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Long-Term Care: The Impact of the Elderly

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Providing accessible, affordable, and high-quality long-term care services to an aging population presents a growing challenge to long-term care providers. As the oldest members of the baby boom generation approach retirement, federal and state policy, makers are exploring policies to care for the increasing number of elderly and to finance expanding long-term care needs. Other concerns include how to provide an adequate mix of institutional care and home and community-based services and how to monitor the quality of services delivered in these settings.

Long term care refers to a wide range of supportive, medical, personal, and social services for people limited in their ability to function independently and to perform every day activities, whether due to chronic illness, injury, or aging. (Campbell) Currently, more than 12 million people, 6.6 million of whom are elderly, receive long-term care assistance. (Campbell) Of elderly long-term care recipients, 1.5 million reside in an institution such as a nursing home and the remainders receive care in their homes or communities. Compared with the rest of the population, long-term care users are disproportionately female, low income, and very old, and they live alone or with a relative other than a spouse. In general, the requirement for long-term care service is measured by the need for assistance in performing basic activities of daily living, such as eating, bathing, and dressing. (Stone)

The likelihood of needing long-term care increases with age, and the elderly population is growing. Population aging reflects high birthrates between 1946 and 1964, improvements in medical care, and a longer life expectancy. People age 85 and older make up the fastest-growing population, projected to increase from four million in 2000 to 14.5 million in 2040. (Stone)

While future demand for long-term care services may exceed supply, providers have difficulty meeting even the current needs. Despite all of the long-term care options available, many older people face significant barriers to obtaining these services. Medicaid is targeted to the poorest population, but many that are not very poor cannot afford paid help. Current changes in the family structure, such as smaller and more dispersed families, can limit potential informal caregivers. People without informal care often are forced to leave their homes and seek institutional care. Most elderly and disabled people say they prefer to remain at home rather than move into nursing homes, but many families cannot provide the appropriate level of informal care or cannot afford formal home health care. Due in part to these access barriers, one in five elderly persons with long-term care needs living in the community reports an inability to get appropriate care. (Finkelstein)

The anticipated need for institutional and community-based long-term care services may be greater than the state’s ability to pay for it. Recent federal policy changes in Medicare’s home health payment methodology led to service reductions that force many beneficiaries to seek private, state and Medicaid-funded alternatives to supplement or replace their Medicare home health services. States largely control who gets what services under Medicaid by determining eligibility levels, establishing limits on total enrollment, targeting programs to selected areas and population groups, and regulating the supply of nursing home beds. (Netting)

Private long-term care insurance can reduce potential financial losses for the elderly and relieve some of the financial pressure on public long-term care programs. Over half of private long-term care insurance claimants said that without their policy they could not afford their current level of services, would have to consume fewer hours of paid care, and would seek institutional alternatives to their home health care arrangements. (Netting) Only a small number of employers sponsor group coverage and take-up rates are low, with less than 10 percent of eligible employees purchasing coverage. The affordability of long-term care insurance is an essential factor in the decision to purchase a policy. Unfamiliarity with long-term care policies, uncertainty about the value of coverage, and underestimating the need for long-term care insurance may deter people from purchasing a private policy. (Stone)

Long-term care is expensive, with costs for a year in a nursing home averaging $55,000. Through Medicaid and Medicare, the government is the single largest payer of long-term care costs. Medicaid, the largest source of public funding accounted for 45 percent of all long-term care spending, 46 percent of nursing home revenues, and 38 percent of home care revenues in 1998. Of the $68 billion spent by Medicaid on long-term care in 2000, 73 percent financed institutional care. (National Conference of State Legislatures)

In 1986, the Institute of Medicine (IOM) released a report that documented quality of care problems in nursing homes. The report resulted in the passage of nursing home reform legislation as part of the Omnibus Budget Reconciliation Act of 1987. Research has shown that the percentage of Medicare and Medicaid patients in a nursing home is an important factor in quality. Nursing homes have historically considered Medicaid reimbursement rates to be low and prefer private pay patients. (CMS)

Federal and state governments share responsibility for regulating long-term care quality. The Centers for Medicare and Medicaid Services (CMS) sets standards for nursing homes, which must comply to receive Medicare and Medicaid funds. By law, nursing homes are inspected annually and can be fined up to $10,000 for each serious incident that threatens residents’ health and safety. Since 1998, the proportion of deficiencies resulting in harm to nursing home residents has decreased by 35 percent. Yet, concerns about the quality of nursing home care persist. Recent reports indicate that about 25 percent of all nursing homes continue to have serious deficiencies. (CMS)

Questions about the effectiveness of state and federal regulatory policies extend beyond nursing homes to alternative long-term care settings, such as home and community-based services and residential care facilities. States attempt to ensure quality of care in home and community-based services through consumer complaint programs, licensing, certification, and regulatory requirements. However, little is known about the quality of home and community-based services and care provided by home health agencies. (Finkelstein)

Providing high-quality long-term care requires an adequately trained and skilled workforce. Registered nurses, licensed practical nurses, nursing aides, and home health aides represent the largest component of the paid long-term care workforce. The quality of care often depends on their performance, but professional standards vary across states and long term care settings.

Staffing levels may be related to problems with the quality of nursing home care. Low wages and the difficulty of the work make hiring and retaining qualified workers very hard, leading to high turnover rates and staff shortages. The future demand for long-term care services will likely outdo the supply of qualified workers to provide such services. Improving the workforce could be difficult without increased resources. (Netting) Higher payment does not ensure high quality, but payment rates can be too low to support adequate quality.

Policy makers have proposed expanding coverage of long-term care services for chronically dependent individuals through Medicare, by expanding Part A coverage of nursing facility services and providing for coverage of home care services under Part B. Alternatives for improving the current system include expanding the supply of home and community-based services, promoting the purchase of private long-term care insurance policies, developing programs that support informal family care giving, and integrating acute and long-term care services.

Better integration of care services, programs, and funding could increase access and improve the quality and efficiency of care. An example of such integration is the Program of All-Inclusive Care for the Elderly (PACE). PACE projects include a full range of acute and long-term care services, including all Medicare and Medicaid services made available by a state, to Medicaid-eligible individuals. PACE services are generally offered in an adult care setting, and can permit recipients to live at home rather than be institutionalized. PACE projects receive a fixed monthly payment per enrollee from Medicare and Medicaid. (Campbell)

An improved system of public and private financial support could ensure that all elderly and disabled Americans have access to quality long-term care. Several steps can be considered to improve the current system including: provide enhanced support to informal caregivers, improve the monitoring and measuring of home and community-based service quality, increase the supply of skilled long-term care workers and to reduce deficiencies in institutional care.

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