Three researchers at the LeadingAge LTSS Center @UMass Boston contributed articles to the Spring 2019 issue of Generations, which explores “The Financing of Long-Term Care: An American Conundrum.”
Why won’t Americans, who are living longer lives, plan for their long-term care? And where are the policies for financing it?
Those two questions kick off an article in the Spring 2019 issue of Generations by Ruth Katz, senior vice president for public policy/advocacy at LeadingAge.
Katz is guest editor of the issue, which explores “The Financing of Long Term-Care: An American Conundrum.” She is joined by a group of 25 contributors, many of whom “have been working on LTSS financing reform for decades,” according to Katz.
“What we have in common is that we have failed at this so elegantly, and so many times,” says Katz. “Each time, we retrieved something from the rubble … but the heavy lifting is done … the benefit design choices and actuarial models are on the shelf, ready to be pulled into services; what remains is to figure out how to pay for it.”
Three researchers from the LeadingAge LTSS Center @UMass Boston—Marc Cohen, Robyn Stone, and Alisha Sanders—contributed their expertise to help the journal of the American Society on Aging address that last, remaining goal: figuring out how to pay for long-term services and supports (LTSS).
COHEN: STATE ACTION TO FINANCE LTSS
In “The States Can’t Wait: The Long-Term-Care Financing Imperative,” LTSS Center Co-Director Marc Cohen and Eileen Tell, principal of ET Consulting in Belmont, MA, describe how states are facing mounting pressure to increase their contributions to the Medicaid program, which is the largest LTSS public payer.
“As pressure on the financing system mounts, states feel the pain,” write the authors.
That pain has led a number of states to explore new ways—including state-based special insurance initiatives—to address LTSS financing issues.
“State action has the potential to advance innovative approaches because states are better positioned to design programs more appropriate to their unique demographic, financial, and social environments,” write Cohen and Tell. “And the opportunity to listen to and include the concerns of relevant stakeholders and to garner political support for the initiative, while never easy, is likely to be less challenging at the state level.”
The authors suggest that any social insurance program must deal with several critical issues, including:
- Who will be eligible.
- How benefits will be designed and structured.
- How the program will be financed and implemented.
Cohen and Tell offer several recommendations for addressing these issues, and then provide examples of states—including Hawaii, Washington, Maine, California, and Minnesota—that are making “ongoing and notable efforts to shape and enact initiatives to address the LTSS needs of their residents.”
STONE: STRUGGLING WITH UNDERLYING ASSUMPTIONS
In “Financing Long-Term Services and Supports—and the Challenge of Underlying Assumptions,” LTSS Co-Director Robyn Stone identifies several questions that affect the nature, scope, and political viability of LTSS financing options. Those questions include:
Whether LTSS is a medical or functional-quality-of-life issue: “The vehicle used to ensure against the risk of needing LTSS depends upon the definition of the benefits to be covered,” writes Stone. A functional-quality-of-life framework might build on exiting mechanisms like Social Security, for example, while a medical framework might build on programs like Medicare.
Whether all people or just older adults should be covered: “Limiting insurance coverage to older adults would raise serious concerns among policy advocates for younger people with disabilities,” writes Stone.
Whether participation would be mandatory or be voluntary: “I believe a federally sponsored social insurance programs for LTSS must be mandatory to achieve the risk-spreading required to assure successful implementation and sustainability,” writes Stone, who adds, however, that a mandatory benefit is a political “non-starter” right now.
If the program should be funded at the national or state level: There’s probably more political will to support state-based LTSS financing strategies, even though state action could create variation in access to LTSS insurance across the country, writes Stone. Ultimately, she add, “success in various states may provide models for a federal effort and also garner more interest and support at the national level.”
SANDERS: FINANCING HOUSING PLUS SERVICES
In “Housing Plus Services: A Model that Supports the ‘Whole’ Person,’” Alisha Sanders, the LTSS Center’s director of housing and services policy research, discusses a care delivery model that links affordable housing settings with services to help older adults with low incomes better manage their health and LTSS needs, and age in their communities.
Sanders outlines the model’s benefits, which include service-delivery efficiencies and the availability of existing housing staff who know residents well and can help them access resources to support their social and medical needs. Despite these benefits, however, “the availability of options to meet current and future demand looks bleak,” writes Sanders.
Sustainability is a key challenge. Housing plus services programs are funded through a variety of mechanisms, including support from the U.S. Department of Housing and Urban Development for a modest service-coordinator function. Programs also receive direct support from health systems and health plans, hospital community benefit dollars, pubic or philanthropic grants, and in-kind contributions from community-based organizations.
Sanders describes these financing sources as “ad hoc, intermittent, and generally inadequate to fund a more comprehensive program.” She suggests that creating a more sustainable financing mechanism for these models “would provide a solution for comprehensively addressing the social, health, and LTSS needs for vulnerable, low-income older adults.”
(See the LTSS Center’s recent publication exploring financing mechanisms for housing-based services.)
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Visit the Generations website to purchase single copies of the Spring 2019 issue.