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Friday, February 19, 2016

New Momentum on Long Term Services and Supports

John Cutler, Senior Fellow, National Academy of Social Insurance

The Academy, which has a long tradition of exploring policy solutions to the challenges of long-term care, devoted a session at its January policy research conference to the financing of long-term services and supports.

The session, sponsored by The SCAN Foundation, presented data from modeling done by the Urban Institute and Milliman, Inc. which creates the basis for informed consideration of policy options regarding the future of long-term care. Presentations by Richard Johnson (Urban) and Chris Giese (Milliman) walked attendees through the tradeoffs inherent in various policy approaches, e.g. between voluntary versus mandatory insurance, subsidized versus unsubsidized approaches, and front-end versus catastrophic back-end designs. These are key issues which have bedeviled the reform debate for some time. Should we allow people to voluntarily decide to cover the risk or mandate that it be covered? The modeling suggests less than 20 percent take up in almost all scenarios in the absence of a mandate. But as Johnson and others pointed out, another approach would be a ‘soft’ mandate, e.g. auto enrollment with a possibility of opting out.

Another question is whether to subsidize private long-term care insurance coverage. This has been the model for health insurance coverage in the Affordable Care Act. It works well both for those who cannot otherwise afford premiums and for those who could afford some level of coverage but need an additional incentive. The modeling predicts, however, that this approach, without a mandate could leave many without adequate coverage.

The third concept tested was front- vs. back-end coverage. Front-end coverage is defined here as a two-year coverage period after which the person has to fund coverage by other means (most likely by spending down until eligible for Medicaid). A back-end design would provide catastrophic insurance coverage after a fixed term, without people having to spend down their assets. (The project also released a report on how reforming long-term services and supports could alleviate the burden on Medicaid.)

The next step for policymakers, researchers and advocates will be to analyze the data provided by Urban and Milliman and use it to design policy options for financing long-term care. The Long-Term Care Financing Collaborative, a group of policy experts representing a wide range of interests and ideological perspectives looking to re-focus attention on the urgent need to find ways to meet the challenge of financing long-term services and supports for seniors and people with disabilities, releasing a series of  consensus recommendations on Monday, February 22nd, at an event at the National Press Club. In addition, Leading Age and the Bipartisan Policy Center took first steps in this direction with reports released this month. These reports represent significant progress, but more work will be needed in the coming years to flesh out how specific approaches would work in practice.

All Comments

There is definitely some movement at the national level as shown by session at the NASI conference and the work being done by the Long Term Financing Collaborative and others to discuss Long Term Services and Supports (LTSS). But until there is action at the national level any changes will be happening at the State level. We have already seen the move to Medicaid Managed Long Term Services and Supports (MLTSS) by a number of states and there is interest and movement by other states in that direction. What states have demonstrated is that with the move to MLTSS more seniors and people with disabilities are receiving services through home and community-based services rather than in institutional settings such as nursing homes. Yes, there will always be a need for nursing homes to serve the most frail, but the institutional bias of Medicaid is dissipating with MLTSS. For example, in New Jersey, approximately 57% of all new Medicaid beneficiaries needing LTSS and Medicaid Aged, Blind and Disabled beneficiaries who are eligible for LTSS are now receiving services through Home and Community Based Services. Although there are no formal national quality indicators, evidence from state is showing that integration of acute health care, behavioral health, and long term services is promoting quality outcomes for seniors and people with disabilities.

At the national level there needs to be an understanding that many of the supports and services in the Older Americans Act delay the need for LTSS and promote home and community-based living. Unfortunately, the Older Americans Act still has not be re-authorized. The Older Americans Act was enacted in the same year as Medicare and Medicaid but is still not formally recognized as a key component in assisting seniors to live and function in their homes and the community. States, such as Massachusetts, have analyzed and determined that Older Americans Act programs and state-funded program are delaying seniors use of Medicaid LTSS.

Discussions about how to develop a national effort on LTSS have been going on for decades. Although no consensus has been forthcoming there are some key issues which most can agree upon. With the Baby Boomer generation beginning to retire, we need to quickly focus our nation's energy to support and enhance services for seniors and to their caregivers.

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