By Geralyn Magan
What does the Trump Administration and the Republican Congress mean for older Americans? The Journal of Aging and Social Policy offers some answers.
How are Trump Administration policies likely to affect the social safety net for older Americans? Twelve articles in a recently published special issue of the Journal of Aging and Social Policy offer a variety of responses to that question. Two of the articles were authored by Robyn Stone and Marc Cohen, co-directors of the LeadingAge LTSS Center @UMass Boston.
The special issue provides “a snapshot of the best thoughts on what this administration and the Republican Congress mean for older Americans,” according to Edward Miller, an LTSS Center fellow and co-author of the issue’s introductory article, “The state of aging policy and politics in the Trump era.” The journal’s other articles explore aging policy and politics relating to long-term care and housing, health care, retirement security, and aging politics.
FINANCING LONG-TERM SERVICES AND SUPPORTS
In “Financing long-term services and supports: challenges, goals, and needed reforms,” Cohen and co-author Judith Feder suggest that the need for long-term services and supports (LTSS) presents a growing financial risk for people with disabilities, their families, and state Medicaid budgets.
Despite this risk, however, most people lack protection from LTSS costs because those costs are not covered by private health insurance or by Medicare, and are only available through Medicaid after individuals have spent down their incomes and savings.
“The fundamental LTSS financing problem is the absence of an effective insurance mechanism to protect people against these multiple risks,” write the authors.
Cohen and Feder explain the choices and trade-offs policy makers face in designing new ways to pay for LTSS. They then outline their proposal to develop a new public-private partnership that combines catastrophic public insurance with front-end private LTSS insurance.
Such a partnership would have these elements, according to the authors:
- A new public insurance program would cover the “back-end” risk of LTSS.
- Private insurers would be encouraged to cover the “front end” costs on which they already focus.
- Public benefits would be triggered when individuals are assessed as having 2 or more limitations in activities of daily living or severe cognitive impairment expected to last more than 90 days.
- Public benefits would not begin until people assessed as needing LTSS met a specified waiting period, during which they would rely on private insurance or personal resources to meet their needs.
- Benefits would be provided in cash rather than as reimbursement for incurred expenses.
- The level of benefit would be tied to the cost of home care services. Nursing home users could apply these benefits toward their costs.
“As baby boomers become caregivers and then care recipients, they will likely demand improved access to affordable quality care,” conclude Cohen and Feder.
The authors underscore the need to ensure that the “unpredictable, catastrophic risk” of LTSS is shared by individuals and the community as a whole, rather than by individuals and families in isolation.
“In short,” conclude Cohen and Feder, “the challenge of fair and adequate LTSS financing can and should be addressed in a manner that promotes widespread sharing of risk across the population.”
ADDRESSING THE HOUSING CHALLENGES OF LOW-INCOME ELDERS
“The availability and quality of housing is considered one of the most significant social determinants of health; it is the linchpin of well-being and a good quality of life for older adults,” writes Robyn Stone in “The housing challenges of low-income older adults and the role of federal policy.”
Stone maintains that the current housing landscape does not meet the evolving needs of the aging population. However, she points to promising new strategies that use publicly assisted housing to serve as a platform for identifying and addressing the health and social challenges of older residents.
These strategies have received increased attention over the past decade, despite reduced federal investment in affordable rental housing for older adults, writes Stone.
Since 2010, for example, the U.S. Department of Housing and Urban Development (HUD), and the U.S. Department of Health and Human Services have jointly invested in research and demonstration projects that explore the extent to which publicly assisted senior housing can help health and social service providers:
- Reach a large population of low-income older adults living under the same roof;
- Achieve economies of scale in the delivery of prevention, care coordination, and transitional care; and
- Optimize compliance and self-care management through peer-to-peer engagement.
These federally supported research and demonstration projects focus on a model that relies on HUD-financed service coordinators to assess and address the needs of residents through “individual and property-level programming, and strategic partnerships with local hospitals, health plans, primary care offices, and social services providers,” writes Stone. The LTSS Center participated in several of these research initiatives.
Stone sees increased investments in housing plus services models as a possible solution to the growing affordable housing crisis facing older Americans with low incomes. Those investments could come through partnerships between health systems/insurers and housing developers/operators, she suggests.
“As Medicare Advantage Plans, Medicare Accountable Care Organizations, and other health insurers and health care systems strive to be more efficient and reduce health care costs attributed to low-income, high-risk elderly beneficiaries, they may be willing to pay for the service coordination and wellness services delivered in housing,” writes Stone.
“Over time, and assuming that Medicare allows more flexibility in how dollars are used, some plans may also see the value in providing rental subsidies and even construction funds to help build more affordable senior properties for their high-cost, high-risk enrollees,” she concludes.