Every year, millions of people choose to live independently and receive care services in their homes and communities; opting for this over moving to a care facility or institution. For many, this choice is made possible thanks to home and community-based services (HCBS), an essential program that offers home health care services and daily living support to older adults and those living with complex health needs. 

In March 2021, HCBS programs across the country received additional funding through the American Rescue Plan Act (ARPA). This funding was designed to provide immediate aid in a very short window of time and, true to its intent, this year, Vice President Harris announced that ARPA investments in HCBS had reached approximately $37 billion across all 50 states. Following this announcement, the White House hosted a convening and released updated CMS data on ARPA HCBS spending trends across states. Since then, CMS has also come out with a detailed report documenting ARPA HCBS spending as of Oct. 1, 2022. 

President Biden’s ARPA spending package included historic and unprecedented investments in HCBS. With the influx of funds came immense opportunity and a new set of challenges. In the limited time they had, how successful were states and municipalities in allocating these funds in a way which addresses inequities in HCBS? The new CMS data and report may be able to give us some additional insight into this. 

What did we learn? 

The largest areas of ARPA HCBS planned investment across states are: 

  • Workforce recruitment and retainment 
  • Workforce training 
  • Quality improvement 
  • Reducing or eliminating HCBS waiting lists 
  • Expanding use of technology 

Additionally, states designated ARPA HCBS funds to address social determinants using a variety of  methods. Twenty-four states allocated funding to address housing barriers, 15 states have committed funds to activities focused on community integration and social supports, and 13 states have directed funds towards case management. 

How does this compare to our learnings on equitable ARPA HCBS funds implementation? 

As an organization whose aim is to build a more equitable infrastructure for future investments, we are pleased to see that some priority areas to advance an equitable HCBS system that we found in our initial research are reflected in a portion of states’ spending. In particular, widespread investments in workforce, housing barriers, and increasing technology infrastructure and access reflect themes across our ARPA HCBS learnings, as well as findings from our research on improving access and utilization of HCBS among older adults of color.  

Alignment and Misalignment of State Section 9817 Investments with Priority Areas 
Graphic that shows the alignment and misalignment of State Section 9817 Investments with Priority Areas in the housing, workforce, technology, cultural and linguistic competency, transportation, rural areas, addressing waiting lists, and outreach

Areas for growth: 

  • Culturally and linguistically appropriate services 
  • Focus on rural areas 
  • Transportation 
  • Outreach and awareness 

In both our learnings about equitable ARPA implementation and our research on reducing disparities in HCBS, culturally and linguistically appropriate services were a top priority. However, while there was significant interest for investment in this area from advocates, the dollar amount committed to culturally and linguistically appropriate services was much less than other areas and the number of states that focused on this area was much fewer. In our discussions with both beneficiaries and advocates, services that align with cultural needs such as how family and aging is viewed, and what food, art and music is available at service locations, along with access to providers that speak peoples preferred language was critical.  Similarly, throughout our work, addressing the unique HCBS needs of people in rural areas was a priority area but was not thoroughly reflected in state spending. Challenges unique to rural areas include provider shortages, limited access to services, technology and public transportation. State investments in workforce and technology do help support needs of rural populations. For example, Colorado created an online train-the-trainer model to support personal care workers in rural areas on specialized topics such as Alzheimer’s disease and behavioral health. Similar, Nebraska committed funding for agencies to purchase telehealth equipment which allows for two-way communication and remote monitoring of chronic diseases. However, issues like transportation, which many direct care workers and beneficiaries need to either get to work or to access services, and comprehensive outreach both fell short. 

What does this mean? 

These learnings are both a cause for celebration — significant investments and momentum has bolstered HCBS — and reflection. Some of the most poignant lessons learned from ARPA HCBS spending plans pertain to the lack of community engagement infrastructure, transparency around community input, and practices that center equity. Had these pieces been in place and further collaboration occurred, would there have been closer alignment across states initiatives with the priority areas our ARPA learnings uncovered related to race equity and health justice? For example, the lack of committed funding in things such as subsidized and expanded transportation, and culturally and linguistically tailored outreach is a missed opportunity to enhance equity in HCBS services. These issues of lack of infrastructure leading to misalignment are not unique to ARPA implementation. Community Catalyst’s Vaccine Equity and Access Program has been working with partners across the country to build up the public health infrastructure in a way that centers the needs of communities and ensures that the system is responsive, representative and equitable.   Creating robust and long-term connections between local/state agencies, governments and community groups ensures public health infrastructure is responsive, representative and equitable. At Community Catalyst, we believe that meaningful community engagement is a key driver in advancing race equity and health justice. Had this kind of infrastructure existed, would the areas identified for future growth be more accurately reflected in the current investments? 

What’s next? 

For many states, equipping themselves with this new information marks an opportunity for growth; the potential to learn from neighbor states and peer organizations how they effectively, or ineffectively, distributed these critical resources. While in many ways the implementation of ARPA funding may feel like it’s slowing down, many counties, cities and states are still working to spend the funds outside of HCBS — one example being State and Local Recovery Funds (SLRF). Recent news has highlighted that updated guidance from the Treasury Department has caused some states to scramble to infuse SLRF into this years’ budget to avoid funds being recalled to the federal government. Findings from the Economic Progress Institute has also indicated that counties and cities tend to have larger amounts of unspent ARPA SLRF funds. While counties, cities and states navigate the implementation of multiple buckets of ARPA funding, Community Catalyst continues to partner with the Whitman-Walker Health System and the Somali Community Resettlement Services to examine how states did, or did not, equitably use ARPA funds to enhance, expand or strengthen HCBS.