Part of the Political Issues and Policies Special Report
Survey after survey shows that people want to continue living in their homes as they age, rather than moving to a nursing home or an assisted living facility. (In a recent Nationwide Insurance survey of Americans 50 and older, 61 percent said they’d rather die than live in a nursing home.) But whether you or your parents will be able to receive long-term care benefits at home through Medicaid — assuming Medicaid-eligibility — is an open question.
That’s because state rules vary enormously regarding whether Medicaid — the leading payer of long-term care in America — will pay for a person’s long-term care at home. But a new report from the Center for Health Care Strategies (a nonprofit health policy resource center focused on low-income Americans) and Manatt Health (a health policy and business strategy advisory subsidiary of the Manatt, Phelps & Phillips law firm) aims to broaden the availability of Medicaid at home and in community-based settings.
A Toolkit for Medicaid at Home
Strengthening Medicaid Long-Term Services and Supports in an Evolving Policy Environment: A Toolkit for States describes innovative state programs that other states might replicate to serve their older residents. It was funded by The SCAN Foundation (a funder of Next Avenue, too) and the Milbank Memorial Fund.
“There’s a lot of innovation going on, but it can be a little dizzying in some respects,” said Cindy Mann, a partner at Manatt Health who worked on the report. “We wanted to present options that states might consider.”
Currently — and this may surprise you — more Medicaid money for long-term care services and supports is spent on home- and community-based services than in nursing facilities. That’s a welcome change. In 1995, only 18 percent of Medicaid long-term care spending supported home- and community-based services; today, 55 percent does.
Why not even more? “It’s hard, for a number of reasons,” says Dr. Bruce Chernof, president and CEO of The SCAN Foundation. “States want to make changes cautiously. They don’t want to start a program they might have to pull back on.”
The Medicaid Toolkit report featured three strategies states can adopt, and how certain states have already have done so. The strategies:
1. Developing the infrastructure to promote greater access to home- and community-based services.
“When someone is in need of long-term care services, figuring out where to go and how to get the services can be difficult,” said Alexandra Kruse, senior program officer at the Center for Health Care Strategies.
But Massachusetts, the report notes, has a nifty, free, one-stop information and referral network (a website and call center called MassOptions) to help residents understand how, or whether, they can get Medicaid reimbursement at home.
Even allowing people to provide long-term care at home through Medicaid is critically important. California, the report says, has implemented paid family leave to support family members providing long-term care for loved ones. “It’s hard to take time for caregiving without getting paid,” said Mann. “Paid family leave is a really terrific advance.”
2. Helping nursing facility residents return to, and remain in, communities.
“A lot of people in nursing homes could be getting care and services in the community and outside of the nursing home,” said Mann.
Problem is: Medicaid doesn’t pay for housing. “But there are opportunities for states to pull down funding from other programs to help reestablish somebody in the community,” said Mann. Arizona and Texas, the report said, are already providing housing supports to help nursing facility residents remain in their communities.
“And some health plans help families secure housing because it’s likely to be less expensive supporting them in the community than in a nursing home,” noted Mann.
In fact, a June 2017 report from the U.S. Department of Health and Human Services (HHS) said a program to bring nursing home residents back to their communities has shown significant cost savings to Medicaid.
On average, per-beneficiary, per-month expenditures declined by $1,840 (23 percent) among older adults transitioning from nursing homes through state pilots of the Money Follows the Person Rebalancing Demonstration program. Translation: average cost savings for Medicaid and Medicare programs of $22,080 per beneficiary during the first year after the transition. By the end of 2015, states had transitioned 63,337 Medicaid beneficiaries from long-term institutional care to community-based care.
Texas’ pilot Money Follows the Person program resulted in 68 percent of participants remaining in the community, saving $24.5 million in Medicaid funds.
The overall Money Follows the Person program, the HHS report added, “provides strong evidence of success at improving the quality of life of participants.” These people experienced “the highest levels of satisfaction with their living arrangements” and nearly all liked where they lived one year after community living — a 32 percentage point increase compared to when they were in institutional care. Their care didn’t suffer, either, after leaving the nursing homes, the HHS report noted.
3. Expanding access to home- and community-based services for “pre-Medicaid” individuals to prevent or delay nursing facility use.
Few older people suddenly need long-term care; typically, their health gradually devolves. That’s why it’s useful for states to offer access to home- and community-based services before someone will apply for full Medicaid.
“Washington and Vermont are looking to invest in some services for people who may not need a very significant amount of long-term care supports and services but may need moderate or light help,” said Mann. “If they’re provided that help, they may be able to avoid or postpone needing long-term services.”
In Vermont’s Choices for Care program, people are divided into three groups, including those who could benefit from in-home care, but aren’t infirm enough for Medicaid. Satisfaction with this pre-Medicaid program, the toolkit report said, “is very high.” Washington offers support to caregivers assisting state residents who don’t yet qualify for full Medicaid benefits.
An obvious question: If Congress cuts Medicaid, as seems increasingly likely, will that inhibit these types of state initiatives?
“It’s a serious concern,” said Chernof, who chaired the federal Commission on Long-Term Care in 2013. “You can’t take enormous bites out of Medicaid and Medicare and serve the same number of people with the same needs. Substantial cuts to either program will put people at risk.”
That said, Chernof added, “what’s interesting is there is bipartisan agreement that there ought to be better care at lower cost.” He’s hopeful the new toolkit “will help states make well-informed decisions.”
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