State Policy on Long-Term Care for the Elderly

Health Affairs

Volumn 17, Issue 3, 1998, Pages 81-100

  Wiener, Joshua M ^a   Stevenson, David G ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; COST CONTROL; ECONOMICS; ELDERLY CARE; GOVERNMENT; HEALTH CARE COST; HEALTH CARE ORGANIZATION; HEALTH CARE PLANNING; HEALTH CARE POLICY; HUMAN; LONG TERM CARE; MEDICAID; POLITICS; UNITED STATES;

AGED; COST CONTROL; HEALTH CARE RATIONING; HEALTH EXPENDITURES; HEALTH POLICY; HEALTH SERVICES FOR THE AGED; HUMANS; LONG-TERM CARE; MEDICAID; POLITICS; STATE GOVERNMENT; STATE HEALTH PLANS; UNITED STATES;

EID: 0032060908     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.17.3.81     Document Type: Article

References (43)

1. K. Levit et al., "National Health Expenditures, 1995," Health Care Financing Review (Fall 1996): 175-214.
2. J.M. Wiener, L.H. Illston, and R.J. Hanley, Sharing the Burden: Strategies for Public and Private Long-Term Care Insurance (Washington: Brookings Institution, 1994).
3. Unpublished estimates of nursing home revenue per day, Office of National Health Statistics, Office of the Actuary, Health Care Financing Administration, January 1997.
4. J.M Wiener, C.M. Sullivan, and J. Skaggs, Spending Down to Medicaid: New Data on the Role of Medicaid in Paying for Nursing Home Care (Washington: American Association of Retired Persons, June 1996).
5. Ibid.
6. For a discussion of the project, see A. Kondratas, A. Weil, and N. Goldstein, "Assessing the New Federalism: An Introduction," in this volume of Health Affairs.
7. Unless otherwise noted, all Medicaid data presented in this paper come from Urban Institute analysis of Health Care Financing Administration (HCFA) Forms 64 and 2082 data for 1995.
8. Authors' estimate based on data from S. Coronel and M. Kitchman, Long-Term Care Insurance in 1995 (Washington: Health Insurance Association of America, 1997). On cost, see Wiener et al., Sharing the Burden; W.H. Crown, J. Capitman, and W.N. Leutz, "Economic Rationality, the Affordability of Private Long-Term Care Insurance, and the Role of Public Policy," Gerontologist 32, no. 4 (1992): 478-485; and A.M. Rivlin and J.M. Wiener, Caring for the Disabled Elderly: Who Will Pay? (Washington: Brookings Institution, 1988).
9. Authors' estimate based on data from S. Coronel and M. Kitchman, Long-Term Care Insurance in 1995 (Washington: Health Insurance Association of America, 1997). On cost, see Wiener et al., Sharing the Burden; W.H. Crown, J. Capitman, and W.N. Leutz, "Economic Rationality, the Affordability of Private Long-Term Care Insurance, and the Role of Public Policy," Gerontologist 32, no. 4 (1992): 478-485; and A.M. Rivlin and J.M. Wiener, Caring for the Disabled Elderly: Who Will Pay? (Washington: Brookings Institution, 1988).
10. Authors' estimate based on data from S. Coronel and M. Kitchman, Long-Term Care Insurance in 1995 (Washington: Health Insurance Association of America, 1997). On cost, see Wiener et al., Sharing the Burden; W.H. Crown, J. Capitman, and W.N. Leutz, "Economic Rationality, the Affordability of Private Long-Term Care Insurance, and the Role of Public Policy," Gerontologist 32, no. 4 (1992): 478-485; and A.M. Rivlin and J.M. Wiener, Caring for the Disabled Elderly: Who Will Pay? (Washington: Brookings Institution, 1988).
11. Authors' estimate based on data from S. Coronel and M. Kitchman, Long-Term Care Insurance in 1995 (Washington: Health Insurance Association of America, 1997). On cost, see Wiener et al., Sharing the Burden; W.H. Crown, J. Capitman, and W.N. Leutz, "Economic Rationality, the Affordability of Private Long-Term Care Insurance, and the Role of Public Policy," Gerontologist 32, no. 4 (1992): 478-485; and A.M. Rivlin and J.M. Wiener, Caring for the Disabled Elderly: Who Will Pay? (Washington: Brookings Institution, 1988).
12. Wiener et al., Sharing the Burden; Rivlin and Wiener, Caring for the Disabled Elderly, and M.A. Cohen, N. Kumar, and S.S. Wallach, "Long-Term Care Insurance and Medicaid," Health Affairs (Fall 1994): 127-139.
13. Wiener et al., Sharing the Burden; Rivlin and Wiener, Caring for the Disabled Elderly, and M.A. Cohen, N. Kumar, and S.S. Wallach, "Long-Term Care Insurance and Medicaid," Health Affairs (Fall 1994): 127-139.
14. Wiener et al., Sharing the Burden; Rivlin and Wiener, Caring for the Disabled Elderly, and M.A. Cohen, N. Kumar, and S.S. Wallach, "Long-Term Care Insurance and Medicaid," Health Affairs (Fall 1994): 127-139.
15. See J.M. Wiener, "Trying to Jump Start the Market: Public Subsidies for Private Long-Term Care Insurance," in Balancing Responsibilities for Financing Long-Term Care: The Integration of Public and Private Roles, ed. L. Walker, B. Bradley, and T. Wetle (Baltimore: Johns Hopkins University Press, forthcoming).
16. For example, a person who buys a policy that pays $100,000 in benefits can keep $100,000 in assets and still qualify for Medicaid nursing home benefits.
17. University of Maryland Center on Aging, "Partnership Update" (College Park: University of Maryland, 1997); and U.S. Department of Commerce, Bureau of the Census, Current Population Projections, 1996 (Washington: U.S. Government Printing Office, 1996).
18. University of Maryland Center on Aging, "Partnership Update" (College Park: University of Maryland, 1997); and U.S. Department of Commerce, Bureau of the Census, Current Population Projections, 1996 (Washington: U.S. Government Printing Office, 1996).
19. B. Burwell and W.H. Crown, "Medicaid Estate Planning: Case Studies of Four States," in Persons with Disabilities: Issues in Health Care Financing and Service Delivery, ed. J.M. Wiener, S.B. Clauser, and D.L. Kennell (Washington: Brookings Institution, 1995), 61-94.
20. G. Kenney and M. Moon, Reining in Home Health Services under Medicare (New York: Commonwealth Fund, 1997).
21. G. Kenney, S. Rajan, and S. Soscia, "State Spending for the Medicare and Medicaid Home Care Programs," Health Affairs (January/February 1998): 201-212.
22. PACE demonstration sites operate as geriatrics-oriented, staff-model HMOs that provide the complete range of acute and long-term care services to persons who meet nursing home admission criteria. Social HMOs extend the traditional HMO concept by adding a modest amount of long-term care benefits. They seek to enroll a cross-section of the elderly population in terms of disability levels.
23. HCFA allows states to require dual eligibles to join HMOs but does not allow states to require beneficiaries to receive Medicare services through the HMOs. If beneficiaries choose to receive services outside of the HMO, then either the state or the HMO must pay the applicable deductibles and coinsurance.
24. Although total Medicaid home and community-based service spending has increased significantly in recent years, almost 80 percent of the growth in these expenditures between 1990 and 1995 was for younger persons with disabilities. Authors' estimate based on Urban Institute calculations.
25. Spending in New York alone accounted for more than 40 percent of all Medicaid home care expenditures for the elderly in 1995 (elderly beneficiaries in New York were almost 10 percent of all elderly Medicaid beneficiaries).
26. E. Kassner and L. Williams, Taking Care of Their Own: State-Funded Home and Community-Based Care Programs/or Older Persons (Washington: AARP, 1997).
27. Although data solely on the elderly are not available, home and community-based waiver programs were 75 percent of total Medicaid home care expenditures in Alabama but only 13 percent in Mississippi. Urban Institute calculations based on HCFA Forms 64 and 2082 data.
28. Using these waivers, states can cover a wide range of nonmedical long-term care services. States must target persons at high risk of institutionalization and assure HCFA that the average cost of providing services with the waiver will not exceed that without the waiver. Because of this cost-effectiveness requirement states may provide these services only to a preapproved number of persons, limiting the potential financial liability that would accompany an open-ended entitlement benefit. Under the waiver provisions, services do not have to be offered statewide and can be limited to highly targeted groups of Medicaid eligibles.
29. G.A. Smith and R.M. Gettings, The Medicaid Home and Community Based Waiver Program (Alexandria, Va.: National Association of State Directors of Developmental Disabilities Services, 1996).
30. J.M. Wiener and R.J. Hanley, "Caring for the Disabled Elderly: There's No Place like Home," in Improving Health Policy and Management: Nine Critical Research Issues for the 1990s, ed S.M. Shortell and U.E. Reinhardt (Ann Arbor, Mich.: Health Administration Press, 1992), 75-110.
31. L.M.B. Alecxih, S. Lutzky, and J. Corea, Estimated Savings from the Use of Home and Community-Based Alternatives to Nursing Facility Care in Three States (Washington: AARP, 1996). A 1994 study by the U.S. General Accounting Office came to similar conclusions in Washington, Oregon, and Wisconsin. U.S. General Accounting Office, Medicaid and Long-Term Care: Succesful Efforts to Expand Home Services while Limiting Costs (Washington: GAO, 1994).
32. L.M.B. Alecxih, S. Lutzky, and J. Corea, Estimated Savings from the Use of Home and Community-Based Alternatives to Nursing Facility Care in Three States (Washington: AARP, 1996). A 1994 study by the U.S. General Accounting Office came to similar conclusions in Washington, Oregon, and Wisconsin. U.S. General Accounting Office, Medicaid and Long-Term Care: Succesful Efforts to Expand Home Services while Limiting Costs (Washington: GAO, 1994).
33. M.A. Sager and G. Arling, A Review of Community Based Long-Term Care with Emphasis on Wisconsin's Community Options Program (Madison: University of Wisconsin, 1995).
34. W.G. Weissert, "One More Battle Lost to Friendly Fire - Or If You Spend Too Much It's Hard to Save Money," Medical Care 31, no. 9 (1993): SS119-SS121.
35. CON requirements and moratoria affect the number of home health agencies, but they have no impact on the amount of services provided or the number of persons served by a particular agency. Any agency that wishes to expand services greatly can do so. Thus, CON in these instances serves to protect existing providers but is a particularly weak expenditure control.
36. C. Harrington et al., "The Effect of Certificate of Need and Moratoria Policy on Change in Nursing Home Beds in the United States," Medical Care 35, no. 6 (1997): 574-587.
37. B. Bedney et al., State Data Book on Long-Term Care Program and Market Characteristics (San Francicso: University of California, San Francisco, 1995).
38. J.K. Weinburg et al., Nursing Home Litigation under the Boren Amendment (San Francisco: UCSF, 1993).
39. The retention of the "equal access provision," a clause within the Medicaid legislation requiring states to set payments "consistent with efficiency, economy, and quality of care," could provide nursing homes with some legal protection, but pysiscians, home care agencies, and other noninstitutional providers generally have not found this standard to be much help in forcing higher Medicaid reimbursement rates.
40. "Fatal Neglect," Time, 27 October 1997, 34-38.
41. In two ANF states high-level bureaucrats have become senior officials in the nursing home association or obtained senior management positions in major nursing home chains. There is nothing inherently wrong in that, but it underlines the ongoing personal relationship between state officials and the industry.
42. Nursing home groups in California, Texas, Florida, and New York contributed $637,737 to political action committees in 1996; California facilities alone contributed $437,946. H.P. Weiss, "What Does $842,000 Buy?" McKnight's Long-Term Care NEWS, November 1997, 1, 13.
43. In Wisconsin the coalition of elderly advocacy groups even had its own Master-Card credit card, the use of which resulted in contributions to the coalition.