Dissertation Title:  "Grey Matters: Political-Economic Analyses of Long-Term Care"Chapter 1. Public financing of long-term care services and supports (LTC) has historically favored institutional over non-institutional care. However, since the passage of the Americans with Disabilities Act in 1990, there has been great interest in expanding home- and community-based services (HCBS). As states face both fiscal and social pressures to provide more care in people's homes and communities, this paper provides a longitudinal, political analysis of interstate variation in spending on different HCBS programs. Fixed effects regression models are used to examine state HCBS expenditures per capita and as a share of total state LTC spending for the period 2001-2010. Generally, a Democratic governorship has a relatively strong and positive effect on HCBS spending, while a socially liberal electorate has a strong but negative effect.

Chapter 2. In 1981, Congress introduced the 1915(c) waiver program to assist state Medicaid programs with expanding their provision of home- and community-based services (HCBS). Given that a waiver for HCBS may only be extended to beneficiaries who meet their state’s eligibility criteria for institutional care, policymakers have long considered the waiver program to be one that lowers Medicaid LTC spending. However, targeting of social services is not perfect, and little is known about the financial impact of the waiver program. Statistical methods are used to analyze different Medicaid LTC expenditure categories using variations in waiver program spending across states and time. The results suggest that no cost savings are occurring.

Chapter 3. Over twenty years ago, public long-term care (LTC) coverage in Germany was much like how it is in Canada today. Programs financed from tax revenues provided means-tested access to nursing home care and, in some areas, to community-based services. Yet, in 1995, Germany implemented a universal social LTC insurance (LTCI) system. Meanwhile, despite the fact that Canada’s elderly now outnumber its children, Canada continues to lack a national strategy for LTC. The exclusion of LTC from the Canada Health Act has led to a patchwork system whereby the scope of care, and its access, varies by region. The German experience, however, can provide useful lessons for Canada. I therefore analyze the German system's experience in both financing and providing user-directed care. My goal is to better understand the groundwork that that helped establish and sustain Germany’s LTCI system as it is designed, and whether Canadian policy actors can replicate some of this work in pursing their own social LTCI system.