Innovation Diffusion: An Event History Analysis of States Adoption of the 1915(c) Waiver for People Living with HIV/AIDS

Long-term care services continue to play an integral role in the lives of people living with HIV/AIDS (PLWHA) despite the introduction of highly active antiretroviral therapy (HAART). The Medicaid 1915(c) waiver is one option available to states which enables them to expand the availability of home and community-based services (HCBS) to communities of people with disabilities who would otherwise be placed in institutions (e.g., nursing facilities, long term care hospitals), including PLWHA. Few states have pursued this option for PLHWA whereas all states have implemented this waiver for older adults and other communities of people with disabilities. The purpose of the research study was to identify factors that influence a state's likelihood of adopting the 1915(c) waiver for PLWHA. ; The theoretical framework that guided the research was the Unified Model of Policy Adoption (Berry and Berry, 1990). An Extended Cox Proportional Hazards Model with Time-Varying Covariates was used to identify state-level characteristics that increase the risk of a state adopting the 1915(c) waiver for PLWHA. Additionally, interviews were conducted with several state Medicaid representatives for supplemental data in Ohio, Washington, Alabama, and Illinois. ; One of the findings was that the influence of states' ""neighbors"" was not constant. Those who adopted the waiver early on were influenced by the behavior of neighboring states whereas later adopters were not. The AIDS cumulative rate in the state positively influenced its likelihood of adoption. Other variables which positively influenced a state's likelihood of adoption included the Federal Medicaid matching rate, presence of a Democratic governor, and the number of residential care beds per capita in the state. ; The policy implications of the study include, a) a state's capacity to provide long-term care services in the community is critical to their adoption of the waiver, therefore states could move toward expanding their HCBS infrastructure, b) the amount of monetary contribution from the Federal government significantly influences states' likelihood of adoption and therefore, the Federal government could consider increasing its financial support of the 1915(c) waiver for PLWHA, and c) since the presence of a Democratic governor positively influences states' adoption of the waiver, governors could seek out forums to discuss the availability of the waiver for this population and its potential benefits to PLWHA as well as for states.