Recently in Federal senior services programs Category

Money Follows the Person is a cornerstone of the federal government's effort to move Medicaid beneficiaries from nursing homes into the community. But a new study commissioned by Medicaid itself shows how difficult those transitions can be. In the 30 states that have been testing the program over the past three years, only 8,500 people have used MFP to return to their communities.

That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.  

The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.     

Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly. 

Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.

Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.  

Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.

Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.   

Powerful Republicans are pushing the twin ideas of capping the federal contribution to Medicaid and eliminating federal regulation of the program. These changes would do profound damage to the Medicaid benefit for long-term care, whether it is provided at home or in nursing facilites.

This plan would turn Medicaid from a federal entitlement into a block grant. Over time, states would be responsible for paying a growing share of the program costs but in exchange would have broad flexibility over who to cover and what benefits they'd receive. In such an environment, chances are good that fewer aged and disabled would be eligible for benefits and they'd receive less assistance than they do today. At the same time, providers such as nursing homes and home health agencies would likely get lower Medicaid payments even though the program reimbursements are already at dangerously low levels.  

Today, the federal government pays about 57 percent of Medicaid costs (the actual amount varies from state to state and ranges from 50 percent to about 80 percent). While the elderly and disabled account for only 25 percent of the 50 million Medicaid enrollees, the program spends two out of every three of its dollars on this population. More than one-third of the total Medicaid budget, or $125 billion, went to long-term care supports and services alone in 2009, according to a new study by the Kaiser Family Foundation.

Under the current arrangement, the federal government pays its share no matter how quickly Medicaid costs rise. Thus, because Medicaid rose by 7.7 percent in 2009 (mostly because the recession drove many newly-unemployed into the program), the federal contribution increased to keep up. In fact, Washington's share actually grew even more thanks to the much-reviled 2009 stimulus law.

By contrast, under a block grant the federal share would increase only up to a cap, say equal to the growth rate of the economy plus one percent. In 2009, this would have resulted in no increase in federal payments for the program. As a result, states would have had to scale back their Medicaid programs, including their long-term care services.

Over time, the federal contribution would fall significantly, leaving the states with more and more responsibility for the program and less and less assistance to pay the bills. Governors who support a block grant insist it would drive greater efficiencies.And it might, for instance, make it easier for states to expand their home and community based long-term care programs. 

But it is also likely to generate major cuts in both benefits and reimbursements. In addition, without minimum federal standards, the differences among state long-term care benefits, already dramatic, would only grow.As a result, residents of one state may receive much better long-term care than residents of a neighboring jurisdiction.  

Despite these risks, GOP governors came to Cngress today to demand the changes. Mississippi Governor Haley Barbour, who is mulling a presidential bid--told a congressional committee that states should not have to "kow-tow" to the federal government and insisted the program be turned into a block grant. Mississippi, as it happens, recieves a greater federal Medicaid payment than any other state.

Even more troubling, these Medicaid cuts would come on top of what are likely to be freezes or cuts in non-Medicaid benefits for the frail elderly, such as nutrition, energy assistance,and housing.  

My guess is that much of this call for a Medicaid block grant is political posturing. It is hard to believe that many governors would turn their backs on hundreds of billions of dollars in federal aid at a time when they are struggling to balance thier budgets. I suspect what Barbour and his colleagues really want is the money with less regulation. But given federal budget pressures, their GOP friends on Capitol Hill may give them both.        

President Obama's 2012 budget is the latest indication of the growing pressures government-provided aging services will face in coming years.  And as tight as his budget is, spending on assistance for poor and frail seniors is likely to end up much lower than Obama proposed. With congressional Republicans vowing to cut $100 billion from domestic spending over the remaining seven months of the current budget year, and even more from Obama's proposals for next year, the future for federal funding for aging services is grim.

There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.

On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.

Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own. 

Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.    

President Obama's 2012 budget is the latest indication of the growing pressures government-provided aging services will face in coming years.  And as tight as his budget is, spending on assistance for poor and frail seniors is likely to end up much lower than Obama proposed. With congressional Republicans vowing to cut $100 billion from domestic spending over the remaining seven months of the current budget year, and even more from Obama's proposals for next year, the future for federal funding for aging services is grim.

There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.

On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.

Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own. 

Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.