LTC Bullet:  LTC Almanac Update (2)

Friday, July 6, 2012


LTC Comment:  Again this week we’re updating the “Almanac of Long-Term Care” in The Zone.  More on the LTC Almanac and today’s update after the ***news.***

*** MEDICAID PLANNING HEARING:  The United States House of Representatives Committee on Oversight and Government Reform’s Subcommittee On Health Care has published a transcript of its September 21, 2011 hearing titled “Examining Abuses of Medicaid Eligibility Rules” at which Center president Steve Moses testified.  Read the transcript here.  Steve’s testimony begins at page 9.  He answers questions, some of which are hostile, at pages 29; 30 top, 30 bottom; 33 top, 33 bottom; 34; 35; 36; 37; 38; 39; 40; 41; and 42.  Pages 44 to 46 contain Steve’s reply to follow up questions from the Committee’s Minority (Democratic) members. ***



LTC Comment:  Do you know and utilize the Center for Long-Term Care Reform’s "Almanac of Long-Term Care" in The Zone, our password-protected website?  You should.

*** SPECIAL.  To celebrate Independence Day and completing half of calendar year 2012, we made access to The Zone, including the "Almanac of Long-Term Care" free until Wednesday, July 11, 2012.  To access this introductory peek into The Zone, go to and use the following case-sensitive user name and password:  UN: IntrotoZone / PW: FreeTrial.  Like what you see?  Then join the Center for Long-Term Care Reform here.  Or contact Damon at 206-283-7036 or  ***

The LTC Almanac is divided into 11 sections:

Aging Demographics 
Unfunded Liabilities--Social Security, Medicare, and Budgets 
Long-Term Care 
Long-Term Care Financing 
Long-Term Care Insurance 
Reverse Mortgages 
Long-Term Care Providers 
Medicaid Planning   

Each section is divided into sub-sections and under each sub-section we provide a list by date of the most important reports and articles published on the topic, usually with a few highlights and sometimes with analysis.

The Almanac of Long-Term Care is a great way to find statistics you need quickly or to get current on topics you need to know the latest information about.

The Zone and the LTC Almanac are for Center for Long-Term Care Reform members only, except during the current free trial offer.  Join the Center here:  Call or email Damon at 206-283-7036 or  He can give you a user name and password to open up The Zone even before your annual dues payment arrives.  Individual annual memberships are $150.  Premium memberships with access to our “Clipping Service” start at $250.  Premium Elite and “Regional Representative” membership (if you qualify professionally) are $500.  Corporate memberships with many extra benefits start at $1,000.  See our "Membership Levels and Benefits" schedule here.

Caveat:  With time, some hyperlinks go bad.  In a huge document like the "LTC Almanac," we can't keep all the links current all the time.  If you find a bad link, but want to get to the material, contact us.  We often have an electronic copy of the document and we can usually find a current live link.  We'll also fix the link in the LTC Almanac so it will be current again for others.

Suggestion:  Read through the following update to stay current on new resource materials.  Then browse through the LTC Almanac at your leisure.  Then, when you need a quick fact or the latest research on a particular topic, you'll know right where to go.  Enjoy.


Chapter 6:  Long-Term Care Financing

Medicare LTC Financing

IPAB by Cannon 0612 URL:; “The Independent Payment Advisory Board: PPACA’s Anti-Constitutional and Authoritarian Super-Legislature by Diane Cohen and Michael F. Cannon  

“In 2010, the Patient Protection and Afford­able Care Act (PPACA) created the Independent Payment Advisory Board, or IPAB. When the unelected government officials on this board submit a legislative proposal to Congress, it au­tomatically becomes law: PPACA requires the Sec­retary of Health and Human Services to imple­ment it. Blocking an IPAB ‘proposal’ requires at a minimum that the House and the Senate and the president agree on a substitute. The Board’s edicts therefore can become law without congres­sional action, congressional approval, meaning­ful congressional oversight, or being subject to a presidential veto. Citizens will have no power to challenge IPAB’s edicts in court.”


Chapter 8:  Reverse Mortgages


MetLife on Reverse Mortgages 0312 URL:  “Changing Attitudes, Changing Motives: TheMetLife Study of How Aging Homeowners Use Reverse Mortgages,” March 2012

First three “Key Findings

• Data from recent reverse mortgage counseling sessions suggest that older homeowners are looking for solutions to help manage their often precarious financial situation, and that a reverse mortgage can play an important role in helping them do so.

• More reverse mortgage borrowers are applying at earlier ages. While the average age of borrowers is about 73 years old, the average age of homeowners who went through HECM reverse mortgage counseling between September and November 2010 was 71.5 years old. Of homeowners who are considering a reverse mortgage, 46% are under age 70. One in five (21%) are leading edge Baby Boomers (age 62 to 64), despite lower available loan limits. In comparison, homeowners who were around the minimum age (age 62) for these loans represented only about 6% of borrowers who applied for reverse mortgage loans during 1999.

• Among HECM counseling clients in 2010, most of these homeowners (67%) wanted to lower household debt. Only 27% were considering a reverse mortgage to enhance their lifestyle. Even fewer (23%) saw the need to plan for the future as a reason to take out this type of loan, indicating that reverse mortgages are no longer a ‘one-size-fits-all’ solution.”


Chapter 9:  Long-Term Care Providers

HCBS:  Cost-Effective or Not? (See also similar section under LTC Financing)

KFF on State Options That Expand HCBS 1011 URL:  “State Options That Expand Access to Medicaid Home and Community-Based Services”

“This background paper examines various aspects of the Medicaid program that can expand access to HCBS and rebalance LTC spending in favor of HCBS. First, the three major categories of Medicaid HCBS benefits available to states are described. Second, various measures of access to HCBS are discussed, and the states with the highest ratings on access to HCBS are identified. Third, the benefits and policies that appear to contribute to high HCBS access in states are identified and discussed. Finally, new options and incentives available to states to expand HCBS under the Patient Protection and Affordable Care Act (ACA) (Public Law 111-148 of 2010), are described.”


Health Affairs on HCBS Cost Effectiveness 0612 URL:  Cite this article as H. Stephen Kaye, “Statistical Model Shows Gradual Rebalancing Of Medicaid Long-Term Services And Supports Saves Money And Serves More People,” Health Affairs, 31, no.6 (2012):1195-1203

“Abstract States are shifting Medicaid spending on long-term services and supports from institutional to home and community-based services, a process known as rebalancing. Using fifteen years of state expenditure data, a statistical model was developed to assess the effect of rebalancing on overall spending for long-term services and supports. The model indicates that spending is affected by the way rebalancing is implemented: Gradual rebalancing, by roughly two percentage points annually, can reduce spending by about 15 percent over ten years. More rapid rebalancing can save money, break even, or increase spending, depending on the pace and program specifics. Cuts to home and community-based services that hinder rebalancing are likely to increase, not decrease, overall spending on long-term services and supports as people who were receiving these services shift into nursing homes. Because many states continue to experience budget crises, policy makers must think carefully before altering spending patterns for long-term services and supports and adopt strategies that particular states have used to successfully reduce overall spending, such as gradually shifting expenditures toward home and community-based waiver programs.”


Health Affairs on HCBS Affordability 0612 URL:  Cite this article as “Users Of Medicaid Home And Community-Based Services Are Especially Vulnerable To Costly Avoidable Hospital Admissions,” R. Tamara Konetzka, Sarita L. Karon and D.E.B. Potter, Health Affairs, 31, no.6 (2012):1167-1175

“ABSTRACT Although Medicaid's coverage of home and community-based services and the program's capacity to provide such services have increased markedly in recent years, relatively little is known about the population that uses these services. We combined Medicaid and Medicare data to characterize the national Medicaid population of service users by key demographic and health-related attributes. We also assessed one important dimension of their health outcomes: potentially avoidable hospital admissions. We found that in 2005 there were 2.2 million users of Medicaid home and community-based services-almost 4 percent of the total Medicaid population-and that two-thirds of these users were dually eligible for Medicare and Medicaid. Users of home and community-based services were particularly vulnerable to avoidable hospital admissions, compared to the full Medicaid and US populations, and these hospitalizations occur at substantial cost to public payers. For the dual eligibles using home and community-based services, Medicare pays most of the costs of these avoidable hospital stays. Our findings emphasize the need for further research to establish policies and practices that can best meet the needs of users of Medicaid home and community-based services.”

LTC Comment:  For our view on the affordability of HCBS, see “Briefing Paper #4: Rebalancing Long-Term Care,” -- (PDF for print).


Managed LTC

AARP on Managed LTC 0212 URL:

LTC Comment:  "On the Verge: The Transformation of Long-Term Services and Supports" examines the explosive growth of managed LTC which has senior advocates very nervous. 

Excerpt:  "Many states are on the verge of transforming the financing and delivery of LTSS. On the heels of the Great Recession, state policymakers are looking at solutions that include moving toward capitated, risk-based managed care for Medicaid enrollees with LTSS needs and focusing on better care and cost containment for people who are dually eligible for both Medicare and Medicaid coverage, the so-called 'dual eligibles.'"

For the possible downside, see:  LTC Bullet:  Double Trouble, Friday, May 11, 2012.


Chapter 10:  Medicaid

Medicaid is the 800-pound gorilla of LTC

Repub Gov's Medicaid Recommendations 0811 URL:   A New Medicaid:  A Flexible, Innovative and Accountable Future  Republican Governors Public Policy Committee  Health Care Task Force  August 30, 2011  

“The Republican Governors Public Policy Committee (RGPPC) is the official policy organization of the nation’s Republican governors. The RGPPC brings together 31 state governors to speak with one voice on public policy issues that impact their states. This report is a collection of policy ideas from the RGPPC Health Care Task Force. This report does not constitute an endorsement of the policy prescription by any specific governor. Instead, these policy proposals should be viewed as among the best ideas from the states to be considered in reforming the nation’s health care system. While this report is focused on specific solutions for the Medicaid program, it is important to note that Medicaid is only one segment of the entire health care system and cannot be considered separately from the overall health care insurance system.”


Medicaid Financing

KFF on LTC Users 1011 URL:

“Medicaid’s Long-Term Care Users:  Spending Patterns Across Institutional and Community-based Settings”

This report documents the disproportionate utilization and cost of Medicaid services for long-term care recipients.  For example:  “Medicaid long-term care users accounted for 6 percent of the Medicaid population in 2007, but nearly half of total Medicaid spending;” “Among those using long-term services and supports, the average annual spending per Medicaid beneficiary was $43,296 compared to just $3,694 for Medicaid beneficiaries who did not use long-term care services;” “One-third of elderly Medicaid beneficiaries used long-term services and supports, but they accounted for 87percent of all Medicaid spending on the elderly;” “Dual eligibles accounted for over two-thirds of Medicaid enrollees who used long-term services and supports and a similar share of spending.”


KFF on State Medicaid Budgets 1011 URL: Focus On Cost Containment As A Loss Of Federal Stimulus Funds Means State Costs For Medicaid Will Jump In Fy 2012”

“Faced with the end of stimulus money and a continuing weak economy, Medicaid officials in virtually every state are enacting a variety of cost cutting measures as states’ spending for Medicaid is projected to increase 28.7 percent this fiscal year [FY 2012] to make up for the loss of federal funds, according to a new survey by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured,”


Medicaid Eligibility

KFF on LTC Planning 0312 URL:

“Key Issues in Understanding the Economic and Health Security of Current and Future Generations of Seniors,” Harriet Komisar, Georgetown University; and Juliette Cubanski, Lindsey Dawson, and Tricia Neuman, Kaiser Family Foundation

LTC Comment:  This report details the dismal economic condition of today’s seniors, laments proposals under consideration to reduce the debt and deficit, but offers no solutions beyond the implicit recommendation to increase, but at least not cut, social expenditures.  Regarding long-term care, the report blames low LTC insurance take up on the usual suspects, i.e. unaffordability, etc., and completely misses the key reason, easy access to Medicaid without significant spend down.  The report says incorrectly:  “Medicaid benefits include long-term services and supports . . . only for people with low financial resources, including those who have exhausted their resources paying for medical care and long-term services and supports.”  There is no evidence of widespread asset spend down and the truth is that Medicaid LTC recipients may retain virtually unlimited exempt assets.


Medicaid Crowd-Out

Brown and Finkelstein on Insuring LTC Fall 2011, Journal of Economic Perspectives URL:

“Insuring Long-Term Care in the United States,” Jeffrey R. Brown and Amy Finkelstein, Journal of Economic Perspectives-Volume 25, Number 4-Fall 2011-Pages 119-142

Excerpt:  “We highlight how the availability of public long-term care insurance through Medicaid is an important factor suppressing the market for private long-term care insurance.”


Brown_Goda_McGarry_on LTC 0811 URL:

“Why Don't Retirees Insure Against Long-Term Care Expenses? Evidence from Survey Responses,” Jeffrey R. Brown University of Illinois and NBER and Gopi Shah Goda Stanford University and NBER and Kathleen McGarry UCLA and NBER.  Prepared for the 13th Annual Joint Conference of the Retirement Research Consortium "Innovations in Retirement Security" August 4-5, 2011 Washington, DC.

Excerpt:  “Individuals are much less likely to purchase private insurance if they believe their family is likely to take care of them, if they are concerned about affordability of insurance, if they are more concerned about counter-party risk, or that the insurance company might deny legitimate claims or raise premiums in the future.”

LTC Comment:  These authors give too little attention to the fact that Medicaid is easy to qualify for without significant asset spend down and the fact that Medicaid has paid for most expensive LTC since 1965.  Clearly Medicaid crowds out LTC insurance demand whether or not consumers are consciously aware of either of these facts.


Dual Eligibles

Health Affairs on Dual Eligibles (Pro) 0612 URL: Cite this article as Patricia Neuman, Barbara Lyons, Jennifer Rentas and Diane Rowland, “Dx For A Careful Approach To Moving Dual-Eligible Beneficiaries Into Managed Care Plans,” Health Affairs, 31, no.6 (2012):1186-1194.

“ABSTRACT Policy makers are moving rapidly to develop and test reforms aimed at doing a better job of managing the costs and care for people dually eligible for Medicare and Medicaid. This commentary underscores the importance of pursuing new initiatives to address care coordination and spending concerns. It then focuses on key issues raised by proposals that would shift dual-eligible beneficiaries into managed care plans. The paper describes the heterogeneity and complexity of this population, emphasizing the need for approaches closely tied to the needs of particular subgroups of dual-eligible beneficiaries. It warns against moving too quickly, noting the time and resources required to build capacity to serve patients, secure provider networks, and develop an infrastructure for integrating and managing both Medicare and Medicaid services. The commentary cautions that optimistic savings assumptions might not materialize, raises questions about how savings will be allocated, and highlights the need for accountability as new models are being developed and tested to improve care for a population with complex needs.”


Health Affairs on Dual Eligibles (Con) 0612 URL:

Cite this article as Marsha R. Gold, Gretchen A. Jacobson and Rachel L. Garfield “There Is Little Experience And Limited Data To Support Policy Making On Integrated Care For Dual Eligibles,” Health Affairs, 31, no.6 (2012):1176-1185

“ABSTRACT Coordinating care for the nine million elderly or disabled and low-income people who are dually eligible for Medicare and Medicaid is a pressing policy issue. To support the debate over this issue, we synthesized public data on how services are provided to dual eligibles receiving covered benefits in both programs. Our analysis confirmed that most dual-eligible beneficiaries receive benefits separately for each program through fee-for-service arrangements. Their enrollment in Medicare and Medicaid managed care is growing but still low, with highly uneven experiences across states. Few states or health plans have experience with coordinating care for dual eligibles within an integrated plan. These findings reinforce the need for caution in considering policies that would rapidly give states the responsibility for coordinating dual eligibles' care and coverage. We also found data gaps that warrant prompt attention in order to provide national-level oversight and improve the evidence base for debating and tracking policy changes.”

LTC Comment:  For more on the possible downsides of managed LTC for dual eligibles, see:  LTC Bullet:  Double Trouble, Friday, May 11, 2012.  For another perspective on dual eligibles, see our Briefing Paper #5: Dual Eligibles and Long-Term Care: How to Save Medicaid LTC $30 Billion Per Year and Pay for the "Doc Fix" -- (PDF for print)


Turner and Helms on IPAB 0612 URL:  "Providing Improved Care Management For Medicare/Medicaid Dual-Eligible Beneficiaries," by Grace-Marie Turner, Galen Institute and Robert Helms, Ph.D., American Enterprise Institute  May 7, 2012,  winning submission to the pioneer institute's  2012 better government competition.

“An integrated Medicare and Medicaid program for dual-eligible beneficiaries would:   Integrate acute and long-term care benefits into a single program they would oversee in which competing private plans (or the states) would provide a coordinated care management program for dually-eligible beneficiaries   Streamline cumbersome rules governing marketing, enrollment, performance monitoring, quality reporting, rate setting, bidding, and grievances and appeals   Eliminate redundant and inefficient spending   Share in the savings achieved through innovative policies, such as disease management and care coordination   Provide both the federal and state governments more predictability in budgeting for the significant part of their Medicare and Medicaid spending on dual eligibles.”