Getting by in the community: lessons from frail elders.

This study explores how functionally impaired, elderly persons are able to remain in the community without home- and community- based care (HCBC) under the Medicaid program. Using HCBC administrative data, Medicare data, and survey data, we find the nonparticipants in the community appear to get by through a combination of reliance on informal care, use of Medicare home care, and going without needed services. Despite their efforts to manage their care in the community, non-participants were significantly more likely than the participants to enter a nursing home during the six months following assessment. While our analysis does not allow us to attribute the higher nursing home entry to the absence of HCBC services with certainty, the finding does raise questions about whether the elements of the HCBC program that discourage participation may save Medicaid dollars in the short-run at the expense of future Medicaid costs from more rapid nursing home entry.