U.S. States Health Policy Analysis


General Statements

  • Community First Choice health care policy;
  • Increase in federal funding for US states;
  • States provide person-centered HCBS;
  • Approved in California, Maryland, Montana, Oregon, Texas;
  • No enrollment caps on statewide HCBS.

Note: Community first choice (CFC) is a policy targeted at the increase of federal funding for states that offer person-centered Home & Community Based Services (HCBS). It is possible for individuals to receive care at home or communities instead of isolated healthcare settings (Sonnega, Robinson, & Levy, 2017). The policy intends to target individuals with physical or developmental disabilities, as well as underserved populations.

Policy Importance

  • Helping citizens requiring institutional levels of care;
  • Supporting Medicare enrollees under State Plans;
  • 6%-point increase in federal matching programs;
  • Increase individuals’ abilities to live in communities;
  • Includes a person-centered service plan.

Note: The program is important for helping individuals overcome the high costs of care. Instead of getting help at healthcare institutions, person-centered service plans allow to select the most appropriate settings for care.

Health Policy Analysis


  • Developed in 2011, amended in 2014;
  • Attendant services and supports provided to patients;
  • Care provided within home and community settings;
  • Settings should be eligible sites for healthcare;
  • Includes a public comment process.

Note: The policy allows states to offer statewide HCBS to assist individuals requiring an institutional level of care. It also provides beneficiary protections in terms of supporting individuals’ choice to receive HCBS in the manner that is the most appropriate and convenient for them.

Intended Impact

  • Provision of long-term care to Medicare beneficiaries;
  • Less costly services compared to institutional care;
  • Decreasing healthcare administrative and renewal requirements;
  • Better focus on quality oversight and implementation;
  • Increasing flexibility to ensure a stronger workforce.

Note: The key impact of the policy is concerned with increasing the flexibility in providing HCBS for vulnerable populations. For patients who require specific care, e.g., the elderly, HCBS can help in reducing spending on nursing home services (Sonnega et al., 2017).

Policy Ethical Implications

  • Greater focus on individual needs and circumstances;
  • Increase access to benefits of community living;
  • Services are received within integrative settings;
  • Allowing to make choices on health care decisions;
  • Greater integration with communities and services.

Note: The ethical implications of the policy are associated with creating an environment in which individuals feel supported by their community. Depending on the needs of each individual, it is possible to develop strategies on appropriate health care decisions.

Alignment with National Population Initiative

Congruence of the Policy

  • Directly related to the Medicaid program;
  • Aligns with State Plan Home and Community-Based Services;
  • Includes state plan HCBS benefits for communities;
  • Aligns with Healthy People in providing accessible care;
  • Supports CMS policies, quality improvement guidelines.

Note: In combination with the support from Medicaid, the policy can offer a wide variety of services within the HCBS plan (Medicaid, 2019). The objectives of the policy align with Healthy People 2020 goal in terms of providing accessible high-quality care.


  • Requires an update in more US states;
  • Effective care for transitioning patients;
  • Services exclusively for the benefit of individuals;
  • Hospitals are not involved in care provision;
  • Not available when individuals reside at institutions.

Note: The policy can work in combination with other available programs that target population health. Since hospitals are not involved in care provision, it is possible to be more flexible for patients.

One Strategy to Address Health Disparity

  • Involvement of healthcare professionals in discussion;
  • Providing personnel training to meet patients’ needs;
  • Increase satisfaction surveys and patient feedback;
  • Provide access to services for patients’ families;
  • Child-based programs for community care.

Note: In order to strengthen the policy, it is recommended to increase the engagement of healthcare personnel into the conversation about the care for communities and individuals with specific needs.

Recommendation for Enhancement

How the Strategy would be Implemented

  • Allowing patients to choose care settings;
  • Increased collaboration with patients’ providers;
  • Family-centered care within home settings;
  • Decreased reliance on healthcare facilities;
  • Providing 24/7 guidance on health questions.

Note: It is possible to implement significant improvements in the care for communities. The establishment of services for support and guidance services can improve the access of individuals to healthcare services.

Opportunities for Interprofessional Collaboration

  • Collaboration between physical and mental health specialists;
  • Home and community settings offer more leverage;
  • Professionals can learn from patients’ feedback on care;
  • Establishing a hotline for increased communication;
  • Creating online resources for patients to access.

Note: The collaboration between healthcare professionals of different specialization can allow to increase the capabilities of a HCBS plan (Aguirre-Duarte, 2015).


Concluding Statements

  • Has a positive impact on a community level;
  • No adverse impact on federal Medicaid funding;
  • Less costly care compared to institutional options;
  • Ensures long-term services for Medicaid beneficiaries;
  • Positively influences patients from underserved areas.

Note: The overall impact of the policy is expected to have a positive influence on individuals who require a personal approach toward health care. The choice of a health care setting that is appropriate for a patient is also expected to increase engagement (Fleming et al., 2017).


  • Program that increases federal funding for states;
  • Is based on person-centered care;
  • Voluntary for states, thus less complex in implementation;
  • Better choice for individuals to save funds and resources;
  • Should be updated to include new developments.

Note: While the policy may be updated to have the most recent information, it still represents a program that allows individuals be proactive in choosing their care settings.


Aguirre-Duarte N. A. (2015). Increasing collaboration between health professionals: Clues and challenges. Colombia Medica (Cali, Colombia), 46(2), 66-70.

Fleming, M. D., Shim, J. K., Yen, I. H., Thompson-Lastad, A., Rubin, S., Van Natta, M., & Burke, N. J. (2017). Patient engagement at the margins: Health care providers’ assessments of engagement and the structural determinants of health in the safety-net. Social Science & Medicine, 183, 11-18.

Medicaid. (2019). Home & community based services 1915(i). Web.

Sonnega, A., Robinson, K., & Levy, H. (2017). Home and community-based service and other senior service use: Prevalence and characteristics in a national sample. Home Health Care Services Quarterly, 36(1), 16-28.

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