ElderWeb

A Government Performance Project report from governing.com discusses problems in the long term care system that will impact its availability in the future.

Senator Chuck Grassley, chairman of the Committee on Finance, headed up a hearing on "Society's Great Challenge: The Affordability of Long-Term Care," and also announced that he and Sen. Bob Graham have re-introduced their Long-term Care and Retirement Security Act, S 627, which they sponsored in the last Congress. The bipartisan measure would allow individuals a tax deduction for the cost of long-term care insurance premiums and give individuals or their caregivers a $3,000 tax credit to help cover their long-term care expenses.

Witnesses in the Finance Committee hearing provided information about the cost and need for long term care, and discussed ways that it can be financed. Carol V. O'Shaughnessy of the Congressional Research Service reported that about 37 million caregivers provide informal, unpaid care to family members of all ages, and that almost 60% of the functionally impaired elderly, and nearly three-quarters of adults under age 65, receiving care rely exclusively on informal, unpaid assistance.

William J. Scanlon, Director of the United States General Accounting Office pointed out that nearly 80 percent of the elderly requiring assistance with ADLs or IADLs live at home or in community-based settings. He said that aging Baby boomers may have a disproportionate effect on the demand for paid services, since many baby boomers will have fewer options besides paid long-term care providers because a smaller proportion of this generation may have a spouse or adult children to provide unpaid caregiving due to the geographic dispersion of families and the large percentage of women who work outside the home.

Scanlon also pointed out that long term care financing is heavily dependent on Medicaid, which is a significant share, about 20%, of state budgets. This makes Medicaid financing vulnerable to states? fiscal health, and a recent fiscal survey of states showed that about one-half of states are expecting declines in revenue growth for 2001 to 2002, and about one-half of the states estimate that Medicaid spending will exceed their current projections. With declining revenue and increasing Medicaid expenditures, maintaining balanced budgets in states may require constraining Medicaid expenditures, including the large share represented by long-term care services.

In spite of the problems on the horizon for public financing of long term care, less than 10 percent of elderly individuals and even fewer near-elderly individuals (those aged 55 to 64) have purchased long-term care insurance, compared to about two-thirds who have private Medicare supplemental. Lisa Maria B. Alecxih of The Lewin Group discussed the cost of long term care insurance. She presented a chart showing that premiums can range from $274 annually for a four-year policy with no inflation protection that covered nursing home, assisted living and home care and was issued at age 40 to $7,022 per year for a policy with similar benefits, but that includes inflation protection and benefits if the purchaser stops paying premiums (nonforfeiture) issued at age 79. She also pointed out that insurance only helps consumers if they still have it when they need it, but said that the limited data available suggests that 30 to 50 percent of all individual purchasers of long-term care insurance lapse within five years.

Governor Jeb Bush of Florida has proposed a series of initiatives designed to make Florida an "Elder-Friendly" state. Among other things, the governor proposes dedicating $46 million in new funding to improve the quality of nursing home care, $52.4 million to expand community-based options in long-term care for elders, $2.5 million to increase Medicaid fees for home health agencies, and $30 million to fund a new program to assist low-income elders in obtaining needed prescription drugs.

He also is encouraging communities and businesses to attain an "Elder-Ready" brand from the state which will greatly improve the livability of a community for elders. An elder-ready community has: easy access to drug stores, reliable transportation to medical care, pedestrian-friendly traffic lights and walkways, adequate lighting in public places, call boxes to enhance safety, zoning for elder-friendly housing, adequate health providers with gerontological training and much more.

In addition, Governor Bush indicated he is in favor of addressing the cost of litigation of long term care facilities, and noted that 30 assisted living facilities have been notified that they are at risk of losing their licenses because they do not carry liability coverage due to the cost or lack of availability of such insurance.

Members of the Minnesota Long Term Care Task Force have agreed on a tentative plan to present to the Legislature when it convenes next month. The plan calls for more home-based and assisted-living care, such as apartment buildings with built-in nursing and social services, and efforts to attract more workers by upgrading jobs and raising wages.

The task force was formed in May 2000 to address the emerging issues in long-term care in Minnesota. The task force members included 12 legislators, six senators and six representatives, named by the leadership in the Senate and House, with bipartisan representation. Members also included three commissioners of state agencies most involved in long-term care issues: the Minnesota Department of Human Services, Minnesota Department of Health and the Minnesota Health Finance Agency.

The task force is charged with drafting legislation needed to reform the long term care system in Minnesota, and they have agreed to consider legislation that would restructure the system that now depends on highly skilled nursing-home care to include more home-based and assisted-living care, provide better consumer information so older people and their loved ones can more easily make informed decisions, and address the worker shortage in a way that would attract qualified people to an upgraded profession.

Governor Jesse Ventura's budget goal is to hold overall spending increases to 5 percent, so the task force's $113 million plan wouldn't work without cutting other programs, although it does fit Ventura's vision for the state, because it encourages independent living and self-sufficiency. The $113 million plan would include:

* $91 million for cost-of-living wages for all long-term-care providers.
* $43 million for increased services for the elderly who otherwise would end up in nursing homes.
* $5.6 million to expand consumer information.
* $4.4 million to build up the market for long-term-care insurance.

The plan also would help nursing homes close or convert to other types of care, make respite care available for home caregivers on a sliding-fee scale, and make state regulations more flexible. The ideas contained in the plan were drawn from comments during meetings of dozens of older people and their families, nursing-home administrators and employees, and other public officials.

One of these projects, whose results are being eagerly awaited by stakeholders across Canada, is taking place here in Montreal. This is a pilot project that will test new ways of delivering integrated health services to vulnerable seniors and evaluate the benefits of this approach. The project involves 600 elderly people in the Bordeaux-Cartierville and C'des-Neiges districts of Montreal. The concept is to work with interdisciplinary teams to offer an integrated range of relevant health services to these individuals.

This project will demonstrate new ways of organizing health services to optimize the quality and level of care afforded the growing segment of the population which is aging. More to the point, this project is not premised on creating a single delivery model that will be broadly imposed. It is premised on creating a knowledge base that all provinces and territories can build on and expand in order to develop new and more effective systems tailored to their distinct realities.

Each of the candidates for U.S. President have published position papers on Medicare, Social Security, and long term care.

>> George Bush on Medicare
>> George Bush on Social Security
>> George Bush on Long Term Care
>> Al Gore on Medicare
>> Al Gore on Social Security
>> Al Gore on Seniors Issues, Including LTC
>> AARP Bulletin Article on Candidate Positions on Social Security
>> AARP Voters Guides - Candidate Responses on LTC Issues
>> League of Women Voters - Comparison of Gore and Bush Proposals on Medicare and LTC

The Florida Legislature has create a Task Force on the Availability and Affordability of Long-term Care, to study issues related to the provision of long-term care to the elderly in nursing homes and alternatives to nursing homes, and to make recommendations to the Governor and the Legislature. The Task Force has until the end of the year to come up with its proposals. The group will hold hearings in Tampa, Miami, Pensacola and Tallahassee this summer and fall to listen to the public.

The legislation states that the task force shall, at a minimum, study and make recommendations concerning the following:

The availability of alternative housing and care settings for the elderly, including the use of rent-subsidized facilities, assisted living facilities, and adult family care homes.

The availability of community-based care arrangements that support elderly individuals to age in place in their own homes and in alternative housing and care settings.

The role of family members in caring for elderly relatives and ways in which quality family care can be encouraged.

The adequacy of reimbursements for the cost of providing care to the elderly in nursing homes and in alternative housing and care settings.

The availability and affordability of long-term-care insurance coverage and the potential for funding long-term care through such coverage.

The role of the certificate-of-need process in the development of systems of long-term care for the elderly.

The extent to which the quality of care in long-term-care facilities in this state is compromised because of market changes that affect the financial stability of the long-term-care industry.

The effect of lawsuits against nursing homes and long-term care facilities on the cost of nursing home care and on the financial stability of the nursing home industry in the state.

The cost and availability of liability insurance coverage for long-term-care providers and the extent to which such costs affect the affordability of care.

The primary causes for recent bankruptcies facing the nursing home industry.

The ways in which other states have promoted the development of alternative and homebased care and what they have learned from these innovations.

The difference between the quality of care provided by for-profit skilled nursing facilities and by not-for-profit skilled nursing facilities.

The current issue of Health Affairs includes an article entitled "Long-Term Care In The United States: An Overview," by Judith Feder, Harriet L. Komisar, and Marlene Niefeld. In this article, the authors do an excellent job of exploring the problems of access to, and funding for, home and community-based long term care services for the elderly in the United States.

The authors discuss the fact that Medicaid's focus on institutional, rather than community-based, long term care makes it harder for people to access the care they need at home, but also noted that it is likely that public funding costs will increase if Medicaid covers more services in the home. Increases would come from the cost of providing help to the many community-dwelling seniors currently unable to get the assistance they need, due to the cost or inavailability of services. The authors note that the public is aware of significant quality assurance problems in nursing homes, but that monitoring quality care in the home will be even more difficult than it has been in nursing homes. They also suggest that long term care insurance will be critically important in financing long term care, since insurance is best used to cover costs that are catastrophic and unpredictable, like long term care costs.

Judith Feder, a political scientist, is dean of policy studies at Georgetown University in Washington, D.C.

Research published in the Archives of Internal Medicine reports that people without health insurance are less likely to get the health care they need. Participants in the National Access to Care Survey were asked whether they had experienced any of 15 highly serious or morbid symptoms. Those who did were asked whether they received medical care and, if care was not received, whether care was thought to have been necessary. The uninsured were more likely to say that they did not even attempt to access care, although they felt that care was necessary. 63% of the uninsured said that not receiving care affected their health, and 57% said they had personal, household, or work problems because they did not receive medical care, compared to 13% and 20% of the insured.

Canada's National Advisory Council on Aging (NACA)has published a report, "Seniors of Tomorrow" in the current issue of their "Expressions" newsletter. In this "Crystal Ball Issue", they discuss demographic trends, policy issues, health, wealth, and make various reflections and prognostications about aging in Canada. For instance, they discuss retirement, and observe several trends:

Involuntary retirement used to happen when people reached mandatory retirement age, but now it's more likely to result from job loss or caregiving.
Reversing retirement (returning to the work force) is a new trend, more common among men than women.
There may be a trend toward no retirement because of the need to supplement income.

The Canadian government wants residents to participate in the health care reform effort by filling out a brief online survey about health care problems and issues. The questionnaire asks the participant to rate the importance of various initiatives, such as the need to expand home and community care to reduce pressure on hospitals. Participants can see the cumulative results as soon as they submit their response to the survey questions.

Michigan's Long Term Care Workgroup published preliminary results of their study into the Michigan long term care system, and are continuing to meet to refine the final report. They made a number of recommendations for changes. Among other things, they recommend development of a "single point of entry" program that will make it easier for beneficiaries to access services provided by different state agencies. They also suggest that the tobacco settlement money be used partly to education Michigan residents about long term care issues to encourage them to take personal responsibility for planning for their long term care needs.

One innovative idea they propose is to require long term care insurance policies to permit the use of benefits as a pool of money, rather than as a daily benefit for a fixed number of years. Instead of a $100 per day three-year maximum benefit policy, such policies would provide a $109,500 pool of money which could be spent to allow the benefits to last more than three years, with no penalty for seeking alternative care, such as assisted living, to make the benefits last longer.

They also recommended that the state consider making insurance premiums and caregiver expenses tax-deductible, and that they extend the "look-back" periods which make people who have divested themselves of assets ineligible for Medicaid from 3 years to 10 years.

Britain's National Health Service (NHS) is in the process of greatly expanding and revamping long term care services. The changes are being made in response to recommendations made by The Royal Commission on Long Term Care. Under the new NHS Plan the government will make new investments in intermediate care and associated services amounting to £900 million a year by 2003/2004 to promote independence, provide more choice for older people and deliver higher quality care. On top of this they will be targeting additional resources, for £360 million a year by 2003/2004, to tackle the anomalies and inequities of the present funding system for long term care. Many of these changes will become effective in April of 2001.

Under the new rules, NHS nursing care will be free in all settings. This change will benefit around 35,000 people at any time who could save up to around £5,000 for a year's stay in a nursing home.

Requirements for people to sell their homes to qualify for care will be softened. For the first three months from admission to residential care, the value of the resident's home will be disregarded from the means test to allow people time to decide whether it will be necessary to sell the property to pay care costs. This change will benefit around 30,000 people each year, who will save up to £2,000- £2,500 during the first three months of their stay. The NHS is still reviewing a suggestion that local councils extend loans to low income persons who need care so that they don't have to sell their homes during their lifetimes.

New statutory guidance will be issued to reduce the variation in the amounts people are asked to pay for help at home, which now vary greatly from one local council to another -- a system critics call the "postcode lottery". The means test for getting assistance from local councils will be increased from £16,000 to £18,000, which will benefit around 20,000 people in residential care homes and nursing homes.
Resources behind two social security benefits, the Preserved Rights to higher levels of Income Support and the Residential Allowance, will be transferred to local councils to make available additional resources to support the care costs of pre-1993 residents whose income support rates have fallen short of their care home fees.

The Government will investigate the regulation of long term care insurance after a Treasury led committee has reported on how the financial services industry can reassure its customers about the quality and reliability of the products available for financing long term care.
The report of the Royal Commission recommended that personal care, including nursing care and some social care tasks such as help with bathing, should be funded from general taxation, subject to an assessment of need. The NHS responded that three quarters of those in residential or nursing care already get some or all of their personal care costs met from public funds through local councils, and that making personal care free for everyone would consume most of the additional resources they plan to make available for older people through the NHS Plan without necessarily improving services. Therefore, this recommendation will not be followed.