LTC Bullet: LTC Almanac Update

Friday, September 6, 2019


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.***

*** SUBSCRIBE to LTC Clippings and Steve Moses—2019 ILTCI Recognition Award Honoree—will become your research assistant. Steve will tip you twice a day (on average) with news and views on things you need to know to stay at the forefront of professional expertise. You’ll see the latest articles, reports, data, and op-eds before your clients confront you with them. You’ll get trenchant analysis and valuable ideas on how to address objections and complaints. Contact Damon at 206-283-7036 or for details or subscribe directly here: Choose “Premium Membership” to receive our LTC Clippings. For example, here are some recent LTC Clippings

8/27/2019, “The elderly aren’t so poor after all,” by Robert J. Samuelson, Washington Post
Quote: “It was probably inevitable that we would have a ‘retirement crisis’ as hordes of baby boomers (people born between 1946 and 1964) sprint and stumble into their ‘golden years.’ But it’s a fake crisis, even though it’s already becoming a staple of journalism and politics. It presumes that most Americans can’t afford to retire comfortably. Not so.”
LTC Comment: Read this and wonder why we still provide Medicaid long-term care to people with big incomes and unlimited assets.  

8/29/2019, “Alzheimer’s care isn’t working; here’s what is,” by Pamela Reese, McKnight’s Senior Living
Quote: “If you don’t work in memory care, then take it from me, a former nurse, chief officer of clinical operations and partner within the skilled nursing industry: The current state of Alzheimer’s care is a rosy portrayal of a diminishing standard. It is the unfortunate truth. … Despite having the power to make constructive change in the field, when it came time to care for my own mother, who received an Alzheimer’s diagnosis, I did not want her living in one of my own facilities. Why, you may ask? There are several reasons that I don’t believe Alzheimer’s care is where it should be. Here are six:”
LTC Comment: Click through to read this sad commentary on the state of Alzheimer’s care.  

8/27/2019, “'Medicare Advantage for All’,” by Ken Janda and Vivian Ho, The Hill
Quote: “We are already on our way to Medicare Advantage for All, but we are not doing it systematically or thoughtfully. A move to Medicare Advantage for All is achievable in a relatively short time frame, without the disruption and risk of Medicare for All, or without the confusion of even more options and funding mechanisms. The majority of Americans who have employer-sponsored insurance would still have it. And Medicaid becomes mainstream.”
LTC Comment: Medicaid becomes mainstream? No thanks. ***



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, September 20, 2019. 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 ***

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.

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.


Chapter 1: Aging Demographics

United States

General Stats

2018OlderAmericansProfile 0519 URL:

5/31/2019, “2018 Profile of Older Americans,” Administration for Community Living

Quote: “In the United States, the population age 65 and over numbered 50.9 million in 2017 (the most recent year for which data are available). They represented 15.6% of the population, more than one in every seven Americans. The number of older Americans increased by 13 million or 34% since 2007, compared to an increase of 4% for the under-65 population.”

LTC Comment: This annual report is the best statistical snapshot you’ll find of aging in America.


Chapter 6: Long-Term Care Financing 

Nursing Home and Home Care Expenditure Data from CMS and Health Affairs

NHE Projections 2018-27 Health Affairs 0219 URL:

2/20/2019, “National Health Expenditure Projections, 2018–27: Economic And Demographic Trends Drive Spending And Enrollment Growth,” by Andrea M. Sisko, et al., Health Affairs
Quote: “ABSTRACT: National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018–27 and represent 19.4 percent of gross domestic product in 2027. Following a ten-year period largely influenced by the Great Recession and major health reform, national health spending growth during 2018–27 is expected to be driven primarily by long-observed demographic and economic factors fundamental to the health sector. Prices for health care goods and services are projected to grow 2.5 percent per year, on average, for 2018–27—faster than the average price growth experienced over the last decade—and to account for nearly half of projected personal health care spending growth. Among the major payers, average annual spending growth in Medicare (7.4 percent) is expected to exceed that in Medicaid (5.5 percent) and private health insurance (4.8 percent) over the projection period, mostly as a result of comparatively higher projected enrollment growth. The insured share of the population is expected to remain stable at around 90 percent throughout the period, as net gains in health coverage from all sources are projected to keep pace with population growth.”
LTC Comment:
The Age Wave cometh.


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

Forgotten Middle 0419 URL:

Pearson, Caroline F., Charlene C. Quinn, Sai Loganathan, A. Rupa Datta, Beth Burnham Mace, and David C. Grabowski. 2019. The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources For Housing And Health Care. Health Affairs. 38 (5)

“ABSTRACT As people age and require more assistance with daily living and health needs, a range of housing and care options is available. Over the past four decades the market for seniors housing and care—including assisted living and independent living communities—has greatly expanded to accommodate people with more complex needs. These settings provide housing in a community environment that often includes personal care assistance services. Unfortunately, these settings are often out of the financial reach of many of this country’s eight million middle-income seniors (those ages seventy-five and older). The private seniors housing industry has generally focused on higher-income people instead. We project that by 2029 there will be 14.4 million middle-income seniors, 60 percent of whom will have mobility limitations and 20 percent of whom will have high health care and functional needs. While many of these seniors will likely need the level of care provided in seniors housing, we project that 54 percent of seniors will not have sufficient financial resources to pay for it. This gap suggests a role for public policy and the private sector in meeting future long-term care and housing needs for middle-income seniors.” (p. 1)

Critiqued in LTC Bullet: Remember the Middle:


LTC Costs and Risk

Johnson on Paid Home Care in Health Affairs 0619 URL:

Johnson, Richard W. and Claire Xiaozhi Wang. 2019. “The Financial Burden Of Paid Home Care On Older Adults: Oldest And Sickest Are Least Likely To Have Enough Income.” Health Affairs. 38 (6)  

6/2019, “Community Care For High-Need Patients,” by Alan R. Weil, Health Affairs
Quote: “Almost everyone wants to live in their own home and community as they age. Yet for many, later age brings frailty and the accumulation of chronic conditions. This month’s issue of Health Affairs examines how we can best provide care in the community for people with advanced illness.”
LTC Comment: The June issue of Health Affairs focuses on problems with home health care for the aging, including caregiver shortages and financing. This month’s issue has several “open access” articles of interest that you can read without paying for a subscription. Check them out, but be skeptical. As usual, Health Affairs predilection is to lament the LTC service delivery and financing systems’ shortcomings without analyzing their cause and to recommend more government spending to address them, ironically doubling down on the unexamined cause of the shortcomings itself.


Johnson on Lifetime Risk 0419 URL:

Johnson, Richard W. 2019. “What Is the Lifetime Risk of Needing and Receiving Long-Term Services and Supports?” Research Brief. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Washington, D.C. (April)

“Medicaid covers LTSS costs for people with limited income and assets, but many people incur substantial out-of-pocket costs until they deplete their financial resources and qualify for benefits (Wiener et al. 2013). Medicaid covers many nursing homes residents (Spillman and Waidmann 2015), but very few recipients of residential care or home care (National Center for Health Statistics 2016). Relatively few home care recipients receive Medicaid benefits because there are long waiting lists for Medicaid home and community-based services (HCBS), especially in such states as Texas, Florida, Ohio, and Louisiana (Ng et al. 2015; Peterson et al. 2014). Moreover, the Medicaid income allowances for HCBS enrollees are often too low to cover reasonable living expenses (Johnson and Lindner 2016). Inadequate reimbursement rates may also make residential care communities reluctant to admit Medicaid beneficiaries (O’Keeffe, O’Keeffe, and Bernard 2003).” 

LTC Comment: Good source for the latest on LTC risk.


Chapter 9: Long-Term Care Providers


NCHS Provider Data 2015-16 URL:

Lauren Harris-Kojetin, Ph.D., Manisha Sengupta, Ph.D., Jessica Penn Lendon, Ph.D., Vincent Rome, M.P.H., Roberto Valverde, M.P.H., and Christine Caffrey, Ph.D., Long-term Care Providers and Services Users in the United States, 2015–2016 Analytical and Epidemiological Studies.

For more about this excellent resource, see 032019 LTC Bullet #1249--Treasure Trove of LTC Provider and User Data and excerpt from which follows:

LTC Comment: Ever wonder exactly how many people are receiving what kind of long-term care in which venues? We refer you today to Long-term Care Providers and Services Users in the United States, 2015–2016 by Lauren Harris-Kojetin, Ph.D., Manisha Sengupta, Ph.D., Jessica Penn Lendon, Ph.D., Vincent Rome, M.P.H., Roberto Valverde, M.P.H., and Christine Caffrey, Ph.D.
According to its Abstract: “This report presents the most current national results from the National Study of Long-Term Care Providers (NSLTCP) conducted by the National Center for Health Statistics (NCHS) to describe providers and services users in five major sectors of paid, regulated long-term care services in the United States.”
We’ll share some highlights followed by our comments below, but if you would like to see how two of its authors summarized the report’s findings, with charts and tables, check out this slide deck from a presentation by Harris-Kojetin and Lendon to the LTC Discussion Group on February 21, 2019.


Chapter 10: Medicaid

Medicaid Financing and Burwell Data

Burwell on 2016 Medicaid Expenditures 0518 URL:

Eiken, Steve, Kate Sredl, Brian Burwell, and Angie Amos. 2018. “Medicaid Expenditures for Long-Term Services and Supports in FY 2016.” May. Official report from the Centers for Medicare & Medicaid Services, prepared by IBM Watson Health.

“The percentage of LTSS expenditures for HCBS continued to vary across population groups. HCBS accounted for 78 percent of spending in programs primarily supporting people with developmental disabilities, compared to 46 percent for behavioral health services provided to people with mental health and substance use disorders and 45 percent for programs primarily supporting older adults and people with physical disabilities.” (pps. i-ii)

This is your go-to source for data on Medicaid expenditures for institutional and HCBS. We regret to report the passing of Steve Eiken, the lead researcher on this annual resource. He was an always eager and helpful source.


Medicaid Eligibility

KFF on Medicaid LTC Elig 0619 URL:

Musumeci, MaryBeth, Priya Chidambaram and Molly O’Malley Watts. 2019. Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey. Kaiser Family Foundation. June 14

LTC Comment: Latest and best source for Medicaid LTC eligibility variations by state. Dip in for a good sense of the mind-bending complexity of the subject.


Johnson on HCBS Income Limits 0517 URL

Richard W. Johnson and Stephan Lindner. 2017. The Adequacy of Income Allowances for Medicaid Home and Community-Based Services. Urban Institute. May.

“Medicaid has always covered nursing home care for people with disabilities and few financial resources who are unable to live independently. Over the past decade, Medicaid spending on home and community-based services (HCBS) for people with disabilities living outside nursing homes has increased sharply, spurred partly by the US Supreme Court’s 1999 Olmstead decision that requires states to provide alternatives to institutional care when they are appropriate and can be reasonably accommodated.1 However, the rebalancing of Medicaid expenditures on long-term services and supports (LTSS) away from institutions toward HCBS has been much slower for older adults—those ages 65 and older—than for younger people with disabilities. Medicaid’s financial eligibility rules for HCBS help explain why Medicaid’s institutional bias in the provision of LTSS has persisted for older Americans after having been largely overcome for younger people with disabilities.” (p. 1)

LTC Comment: This article explains why rebalancing from nursing homes to home care had occurred more and faster for younger people with disabilities than for the elderly.


ASPE (Thach and Wiener) on LTSS and Medicaid 0518:

Thach, Nga T., and Joshua M. Wiener. 2018. “An Overview of Long-Term Services and Supports and Medicaid Final Report.” Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Washington, D.C. (May)

You will not find a better description and explanation of Medicaid’s role in long-term care than this one. Alas it is one of the last works to come from Josh Wiener, an icon in the field of long-term care research, who sadly passed away January 9, 2018.