Reimagining Financing and Payment of Long-Term Care

Abstract

The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk.

Trends in Gender and Racial/Ethnic Disparities in Physical Disability and Social Support Among U.S. Older Adults with Cognitive Impairment Living Alone, 2000–2018

“…According to a caregiving report in the US, caregivers of ethnic minorities report higher average hours of care to their older recipients than White caregivers and are more likely to provide 21 or more hours of care weekly 34 . Extensive costs for long-term care have been a challenge to those in need to access to formal care 35 . Medicaid programs in many states have expanded home care and shifted funds toward home and community-based services in recent decades could also facilitate some Ethnic minorities to benefit from the above expansion.…”

Trends in Gender and Racial/Ethnic Disparities in Physical Disability and Social Support Among U.S. Older Adults With Cognitive Impairment Living Alone, 2000–2018

“…According to a caregiving report in the United States, caregivers of ethnic minorities report providing more hours of care, on average, to their older recipients than White caregivers and are more likely to provide 21 or more hours of care weekly ( 34 ). Extensive costs for long-term care have been a challenge to those in need to access to formal care ( 35 ). Medicaid programs in many states have expanded home care and shifted funds toward home- and community-based services in recent decades, which could also facilitate some ethnic minorities to benefit from this expansion.…”

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long‐Stay Nursing Facility Residents: Lessons Learned

“…Seminal research on Medicaid and nursing home quality found that nursing homes serving a high proportion of residents covered by Medicaid have lower staffing and poorer quality, which suggests that Medicare payments are used by nursing homes to subsidize the care of Medicaid residents 29 . Private pay residents likely do the same as the average Medicaid payment is only 70% of the average private pay rate 30 . Though the Initiative included private pay residents, who in 2014 made up about 17% of all nursing home residents, 31 their effect on the results was not ascertained.…”

“…29 Private pay residents likely do the same as the average Medicaid payment is only 70% of the average private pay rate. 30 Though the Initiative included private pay residents, who in 2014 made up about 17% of all nursing home residents, 31 their effect on the results was not ascertained. However, it is possible that participating nursing homes with higher proportions of private pay residents had better clinical infrastructure.…”