{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T21:34:08Z","timestamp":1764884048965,"version":"3.46.0"},"reference-count":27,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T00:00:00Z","timestamp":1763078400000},"content-version":"unspecified","delay-in-days":13,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["5R01AG069147"],"award-info":[{"award-number":["5R01AG069147"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,27]]},"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To evaluate the impact of the Medicaid Balancing Incentive Programme (BIP) on long-term services and supports utilisation among older adults, focusing on differences in living arrangements.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Quasi-experimental study using a generalised difference-in-differences approach.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>States that participated and completed BIP (treatment group: 18 states) and states that were eligible but did not participate (control group: 17 states).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Older Medicaid beneficiaries from the Health and Retirement Study (2006\u20132018) across states that participated in BIP and those that did not. A negative control analysis was conducted using non-Medicaid beneficiaries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcomes<\/jats:title>\n                    <jats:p>We examined the probability of long-term nursing home stays (over 100 days), professional home healthcare and three types of home care services for activities of daily living: paid professional caregiving, paid informal caregiving and unpaid informal caregiving. Analysis was stratified by living arrangement (living alone vs with others).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>BIP participation was associated with a 5\u2009percentage point (pp) decrease in long-term nursing home stays among Medicaid beneficiaries living alone (average treatment effect on the treated, ATT=\u20130.06, 95%\u2009CI \u20130.10 to \u20130.02; p&lt;0.01). Among Medicaid beneficiaries living with others, BIP was associated with a 5 pp increase in paid informal caregiving (ATT 0.05, 95%\u2009CI 0.03 to 0.08; p&lt;0.01). No significant effects were observed for non-Medicaid beneficiaries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>BIP contributed to a reduction in institutionalisation for individuals living alone while increasing support for family caregivers in multiperson households. These findings highlight the importance of tailoring long-term care policies to the specific needs of populations based on their living arrangements.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104206","type":"journal-article","created":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T06:25:35Z","timestamp":1763101535000},"page":"e104206","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Evaluating the impact of the Medicaid Balancing Incentive Programme on long-term care utilisation by living arrangement: a quasi-experimental study"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-6775-5465","authenticated-orcid":false,"given":"Ah-Reum","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6662-1198","authenticated-orcid":false,"given":"Yulin","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas","family":"Rapp","sequence":"additional","affiliation":[{"name":"LIRAES (URP4470); Chaire AgingUP!, Universit\u00e9 Paris Cit\u00e9, Paris, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jacqueline","family":"Torres","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,11,13]]},"reference":[{"key":"2025120413272171000_15.11.e104206.1","doi-asserted-by":"crossref","unstructured":"OECD . Who cares? Attracting and retaining care workers for the elderly. OECD health policy studies. Paris: OECD Publishing, 2020. Available: https:\/\/doi.org\/10.1787\/92c0ef68-en","DOI":"10.1787\/92c0ef68-en"},{"key":"2025120413272171000_15.11.e104206.2","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-018-3825-z","article-title":"Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review","volume":"19","author":"Bieber","year":"2019","journal-title":"BMC Health Serv Res"},{"key":"2025120413272171000_15.11.e104206.3","doi-asserted-by":"crossref","first-page":"2899","DOI":"10.1007\/s11136-017-1651-0","article-title":"The quality of life of older people aging in place: a literature review","volume":"26","author":"Vanleerberghe","year":"2017","journal-title":"Qual Life Res"},{"key":"2025120413272171000_15.11.e104206.4","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1111\/1475-6773.13267","article-title":"Challenges to community transitions through Money Follows the Person","volume":"55","author":"Robison","year":"2020","journal-title":"Health Serv Res"},{"key":"2025120413272171000_15.11.e104206.5","unstructured":"Mann DR , Ross J , Wysocki A . Medicaid section 1915(c) waiver programs annual expenditures and beneficiaries report: analysis of CMS 372 annual reports, 2018\u20132019. Chicago, IL: Mathematica, 2023. Available: https:\/\/www.medicaid.gov\/medicaid\/long-term-services-supports\/downloads\/cms-372-report-2018-2019.pdf"},{"key":"2025120413272171000_15.11.e104206.6","unstructured":"Karon SL , Knowles M , Lyda-McDonald B , et al . 2019. Final Outcome Evaluation of the Balancing Incentive Program. RTI International, National Academy for State Health Policy, National Association of State Directors of Developmental Disability Services, Available: https:\/\/aspe.hhs.gov\/reports\/final-outcome-evaluation-balancing-incentive-program-0#exhibit2"},{"key":"2025120413272171000_15.11.e104206.7","unstructured":"Centers for Medicare & Medicaid Services . Patient Protection and Affordable Care Act section 10202 State balancing incentive payments program: initial announcement (CFDA 93.778), 2012. 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Difference-in-differences with variation in treatment timing. NBER Working Paper No. 25018. National Bureau of Economic Research, 2018.","DOI":"10.3386\/w25018"},{"key":"2025120413272171000_15.11.e104206.19","unstructured":"Health and Retirement Study . RAND HRS Longitudinal File 2018 (V2) public use dataset. Produced and distributed by the University of Michigan with funding from the National Institute on aging (grant number NIA U01AG009740), Ann Arbor, MI, 2022. Available: https:\/\/hrsdata.isr.umich.edu\/data-products\/rand-hrs-longitudinal-file-2018?_ga=2.258979978.1890758364.1616690587-360856504.1616690587"},{"key":"2025120413272171000_15.11.e104206.20","unstructured":"Health and Retirement Study . Cross-Wave Geographic Information (Detail) Restricted Data, 1992\u20132018: Data Description and Usage. Version 8 (Early). Ann Arbor, MI: University of Michigan; March 2021. 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American Community Survey 1-year estimates: Public use microdata sample (PUMS), Available: https:\/\/www.census.gov\/programs-surveys\/acs\/data\/pums.html"},{"key":"2025120413272171000_15.11.e104206.24","unstructured":"U.S. Census Bureau. U.S. Department of Commerce . Current Population Survey, Annual Social and Economic Supplement (ASEC), Available: https:\/\/www.census.gov\/programs-surveys\/cps.html"},{"key":"2025120413272171000_15.11.e104206.25","unstructured":"Gardner J . Two-stage differences in differences, 2022. 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