Federal approval of Rhode Island’s Global Consumer Choice Compact Global Waiver in 2009 provided Rhode Island with greater flexibility to modify its Medicaid program. Because 96% of long-term care expenditures in Rhode Island were directed toward institutional settings, a primary goal was to facilitate the state’s efforts to shift the locus of long-term care to non-institutional settings. This study draws lessons from Rhode Island’s experience with the Global Waiver for the long-term care rebalancing provisions of the Patient Protection and Affordable Care Act of 2010. Data derive from 325 archival sources and 26 semi-structured interviews. Results suggest that prospectively documenting home- and community-based services (HCBS) capacity is necessary to ensure that sufficient resources are available to meet the complex care needs of an increasingly larger service clientele. Results also suggest that increased reimbursement is especially important for attracting participating providers; so too is maintaining sufficient numbers of state regulators for purposes of monitoring quality. Barring the adoption of even more substantial changes in federal policy than included in the Affordable Care Act the distribution of long-term care spending is likely to remain stagnant in laggard states such as Rhode Island given just how difficult it is to make more than marginal progress despite the provision of additional options and incentives that otherwise should promote rebalancing. Nursing home care continues to be a mandatory benefit while most HCBS remains optional. This leaves investments in HCBS especially vulnerable to the vagaries of state budget and political processes, which when combined with the absence of minimum standards and requirements to cover all geographic areas and target populations, suggest persistent unmet need, both within and across states
