The Aging Network's Role in the Future of Long-Term Care
Polivka, Larry J., Zayac, Helen, Aging Today
How to provide long-term care (LTC) most cost effectively will become an increasingly urgent policy issue at both federal and state levels in the coming years. Discussions of this issue among some journalists and LTC policy experts often take an alarmist tone, generated by the perception that most states and the federal government are unprepared for the vast growth in the older population that will occur during the first half of the 2ist century. LTC spending from all public and private sources, which exceeded $150 billion for people of all ages in 2005, will increase dramatically as the boomer generation ages.
Many states have improved their LTC systems for older adults by using Medicaid waivers allowing them to expand home-based and community-based alternatives to nursing homes. On average, however, states are still spending 70% to 80% of their LTC funds for older people on nursing-facility care. Few states have achieved balanced LTC systems that are responsive to the overwhelming preferences of frail elders for community-based care. But changes are emerging, and the network of services and programs in aging in the United States is well positioned to play a significant role in serving the LTC needs of America's aging population.
The LTC system for elders in the United States involves a loosely organized and fragmented process of gaining access to care with a bias toward institutional care for publicly supported LTC consumers through Medicaid, a meanstested poverty program. This bias limits the availability of home-based and community-based services, restricts the boundaries of consumer choice and creates higher per-recipient Medicaid costs than are necessary or desirable.
Any effort to improve LTC for older individuals qualitatively-and not merely on the margins-must be prepared to address these problems by making access to information and services much easier and faster. Home and community-based services (HCBS) also need to be far more available than they are currently in most states. Fortunately, several conditions are now favorable for fostering a qualitative transformation of LTC for elders.
Consumer preference. Older people vastly prefer obtaining any assistance in community-based settings, ideally their own homes. According to a 2003 AARPsponsored Harris Poll of a national sample of people with disabilities age 50 or older, 87% favor receiving assistance with everyday activities in their own homes, and 73% would prefer to receive even 24-hour help in their own homes, mostly from family and friends. Only 6% would rather have nursing home care for 24-hour needs.
The LTC services at home or in the community. If properly administered, the cost-effectiveness of HCBS has been convincingly demonstrated through research conducted during the past decade and by the success of a few states, which have shifted the balance of their LTC systems from institutional to community-based care. These shifts have allowed some states, such as Oregon and Washington, to maximize the value of their LTC dollars by serving more people in HCBS programs where the per-beneficiary costs are usually much lower than in nursing homes.
The extensive community-based aging network. The aging network in- . eludes state offices on aging, 665 area agencies on aging, approximately 240 tribal organizations, thousands of nonprofit, home and community-residential service providers, as well as monitoring and advocacy groups, such as LTC ombudsmen. These programs and agencies have provided the majority of services for elders outside of institutions for three decades. The aging network has the capacity in many communities to provide a full range of consumer-oriented HCBS for those needing continuing care. A majority of the states have recognized this capacity by giving the aging network, at state and local service-delivery levels, responsibility for administering all or most of the aging-related Medicaid waiver funds for home and community-based assistance. …