LTC Bullet:  Doesn't Everyone Get the Same Care in a Nursing Home?

Monday  October 15, 2001


The following question was posted on a state bar association elder law listserv:

When I visit clients in nursing homes, whether the client is private pay or Medicaid, their level of care appears to be the same.  In fact as I walk down the hall I cannot tell whether any given patient is private pay or public pay.   Are there any studies or surveys . . . which I may cite (for purposes of a case, and also frankly in advising clients) that either would bolster this theory, or defeat it?

We answered the question thus:

We would not expect a subscriber to our free online newsletter "LTC Bullets" to need to ask this question.  We just published our 300th Bullet and many of them have documented exactly the studies and evidence you are trying to find.  All of the LTC Bullets are archived on our website at and the newsletter is free to anyone who asks.  You will also find comprehensive explanations of why America's LTC service delivery system is disintegrating in our three major reports:  "LTC Choice," "The Myth of Unaffordability," and "The LTC Triathlon:  Long-Term Care's Race for Survival," all of which are on the same website in .pdf format. 

Here's the problem in a nutshell.  Medicaid pays something toward 80% of all nursing home patient days.  The program pays at a rate only 80% of the private pay rate and often less than the cost of providing the care.  Nursing homes with a relatively high private pay census--the kind attorneys are likely to visit and place your clients in--are less burdened by inadequate cash flow because of cost-shifting from the private pay residents.  Thus, those relatively well-off homes often provide equal care for Medicaid and private pay residents.  Unfortunately, the 80% to 100% Medicaid nursing homes--to which poor people must go who cannot afford "key money" or a Medicaid planner--are the ones with the worst problems.  Tragically, when Medicaid planners artificially impoverish their clients to qualify them for Medicaid, they not only deny the clients access to home care or assisted living, but they also make them vulnerable to the deteriorating Medicaid nursing home system and accelerate the rate of that deterioration to the detriment of the genuinely needy who have no other options.

We recommend that everyone visit three nursing homes before deciding how to handle the LTC financing issue--a 100% Medicaid home, a 100% private pay home, and one in the middle.  Take a look at assisted living too, which is 90% private pay.  Having done so, very few people--and very few adult children-heirs of the elderly if they have parents’ best interests at heart--would choose to "go bare" if LTC insurance or another planning vehicle is still an option or to jettison their wealth to qualify for welfare nursing home benefits if they already need care.