Colleen M. Grogan
A Marriage of Convenience
The Persistent and Changing Relationship
between Long-Term Care and Medicaid
It is impossible to discuss the nation's need for affordable long-term care services without concurrently discussing America's Medicaid program. Since it was established in 1965, Medicaid has often, in passing, been called our health-care program for "the poor." In truth, the program has always been at once more and less than that. Medicaid is less than that meager description because it has always systematically excluded certain categories of poor people.1 However, Medicaid is also much more than a program for "the poor" because it provides long-term care services to elderly who resided, and whose families reside, firmly in the middle class. Today, nearly seventy percent of nursing home residents are dependent on Medicaid to finance at least some of their care. While about forty percent of nursing home residents are "poor enough" to be eligible for Medicaid upon admission, another forty-five percent begin as private paying residents, spend down their resources, and eventually become Medicaid eligible (Weiner 1999; Cohen et al. 1993). Many senior citizens who receive Medicaid do not have a history of poverty, yet they have long consumed a substantial proportion of Medicaid's resources.2 While the elderly and disabled constitute about thirty percent of program recipients, they consume about seventy percent of program expenditures (CMS website).
Policies that purport to provide a safety net for the poor yet leave millions of people uninsured and with little or no access to medical coverage, while extending "welfare medicine" to America's middle class for the provision of long-term care services, may seem unfair. Not surprisingly, policy makers have questioned the appropriateness of using Medicaid for America's long-term-care program (Grogan 2005; Grogan and Patashnik 2003a). Indeed, some policy