KFF Analysis Explores States’ HCBS Spending Strategies Ahead of HR 1’s Impact

An November 20, 2025 analysis by health policy research organization KFF of data gathered as part of its 25th Annual Medicaid Budget Survey, released earlier this month, explores states' management of Medicaid home care spending and use of waivers and other 'tools.' This analysis of historical approach may provide insights into states' future approaches as they navigate spending constraints imposed by HR 1.

KFF's findings show that 44 of 50 states use limits on waiver enrollment, spending, or services to create budget predictability and curtail spending in home and community-based services (HCBS) programs.

Authors break down waiver caps into populations served and total states deploying each kind of cap.

The most commonly used tools by states are caps on spending per participant and caps on enrollment in a particular waiver; in both instances 37 of 50 states use these methods. Additionally, 47 states report using prior authorization for HCBS.

Authors of the brief don't venture into speculation about how states may respond to H.R.1-imposed budget shortfalls, though the data highlight the most likely policy levers for states to pull.