Federalism and the Growth of Self-Directed Long-Term Services and Supports
The evolution of federal and state policy over the last 35 years has expanded the availability and use of Medicaid home and community-based services (HCBS). Within HCBS, pressure has risen to give participants more control over services via self-directed service options. We document changes in federal legislation, regulation, and practice that have encouraged the growth of self-directed long-term services and supports (LTSS). We also explore how policymakers and advocates foster self-directed LTSS, even as these programs are folded in Medicaid managed care plans—an accelerating trend that presents challenges to the self-directed approach.