It is personally difficult for me to believe that the American Rescue Plan Act (ARPA) – President Biden’s trillion-dollar spending package to alleviate some of the chaos COVID-19 inflicted on our health and economy – was passed two and a half years ago. If, like Community Catalyst, your organization dedicated an immense amount of time and energy into ensuring the legislation made it through Congress with as many provisions as possible to address health inequity, then the bill’s passage likely feels much more recent.  

Thanks to our collective effort, ARPA sent a much-needed infusion of funding to state, local and Tribal governments reeling from a global pandemic. We’re still seeing the benefits of the law in the form of boosted tax credits available during this year’s open enrollment, a growing coalition of states cementing the 12-month postpartum Medicaid coverage spearheaded by ARPA and offered to states indefinitely under the omnibus bill, and guaranteed no-cost coverage for COVID-19 vaccinations for insured people (work remains for those uninsured, however).  

But, as most advocates know, the design and implementation of policy can be two radically different things. Passage of ARPA was a reason for celebration in the health justice community and beyond, but attention in many places turned to the nitty gritty of ensuring the funds would reach communities who needed them the most.  

Down in the Dirt: HCBS Implementation 

One program that was less focused on in post-ARPA press coverage, but still of critical importance was boosted funding for Home and Community-based Services (HCBS). 

HCBS empowers a range of people, notably older adults and/or people with intellectual, developmental and/or physical disabilities, to live independently in their homes and communities as opposed to institutional settings.  

People like Olivia. 

HCBS has been a longtime focus for Community Catalyst’s Center for Community Engagement in Health Innovation, and a recent project has us looking – two years later – at what can be learned by how states did, or did not, successfully implement HCBS services from ARPA and how to ensure future actions center the needs of people served by the program. 

As we close out National Family Caregivers Month, we thought it best to pause and reflect on some recently completed items that reviewed states’ spending plans for ARPA funding and HCBS. The resulting thematic analysis and literature review showed us innovative state approaches, identified some sizeable gaps in equity-focused public policy, and helped us pinpoint opportunities for advocates to support states seeking to advance their community engagement and equity agendas. it is worth exploring what we learned about Home and Community-Based Services (HCBS) in ARPA. 

What, Exactly, Did States Do (Or Not Do)? 

Greater detail lives in the literature review, but we focused on two key drivers of good policy: community engagement and a focus on equity. The topline learnings were that: 

Community Engagement 
  • Community engagement was present, but limited; 
  • Proactive community engagement was scarce; and 
  • States did not always report on how community engagement influenced their spending strategy. 
  • The majority of states did not explicitly name or discuss equity in their plan;  
  • A limited number of states listed equity as a guiding principle of their plan; and 
  • States explained how equity was implemented throughout their spending plan with varying degrees of depth. 

However, a literature review will only tell us so much. Understanding how the work is going on the ground meant speaking directly with partners and administrators engaged in the work to learn their perspective. 

“If you find someone who did it well, what did they do? How can we share that with others when faced with this incredible pressure and circumstance that they were able to do this well? How did they do it I think is important.”

The thematic analysis was informed by interviewing several key informants for their perspectives on states that did or did not do well in implementing HCBS programs that centered community engagement and equity.  

On the equity front, the interviews and policy reviews told us that all states have room to grow, but states with pre-existing equity initiatives were able to incorporate them into their ARPA spending plans. This was due to the nature of ARPA funding being designed to provide immediate aid in a short period of time. As a result, many states faced significant challenges in doing meaningful engagement with communities and stakeholders on a tight timeline if they didn’t already have good existing infrastructure for engagement.  

“But one thing that we’ve noticed that makes a big difference in terms of strategies at the state level is the extent to which the state is rural versus urban. I mean, this is true on any issue as you probably know. But on direct care workforce issues, it’s especially challenging because… the workforce capacity question in rural areas is just so dramatically different.”

The interviews pointed us to 34 states and the District of Columbia that helped inform our learnings on equity and community engagement in ARPA funding and some of the common barriers to success.  

Community Engagement Lesson Learned: Existing forms of community and stakeholder engagement were helpful for states to solicit rapid, informed feedback. This was particularly helpful when governments had already established trusted relationships with Tribal governments, disability councils, and minority health coalitions or had a more unified worker feedback system such as one provided by a unionized direct care workforce. 

Equity Lesson Learned: States with pre-existing equity initiatives were well-positioned to bring an equitable lens into ARPA spending plans. States who struggled here should look to build out equity initiatives in other streams of work to be better prepared for future spending opportunities. 

Ultimately, limited data collection practices and the rapid turnaround forced quick decision-making about spending priorities that couldn’t be developed further. The short-term nature of the ARPA funding also diminished the ability of states to make innovative, equity-driven choices. 

“There’s been a pivot in the degree to which ARPA funding is innovative. A lot of that is focused on this idea that we need to recover from COVID-19. There’s been this incredible drain on state resources. ARPA funding was meant to be something that I’m not totally sure it is at this point or can be at this point.”

Now What? And What’s Next? 

Both the literature review and thematic analysis have been incredibly illuminating at identifying the successes and limitations of ARPA funding to support community-informed, equitably implemented HCBS plans. States that had an existing community engagement infrastructure were able to capitalize on this and move more quickly and strategically allowing them to put some teeth into their community engagement and equity approaches. This illustrates the importance of maintaining that infrastructure, including advocacy coalitions, that have been developed around this work beyond ARPA funding. The good news is that this work doesn’t just exist in the rearview mirror for states, communities, or Community Catalyst.  

This initial work can and should inform states and communities still in the middle of this process and wondering what they can learn about bettering their approaches. At Community Catalyst, we have been partnering with the Whitman-Walker Health System in Washington, D.C. as well as the Somali Community Resettlement Services in Olmsted County, MN, to support and learn from their expertise on ensuring systemically underserved communities have access to high-quality health care services – and that equity is prioritized in health care delivery, particularly with ARPA funding for HCBS. The learnings outlined in the blog about our partners, as well as the findings from the thematic analysis and literature review, hold valuable insight into the work needed in states and communities who have not yet committed the entirety of their ARPA HCBS funds. It also speaks to the greater need to ensure meaningful community engagement and equity-centered health care delivery systems become the norm and not the exception.