Bi-Partisan Think Tank Tackles Long Term Care Financing & Delivery

I appreciate the important Republican and Democratic thought leaders who are focusing on the need to provide long-term services and supports (LTSS) for people with disabilities and chronic health conditions and older Americans. The Bipartisan Policy Center (BPC) recently announced plans to draft policy and legislative solutions that will address public and private financing options, as well as how and where the services and supports are delivered. 

LTSS encompasses assistance with personal care, activities of daily living, housekeeping, health care routines that may be delivered in homes, assisted living developments, group homes, nursing homes, or other facilities. LTSS may be provided by family, friends, hired personal care assistants, other professional health care staff, and sometimes a mix of all of the above. 

With the aging of the baby-boomers, and the recognition of the rights of individuals with disabilities to live in the “least restrictive setting” and integrated into the community under the Americans with Disabilities Act and the Olmstead enforcement, the need for LTSS, particularly those delivered in homes, is expected to grow substantially. Indeed, the BPC projected that the number of people needing LTSS will double to over 27 million over the next three decades, with public and private spending growing from 1.3 to 3 % of the U.S. gross domestic product.

For these reasons, this is the time to act, declared the BPC’s health care program leaders, Former Senate majority leaders, Bill Frist, M.D. (Republican) and Tom Daschle (Democrat), during the public launch of the BPC’s efforts and release of their white paper, “America’s Long Term Care Crisis:  Challenges in Financing and Delivery.”  The BPC plans to build on the work of other studies, like the Federal Commission on Long-Term Care’s September 2013 report (see prior blog), and has enlisted the help of many experts to review data, collect input and draft recommendations later this year.

The BPC recognized the challenges of financing and providing LTSS:

• The LTSS needs, like the individuals, are significantly diverse, requiring a wide range of assistance, and a range of public and private approaches.
• The state-federal Medicaid program, currently the primary financial resource for LTSS, is already stretched too thin, and cannot sustain the projected needs alone.
• Care provided in an individual’s own home is largely preferred to nursing home or institutional care, but currently home-based (often referred to as “home and community-based settings”) services and supports are fragmented, lack coordination, and often are provided in ways that are inefficient, expensive, and not meeting the needs of the individual. The insurance programs are heavily weighted toward covering care in institutions.

My first-hand experience with federal, state, and local governments’ LTSS policies and programs has taught me that strong leadership is required at the highest levels of government to reach within and across agencies. At the state level, when the governor and the legislature work together, they can direct statewide, system-wide collaborations to improve financing and make delivery more effective.

An excellent example is New York’s Medicaid Redesign Team, which pulled the state cabinet-level directors of various services agencies and programs into a Governor’s office supported team. They have also engaged state and local housing agencies and organizations, since many individuals currently living in Medicaid-funded institutions do not have a home and will need low-income, accessible housing. The NY Medicaid Redesign Team has reduced the rate of growth of NY’s Medicaid budget while changing the system to focus more on providing LTSS in home and community-based settings, and less on institutional services. 

Last year, another example occurred in Texas.  As part of a national level collaborative project between the Departments of Health and Human Services (HHS) and Housing & Urban Development (HUD), the HHS-HUD Housing Capacity Building Initiative for Community Living, federal regional HUD and HHS officials attended a meeting with Texas housing agency staff and staff from the Texas Department of Aging and Disability Services’ Money Follows the Person (MFP) project to learn about each other’s programs, and how they could work together to promote home and community based living for individuals with disabilities transitioning out of nursing homes and other institutions. Following the meeting, the HUD and HHS regional officials jointly orchestrated a one-on-one presentation to each of the ten largest public housing agencies in Texas, seeking set asides of housing vouchers or public housing units for MFP participants. These leaders’ direct, personal appeals resulted in the designation of about 200 public housing vouchers and units for the Texas MFP program, so that individuals leaving nursing homes would have access to appropriate housing.

Hopefully, the strong voices of the BPC’s leaders and experts will produce the much-needed national policy actions to address financing and delivery system improvements for LTSS that many of us are likely to need for our loved ones or ourselves.

Stephanie Mensh is a Senior Analyst who has expertise in Medicaid, Medicare and health insurance reimbursement policies; supportive services for independent living; and housing programs for people with disabilities and chronic conditions. Read Stephanie's bio.