Why Is Florida the Worst State for Long-Term Care?
Inside the analysis of the new 50-state scorecard
Florida is essentially tied with Maine for the highest percentage of residents age 65 and older — roughly 21%, vs. 16% for the U.S. population. And about one in 10 people in The Sunshine State are 75 or older, the highest percentage in the nation. So how is it possible that, according to a recent data-driven report, Florida ranks dead last for long-term care services and supports?
Tim Russert, the late host of NBC's "Meet the Press," famously said about the 2000 presidential election: Florida. Florida. Florida. Based on "The 2020 Long-Term Services and Supports State Scorecard" produced by the AARP Foundation, The Commonwealth Fund and The SCAN Foundation, I'd say: Florida? Florida? Florida?
'It's Not a Surprise'
"It's not a surprise," said Jeff Johnson, state director for AARP Florida, speaking of his state's cellar ranking in the Scorecard. "We've been in the bottom tier for as long as we've been doing Scorecards and I've been here twenty years."
Johnson said that Florida has an "overreliance on nursing homes," calling them "a first, and often only, option for long-term care."
One caveat: Data for the new Scorecard — the fourth edition — was analyzed in 2019, before the COVID-19 outbreak. That said, the researchers were exhaustive in culling statistics to compare state performances of their long-term services and supports systems for older adults, people with physical disabilities and family caregivers.
Florida ranked in the bottom of the four quartiles of states in three categories and in the next-to-worst quartile for the other two.
I'll spare you some of the wonky methodology, but will tell you that the 2020 Scorecard looked at five broad categories: Affordability & Access; Choice of Setting & Provider; Support for Family Caregivers; Effective Transitions (which includes data on transitioning from hospitals to nursing homes and successful discharges to the community) and Quality of Life & Quality of Care.
What the Long-Term Care Scorecard Looked At
Florida ranked in the bottom of the four quartiles of states in the first three of those categories and was in the next-to-worst quartile for the other two.
Looking at 21 trend indicators that went into the rankings, the researchers found that Florida had little or no change in 17 over the past three years, a substantial decline in two and a substantial improvement in two.
Susan Reinhard, who directs AARP's Public Policy Institute and headed the scorecard team, thinks it's important to put Florida's results in context and look at how well the nation is providing older adults and caregivers with long-term care services and supports.
"With every Scorecard, we say: 'We've made some progress. We need to do more," Reinhard said. "This just gets more evident as the population is aging."
Overall, Reinhard said, the United States is doing "fair" for long-term services and supports.
Here's why Florida ranked so poorly, what that means if you or a loved one will need long-term care there and prospects for future long-term care in the state:
Affordability & Access (cost of nursing homes and home care; percentage of adults 40+ with long-term care insurance; percentage of people on Medicaid and access to long-term care resources): Florida nursing homes are pretty pricey; the state ranked 39 for the cost as a percentage of median household income for people 65+.
In Florida, Johnson said, compared to many other states, nursing homes are expensive and older adults have lower incomes.
"People think of Florida as beach condos and living large off retirement savings and certainly there are people here like that," said Johnson. "But there are many people who had median incomes when they worked and stayed here or retired here. Some are living on just Social Security."
Context: According to the Scorecard report, "the cost of nursing home care is unaffordable for middle-income Americans in every state." The average annual per person cost: over $100,000 a year in a private room. The most affordable states for nursing homes: Kansas, Missouri, Oklahoma, Texas and Utah.
Florida showed a substantial improvement from the last Scorecard in the use of antipsychotics for nursing home residents.
Choice of Setting & Provider (home and community-based service services; assisted living and residential care units; adult day services; subsidized housing and home health and personal care aides for people with activities of daily living disabilities): Florida was next to last in this category, just ahead of Alabama.
It scored especially low for the number of home health and personal care aides and subsidized housing opportunities. Fewer than 5% of all housing units in Florida are subsidized housing; in New York, by contrast, about 10% are.
"People coming to Florida from up North may not have a social system here," said Johnson. "So, when they need help, they don't have that social infrastructure."
And, he added, Florida is a state built around cars, with little public transportation to help older residents age in place.
Support for Family Caregivers (this category includes things like state supports for working caregivers; assessing family caregiver needs and the ability to delegate nursing tasks): Ten states offer residents more than the federal minimum Family and Medical Leave Act rules and Florida isn't one of them.
But, Reinhard said, the Florida state legislature recently gave nurse practitioners more autonomy, which could help some older adults living at home and needing long-term care.
Effective Transitions: Florida was a mixed bag here but ranked last among states for the percentage of nursing home residents with "one or more potentially burdensome transitions at end of life."
Quality of Life & Qualify of Care (this includes things like the percentage of high-risk nursing home residents with pressure sores and the percentage of long-stay nursing home residents who inappropriately receive antipsychotic medication). Florida showed a substantial improvement from the last Scorecard in 2017 in the use of antipsychotics for nursing home residents.
But the state ranked just 35 for pressure sores in nursing homes. "I started working at AARP in 2000, working on nursing home staffing standards, and it has always been a battle," Johnson said. "Our standards of care are good, but not the best."
Johnson and Reinhard are somewhat hopeful about long-term care improvements in Florida, though.
The state legislature has passed a law "drastically reducing the number of poor, disabled and elderly residents on the waiting list for placement in Florida's Medicaid managed long-term care program," Johnson said. Before that, roughly 60,000 were on that list.
And, Johnson noted, "one glimmer of hope that doesn't show up in the Scorecard is just beginning."
He's talking about the group of leaders from AARP, the Florida Health Care Association, LeadingAge Florida and a health care union group (its grating name: The Coalition for Silver Solutions) who've been meeting to come up with better short-term and long-term strategies to meet the long-term care needs of Florida's aging population in 2020 and beyond.
"I think the state government is very much aligned with this work," Johnson said.
The next Scorecard will show whether these efforts pay off.
In the meantime, Johnson said, if you or your parent plan to move to Florida for retirement, "think of the whole span of your life." In other words: consider the possibility of needing long-term care and do some research.
Added Reinhard: "Don't expect someone swooping in to take care of you for free." Instead, she said, "look for a residence that is accessible, try to make friends, get connected to the community and take care of your health. Do as much prevention as you can."
Florida's Scorecard ranking "doesn't mean there aren't older people who have had good experiences aging in place and in facilities here; there is quality care," Johnson said.
But "it means you may have to look harder for it and know what you can afford and assess options in your price range," he added. "Think of Florida not as an extended vacation but as a true move where you're prepared to spend the rest of your life."