LTC Bullet:  LTC Almanac Update

Friday, March 10, 2017


LTC Comment:  We’ve updated the “Almanac of Long-Term Care” in The Zone.  More on the LTC Almanac and today’s update after the ***news.***

*** AGING: CONCEPTS AND CONTROVERSIES, 9th edition: For over 25 years Harry R. “Rick” Moody’s and Jennifer R. Sasser’s textbook on aging has introduced college students to the pros and cons of a broad range of age-related issues. The style is debate. Whether you agree or disagree with each author’s position on any topic, you get the best arguments from both perspectives. Steve Moses’s 1990 Gerontologist article titled “The Fallacy of Impoverishment” was in earlier editions of the book. The new, 9th edition contains a slightly abridged version of Steve’s 2005 Cato piece titled “Aging America’s Achilles’ Heel: Medicaid Long-Term Care.” Textbooks don’t come cheap; this one costs $118. But if you’re looking for a single book to introduce new hires or seasoned staff to the sensitive controversies of the aging field, you couldn’t do better than this one. ***



LTC Comment:  Center members know and appreciate our "Almanac of Long-Term Care" in The Zone, our password-protected website. 

*** SPECIAL:  We are making access to The Zone, including the "Almanac of Long-Term Care," free for two weeks—today through Friday, March 24, 2017.  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 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 the full LTC Almanac at your leisure.  When you need a quick fact or the latest research on a particular topic, you'll know right where to go.  Enjoy.


Chapter 1:  Aging Demographics

United States

General Stats

Older Americans 2016 Key Indicators of Well-Being, Federal Interagency Forum on Aging-Related Statistics, August 2016

8/16/2016, “7 new, free LTC marketing graphics,” by Allison Bell, LifeHealthPRO 

Quote:  “The Federal Interagency Forum on Aging-Related Statistics, a body based at the Administration for Community Living at the U.S. Department of Health and Human Services, recently published a public-domain report of interest to any financial professional involved in retirement planning, including planning for post-retirement acute care and long-term care costs.  Earlier this month, the forum published "Older Americans 2016: Key Indicators of Well-Being," a 179-page collection of aging statistics from 16 federal agencies. The report includes information on the size of the older population, aging-related behavior, and aging-related health risks and health care services.

LTC Comment:  Just about every imaginable chart and statistic on aging Americans.

Housing Report 1216 LINK

12/14/2016, “Harvard study: Elderly demographics will crush existing housing and service options,” by John O’Connor, McKnight's Senior Living

Quote:  “The nation's surging elderly population will create unprecedented demand for affordable housing and service options within two decades, a Harvard University study asserts.  In fact, rising needs will far outstrip current capacity on both fronts, according to ‘Projections and Implications for Housing a Growing Population: Older Adults 2015-2035.’

LTC Comment:  A big problem and getting worse every day, but as usual, this report recommends only more government spending.  Read its executive summary here.

Retirement Planning

Greenwald Survey on Retirement 0217 LINK:

3/1/2017, “Dems, Republicans All Worrying About Economic Security in Retirement,” Advisor Magazine

Quote:  “A new report finds that 76 percent of Americans are concerned about their ability to achieve a secure retirement, with that level of worry at 78 percent for Democrats and 76 percent for Republicans. Some 88 percent of Americans agree that the nation faces a retirement crisis, and the concern is high across party lines. . . . Download the full study here.”

LTC Comment: Well, at least there’s something on which we can almost all agree. Unfortunately, this is one topic President Trump did not touch on in his remarks to Congress last night.


Chapter 3:  Unfunded Liabilities--Social Security, Medicare, Pensions and Budgets

National Health Expenditures

NHE 2016-2025 Projections URL

2/18/2017, “National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy,” by Sean P. Keehan, Devin A. Stone, John A. Poisal, Gigi A. Cuckler, Andrea M. Sisko, Sheila D. Smith, Andrew J. Madison, Christian J. Wolfe, and Joseph M. Lizonitz, Health Affairs

Quote:  “ABSTRACT Under current law, national health expenditures are projected to grow at an average annual rate of 5.6 percent for 2016–25 and represent 19.9 percent of gross domestic product by 2025. For 2016, national health expenditure growth is anticipated to have slowed 1.1 percentage points to 4.8 percent, as a result of slower Medicaid and prescription drug spending growth. For the rest of the projection period, faster projected growth in medical prices is partly offset by slower projected growth in the use and intensity of medical goods and services, relative to that observed in 2014–16 associated with the Affordable Care Act coverage expansions. The insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent by 2025.”

LTC Comment:  More “rosy scenario” from CMS actuaries.  They say “national health expenditures (NHE) is projected to average 5.6 percent, outpacing average growth in gross domestic product (GDP) by 1.2 percentage points.” So GDP growth will be 4.4% annually for the next decade? Dream on.

Health Affairs NHE through 2025 URL

7/13/2016, “National Health Expenditure Projections, 2015–25: Economy, Prices, And Aging Expected To Shape Spending And Enrollment,” by Sean P. Keehan, et al. , Health Affairs

Quote:  “New estimates released today from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) project an average rate of national health spending growth of 5.8 percent for 2015–25, exceeding the expected average growth in gross domestic product (GDP) by 1.3 percentage points per year. As a result, the health share of the economy is projected to be 20.1 percent at the end of this period, up from 17.5 percent in 2014. The study also finds that the percentage of the US population that is uninsured is expected to be 8 percent in 2025, down from about 11 percent in 2014.”

LTC Comment:  Rosy scenarios like this are a real disservice.  No one knowledgeable expects GDP growth to be 4.5% (5.8% minus 1.3%) over the coming decade.  Besides, the next 10 years are nearly irrelevant.  What matters is what happens in 2031 when the boomers start turning 85, LTC costs explode, and the Social Security and Medicare trust funds have disappeared.

National Health Spending, 2015 URL

12/5/2016, “National Health Spending: Faster Growth In 2015 As Coverage Expands And Utilization Increases,” by Anne B. Martin, Micah Hartman, Benjamin Washington, Aaron Catlin, and the National Health Expenditure Accounts Team, Health Affairs

Quote:  “Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014.  . . .  Slightly offsetting the slowdown in Medicare hospital and prescription drug spending growth was faster growth in Medicare spending for nursing home care (which increased 5.6 percent in 2015, compared to growth of 2.5 percent in 2014) and home health care (which increased 2.6 percent in 2015 after growth of 1.7 percent in 2014).  . . .  Medicaid spending continued to grow at a strong rate of 9.7 percent in 2015, following growth of 11.6 percent in 2014 . . ..”

LTC Comment:  Relentless growth in health care expenditures (and the government’s role in paying for them) continues to exceed growth in the GDP, a deadly downward economic spiral over time.

CBO on Unfunded Liabilities

CBO “The 2016 Long-Term Budget Outlook” 0716 URL 

This is the annual dismal federal budget outlook from the Congressional Budget Office.  Read it and weep.

GAO on Unfunded Liabilities

GAO on US Fiscal Health 0117 URL:

1/17/2017, “The Nation's Fiscal Health:  Action is Needed to Address the Federal Government's Fiscal Future,” by Government Accountability Office (GAO)

Quote:  “Federal spending continues to outpace revenue—by $587 billion in 2016—and, absent policy changes, the structural gap between revenues and spending puts the federal government on an unsustainable long-term fiscal path.  Federal policymakers face economic, security, and social challenges requiring difficult policy choices, but a long-term fiscal plan is also needed to preserve flexibility to address unforeseen events.”

LTC Comment:  “(GAO) today issued its first annual outlook on the nation’s fiscal future.”  Well, it’s about time!

Unfunded Liability Estimates

AEI on Entitlements 2016:  “Increasing the Effectiveness and Sustainability of the Nation’s Entitlement Programs,” by Andrew Biggs, James c. Capretta, Robert Doar, Ron Haskins, and Yuval Levin, June 2016;

Shows difference between federal expenditures in 1965 and 2015.  Makes the point that interest on the federal debt is less now on much greater debt than it was on much smaller debt in 1965 because the Federal Reserve artificially forced interest rates down.


Chapter 4:  Long-Term Care

Home and Community-Based Services

GAO on HCBS Monitoring 0117 URL

1/3/2017, “CMS should improve oversight of HCBS, GAO says,” by Lois A. Bowers, McKnight's Senior Living

Quote“The Centers for Medicare & Medicaid Services should standardize federal requirements for programs providing personal care services for Medicaid beneficiaries, including residents of assisted living communities, to protect beneficiaries from care-related harm and ensure that billed services are provided, the Government Accountability Office said in a new report publicly released Dec. 22.”

LTC Comment:  The practical challenges we’ve predicted would bedevil the program as Medicaid moves from mostly institutional LTC to mostly home and community-based care are on the upswing.  Maintaining care quality and reimbursement accuracy is much more difficult when dealing with individual recipients in their own homes than dealing with nursing homes into which teams of care reviewers and accountants can be sent to ensure standards or care and payment are met or exceeded.


Chapter 5:  Caregiving


Caregiving-RiB 0916 URL

9/13/2016, “Families Caring for an Aging America,” National Academies of Sciences, Engineering, and Medicine

Quote:  “At least 17.7 million individuals in the United States are providing care and support to an older parent, spouse, friend, or neighbor who needs help because of a limitation in their physical, mental, or cognitive functioning. The circumstances of individual caregivers are extremely varied. They may live with, nearby, or far away from the person receiving care. The care they provide may be episodic, daily, occasional, or of short or long duration. The caregiver may help with household tasks or self-care activities, such as getting in and out of bed, bathing, dressing, eating, or toileting, or may provide complex medical care tasks, such as managing medications and giving injections. The older adult may have dementia and require a caregiver’s constant supervision. Or, the caregiver may be responsible for all of these activities.  With support from 15 sponsors, the National Academies of Sciences, Engineering, and Medicine convened an expert committee to examine what is known about the nation’s family caregivers of older adults and to recommend policies to address their needs and help to minimize the barriers they encounter in acting on behalf of an older adult. The resulting report, Families Caring for an Aging America, provides an overview of the prevalence and nature of family caregiving of older adults as well as its personal impact on caregivers’ health, economic security, and overall well-being. The report also examines the available evidence on the effectiveness of programs and interventions designed to support family caregivers. It concludes with recommendations for developing a national strategy to effectively engage and support them.

LTC Comment:  Yet another long and expensive study and report on the problem of long-term caregiving with lots of expensive recommendations and no clue how to pay for them.


Chapter 6:  Long-Term Care Financing

Who Will Pay for LTC? (includes "Not the VA")

Warshawsky on LTC 0217 URL  “Improving the System of Financing Long-Term Services and Supports for Older Americans,” by Mark J. Warshawsky and Ross A. Marchand, Mercatus Working Paper, January 2017

We analyzed this report in LTC Bullet: The LTC Wars (shawsky), Friday, February 24, 2017; LTC Comment: The self-styled conservative LTC Commission co-chair has declared war on government-financed long-term care proposing private sector solutions that mirror our own. Details follow.

See also this on another Warshawsky publication:  2/15/2017, “The Urban Institute Model Of Financing Long-Term Services And Supports: A Critical Review,” by Mark Warshawsky, Health Affairs Blog

Quote:  “Scoring in the LTSS area needs to be based on widely accepted facts (i.e., a fair reading of the literature and/or settled empirical findings), completely transparent (with all major assumptions disclosed and justified), and robust (to consider all types of policy interventions). Scoring should also be alternatively illustrated by conservative results and assumptions, to give a sense of the possible range of outcomes. Unfortunately, despite the great apparent effort of the Urban Institute, their model, as presently constituted, cannot serve this purpose.”

LTC Comment:  This is a devastating refutation of the data and reasoning employed by advocates of a new, compulsory, payroll-financed government LTC program.  See our earlier critique of the same work in “LTC Bullet:  LTC at a Crossroads,” Friday, June 3, 2016.


Chapter 7:  Long-Term Care Insurance

Why Don’t More People Buy LTCI?

LifePlans Buyers Non-Buyers 0117 URL

1/10/2017, “Don’t Underestimate the Value of Long-Term Care Insurance,” by Alicia Caramencio, AHIP

Quote“Many people underestimate their likelihood of needing need long-term care (LTC) and how much that care will cost. People have a 50 percent chance of needing LTC at some point in life, and about 30 percent of people who do may need care for five years or more, according to a new study by LifePlans, Inc. on behalf of America’s Health Insurance Plans (AHIP).  . . .  Read the full report to understand the long-term care (LTC) insurance marketplace from the consumer’s point of view.”

LTC Comment:  This is the latest version of LifePlans’ periodic report on “Who Buys Long-Term Care Insurance?  Twenty-Five Years of Study of Buyers and Non-Buyers in 20152016.”  We’ll review and comment on its key findings in an LTC Bullet soon.

UI on LTCI 0816 URL

8/18/2016, “Who Owns Long-Term Care Insurance?,” by Howard Gleckman, Forbes 

Quote:  “Overall, the share of older adults who own long-term care insurance (LTCi) has barely changed since 2002, according to new research by my Urban Institute colleague Rich Johnson. In 2002, about 10 percent of those 65 and older had coverage. By 2008 that share had ticked up to 12 percent, but in 2014, it dropped back to 11 percent. Among those aged 55-60, the share of policyholders slipped from 7 percent in 2002 and 2008 to just 5 percent in 2014.”

LTC Comment:  Interesting numbers, but this author and his source remain clueless about the cause.  No mention of the real reasons why LTCI has lagged, i.e. Medicaid crowd out of demand and Federal Reserve interest-rate crowd out of profits.


Chapter 10:  Medicaid

Medicaid Financing and Burwell Data

Burwell on LTC 2014:   “Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2014: Managed LTSS Reached 15 Percent of LTSS Spending,” April 15, 2016; 
This is the best data available.

Dual Eligibles

MedPAC Data Book on Duals 0117 URL

“Beneficiaries Dually Eligible for Medicare and Medicaid,” a data book jointly produced by the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission, January 2017.