The Impact of the Great Recession on Long-Term Services and Supports in the United States and England.

The Great Recession substantially affected most developed countries. How countries responded to the Great Recession varied greatly, especially in terms of public spending. We examine the impact of the Great Recession on long-term services and supports (LTSS) in the United States and England. Financing for LTSS in these two countries differs in important ways; by examining the two countries' financing and program structures, we learn how these factors influenced each country's response to this common external stimulus. We find that between 2006 and 2013, LTSS increased in the United States in terms of spending (17%) and number of people served; in contrast, over the same period, LTSS in England decreased in terms of spending (6%) and people served. We find that the use of earmarked LTSS funding in the United States, compared to non-earmarked funding in England, contributed to different trajectories for LTSS in the two countries. Other contributing factors included differences in service entitlements, variations in ability of state and local governments to tax, and larger macroeconomic strategies implemented to combat the recession. We analyze the implications of our findings, especially as related to the potential shift to Medicaid block grant LTSS funding in the United States.

Medicare Expenditures Associated With Hospital and Emergency Department Use Among Beneficiaries With Dementia.

Understanding expenditure patterns for hospital and emergency department (ED) use among individuals with dementia is crucial to controlling Medicare spending. We analyzed Health and Retirement Study data and Medicare claims, stratified by beneficiaries' residence and proximity to death, to estimate Medicare expenditures for all-cause and potentially avoidable hospitalizations and ED visits. Analysis was limited to the Medicare fee-for-service population age 65 and older. Compared with people without dementia, community residents with dementia had higher average expenditures for hospital and ED services; nursing home residents with dementia had lower average expenditures for all-cause hospitalizations. Decedents with dementia had lower expenditures than those without dementia in the last year of life. Medicare expenditures for individuals with and without dementia vary by residential setting and proximity to death. Results highlight the importance of addressing the needs specific to the population with dementia. There are many initiatives to reduce hospital admissions, but few focus on people with dementia.

Experience, Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform.

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans' experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.

Who Wants Long-Term Care Insurance? A Stated Preference Survey of Attitudes, Beliefs, and Characteristics.

Approximately half of people turning 65 years between 2015 and 2019 are projected to need long-term support and services. Yet the long-term care insurance (LTCI) market is depressed, with only 7.4 million people owning policies. The objective of this study was to provide an analysis of potential LTCI purchasers. We investigate (1) who wants to purchase LTCI, (2) what are the attitudes and beliefs among those who have a preference for LTCI, and (3) who would prefer a law mandating the purchase of LTCI and how that view relates to willingness to purchase LTC. We combine a discrete choice experiment with a survey on attitudes toward LTCI. We estimate odds ratio for choosing a plan based on sociodemographic characteristics, attitudes, and beliefs. Our sample consists of a population of 12 936 people who completed an Internet panel survey. Female respondents were substantially less likely to choose an LTCI plan (OR = 0.74). Income and assets over $100 000 were strong predictors of LTCI uptake (OR = 1.27 and OR = 1.48, respectively). Having adult children live close by was not associated with preference for LTCI. People who support almost any government intervention are more likely to purchase private insurance (OR = 1.12-1.33). Minorities expressed a preference for mandatory enrollment relative to whites. There is a relationship between attitudes toward long-term care financing reform and preference for LTCI, but it is not limited to supporters of private sector initiatives. While support for mandatory LTCI is low overall, it is strongest among racial/ethnic minorities and people with health problems, who potentially have the most to gain.

Hospital and ED use among Medicare beneficiaries with dementia varies by setting and proximity to death.

Hospitalizations and emergency department (ED) visits for people with Alzheimer's disease and related disorders are of particular concern because many of these patients are physically and mentally frail, and the care delivered in these settings is costly. Using data from the Health and Retirement Study linked with Medicare claims from the period 2000-08, we found that among community-dwelling elderly fee-for-service Medicare beneficiaries, those who had dementia were significantly more likely than those who did not to have a hospitalization (26.7 percent versus 18.7 percent) and an ED visit (34.5 percent versus 25.4 percent) in each year. Comparing nursing home residents who had dementia with those who did not, we found only small differences in hospitalizations (45.8 percent versus 41.9 percent, respectively) and ED use (55.3 percent versus 52.7 percent). As death neared, however, utilization rose sharply across settings and by whether or not beneficiaries had dementia: Nearly 80 percent of community-dwelling decedents were hospitalized, and an equal proportion had at least one ED visit during the last year of life, regardless of dementia. Our research suggests that substantial portions of hospitalizations and ED visits both before and during the last year of life were potentially avoidable.

Obesity and people with disabilities: the implications for health care expenditures.

OBJECTIVE: This study estimates additional average health care expenditures for overweight and obesity for adults with disabilities vs. without. DESIGN AND METHODS: Descriptive and multivariate methods were used to estimate additional health expenditures by service type, age group, and payer using 2004-2007 Medical Expenditure Panel Survey data. RESULTS: In 2007, 37% of community-dwelling Americans with disabilities were obese vs. 27% of the total population. People with disabilities had almost three times ($2,459) the additional average obesity cost of people without disabilities ($889). Prescription drug expenditures for obese people with disabilities were three times as high and outpatient expenditures were 74% higher. People with disabilities in the 45- to 64-year age group had the highest obesity expenditures. Medicare had the highest additional average obesity expenditures among payers. Among people with prescription drug expenditures, obese people with disabilities had nine times the prevalence of diabetes as normal weight people with disabilities. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. CONCLUSIONS: Obesity results in substantial additional health care expenditures for people with disabilities. These additional expenditures pose a serious current and future problem, given the potential for higher obesity prevalence in the coming decade.

The CLASS Act: is it dead or just sleeping?

The Affordable Care Act (ACA) established a voluntary public insurance program for long-term care: the Community Living Assistance Services and Supports (CLASS) Act. In October 2011, the Obama Administration announced that the program would not be implemented because of the high risk of fiscal insolvency. Under the legislative design, adverse selection was a major risk and premiums would have been very high. This article discusses several CLASS Act design and implementation issues, including the design features that led to the decision not to implement the program: the voluntary enrollment, the weak work requirement, the lifetime and cash benefits, and the premium subsidy for low-income workers and students.

Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs.

OBJECTIVES: Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population. DESIGN: Retrospective study of hospitalizations. SETTING: Hospitalizations from nursing facilities (NF) including Medicare and Medicaid-covered stays, and Medicaid Home and Community-Based Services (HCBS) waiver programs. PARTICIPANTS: Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005. INTERVENTIONS: None. MEASUREMENTS: Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization. RESULTS: More than one-third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%-60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population. CONCLUSION: Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.

Immigrant and non-immigrant certified nursing assistants in nursing homes: how do they differ?

This study analyzes the 2004 National Nursing Assistant Survey and other survey data to examine the characteristics and experiences of immigrant and non-immigrant certified nursing assistants (CNAs) in nursing facilities. Descriptive results focus on differences in personal characteristics, working conditions, extrinsic rewards, work experiences, job satisfaction, and workplace discrimination. The findings indicate that immigrant CNAs are older, better educated, and somewhat more highly paid than their non-immigrant counterparts but also experience substantial levels of discrimination and language-related communication barriers at work. The paper discusses major policy issues that arise from the increase in immigrant labor in long-term care.

Estimates of state-level health-care expenditures associated with disability.

OBJECTIVES: We estimated state-level disability-associated health-care expenditures (DAHE) for the U.S. adult population. METHODS: We used a two-part model to estimate DAHE for the noninstitutionalized U.S. civilian adult population using data from the 2002-2003 Medical Expenditure Panel Survey and state-level data from the Behavioral Risk Factor Surveillance System. Administrative data for people in institutions were added to generate estimates for the total adult noninstitutionalized population. Individual-level data on total health-care expenditures along with demographic, socioeconomic, geographic, and payer characteristics were used in the models. RESULTS: The DAHE for all U.S. adults totaled $397.8 billion in 2006, with state expenditures ranging from $598 million in Wyoming to $40.1 billion in New York. Of the national total, the DAHE were $118.9 billion for the Medicare population, $161.1 billion for Medicaid recipients, and $117.8 billion for the privately insured and uninsured populations. For the total U.S. adult population, 26.7% of health-care expenditures were associated with disability, with proportions by state ranging from 16.9% in Hawaii to 32.8% in New York. This proportion varied greatly by payer, with 38.1% for Medicare expenditures, 68.7% for Medicaid expenditures, and 12.5% for nonpublic health-care expenditures associated with disability. CONCLUSIONS: DAHE vary greatly by state and are borne largely by the public sector, and particularly by Medicaid. Policy makers need to consider initiatives that will help reduce the prevalence of disabilities and disability-related health disparities, as well as improve the lives of people with disabilities.

Making the system work for home care quality.

The post-acute and long-term care systems are changing rapidly, with an increasingly important role being played by home care. Under the current system, home care does not consistently meet the needs of older people living in the community. This problem is caused, in large part, by the existing system of financing and regulating home care. This paper examines how the current system funded by Medicare, Medicaid, state programs, private insurance, and out-of-pocket spending affects the delivery and quality of home care services. Specifically, this paper analyzes how financing, coverage of services, reimbursement, quality regulation and assurance, and information coordination affects the quality of home care. The paper concludes by drawing implications for policy.

Are consumer-directed home care beneficiaries satisfied? Evidence from Washington state.

PURPOSE: This study analyzed the effect of consumer-directed versus agency-directed home care on satisfaction with paid personal assistance services among Medicaid beneficiaries in Washington State. DESIGN AND METHODS: The study analyzed a survey of 513 Medicaid beneficiaries receiving home- and community-based services. As part of a larger study, we developed an 8-item Satisfaction With Paid Personal Assistance Scale as the measure of satisfaction. In predicting satisfaction with personal assistance services, we estimated an ordinary least squares regression model that was right-censored to account for the large percentage of respondents who were highly satisfied with their care. RESULTS: Among the older population, but not younger people with disabilities, beneficiaries receiving consumer-directed services were more satisfied than individuals receiving agency-directed care. There was no evidence that quality of care was less with consumer-directed services. In addition, overall satisfaction levels with paid home care were very high. IMPLICATIONS: This study supports the premise that consumer satisfaction, an important measure of quality, in consumer-directed home care is not inferior to that in agency-directed care. The positive effect of consumer direction for older people underlines the fact that this service option is relevant for this population. In addition, this research provides evidence that home- and community-based services are of high quality, at least on one dimension.

End of life Medicare and Medicaid expenditures for dually eligible beneficiaries.

In 1995, combined Medicare and Medicaid spending in the last year of life for dually eligible beneficiaries was more than $40,000 per beneficiary. Medicaid's share, primarily for long-term care (LTC), constituted about 40 percent of the total. Beneficiaries under age 65, Black persons, and individuals who died in a hospital had higher than average expenditures. The vast majority (86 percent) received some form of supportive services (nursing home, home care, hospice services). It is critical that policy deliberations consider both acute and LTC use concurrently because of their extensive use by dually eligible beneficiaries, as well as the interaction of the two funding sources (Medicare and Medicaid) that cover them.

Personal care satisfaction among aged and physically disabled Medicaid beneficiaries.

We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.

Medication use among Medicaid users of home and community-based services.

This study examines factors associated with access to medications for older persons and younger adults with physical disabilities who use Medicaid home and community-based services (HCBS). Using data from a six-State survey, we find the large majority of this population receives the medications it needs and has needed assistance in taking these drugs. However, 6.3 percent of this population reports unmet medication needs with financial access listed as the primary reason. Lack of transportation increases the probability of unmet need, while increased satisfaction with paid help lowers this probability. This study highlights the need to study the interaction of Medicaid, social services programs, and financial barriers for this disabled population.

Workforce issues and consumer satisfaction in Medicaid personal assistance services.

This study used a survey of older people and younger persons with disabilities who were receiving Medicaid-financed home and community-based services (HCBS) to assess the effect of workforce issues on consumer satisfaction. We found that recruitment problems had very strong negative and significant effects on consumer satisfaction. An interruption in service was a more important and significant indicator of consumer dissatisfaction than not having the same worker over time. We also found that problems with worker training and respect and treatment of consumers strongly and significantly affected satisfaction with paid care. Efforts to improve workforce issues are needed to improve the quality of care of these services.

An assessment of strategies for improving quality of care in nursing homes.

PURPOSE: Despite substantial regulatory oversight, quality of care in nursing homes remains problematic. This article assesses strategies for improving quality of care in these facilities. DESIGN AND METHODS: This article reviews the research literature on eight strategies: strengthening the regulatory process, improving information systems for quality monitoring, strengthening the caregiving workforce, providing consumers with more information, strengthening consumer advocacy, increasing Medicare and Medicaid reimbursement, developing and implementing practice guidelines, and changing the culture of nursing facilities. RESULTS: Although individual approaches vary, several themes emerge. First, several strategies require substantially more resources and will increase costs. Second, the research literature does not provide much guidance as to the effectiveness of these options. Third, several strategies assume a degree of data sophistication on the part of nursing homes that may not exist. Fourth, regulation is likely to continue to be the main strategy of quality assurance. Finally, the political saliency of nursing home quality issues is uneven. IMPLICATIONS: Quality of care in nursing homes is a major issue for which there is no simple solution.