New CHCF report reveals potential inequities in Medi-Cal HCBS


Soraya Marashi


A new California Health Care Foundation (CHCF) publication details an equity framework for evaluating the state’s Medi-Cal home and community-based services (HCBS) for older adults and people with disabilities. 


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According to the report, inequities in California’s long-term care system are likely to persist, even as the state continues to make investments in this area, if California does not take intentional action to ensure that its efforts to expand the availability of at-home care are centered on equity.

The report reveals several aspects of HCBS where inequities can arise, including in HCBS program design. 

“Each decision point in program design is an opportunity to make equity a primary focus, starting with which federal Medicaid authority the state chooses to create an HCBS program and which services the state decides to cover in each HCBS program,” the report says.

CHCF emphasized the importance of conducting an equity analysis across HCBS programs and initiatives. The report specifically identifies that community voice and lived experience are essential to equitable HCBS program design, and that inequities can arise if input is not sought from a diverse array of HCBS users and providers during the program design process, including vetting program policies and developing guidance. 

CHCF also states that inequities can emerge in which services are included or omitted in an HCBS program.

“For example, in the In-Home Supportive Services program, providers are not authorized to read clients’ mail as a covered service, which limits the program’s assistance for people with visual impairments and disproportionately impacts those individuals who have fewer family or unpaid supports, such as LGBTQ individuals.”

The report also states that inequities in access to HCBS programs can arise from the availability of service providers. 

According to CHCF, to support the equitable availability of providers, efforts should be made to increase the diversity of participating providers through strategies that ease the administrative burden on providers, drive reimbursement and compensation policies, expand outreach, education, and technical assistance to support providers from all communities, and increase the cultural competence of the state officials reviewing provider applications and providing support and guidance to participating providers.

Inequities in HCBS programs can also be seen in the awareness of and enrollment in these programs, citing program websites that are not consumer friendly and complicated application processes.

“Inequities are more likely to arise when programs have gatekeepers who may have biases about who might be well-suited for referral and enrollment in an HCBS program,” the report states. “When conducting an equity evaluation of awareness and enrollment in HCBS programs, it is particularly important to focus on the role of state departments in ensuring HCBS programs are widely known about and in easing application processes; and the role of providers in sharing information about the HCBS program and in identifying individuals to participate in the HCBS program.”

The report also notes that inequities can be present in the assessments and authorization of HCBS services, and subjective perceptions by individuals tasked with using these tools to conduct assessments may also be biased.

CHCF suggests performing an equity evaluation of assessments and authorization processes for HCBS with an audit of assessment tools for potential bias, as well as regular bias training for individuals conducting assessments, and the simplification of assessments where possible. 

The provision of HCBS can also be a source of inequities with the quality of services provided, according to the report.

“Inequities in access to high-quality HCBS have been demonstrated by research. For example, one study found that Black HCBS users are more likely to be hospitalized than white HCBS users. This disparity becomes more pronounced when looking at the intersection of race and disability for individuals with dementia where Black HCBS users with dementia had the highest rates of hospitalization, including avoidable hospitalizations.

Inequities can also arise because the types of services being rendered do not take into consideration a recipients’ unique needs and are not person-centered.”