A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.