Saint Louis University Journal of Health Law & Policy

Document Type

Symposium Article


Medicaid fills a gap in the U.S. health care system as the primary payor for long-term services and supports (LTSS). These services enable seniors, people with disabilities, and those with chronic illnesses to live independently in the community, outside of nursing homes and other institutions. Most Medicaid home and community-based services (HCBS) are covered at state option, unlike nursing home care, which all state Medicaid programs must cover. States have substantial flexibility in designing their Medicaid HCBS programs under federal law, and Medicaid provides an important source of federal funding to states to help meet the LTSS needs of seniors and people with disabilities. The optional nature of most HCBS puts the populations receiving these services at risk if Medicaid’s federal financing structure were to change in a way that would decrease federal funding to states, such as through a block grant or per capita cap. These remarks were delivered at Saint Louis University School of Law’s 31st Annual Health Law Symposium: The Struggle for the Soul of Medicaid on April 5, 2019, and have been edited for clarity.