Brief Research Report
Determinants of State Utilization of Public Institutions for Persons with Intellectual Disabilities in the United States

Journal of Policy and Practice in Intellectual Disabilities
Volume 2 Number 1 pp 60–62 March 2005

Mary C. Rizzolo*, Tamar Heller*, and David Braddock†
*Institute on Disability and Human Development, Department of Disability and Human Development, University of Illinois at Chicago, Chicago, IL; and †University of Colorado System and the Coleman Institute for Cognitive Disabilities, Boulder, CO, USA

Abstract Tested was a political socio-economic model of state institution utilization for persons with intellectual disabilities in the
United States. The variables examined included state personal income, political culture, legislative professionalism, size of state’s chapter of The Arc, state spending per capita on the Home and Community Based Services (HCBS) Waiver, and utilization of nursing homes for the elderly. Results indicate the significance of the political culture and HCBS Waiver variables.
Keywords: deinstitutionalization, state institutions, public institutions, nursing hornes, political culture, HCBS Waiver

INTRODUCTION
Since the 1970s, most states have aggressively reduced their reliance on institutional settings for persons with intellectual disabilities (ID) in favor of smaller, community-based options. Although the advantages of community integration for persons
with ID from both functional and theoretical perspectives have been frequently noted in the literature, most states in the United
States continue to utilize state institutions for persons with ID. The federal government does not dictate to states which settings
they must provide to persons with ID; states have great latitude in deciding whether to utilize institutional or community services
(Braddock & Fujiura, 1987). In 2002, 44,252 persons with ID were receiving residential support in state institutions (Rizzolo,
Hemp, Braddock, & Pomeranz-Essley, 2004). Alaska, the District of Columbia, Hawaii, New Hampshire, New Mexico, Rhode Island, Vermont, and West Virginia no longer operate state institutions for persons with ID.

METHOD AND STUDY DESIGN
This study tested a political socio-economic model of stateoperated institution utilization for persons with ID in the United
States. A series of hierarchical regressions were conducted with the following variables: state personal income, political culture,
legislative professionalism, size of the state’s chapter of The Arc (a national grassroots advocacy and service organization with
over 140,000 members across the nation), state spending per capita on the Home and Community Based Services (HCBS)
Waiver, and utilization of nursing homes for the elderly. This brief focuses on the use of state institutions for persons with ID in
2000. Information on the number of persons with ID in state institutions was obtained from the State of the States in Developmental Disabilities Project at the University of Colorado. The State of the States project maintains a 26-year longitudinal record of revenue, spending, and programmatic trends in ID services in the 50 American states, the District of Columbia, and the United States as a whole. State wealth was defined as state personal income per capita.
Personal income includes the income of citizens from all sources and is an indicator of a state’s economic capacity to fund programs and services. Political culture is defined as the attitudes, values, beliefs, and orientations that individuals in a society hold regarding their political system (Riley, 2004). States can be traditionalistic, individualistic, or moralistic. Traditionalistic states have a desire to maintain the status quo; they typically resist change. Individualistic states are often driven by pragmatic
concerns, such as getting and staying elected. Moralistic states support programs if they promote the good of the community
(Sharkansky, 1969). Professional legislatures are characterized by full-time staff members, relatively highly paid members, and
substantial staff support (Patterson, 1996). The fourth variable, advocacy, was measured as per capita membership in the state’s chapter of The Arc. The Medicaid Home and Community Based Services (HCBS) Waiver, enacted in 1981, allows states to provide case management, homemaker assistance, home health aides, personal care, residential and day habilitation, respite, transportation, supported employment, home modification, and occupational, speech, physical, and behavioral therapy. Advocates champion the HCBS Waiver because it is significantly more flexible than the Medicaid Intermediate Care Facility for People with Mental Retardation Program (ICF/MR) (Duckett & Guy, 2000), which is the primary funding mechanism for large, institutional settings. Use of nursing homes for the elderly (age 65+) was used to discern whether a state that tended to use large, congregate settings for the elderly also used institutional settings for persons with ID.

RESULTS
The full model accounted for 57% of the variance among the states in utilization of state-operated institutions for persons with
ID in 2000 (Table 1). The majority of the explained variance was accounted for by the political culture variable. More traditionalistic states used institutions more (Rizzolo, 2005). Furthermore, participation in the HCBS Waiver was inversely correlated with state institution utilization; higher state funding for the Waiver was associated with lower rates of utilization. The study also found that state wealth was positively associated with use of state institutions for persons with ID. Wealthy states could afford to operate dual systems of care (institutions- and community-based supports).

COMMENTS

The results of this study illustrate the importance of HCBS Waiver funding in promoting community supports for persons
with ID. The HCBS Waiver has now emerged as the principal Medicaid program underwriting ID long-term care, surpassing
Medicaid ICF/MR spending in the states in the fiscal year of 2001.These findings also illustrate the robustness of the political culture variable. Although the variable was created decades ago, it remains a significant predictor of many public policies. “Many of the political differences in states today – differences in voter turnout and party competition, for example – are long-standing ones” (Gray, 1996). Although community-based long-term care has been described as a quasicivil right for persons with developmental disabilities (Braddock, 2002a,b), the commitment to this right appears to vary from one state to another depending on each state’s political culture.

ACKNOWLEDGMENTS
Funding was provided through the Rehabilitation Research and Training Center on Aging with Developmental Disabilities
(http://www.uic.edu/orgs/rrtcamr/), National Institute on Disability and Rehabilitation Research (Grant # H133B031134), and
the State of the States in Developmental Disabilities Project (http://www.cu.edu/ColemanInstitute/stateofthestates/) at the
University of Colorado, supported in part by a grant from the Administration on Developmental Disabilities, U.S. Department
of Health and Human Services.

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