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This was almost triple the number available in 1992. The number of residences from between seven and fifteen people remained about the same, and the number of larger facilities (16 people or more) decreased.

On the one hand, the availability of community alternatives increased dramatically, and at the same time, waiting lists remained long. One of the reasons for the dramatic growth in community alternatives were additional changes to the Medicaid waiver rules.

In 1993, the Health Care Financing Administration (now called the Centers for Medicare and Medicaid Services or CMS) only required states to demonstrate that the total expenditures for a waiver program would not exceed the cost of serving an equivalent group of people in an institution.

In 1990, Medicaid spent $3.9 billion for home-and-community-based care (for all populations). That represented 13% of the Medicaid long term care spending. By 2000, the total amount was more than four times greater ($18.2 billion) and 27% of the long-term care spending.

Accessible transportation
Photo courtesy William Bronston, M.D.