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Can’t the Government Pay For This?

April 23, 2018 by Honey Leveen Leave a Comment

There is a growing trend in the United States. More and more Americans now want the government pay for programs that meet our daily needs. Does this surprise you? It sure isn’t what I expected to find.

For years, the rallying cry has been for smaller government. In fact, this recent shift marks the first time in 8 years that a majority of Americans now favor an increase in government participation. A report from the Pew Research Center found that most Americans think the government is doing too little to help young people, the elderly, the middle class and the poor.

This new trend was also reported by William A. Galston’s article (WSJ, “Americans Want Big Government“):

“In the NBC/Wall Street Journal poll last month, 58% of Americans—the highest share ever recorded—agreed that ‘government should do more to solve problems and help meet the needs of people,’ compared to only 38% who thought that ‘government is doing too many things better left to businesses and individuals.”

Galston also cited a Kaiser survey that reports an interest in increased spending on defense and education.

As early as 2017, a separate Pew survey found broad support across both Republicans and Democrats for increased spending on veterans’ benefits, infrastructure, scientific research, environmental protection and assistance to the needy.

Can the Government Pay for Programs?

Not this government. Not today. “The federal deficit is big and getting bigger… Its balance sheet reveals that the public debt will reach $15.7 trillion by October.” And these numbers don’t include “unfunded liabilities, reported by the Social Security and Medicare Trustees, that are four times the current public debt.” (John F. Cogan, WSJ, “Why America is Going Broke.“)

So, if you’re counting on Medicaid…

I’ve written a number of articles urging you to become more self-reliant when planning for your future. Our nation’s financial uncertainty does not have to limit your access to quality care. You just need to do a little planning today.

The first step is to click here to receive your personal quote for Long Term Care Insurance.

So What if the Government Pays for Most LTC?

December 7, 2016 by Honey Leave a Comment

The following is re-published courtesy of friend and highly respected colleague Stephen Moses, President of The Center for Long-Term Care Reform. Steve explains in a nutshell, why Americans are not more motivated to plan for paying for their own long-term care (LTC).

Tuesday, December 6, 2016

Seattle–

LTC Comment: Heads up! We’re about to explain why long-term care insurance sales have disappointed, why people don’t “use their homes to stay at home” and why LTC providers who depend on public financing are at risk.
LTC BULLET: SO WHAT IF THE GOVERNMENT PAYS FOR MOST LTC?, 2015 DATA UPDATE

LTC Comment: Once a year around this time the Centers for Medicare and Medicaid Services (CMS) report health care expenditure data for the latest year of record. Recently, CMS posted 2015 statistics on its website at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Tables.zip.

Health Affairs has published a summary and analysis of the new data titled “National Health Spending: Faster Growth In 2015 as Coverage Expands and Utilization Increases.” Registered subscribers to Health Affairs can access the full text of that article here; the “Abstract” is available free.

Following is our annual analysis of the latest nursing home and home health care data.*

Heads Up: This may be the most important LTC Bullet we publish all year. It is the fourteenth in a row we’ve done annually analyzing the federal government’s enormous, and we argue, often detrimental, impact on long-term care financing. If you’d like to see the earlier versions, go here and search for “So What if the Government Pays for Most LTC.” You’ll find our yearly analyses of the data going back to “So What If the Government Pays for Most LTC, 2002 Data Update.”

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“So What If the Government Pays for Most LTC?, 2015 Data Update”
by
Stephen A. Moses

Ever wonder why LTC insurance sales and market penetration are so discouraging? Or why reverse mortgages are rarely used to pay for long-term care? Or why LTC service providers are always struggling to survive financially and still provide quality care? Read on.

Nursing Homes

America spent $156.8 billion on nursing facilities and continuing care retirement communities in 2015. The percentage of these costs paid by Medicaid and Medicare has gone up over the past 45 years (from 26.8% in 1970 to 55.7% in 2015, up 28.9 % of the total) while out-of-pocket costs have declined (from 49.2% in 1970 to 25.6% in 2015, down 23.6% of the total). Source: Table 15: Nursing Care Facilities and Continuing Care Retirement Communities Expenditures; Levels, Percent Change, and Percent Distribution, by Source of Funds: Selected Calendar Years 1970-2015.

So What? Consumers’ liability for nursing home and CCRC costs has declined by nearly half, down 48.0% in the past four decades while the share paid by Medicaid and Medicare has more than doubled, up 107.8%.

No wonder people are not as eager to buy LTC insurance as they would be if they were more at risk for the cost of their care! No wonder they don’t use home equity for LTC when Medicaid exempts at least $552,000 and in some states up to $828,000 of home equity (as of 1/1/17). No wonder nursing homes are struggling financially–their dependency on parsimonious government reimbursements is increasing while their more profitable private payers are disappearing.

Unfortunately, these problems are even worse than the preceding data suggest. Over half of the so-called “out-of-pocket” costs reported by CMS are really just contributions toward their cost of care by people already covered by Medicaid! These are not out-of-pocket costs in terms of ASSET spend down, but rather only INCOME, most of which comes from Social Security benefits, another financially struggling government program. Thus, although Medicaid pays less than one-third of the cost of nursing home care (31.7% of the dollars in 2015), it covers nearly two-thirds (63%) of all nursing home residents. Because people in nursing homes on Medicaid tend to be long-stayers, Medicaid pays something toward nearly 80 percent of all patient days.

So What? Medicaid pays in full or subsidizes almost four-fifths of all nursing home patient days. Even if Medicaid pays nothing with the entire amount due contributed from the recipient’s income, the nursing home receives Medicaid’s dismally low reimbursement rate.

No wonder the public is not as worried about nursing home costs as they would be if they were more at risk for the cost of their care. No wonder nursing homes risk insolvency when so much of their revenue comes from Medicaid, often at reimbursement rates less than the cost of providing the care. The 2015 national projected shortfall in Medicaid reimbursement is $22.46 per patient day and over $7 billion in total. Source: 2015 Report on Shortfalls in Medicaid Funding for Nursing Center Care.

Private Health Insurance

Don’t be fooled by the 8.6% of nursing home costs that CMS reports as having been paid by “private health insurance” in 2015. That category does not include private long-term care insurance. (See category definitions here.) No one knows how much LTC insurance pays toward nursing home care, because many LTCI policies pay beneficiaries who then pay the nursing homes. Thus, a large proportion of insurance payments for nursing home care gets reported as if it were “out-of-pocket” payments. This fact further inflates the out-of-pocket figure artificially.

Assisted Living

How does all this affect assisted living facilities? ALFs are 81% private pay (Source: AHCA/NCAL Issue Brief) and they cost an average of $43,200 per year (Source: Genworth 2015 Cost of Care Survey). Many people who could afford assisted living by spending down their illiquid wealth, especially home equity, choose instead to take advantage of Medicaid nursing home benefits. Medicaid exempts one home and all contiguous property (up to $552,000 or $828,000 depending on the state), plus—in unlimited amounts—one business, one automobile, prepaid burials, term life insurance, personal belongings and Individual Retirement Accounts not to mention wealth protected by sophisticated asset sheltering and divestment techniques marketed by Medicaid planning attorneys. Income rarely interferes with Medicaid nursing home eligibility unless such income exceeds the cost of private nursing home care.

So What? For most people, Medicaid nursing home benefits are easy to obtain without spending down assets significantly and Medicaid’s income contribution requirement is usually much less expensive than paying the full cost of assisted living.

No wonder ALFs are struggling to attract enough private payers to be profitable. No wonder people are not as eager to buy LTC insurance as they would be if they were more at risk for the cost of their care. This problem has been radically exacerbated in recent years because more and more state Medicaid programs are paying for assisted living as well as nursing home care, which makes Medicaid eligibility more desirable than ever.

Home Health Care

The situation with home health care financing is very similar to nursing home financing. According to CMS, America spent $88.8 billion on home health care in 2015. Medicare (39.6%) and Medicaid (36.1%) paid 75.7% of this total and private insurance paid 10.6%. Only 9.9% of home health care costs were paid out of pocket. The remainder came from several small public and private financing sources. Data source: Table 14: Home Health Care Services Expenditures; Levels, Percent Change, and Percent Distribution, by Source of Funds: Selected Calendar Years 1970-2015.

So What? Only one out of every ten dollars spent on home health care comes out of the pockets of patients and a large portion of that comes from the income (not assets) of people already on Medicaid.

No wonder the public does not feel the sense of urgency about this risk that they would if they were more at risk for the cost of their care.

Bottom line, people only buy insurance against real financial risk. As long as they can ignore the risk, avoid the premiums, and get government to pay for their long-term care when and if such care is needed, they will remain in denial about the need for LTC insurance. As long as Medicaid and Medicare are paying for a huge proportion of all nursing home and home health care costs while out-of-pocket expenditures remain only nominal, nursing homes and home health agencies will remain starved for financial oxygen.

The solution is simple. Target Medicaid financing of long-term care to the needy and use the savings to fund education and tax incentives to encourage the public to plan early to be able to pay privately for long-term care. For ideas and recommendations on how to implement this solution, see www.centerltc.com.

The Government Doesn’t Pay For Long-Term Care!

September 17, 2012 by Honey Leave a Comment

I can’t say it any better than William Gaston in the fall edition of Democracy: A Journal of Ideas (818 18th Street, NW Suite 750 Washington, DC 20006): “Medicaid already constitutes the single largest share of state budgets—24 percent, a figure that rises relentlessly year by year. State spending on the program rose by 20 percent in the most recent reporting year and by even more—23 percent—in the previous year. By the end of fiscal year 2013, total Medicaid enrollment for low-income Americans and the dependent elderly will have risen by 12.5 percent in just three years.”

“Because state revenues are growing much more slowly than Medicaid outlays, other priorities are getting squeezed. In many states, for example, public higher education—key not only to future prosperity and competitiveness but also to opportunity and mobility—is reaching a breaking point.”

“I had no idea how long-term care was financed. I soon learned that Medicare paid for at most 100 days of rehabilitation (useless in my mother’s case) and that Medicaid required beneficiaries to “spend down” nearly all their assets. Private long-term care insurance policies were available, I learned, but my parents—along with most Americans who can afford them—had not purchased one.”

Please take heed and plan responsibly, ahead of time, for a possible long-term care need.

Government Shift to Care at Home

May 10, 2012 by Honey Leave a Comment

In “A Shift From Nursing Homes To Managed Care at Home” (New York Times, February 24, 2012) Joseph Berger notes that shrinking Medicaid and Medicare funds are forcing closure of more and more nursing homes – 350 nursing home have closed over the past six years nationally. For example, New York State plans to transfer 70,000 to 80,000 people needing over 120 days of Medicare-covered long-term care (LTC) to their homes. Studies suggest that care at home can cost less than in a nursing home, so such a policy may stretch scarce Medicaid funds a little further.

Shifting Medicaid funding from nursing homes to in-home care sounds great. Caregivers really like this idea. The whole notion of avoiding nursing home stays is very appealing.

Many policymakers cling to the notion that such a shift will save money, but this is far from the truth.

I quote the following from Steve Moses of the Center for Long-Term Care Reform:

When compared to an elderly population for whom traditionally available care is offered, recipients of expanded community-based services do not use significantly fewer days of nursing home care.[1]

An increasingly large number of studies, including the results of a national channeling demonstration program, have shown that non-institutional services typically do not substitute for nursing home care, but, rather, represent additional services most often to new populations.[2]

Although community-based LTC programs proved beneficial to both clients and informal caregivers in the LTC demonstrations, they did not prove budget neutral or cost effective.[3]

For Medicaid to afford quality home health care for all recipients it must have fewer recipients. By tightening eligibility, closing eligibility loopholes, preventing Medicaid planning, and enforcing estate recovery, the program can do a better job for fewer genuinely needy eligibles. When middle class and affluent people understand their savings and home equity are at risk for LTC, they will avoid Medicaid dependency by paying privately from savings, home equity conversion and private insurance.

Here are the footnotes:

[1] General Accounting Office, “The Elderly Should Benefit From Expanded Home Health Care But Increasing Those Services Will Not Insure Cost Reductions” (Dec. 7, 1982) p. 43, http://archive.gao.gov/f0102/120074.pdf.
[2] John F. Holahan and Joel W. Cohen, Medicaid: The Trade-off between Cost Containment and Access to Care, (Washington DC: The Urban Institute Press, 1986), p. 106.
[3] Kenneth G. Manton, “The Dynamics of Population Aging: Demography and Policy Analysis,” The Milbank Quarterly, vol. 69, no. 2, 1991, p. 322.

So What If the Government Pays for Most LTC?

January 14, 2012 by Honey 1 Comment

Thanks to my good friend and colleague Steve Moses, of the Center for Long-Term Care Reform for the following guest column. I am re-publishing his blog because it gives unusual insight and makes complicated information easy to understand.

“So What If the Government Pays for Most LTC?, 2010 Data Update”
by
Stephen A. Moses

America spent $143.1 billion on nursing facilities and Continuing Care Retirement Communities in 2010. The percentage of these costs paid by Medicaid and Medicare has gone up over the past 40 years (from 26.8% in 1970 to 53.8% in 2010, up 27.0 % of the total) while out-of-pocket costs have declined (from 49.5% in 1970 to 28.3% in 2010, down 21.2% of the total). Source: http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf, Table 12.

SO WHAT? Consumers’ liability for nursing home and CCRC costs has declined by 43% in the past four decades, while the share paid by Medicaid and Medicare has more than doubled.

No wonder people are not as eager to buy LTC insurance as insurers would like them to be! No wonder they don’t use home equity for LTC when Medicaid exempts most home equity. No wonder nursing homes are struggling financially–their dependency on parsimonious government reimbursements is increasing while their more profitable private payers are disappearing.

Unfortunately, these problems are even worse than the preceding data suggest. Over half of the so-called “out-of-pocket” costs reported by CMS are really just contributions toward their cost of care by people already covered by Medicaid! These are not out-of-pocket costs in terms of ASSET spend down, but rather only INCOME, most of which comes from Social Security benefits, another government program. Thus, although Medicaid pays less than one-third the cost of nursing home care (31.5% of the dollars in 2010), it covers two-thirds of all nursing home residents. Because people in nursing homes on Medicaid tend to be long-stayers, Medicaid pays something toward nearly 80 percent of all patient days.

SO WHAT? Medicaid pays in full or subsidizes almost four-fifths of all nursing home patient days. If it pays even one dollar per month (with the rest contributed from the recipient’s income), the nursing home receives Medicaid’s dismally low reimbursement rate.

No wonder the public is not as worried about nursing home costs as LTC insurers think they should be. No wonder nursing homes are facing insolvency all around the United States when so much of their revenue comes from Medicaid, often at reimbursement rates less than the cost of providing the care.

Don’t be fooled by the 8.9% of nursing home costs that CMS reports as having been paid by “private health insurance” in 2010. That category does not include private long-term care insurance. (See category definitions here.) No one knows how much LTC insurance pays toward nursing home care, because most LTCI policies pay beneficiaries, not nursing homes. Thus, a large proportion of insurance payments for nursing home care gets reported as if it were “out-of-pocket” payments because private payers write the checks to the nursing home but are reimbursed by their LTC insurance policies. This fact further inflates the out-of-pocket figure artificially.

How does all this affect assisted living facilities? ALFs are 90% private pay and they cost an average of $41,724 per year (Source: 2011 MetLife survey at http://www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-market-survey-nursing-home-assisted-living-adult-day-services-costs.pdf). Many people who could afford assisted living by spending down their illiquid wealth, especially home equity, choose instead to take advantage of Medicaid nursing home benefits. Medicaid exempts one home and all contiguous property (up to $525,000 or $786,000 depending on the state), plus one business, and one automobile of unlimited value, plus many other non-countable assets, not to mention sophisticated asset sheltering and divestment techniques marketed by Medicaid planning attorneys. Income rarely interferes with Medicaid nursing home eligibility unless such income exceeds the cost of private nursing home care.

SO WHAT? For most people, Medicaid nursing home benefits are easy to obtain without spending down assets significantly and Medicaid’s income contribution requirement is usually much less expensive than paying the full cost of assisted living.

No wonder ALFs are struggling to attract enough private payers to be profitable. No wonder people are not as eager to buy LTC insurance as insurers would like them to be.

The situation with home health care financing is very similar to nursing home financing. According to CMS, America spent $70.2 billion on home health care in 2010. Medicare (44.9%) and Medicaid (37.3%) paid 82.2% of this total and private insurance paid 6.4%. Only 7.1% of home health care costs were paid out of pocket. The remainder came from several small public and private financing sources. Data source: http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf, Table 4.

SO WHAT? Only one out of every 14 dollars spent on home health care comes out of the pockets of patients and a large portion of that comes from the income (not assets) of people already on Medicaid.

No wonder the public does not feel the sense of urgency about this risk that long-term care insurers think they should.

Bottom line, people only buy insurance against real financial risk. As long as they can ignore the risk, avoid the premiums, and get government to pay for their long-term care when and if such care is needed, they will remain in “denial” about the need for LTC insurance. As long as Medicaid and Medicare are paying for a huge proportion of all nursing home and home health care costs while out-of-pocket expenditures remain only nominal, nursing homes and home health agencies will remain starved for financial oxygen.

Note especially:

“Medi-Cal Long-Term Care: Safety Net or Hammock?” at https://www.pacificresearch.org/medi-cal-long-term-care-safety-net-or-hammock/;

“Doing LTC RIght” at http://www.centerltc.com/pubs/Doing_LTC_RIght.pdf;

“The LTC Graduate Seminar Transcript” at http://www.centerltc.com/members/LTCGradSemTranscription.pdf (requires password, contact smoses@centerltc.com);

“Aging America’s Achilles’ Heel: Medicaid Long-Term Care” at http://www.centerltc.com/AgingAmericasAchillesHeel.pdf; and

“The Realist’s Guide to Medicaid and Long-Term Care” at http://www.centerltc.org/realistsguide.pdf.

In the Deficit Reduction Act of 2005, Congress took some small steps toward addressing these problems. A cap was placed on Medicaid’s home equity exemption and several of the more egregious Medicaid planning abuses were ended. But much more remains to be done. With the Age Wave starting to crest and threatening to crash over the next two decades, we can only hope it isn’t too late already.

Stephen A. Moses is president of the Center for Long-Term Care Reform in Seattle, Washington. The Center’s mission is to ensure quality long-term care for all Americans. Steve Moses writes, speaks and consults throughout the United States on long-term care policy. He is the author of the study “Aging America’s Achilles’ Heel: Medicaid Long-Term Care,” published by the Cato Institute (www.cato.org). Learn more at www.centerltc.com or email smoses@centerltc.com.

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