Barriers to Care Lack of Long Term Care
Barriers to Care: Lack of Long Term Care Coverage Charlene Harrington, Ph. D. , RN Professor of Nursing and Sociology University of California San Francisco
How many people need long term services and supports (LTSS)? 13. 9 million total: 12. 3 million community residents (from the 2016 National Health Interview Survey) and 1. 7 million institutional (2010 Census) (S. Kaye, UCSF). Institutional Kaye, Harrington, La. Plante. Health Affairs 2010. Sources: 2005 -06 Medical Expenditure Panel Survey & 2004 National Nursing Home Survey
Need for LTSS and Age 0, 5 The risk of needing LTSS increases exponentially with age 0, 45 Percent needing help with I/ADL 0, 4 0, 35 18 -34 9% 35 -44 10% 85+ 15% 0, 3 0, 25 0, 2 0, 15 65 -74 15% 0, 1 0, 05 55 -64 14% 65+ = 54% Age 84 78 72 66 60 54 48 42 36 30 24 0 18 45 -54 13% 75 -84 24% 18 -64 = 46% Almost half the population with a need for help is 18 -64 years old Source: Survey of Income and Program Participation, 2003. US Census Bureau
LTSS Payers Medicare program -- for 51 million aged and disabled covers ONLY short-term LTC Nursing home users – 1. 7 million individuals; 2. 5 million admissions (27 days of care average in 2012) Home health users - 3. 4 million individuals (34 visits average in 2012) State Medicaid - for 73 million low income people (38 million aged and disabled, 35 mil children) (10 million dual eligibles) covers long-term nursing home, home care, personal care, AT and other) Nursing homes – 1. 6 million individuals 2011 Home health – 1. 09 individuals 2011 If not covered, individuals must pay out of pocket and must become poor to receive Medicaid long term care https: //www. cms. gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and. Reports/Archives/MMSS/2013. html
Private Long Term Care Insurance Private long term care insurance - 7. 5 million policies (5% of those age 40 plus) ($9 billion in claims was paid in 2012) Annual policy costs - between $2600 for age 55 -64 to $5200 for 75+ Private pay costs are high -- annually in 2017 Nursing homes - $97, 452 Assisted living - $45, 000 Homemaker services - $33, 540 K. Ujvari, AARP Public Policy Inst. Aug, 2018; Genworth Financial Inc. 2017
Total US Short-term and Long-term LTSS Expenditures, Projected 2018 $469 billion (13% of total Personal Health) Total Personal Health Care Medicaid Out-ofpocket Private Ins & Other $3, 504. 3 Nursing home/Residential care $174. 6 24% 40% 27% 9% Home health $102. 8 41% 8% 10% Other health/personal care $191. 6 3% 86% 4% 8% Total LTSS $469. 0 19% 59% 13% 9% Source: Projected National Health Expenditure Data, CMS 2017 https: //www. cms. gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and. Reports/National. Health. Expend. Data/National. Health. Accounts. Projected. html
Type of LTSS at Home Paid help 13% No help 3% Unpaid help [VALUE] Kaye, Harrington, La. Plante Health Affairs 2010
Number & Type of Unpaid Caregivers in the US in 2014 Total 43. 5 million (24. 4 hrs per week) Worth $470 billion For [CATEGORY NAME] - 14. 9% For [CATEGORY NAME] - 8. 5% For Adults -76. 5% Source: AARP Inst. For Public Policy & National Caregivers Alliance, Caregiving in the US 2015. https: //blog. aarp. org/2015/07/16/family-caregiving-worth-470 -billion-a-year-aarp-finds/
Overall Poor NH Quality � 15, 500 NHs, 67% for-profit, 56% chains � 20% received deficiencies for harm or jeopardy of residents in 2016 (KFF Nursing facilities 2009 -2016) � 33% of 2. 5 million Medicare NH Residents experienced adverse events or temporary harm during their shortterm SNF stays in 2011 ◦ 59% of those were preventable � Over 25% of Medicare nursing home residents were sent back to the hospital for an estimated costs of $14. 3 billion – for common problems �US DHHS Office of Inspector General 2014 Reports
State Medicaid Policies That Limit Access • • • Cost control policies on financial eligibility, need criteria, hourly limits, cost limits, geographic limits, waiting lists Fragmentation across many agencies/ programs Medicaid managed care has expanded to integrate services & financing and control LTSS costs – ◦ Total enrollment in MLTSS programs more than doubled, from 800, 000 in 2012 to 1. 8 million in 2017 in 24 states. • MCOs lack expertise & experience in providing LTSS
Class Act of 2010 (Part of ACA) � Class Act initiated by T. Kennedy 2003 was incorporated into the ACA � Established a voluntary national LTC insurance program as part of the ACA � Initially estimated to save $80 billion & reduce Medicaid costs because initial 5 yrs would not pay benefits � Problems with a voluntary program, potential adverse selection, and high projected costs � Withdrawal of White House support & strong Republican opposition � Congress repealed the provision – Jan 2013 Caldwell & Bedlin, Public Policy & Aging Report, 2014
Overall Policy Recommendations � Need comprehensive mandatory public coverage for LTSS preferably through Medicare – strong political opposition because of the costs. � Other countries have mandatory public LTSS coverage including Canada, Scandinavia, Germany and Japan � Some states are proposing LTSS coverage ◦ Maine initiative of 3. 8% marginal tax on high gross adjusted income ◦ CA considering an initiative for a direct cash benefit for LTSS at home – CA Collaborative for LTSS ◦ WA state working on a design and feasibility study for a public LTSS initiative ◦ NY state health act may include LTSS
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