Recently in Medicaid Category

I spent today with the New Hampshire legislature's long-term care caucus and a group of  stakeholders as they wrestled with the challenges of expanding the state's Medicaid home and community based care program for the elderly and adults with disabilities. Thanks to a kind invitation from State Representative Kate Miller, who chairs the caucus, AARP executive vp John Rother and I were able to give the group our sense of what is going on with long-term care issues in Washington. In return, we heard their views from the grassroots.

New Hampshire faces some special challenges. Only about 13 percent of its Medicaid dollars for adults with disabilities and the elderly are spent on home and community care. The rest goes to county-run nursing homes, which receive Medicaid payments that are among the highest in the nation. On top of that, it is not easy to deliver home care in a state that is both overwhelmingly rural and faced with snowy and cold winters. Finally, New Hampshire faces a very difficult budget environment in the current recession, in part because of its very narrow tax base.  

At the same time, like many other states, New Hampshire also must also deal with a severe shortage of health aides and other dirct care workers--a resource that is key to any successful home care program.

The caucus would like to find ways to expand the state's Medicaid home care program, but skeptical lawmakers fear it would only increase overall Medicaid spending. Already worried  that federal health reform will put new pressure on that part of Medicaid that provides health care for poor mothers and their children, the state is especially wary of taking on new, and potentially more costly, obligations to seniors. 

There are no easy answers, but it is good to see a group of commited legislators trying to come to grips with a tough set of issues.

In a bit of surprising news, Senate Finance Committee Chair Max Baucus (D-Mont) added some key long-term care amendments to his health reform bill. The provisions, first proposed by senators John Kerry (D-Mass), Maria Cantwell (D-WA), and Chuck Schumer (D-N.Y.) would all make home and community based care more accessible under Medicaid.

Currently, Medicaid is only required to provide long-term care in nursing homes. States provide limited home care services, but in most, the benefits are very limited. The amendments would make more frail seniors and younger people with disabilities eligible for home care, and provide financial incentives for states to expand these benefits.

Baucus also added a separate proposal that would allow hospice patients to receive full Medicare benefits. This three-year demonstration project would make it possible for hospice patients to get both hospice benefits and treatment for their terminal illness. 

Baucus added the changes as the Finance Committee began drafting its version of health reform.  

For those interested in long-term care, the House Democrats' consensus health reform bill is pretty disappointing. Unlike the Senate Health, Education, Labor, and Pensions Committee version, it includes no proposal for national long-term care insurance. And it largely ignores efforts to expand access to home care for those on Medicaid, who now often can only get care in nursing facilities, or to better coordinate care for those receiving both Medicaid and Medicare benefits.

Key House Democrats, including Representative Frank Pallone (D-N.J.), are long-time supporters of Sen. Ted Kennedy's plan to provide national long-term care insurance (the CLASS Act). Still, the draft is silent on the issue. Similarly, despite strong Democratic support for efforts to enhance Medicaid home care, the proposal calls for little more than studies. Better than nothing, I suppose, but not by much. 

I expect lawmakers will attempt to add some long-term care provisions to the House draft, which will be considered by three committees over the next few weeks, For those of us looking for help caring for our parents, it will be interesting to see how they fare.   

The Democrats on the Senate Health, Education, Labor, and Pensions Committee have, as I expected, included three key long-term care services proposals in their massive 615-page health reform bill. The measure would require states to offer the same access to home and community care as they currently provide for skilled nursing facilities under Medicaid. It would provide new incentives for training both paid and family caregivers. And, the bill includes Senator Ted Kennedy's CLASS Act, which would create a national long-term care insurance program. 

It is hard to overestimate just how far-reaching these changes would be. In my new book, Caring for Our Parents, I discuss each of these ideas. The long-term care training proposal has a good chance of passing this year. The Medicaid changes may be quite costly--as much as $5 billion-a-year--and supporters will have to compete for scarce dollars with dozens of other health reform proposals. The CLASS Act may face the longest odds this year, but at the very least it will focus a tremendous amount of attention on the critical issue of how we pay for long-term care.

Unfortunately, the Democratic leaders of three House committees also laid out their broad blueprint for health reform, but said barely a word about long-term care. Except for worker training incentives, reforms aimed at caring for the disabled as well as the the frail elderly seem to be on the back-burner.

But remember, this is just the first leg in what will be a very long race. Congress will be debating health reform at least through the end of this year.    

If you are impoverished and unable to care for yourself, Medicaid is required by law to provide long-term services--in a nursing home. Although the frail elderly and younger people with disabilities overwhelmingly prefer to stay at home, states are under no obligation to offer care in the community.

So here is an idea: Why doesn't Medicaid make home care the default option for assistance? The joint state/federal program would still pay for care in nursing facilities when this assistance is appropriate, but the first option would be help at home. This idea is included in a bill called the Community Choice Act, introduced by Senator Tom Harkin (D-IA) and Representative Danny Davis (D-Il).   

Most state Medicaid programs do provide some limited home care, under a complex set of Medicaid "waiver" rules. But benefits vary widely among the states, and in many jurisidictions, seniors must wait years before a home care slot becomes available for them.

Recently, Medicaid has slowly expanded its home care benefit, but progress has been very slow. According to a recent study by AARP, three-quarters of Medicaid long-term care spending for older people and younger adults with disabilities still goes to nursing facilities. In 2007, only five states spent more than half of their Medicaid long-term care dollars on home care. Nine states spent less than 10 percent .

Amazingly, Medicaid home care is expanding at this glacial pace even though it has been more than a decade since the U.S. Supreme Court ordered states to provide community assistance to all who need it.

So why have states been so slow to embrace the home care option? Mostly because they worry it will be too popular. Many state officials are driven by the fear of what is known as "the woodwork effect." The idea: If you make Medicaid benefits too attractive, more families will apply for them and state costs will explode.

Remember, today most of us are caring for our parents and other relatives with disabilities  without any government help. And states like it that way. As long as the choice is between helping mom at home without any support or putting her in a nursing home, many families will make huge sacrifices to keep her at home. And when it comes to Medicaid-eligible families, that choice can save government a lot of money.

To be sure, many people with disabilities require institutional care. They may not have the family support they need to stay at home, or the nature of their illness may mean a skilled nursing facility is the best setting for them. And they should have access to an institutional benefit. But for most of the frail elderly and disabled, home care is the best option. Government should do its part to make it work.            

I heard a great presentation this morning by Shawn Bloom of the National PACE Association on how goverment tries to coordinate care for those elderly who are both frail and very poor--among the most at-risk people in the country.

PACE is an innovative program that is geared to seniors still living at home. It combines adult day services with medical care and other assistance. PACE so unusual because it is jointly financed by both Medicare, the federal health program for seniors, and Medicaid, the state/federal health program for the poor. This is a lot more complicated than it seems and, because the two program often work so badly together, the more than 7 million frail and poor elderly who are not in programs like PACE often get very poor care.

Here is the problem: Most of these seniors suffer from multiple chronic conditions. They may have heart failure, diabetes, arthritis, and perhaps some dementia. Health experts agree they desparately need someone to coordinate their care, including both medical treatment and non-medical services, such as transportation, housing, and meals. Without this full package, they will almost certainly lose their ability to stay at home.  

Success for these patients often means keeping them out of the hospital. And that's the problem. Because of the crazy way Medicare and Medicaid work--an artifact of a backroom political deal made in the early 1960s--it is easy for these seniors to fall through the cracks.

Take a heart failure patient. When her medications are not working properly, she is very likely to have trouble breathing and, inevitably, will end up in the hospital emergency room. This can be easily prevented by a skilled health aide, who can identify early warning signs simply by checking to see if the patient is gaining weight--a dead giveaway that trouble is ahead. 

But building a system of coordinated care can be expensive, and it usually falls to the state Medicaid program. But because it is Medicare, not Medicaid, that would pay for her visit the emergency room, it is Medicare that receives the financial benefit of keeping her out of the ER.

So states are reluctant to commit to PACE and programs like it. Once, governors talked about a grand bargain: They would turn care of the frail elderly and disabled adults over to the federal government while keeping responsibility for poor mothers and their children. But Washington is not likely to accept such a deal.

Millions of sick and low-income seniors are caught in the middle. Many were once middle-class people who have spent through their assets and now find themselves in these government programs. They deserve better.