State Aging and Disability Policy: 50 years backwards, 50 years forward

1. State Aging and Disability Policy: 50 years backwards, 50 years forward John Michael Hall, Senior Director of Medicaid Policy & Planning NASUAD

2. 50 years of history of aging and disability policy “Quotes—use quotes and other facts over images to create more visual interest, pauses and color fields.” —Name, title

3. 1960s—Older Americans Act

4. 1970s—establishing the aging network • Started congregate meal program • Served 200,000 meals • $100 million program • Formed the Aging Network (AAAs) Arthur Flemming, Commissioner on Aging

5. 1980s -- Creating the Waiver • Omnibus Reconciliation Act of 1981 created §1915(c) waiver, states were slow to take up the option in part because of the “cold bed” rule. Now, every state has some form of HCBS waiver. • Permits states to provide HCBS to individuals who require the level of care provided in institutional settings. • Most states have several HCBS waivers, different populations • Often administered in different agencies

6. 1990s—Americans with Disabilities Act

7. 1990s—Olmstead Decision

8. 2000s--

9. 2011—First Boomer turns 65

10. 2005 -2010 15.3% increase

11. 2010—Affordable Care Act

12. HCBS Provisions in the ACA • Balancing Incentive Program (BIP) • Extending Money Follows the Person (MFP) • Consumer First Choice -- §1915(k) • Moving HCBS Into the Mainstream – State Plan Option §1915(i) • Waiver Consolidation • Health Homes

13. What will the next 50 years bring?

14. What if funding continues to slide?

15. Compare where the beneficiaries are . . . 15

16. . . . to where the money is: 16

17. Funding for Seniors Not Keeping Pace NOW…From 1980 to 2010 60% Population Increase Adults 65+ 34% Funding Decrease AoA Funding

18. Funding for Seniors Not Keeping PaceCurrent Funding Levels Unable to Meet Increased Need $9.24 Per Adults 65+ $3.85 Per Adults 65+ 1980 2010

19. Funding for Seniors Not Keeping PacePercent of Seniors Continues to Grow 2010 2030 One in Eight One in Five Adults 65+ Adults 65+

20. Aging services unable to meet demand 57 Million Adults 60+ 11 Million Served ONLY

21. Aging services unable to meet demandIf these trends continuemillions will be eligible, few will be served. 1980 2010 2030 1980 2010 2030 236 155 ??? 36 57 92 Millions of Seniors Millions of Dollars

22. Aging in place is Cost EffectiveAnnual Facility Care Cost $42,600 Private pay Assisted living $66,000 MEDICAID FINANCED NURSING FACILITY $81,030 Private pay Nursing Facility

23. Aging in place is Cost EffectiveAnnual Facility Care Cost $18,200-$20,800 Homemaker & Adult Care Services $24,675 Home & Community Based Medicaid Services

24. Older Americans Act ServicesHelp Seniors stay at home

25. Will Aging and Disability Working Together Make a Difference?

26. States Restructuring State Aging and Disability Agencies VT ME WA ID MT MN ND OR NY WI MI SD NH RI WY PA CA CT IA MA NV OH IL NE UT IN WV DE VA CO MO KS KY DC NJ NC TN AZ NM OK AR SC MD TX GA AL MS LA FL AK HI • States restructuring since 2011(CT, DE, HI, IA, IN, KS, ME, NC, NH, OH, OR, PA, VT, VA, WA, WY) • States with plans for restructuring (CO, DC, LA, NV, WV) • States both restructuring since 2011 and with plans (AL, MD, NJ)

27. Factors Driving State Aging and Disability Agency Restructuring Comprehensive vision Consistent policy making Administrative simplification Improved access to services (no wrong door) Accountability Quality management Consolidation of program authority Budget and personnel reductions Preparation for managed long-term services and supports Other Reduction of institutional bias Global budgeting Address functions that present conflict of interest 0 5 10 15 20 Number of States

28. What changes will MMLTSS have on the network?

29. Medicaid Managed LTSS & Medicare-Medicaid Care Coordination Initiatives (Current as of 10/3/2013) VT ME WA* ID MT MN (W)** ND OR (W)** NY* WI** NH** MI SD WY RI MA* PA CA* CT IA NV OH* IL* NE UT IN** WV DE RI VA* CO MO KS KY NJ** DC NC TN (W) AZ (W) MD NM (W) OK AR SC TX GA AL MS LA FL** AK HI (W) • Medicaid Managed LTSS (MMLTSS) • Medicare-Medicaid Coordination Initiative • Both MMLTSS and Medicare-Medicaid • Coordination Initiative * Financial Alignment (FA) demonstration proposal approved by CMS ** Initiatives other than FA demonstration (W) No longer pursuing FA demonstration Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

30. What impact will the Affordable Care Act have?

31. Medicaid Expansion (Current as of 10/3/2013) VT ME WA ID MT MN ND OR NY WI MI SD NH WY RI PA CA CT IA NV OH MA NE IL UT IN WV DE VA CO MO RI KS KY DC NJ NC TN AZ NM OK AR SC TX MD GA AL MS LA FL AK • Expanding Medicaid • Likely to Expand • Alternative Expansion Approved • Unlikely to Expand • Not Expanding HI Source: NASUAD Medicaid Expansion Tracker

32. Other LTSS Activities (Current as of 10/3/2013) VT ME WA ID MT MN ND OR NY WI MI SD NH WY RI PA CA CT IA NV OH MA NE IL UT IN WV DE VA CO MO RI KS KY DC NJ NC TN AZ NM OK AR SC TX MD GA AL MS LA FL AK • More than One Activity • Balancing Incentive Program Only • Section 1915(i) State Plan Amendment Only • Section 1915(k) Community First Choice Only • Health Homes Only HI Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

33. Will we measure Quality? Outcomes?

34. If not…boomers don’t wait patiently