Date of Award


Document Type

Open Access Dissertation

Degree Name

Doctor of Philosophy (PhD)


Public Policy

First Advisor

Edward A. Miller

Second Advisor

Amy E. Smith

Third Advisor

Pamela Nadash


The Patient Protection and Affordable Care Act (ACA) sought to improve the United States’ long-term services and supports (LTSS) system by expanding home and community-based services (HCBS). The ACA contained several optional Medicaid HCBS opportunities for states, including the Balancing Incentive Program, the 1915(k) Community First Choice personal care benefit, and the revised 1915(i) state plan benefit. This research examined these HCBS provisions to explain what factors determine whether states participate in the ACA’s new HCBS programs and, after adoption, what factors facilitate or impede implementation of these programs. To answer these questions, this study used a mixed methods research design. The quantitative portion of this research relied on several modeling approaches to identify the factors that affected states’ decisions to adopt these policies. The qualitative research used case studies of three states to examine the state-level decision-making processes around adoption and then subsequent implementation of these policies.

This research has implications for federal officials interested in spurring states to achieve greater rebalancing of Medicaid LTSS toward home and community-based care, and state officials interested in pursuing new HCBS policy opportunities. In the quantitative results, more liberal political ideology, more 1915(c) waivers, and lower Medicaid LTSS spending on HCBS were key factors that increased the likelihood of state adoption of the ACA HCBS programs. The qualitative findings identified the important role that leaders within the state Medicaid agency or disability services agencies played in the policy adoption decisions. Consistent with the quantitative results, these leaders recognized that the three ACA policies would complement or substitute for existing HCBS policies and fill gaps in HCBS offerings. When implementing these polices, additional financial resources, frequent communication with the Centers for Medicare and Medicaid Services, and leveraging existing HCBS programs and infrastructure facilitated the implementation process. Barriers to implementation included aggressive timelines, insufficient staff, and limited engagement with external stakeholders.