group are at risk for institutionalization and could benefit from HCBS. 
High Poverty Levels and Risk of Homelessness:
Seniors in Miami-Dade County are among the poorest in the state. About 20% of Florida’s elders and 40% of the state’s elders of color under the Federal Poverty Line (FPL) live in Miami-Dade County.  With the high cost of living in South Florida, approximately 30% of seniors in this area spend more than half of their monthly income on housing expenses, leaving many seniors unable to afford much needed care and services  and/or at risk of homelessness. As of 2022, over 30 % of those served by Miami-Dade Continuums of Care were over age 55.  Additional HCBS funding will help alleviate the burden of high housing costs and attendant housing instability.
Long Waitlist Concerns:
As of September 2023, there are 17,631 Miami-Dade County residents on the LTC waitlist,  representing approximately one-third of those on the waitlist state-wide.  Increased funding is essential to allowing more individuals off the waitlist to receive needed services at home and avoid institutionalization. If enacted, the HCBS Access Act would over time eliminate the waitlists and provide states with continuous funding to place HCBS on equal footing as nursing facility care.
High Percentage of Disabled Seniors and Health Concerns:
Nearly one-third of the senior population in Miami-Dade County have a disability that affects their quality of life,  and about 13% of the County’s senior population has a disability that affects their ability to live independently or provide self care. Additionally, Miami-Dade seniors have a high probability of developing Alzheimer’s disease, which is more prevalent among Black and Hispanic individuals than their White counterparts. 
Federal Call to action: Home & Community-based Services (HCBS) Access Act Opportunity 2023-2024
The HCBS Access Act (HAA), which was introduced on March 9, 2023 to the Senate by Senator Robert Casey Jr. (D-PA) and House by Representative Debbie Dingell (D-MI-6), provides for increased access and quality for Medicaid HCBS.  It would provide permanent enhanced federal funding to ensure eligible older adults and people with disabilities are able to live at home and connected to their communities by placing HCBS on equal footing as institutional care. Overtime, the bill would eliminate HCBS waiting lists and improve the direct care workforce shortage.
Benefits of the HCBS Access Act include:
• Eliminating the waitlist and enrollment caps for the HCBS program;
• Creating a more uniform and expansive eligibility criteria based on income and health function;
• Providing caregiver resources to allow for additional training and support, in addition to a living wage; and
• Removing the administrative barriers for continued HCBS funding by eliminating the need for states to apply for multiple waivers.
HCBS Access Act Structure and Funding Scheme:
The HAA would mandate states to treat HCBS as an entitlement under the Medicaid program, providing an equal right to institutional care or HCBS. Federal funding would be provided to support states for 100% of HCBS costs for 10 years. 
Current Polling Support:
An April 2022 survey of over 1200 likely voters shows that 87% of all respondents and 85% of Republicans support federal investments in affordable long-term care for seniors and people with disabilities. 
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