Long-Term Care: Options in an Era of Health Reform

1. Long-Term Care:Options in an Era of Health Reform Joshua M. Wiener, Ph.D. RTI International

2. Why Long-Term Care? • Large projected growth in the number of people with disabilities • Federal and state governments spend over $200 billion on long-term care • People with long-term care needs have high physician, hospital, prescription drug and other acute care costs • Current long-term care system is broken

3. Long-Range Options for Reform: Financing • Political divide over role of government programs vs. private sector initiatives • Key issue is fiscal sustainability for the future • Private insurance and reverse mortgages • Social Insurance, Medicare and Medicaid expansion, and increases in Older Americans Act and other appropriated programs • Major changes (including private insurance) will require large increases in direct government spending or expensive tax incentives

4. Long-Range Options for Reform:Service Delivery • Broad, bipartisan, liberal/conservative consensus to promote a more balanced long-term care system and more consumer control • Participant-directed home care, money follows the person, expansion of assisted living • States may lack the will or the wallet, but already have the legal authority • More direct government service funds (e.g., Medicare, Medicaid or Older Americans Act, or other appropriated programs) or infrastructure grants

5. Long-Range Options: Workforce • Long-term care is provided primarily by people not machines • Long-term care workforce shortages, problems of recruitment and retention, understaffed facilities, inadequate training and career ladders, low salaries and fringe benefits • Overlap with quality issues • Increasing staffing in nursing homes, wages, and fringe benefits potentially expensive • Grant programs for workforce initiatives, such as worker registries, training, and culture change

6. Long-Range Options: Quality • Quality an ongoing issue in long-term care • Reform options include: • Increase mandatory requirements, such staffing levels in nursing homes, minimum training for direct care workers • Voluntary approaches that are external to providers, such as Nursing Home Compare, increase funding for AoA Ombudsman program, reform payment system • Voluntary strategies that are internal to providers, such as practice guidelines and change organizational culture • Some options, such as increasing staffing levels, will increase costs to Medicare and Medicaid • Create new grant programs to states, providers and others to improve workforce

7. Starting the Conversation • Bipartisan consensus “low-cost” recommendations • Focus more on service delivery system, workforce, and quality rather than financing reform • Assume availability of couple of billion dollars maximum • What can be done at the federal level? • Way too timid or way too bold?

8. Starting the Conversation: Options (cont.) • Educating the American people • National Commission on Long-Term Care • Relatively minor changes to Medicaid program, such as medically needy, personal needs allowance, and spousal impoverishment • Increase funding for direct service programs, such as Older Americans Act and other appropriated programs • Establish grants to states and others for infrastructure development (e.g., Aging and Disability Resource Centers and participant-directed services)

9. Starting the Conversation: Options (cont.) • Establish workforce grant program to promote culture change, worker registries, and training programs • Increase financial support for relatively low-cost quality initiatives, such as AoA Ombudsman program, Medicaid pay-for-performance demonstrations, and strengthen federal requirements that states monitor quality of home and community-based services • Increase funding for research and development, including demonstrations that address chronic illness, disability, and long-term care

10. Conclusions • Long-term care is not the centerpiece of health reform, but it can and should play a role • Our day will come • Comprehensive reform will cost money, but low-cost options can make contribution • The “window” for health reform