State Medicaid spending for long-term services and supports (LTSS) and the self-reported health of spousal caregivers of community-dwelling older adults with dementia

• Each $1,000 increase in LTSS spending linked to a 4.2-pp lower risk of poor health • No significant link between HCBS spending share and spousal caregivers’ poor health • Integrate caregiver assessments into LTSS and HCBS to better support caregiver health To examine the relationships between state Medicaid total Long-Term Services and Supports (LTSS) expenditures and the LTSS rebalancing ratio (i.e., the proportion allocated to Home- and Community-Based Services [HCBS]) with the self-reported health of spousal caregivers of community-dwelling older adults with dementia. This study used multiple data sources, including the Health and Retirement Study (HRS) and annual Medicaid LTSS user and expenditure reports. The analytic sample included 1,232 respondent-waves of spousal caregivers who participated in at least one of the seven HRS waves between 2008 and 2020 and provided care for their community-dwelling spouse with dementia. We employed generalized linear models (GLMs) for both bivariate and multivariable analyses, with the outcome of interest being a dichotomous variable for self-reported poor health. Each additional $1,000 of annual LTSS spending per older adult was associated with a marginally significant 4.2-percentage point reduction in the probability of reporting poor health (Average Marginal Effect [AME] in percentage points [PP] = -4.21, 95% Confidence Interval [CI]= -9.12-0.70, p=0.093). However, no statistically significant association was observed between the LTSS rebalancing ratio and spousal caregivers’ self-reported health (AME in PP=2.22, 95% CI = -2.07-6.49, p=0.310). Higher state Medicaid LTSS spending per older adult was moderately associated with better self-reported health among spousal caregivers of individuals with dementia. As the demand for informal caregiving continues to rise, this study underscores the importance of state investments in protecting caregivers’ health and highlights the need to incorporate caregiver-focused assessments into the design and evaluation of LTSS policies.