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

Joshua M. Wiener, Ph.D.

RTI International

www.rti.org 04/19/23

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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

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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

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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

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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

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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

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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?

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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)

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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

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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