Evaluating the impact of the Medicaid Balancing Incentive Programme on long-term care utilisation by living arrangement: a quasi-experimental study.

OBJECTIVES: To evaluate the impact of the Medicaid Balancing Incentive Programme (BIP) on long-term services and supports utilisation among older adults, focusing on differences in living arrangements. DESIGN: Quasi-experimental study using a generalised difference-in-differences approach. SETTING: States that participated and completed BIP (treatment group: 18 states) and states that were eligible but did not participate (control group: 17 states). PARTICIPANTS: Older Medicaid beneficiaries from the Health and Retirement Study (2006-2018) across states that participated in BIP and those that did not. A negative control analysis was conducted using non-Medicaid beneficiaries. OUTCOMES: We examined the probability of long-term nursing home stays (over 100 days), professional home healthcare and three types of home care services for activities of daily living: paid professional caregiving, paid informal caregiving and unpaid informal caregiving. Analysis was stratified by living arrangement (living alone vs with others). RESULTS: BIP participation was associated with a 5 percentage point (pp) decrease in long-term nursing home stays among Medicaid beneficiaries living alone (average treatment effect on the treated, ATT=-0.06, 95% CI -0.10 to -0.02; p<0.01). Among Medicaid beneficiaries living with others, BIP was associated with a 5 pp increase in paid informal caregiving (ATT 0.05, 95% CI 0.03 to 0.08; p<0.01). No significant effects were observed for non-Medicaid beneficiaries. CONCLUSIONS: BIP contributed to a reduction in institutionalisation for individuals living alone while increasing support for family caregivers in multiperson households. These findings highlight the importance of tailoring long-term care policies to the specific needs of populations based on their living arrangements.