January 2011 Archives

Prepare yourself for big new cuts in government support for elder care.  

In his State of the Union address last evening, President Obama called for a five-year freeze on a narrow slice of the federal budget. Unfortunately, programs subject to the freeze would include many that are critically important to the frail elderly and younger people with disabilities--especially those living in the community.

This is only the beginning of what will be a very difficult period. Yet it is an opportunity for communities to pull together to provide services that government may no longer offer.

The freeze would not include Medicare or Medicaid, although Medicaid long-term care benefits are already being cut at the state level. However, it is very likely that programs such as meals-on-wheels, adult day care, transportation, housing, aging and disability resource centers, and Area Agencies on Aging would all be hit by this freeze.

It is not clear exactly how the freeze would work. It could be an across-the-board cut in all so-called domestic discetionary programs. These are programs that are subject to annual congressional review, but exclude entitlements such as Medicare, Medicaid, and Social Security. Alternatively, Congress could pick and choose which programs to cut, as long as the total amount of all domestic non-entitlement spending did not rise from year to year.

Either way, a freeze will inevitably result in fewer services since demand for this assistance is growing as the population ages and the cost of services rises.

Congressional Republicans are already criticizing Obama's plan as too weak and vow to cut even more deeply into these programs. Some would return spending to 2008 levels, others to 2006 funding. However it finally works out, there is little doubt that many of the long-term care supports and services that seniors now rely upon are in line for major cuts.

With a national debt of $14 trillion and annual deficits of more than $1 trillion, there is no doubt that government spending is going to be trimmed--perhaps quite substantially.It is also likely that sooner or later, federal payments for Medicaid services will also be slashed. One can hope that an eventual budget deal will eventually include tax increases as well, which would help soften the spending blow. But in the current political environment, that is not likely--at least until after the next presidential election.

So what do families and advocates do? I believe we need to begin to look for community, non-government solutions. If transportation services are cut, we should pull together to create volunteer ride programs. Senior villages are one way to build such an infrastructure. So are more informal groups organized around neighborhoods, churches, synagogues, or fraternal organizations.

If budgets for government-funded resource centers are slashed, we should support private non-profits that pick up the slack.(Full disclosure: I serve on the board of one of these--the Jewish Council for the Aging of Greater Washington--and as an adviser to another--Caring from a Distance). 

As needs grow and government services shrink, we all face a huge challenge. But it is also an opportunity to rethink our obligations to, not only our own parents, but to our neighbors and friends. I hope we will be creative enough to take up this challenge.    



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The news for critical long-term care services and supports provided by the states--either through Medicaid or other funding--keeps getting worse. The toxic combination of a still-slow economy, huge structural budget pressures on all levels of government, and growing demands for aging and disability services is leading to ongoing cuts in both critical benefits to individuals and payments to providers.

The latest evidence comes from two new reports. Following an extensive survey of state officials, AARP reports that 31 states cut their non-Medicaid long-term care services programs in Fiscal Year 2010 and at least 28 expect to slash them in the coming budget year. These essential programs include home-delivered meals, transportation, adult day care, housing, and foster care.

At the same time, a report by the American Health Care Association--which represents mostly for-profit nursing homes-- concludes that skilled nursing facilites are losing increasing amounts of money on their Medicaid long-term care beds. It concludes that nursing facilities are paid $17 per day less for long-term care than it costs them to provide these services. It is easy to criticize these results as self-serving, but the general trend is hard to dispute. And it could result in dramatic cuts in these long-term care resources. While this may not be a short-term problem in communities with an oversupply of nursing homes, this trend may already be curbing services in low-income areas. 

The AARP study reported that only a handful of states cut Medicaid benefits last year, but that was because the federal government, as part of its stimulus effort, increased its share of program payments. In addition, states that took the extra federal money were barred from cutting Medicaid benefits--although they could trim or freeze provider payments. Normally, the federal government pays about 60 percent of the cost of Medicaid while the states pay the rest (the amount varies from state to state).

However, this additional federal Medicaid funding is already winding down, and will disappear completely on July 1. Even more troubling, AARP found many states built the higher federal payments into this year's budgets, a decison that will force even deeper cuts in state programs as those dollars dry up. Just this week, lawmakers in Texas and Ohio proposed major cuts in Medicaid.  

AARP also asked state officials whether they intended to pursue additional federal funding for home and community based services that's been promised under the 2010 health reform law. Despite their serious financial shortfalls and the growing interest among policy analysts and advocates in expanding community services, state officials were remarkably cautious about whether they'd embrace these initiatives.

I'll have more to say about these studies soon, but they are both worth reading.       

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In the decade between 1999 and 2008, almost 3,000 nursing homes closed while the number of skilled nursing facility beds shrunk by nearly 100,000, or about 5 percent, according to a new study in the Archives of Internal Medicine. In a nation with more nursing homes than McDonald's, and at a time when long-term care can be provided in other settings, that may not be a bad thing. These days, many frail elderly receive care at home or in assisted living facilities, settings they often prefer to skilled nursing facilities.

But the Archives study by Zhanlian Feng and coauthors also raised some serious concerns. The report concluded that many of these closures occured in minority and low-income communities, the same areas where other care alternatives may be unavailable.

Other studies have shown that relatively few assisted living facilities--which are overwhelmingly private pay--are located in these neighborhoods. In addition, while data are scarce, it appears that many low-income and minority serniors may have limited access to high-quality home care. In other words, for one segment of the population, good care may increasingly be unavailable. 

A study published last year in Health Affairs, David Stevenson and David Grabowski of the Harvard Medical School found that larger assisted living facilities (those with 25 beds or more) were far more likely to be located in higher income counties than in poor jurisdictions. 

As a result, low-income seniors who are unable to live at home--perhaps because there may be no one to care for them or because their home may not be suitable for someone with disabilities--have very few options. Many may move to small board-and-care homes--often a room they rent in a local home where assistance is provided by an unlicensed caregiver. Others may get no care at all.  

From the perspctive of the long-term care industry, the Archives paper reflects another troubling trend. Most long-term care in SNFs is paid by Medicaid, and reimbursements for these patients are often lower than the cost of providing care. By contrast, Medicare, which pays for post-acute and rehabilitation services, is far more generous. Medicare typically pays $500 or more per day for these services while Medicaid may pay just $125 for a long-term care bed (these payments vary by state and Medicare payments are adjusted to reflect patient needs).

The result: Growing industry consolidation and an increasing shift away from long-term care and towards more lucrative post-acute services. These choices make perfect economic sense. And they are often praised by advocates for the elderly, who argue that aging services should be provided in the community. However, for some seniors, including some with dementia or those with no family members to help provide care, nursing homes or assisted living facilities may be their only alternatives. Sadly, for many, those options are increasingly unavailable.           

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For the second time, President Obama has bowed to conservative critics and backtracked on a plan to allow Medicare to pay physicians for end of life consultations with their patients. He should be ashamed.

In late November, the government adopted new rules that included discussion of advance directives as one of many services physicians could provide during routine annual physicals for their Medicare patients. But The New York Times reported this morning that the White House has now overruled the Department of Health and Human Services and withdrawn the provision.

The decision echoes the decision by the White House and congressional Democrats who dropped a similar provision from the 2010 health reform law in the face of pressure from the political right. During that congressional debate, Sarah Palin and others made the absurd claim that Medicare payments to doctors for discussing advance directives was akin to creating "death panels" where government officials would withhold care from some patients. Democrats were so slow to respond to these charges that even recent polls reported many seniors still believe the death panel canard.

Obama's decision is a tragedy for patients. The rule would have done nothing more than pay doctors for the time they took to discuss advance directives during annual Medicare "wellness visits." Patients could have refused this service if they chose. And nothing in the rule would have in any way constrained end-of-life choices by patients. They could have written living wills however they wanted, or not prepared such a document at all.

The Times quoted new House speaker John Boehner (R-OH) as saying the provision "could be a step down a treacherous path toward government-encouraged euthanasia." Nothing could be further from the truth. In fact, frank talk about end-of-life choices achieves exactly the opposite result. Advance directives give patients more control over medical decisions, not less. It allows them to make their own choices based on  their own moral, ethical, and religious views.  

As a society, we struggle to confront death. Patients struggle, and so do many physicians.  This modest Medicare rule would have provided a small incentive for doctors to take a more active role in helping their patients think about end of life care. And perhaps it might have encouraged better training for those physicians who are not prepared to discuss these issues.

Now, thanks to a toxic mix of conservative ideology, Obama's lack of political courage, and more than a little political cynacism, patients and doctors are left with only confusion and uncertainty. They and their families deserve so much more.          


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About this Archive

This page is an archive of entries from January 2011 listed from newest to oldest.

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February 2011 is the next archive.

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