Medicaid’s Role in Meeting Seniors’ Long-Term Services and Supports Needs

Ninth Annual Symposium on Access to Health CareBeazley Institute for Health Law and Policy

November 13, 2015

Erica L. ReavesPolicy Analyst, Kaiser Family Foundation’s Commission on Medicaid and the Uninsured

Figure 2

LTSS needs are relatively common among seniors living in the community

Share with:

Any LTSS Need Self-Care Need Household Need

46%

36%33%

SOURCE: KCMU analysis of 2011 NHATS data; see Rachel Garfield et al., Serving Low-Income Seniors Where They Live: Medicaid’s Role in Providing Community-Based Long-Term Services and Supports (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), http://kff.org/medicaid/issue-brief/serving-low-income-seniors-where-they-live-medicaids-role-in-providing-community-based-long-term-services-and-supports/.

Figure 3

65-74 75-84 85+

37%*

51%*

74%

NOTES: *Significantly different from age 85+ at p<0.05 level. ^Significantly different from male at the p<0.05 level. ~Significantly different from White, Non-Hispanic at the p<0.05 level. SOURCE: KCMU analysis of 2011 NHATS data.

Fe-male

Male

52%^

40%45%

54%~58%~

Multiple factors influence seniors’ risk of needing LTSS

Age Gender

Race/Ethnicity

Non-Hispanic

White,Non-

Hispanic

Black, Hispanic

Share of community-based seniors with any need:

Figure 4

NOTES: Total LTSS expenditures include spending on residential care facilities, nursing homes, home health services, and home and community-based waiver services. Expenditures also include spending on ambulance providers and some post-acute care. This chart does not include Medicare spending on post-acute care ($74.1 billion in 2013). All home and community-based waiver services are attributed to Medicaid. SOURCE: KCMU estimates based on CMS National Health Expenditure Accounts data for 2013.

Medicaid is the nation’s primary payer for LTSS

Out-of-Pocket,

19%

Med-icaid; 51%

Out-of-Pocket;

19%

Private Insur-ance,

8%Other Public; 21%

Total National LTSS Spending in 2013 = $310 billion

Figure 5

2002 2004 2006 2008 2010 2012 2013

Home and Community-Based LTSSInstitution-Based LTSS

$93$100

$113$121 $123 $123

68%

37%

63%

42%

58% 55%

45%

32%

55%

45%

54%

46%

Medicaid LTSS spending is increasingly devoted to HCBS as opposed to institutional care

NOTES: Home and community-based services (HCBS) include state plan home health, state plan personal care services and § 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals with intellectual/developmental disabilities, nursing facilities, and mental health facilities.SOURCE: KCMU and Urban Institute analysis of CMS-64 data.

(in billions)

$109

41%

59%

Figure 6

Seniors Non-Elderly People with Disabilities

50%

20%

50%

80% Predominantly Community-Based CarePredominantly Institutional Care

1.9 million 1.7 million

NOTE: Individuals who used both institutional and community-based services in the same year are classified as using institutional services in this figure. SOURCE: KCMU and Urban Institute estimates based on MSIS and CMS-64 FY 2011 data.

Seniors are more likely than non-elderly people with disabilities to use institutional LTSS vs. HCBS

Figure 7

All Benefi-ciaries

Non-Elderly People with Disabilities

Seniors Adults Children

$6,502

$18,518 $17,522

$4,141 $2,492

Per capita Medicaid LTSS spending is relatively high for seniors

NOTE: Per capita calculations include only full-benefit enrollees.SOURCE: KCMU and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. In cases where 2011 MSIS data were unavailable, 2010 MSIS & CMS-64 data were used.

Figure 8

Participants Expenditures

47%

74%

29%

15%24%

11%

State Plan Home Health Services

State Plan Personal Care Services

Section 1915(c) Waiver Services

The majority of Medicaid HCBS are delivered via § 1915(c) waivers

3.2 million $55.0 billion

764,487

944,507

1,497,528

$5.8 billion

$8.4 billion

$40.8 billion

SOURCE: Terence Ng et al., Medicaid Home and Community-Based Service Programs: 2012 Data Update (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2015), http://kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/.

Total:

Figure 9

Section 1915(c) waiver enrollment and spending are disproportionate for the aged and disabled population

NOTES: Percentages may not sum to 100 percent due to rounding. The “Other” enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain and spinal cord injuries.SOURCE: KCMU and UCSF analysis of 2012 CMS Form 372 data.

Total = $40.8 billion

Aged and Disabled

Enrollees Expenditures

Other

Persons with Intellectual/Developmental

Disabilities

Aged and Disabled

163,638 (11%)

720,204 (48%)

613,685(41%)

$29.2B (72%)

$8.5B (21%)

Other$3.2B (8%)

Total = 1.5 million

Persons with Intellectual/Developmental Disabilities

Figure 10

NOTES: Percentages may not sum to 100 percent due to rounding. The “Other” enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain and spinal cord injuries. SOURCE: KCMU and UCSF analysis of CMS Form 372 data and program surveys.

53% 47% 45%

Section 1915(c) waiver enrollment can be capped, resulting in waiting lists

64%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

OthersAged/DisabledPersons with Intellectual/Developmental Disabilities

60%

45% 53%53%

68%64%

26%

53%41%

42% 26%

30%

14%

1%6%

5%6%

6%

61%

10%

29%

63%

9%

28%

58% 62%

32%

10%8%

60%

29%

11%

582,066206,427 260,916 280,176 331,689 393,096 365,553 428,571 511,174Total: 523,710 536,464

29%

Figure 11

NOTES: Total counts equal the number of states that were approved by CMS to participate in the option as of October 2015. States with planning grants, pending state plan amendments, and/or pending demonstration proposals are not captured in this figure. SOURCES: CMS, Medicaid.gov, and state websites.

The Affordable Care Act offers states additional options to provide Medicaid HCBS

44

20 18 1712

5

Figure 12

• Mary Francis | Richmond, VA

“My mom had Medicare at the time of her stroke but it did not cover long-term care. To us, Medicaid means being able to live with dignity, in the community, with friends and family.”

• Maxine | Kansas City, KS

“Because she [Maxine] is able to stay in her own home, she feels a certain amount of independence.”

• Penny | Braintree, MA

“Medicaid allowed me to have the same care as everybody else, in the same respiratory hospital and in this nursing home…there’s no discrimination.”

SOURCE: KCMU, Faces of Medicaid (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), http://kff.org/medicaid/video/faces-of-medicaid/.

Personal stories highlight the diverse experiences of seniors who rely on Medicaid LTSS

Figure 13

• No Wrong Door/Single Entry Point systems and universal functional needs assessment

• State take-up of Medicaid HCBS options

• Length and duration of HCBS waiver waiting lists

• HCBS provider payment rates and workforce adequacy

• Delivery system reforms including managed LTSS and initiatives to integrate acute care and LTSS

• Oversight and monitoring of HCBS programs and quality measures

Looking ahead, Medicaid policymakers will be challenged to find innovative ways to meet seniors’ LTSS needs