
READ STEVE'S BIO.JPG)
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Updated, Friday, September 22, 2023,
10:40 AM (Pacific)
Seattle—
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LTC BULLET:
LONG-TERM CARE RACISM: DIAGNOSIS, TREATMENT, AND CURE
LTC Comment: Once you understand its cause and
effects, LTC racism’s cure becomes manageable. Analysis after the
***news.***
*** “LONG-TERM CARE: THE SOLUTION,”
Paragon Health Institute’s long-awaited sequel to “Long-Term
Care: The Problem,” published last fall, is due to be published on
October 2. “The Solution” explains why the challenge of financing LTC for
burgeoning numbers of aging Americans remains unmet and proposes a
solution. As Medicaid caused most of LTC’s problems, that program’s
radical reform is the key to resolving them. The same Medicaid reform is
also the crucial step required to eliminate systemic LTC racism. Stay
tuned. ***
LTC BULLET: LONG-TERM CARE RACISM: DIAGNOSIS,
TREATMENT, AND CURE
LTC Comment: Our
previous LTC Bullet offered a selection of quotes about LTC
racism from peer-reviewed journal articles and invited readers to reflect
on the material and its meaning before turning to analysis and
recommendations. Let’s go now to that next step.
What is LTC racism?
“Structural [LTC] racism
operates through laws and policies that allocate resources in ways that
disempower and devalue members of racial and ethnic minority groups,
resulting in inequitable access to high-quality care.” (“Structural
Racism In Historical And Modern US Health Care Policy,” 2022,
Abstract)
What are some examples
of LTC racism?
“The long-term services and supports (LTSS) sector is
a microcosm of systemic racism that exists in our society. Nationally,
half of frontline professional caregivers are nonwhite, while mid- and
executive-level managers and board members are predominately white.” (“The
Value Proposition for Diversity: Creating A Pipeline of Diversity in The
LTSS Sector,” 2022, Abstract)
“Long-term services and supports (LTSS), including
care received at home and in residential settings such as nursing homes,
are highly racially segregated; Black, Indigenous, and persons of color (BIPOC)
users have less access to quality care and report poorer quality
of life compared to their White counterparts. Systemic racism lies at
the root of these disparities,
manifesting via racially segregated care, low Medicaid reimbursement, and
lack of livable wages for staff, along with other policies and processes
that exacerbate disparities.” (“Evidence
for Action: Addressing Systemic Racism Across Long-Term Services and
Supports,” 2022, p. 1)
“Findings revealed that black residents are more
likely than white residents to be restrained with bed rails, side rails,
and trunk restraints. Findings suggest that racial disparities exist in
the use of physical restraints. Implications for practice, policy, and
research are discussed.” (“Racial
disparities in the use of physical restraints in U.S. nursing homes,”
2013, Abstract)
“Racial disparities in nursing homes have been
reported for a number of outcomes, including pressure ulcers, influenza vaccination rates, pain
management, hospice use and in-hospital death. (16–19, 22) Our findings confirm that compared
to Whites, Black residents experience more aggressive EOL[End of Life] care with higher
rates of in-hospital deaths and lower rates of hospice use.” (“Racial
Disparities in In-Hospital Death and Hospice Use Among Nursing Home
Residents at the End-of-life,” 2012, p. 6)
What causes LTC racism?
“Nursing home care is currently a two-tiered system.
The lower tier consists of facilities housing mainly Medicaid residents
and, as a result, has very limited resources. The nearly 15 percent of
U.S. nonhospital-based nursing homes that serve predominantly Medicaid
residents have fewer nurses, lower occupancy rates, and more
health-related deficiencies. They are more likely to be terminated from
the Medicaid/Medicare program, are disproportionately located in the
poorest counties, and are more likely to serve African-American residents
than are other facilities. The public reporting of quality indicators,
intended to improve quality through market mechanisms, may result in
driving poor homes out of business and will disproportionately affect
nonwhite residents living in poor communities. This article recommends a
proactive policy stance to mitigate these consequences of quality
competition.” (“Driven
to Tiers: Socioeconomic and Racial Disparities in the Quality of Nursing
Home Care,” 2004, Abstract)
“A tiered system of nursing home care that
concentrates blacks in marginal-quality nursing homes also appears to
exist.” (p. 1449) “We found that nursing home care was relatively
segregated in 2000, with two thirds of all black residents living in just
10 percent of all facilities.” (p. 1453) “Disparities in payment between
Medicaid and private payers make the financial viability of a nursing home
dependent on the proportion of private-pay patients it is able to attract.
Homes unable to attract sufficient private-pay patients will tend to have
lower nurse staffing levels and more-serious inspection deficiencies.” (p,
1456) “Nursing home operators might also try to control admissions to
their facilities, limiting the number of first-day-eligible Medicaid
admissions and expanding as much as possible admissions of those with
sufficient resources that are unlikely to spend down and become eligible
for Medicaid.” (p. 1456) “It [discrimination] might also play a role in
shaping the decisions of white private-pay nursing home patients and their
families about where to get care, including whether to opt for non–nursing
home alternatives altogether.” (p. 1456) (“Separate
And Unequal: Racial Segregation And Disparities In Quality Across U.S.
Nursing Homes,” 2007)
LTC racism: Diagnosis
The definition above attributes structural LTC racism
to the “laws and policies that allocate resources in ways that disempower
and devalue members of racial and ethnic minority groups, resulting in
inequitable access to high-quality care.” What are those laws and
policies? They are the statutes, regulations, policies, procedures, and
guidelines that cause long-term care’s two-tiered structure: one top
quality tier for private payers and a lower tier for Medicaid dependents.
Specifically, Medicaid LTC financial eligibility
rules sort people who need extended care into two groups. Those who have
too much income and resources are expected to spend down in the private
market. Those who have liquid wealth low enough to qualify become Medicaid
recipients with all that entails for the access and quality of care they
can expect. This is cause number one of LTC racism. People with wealth,
privileged majorities, enjoy the better LTC tier, while underprivileged
marginalized groups rely predominantly on Medicaid, in the lower tier.
But the reality is actually much worse than this
simple sorting of people by wealth suggests. Medicaid financial
eligibility rules allow people with substantial income and assets to
qualify for LTC benefits along with the poor and disadvantaged. States
either subtract private health and LTC expenses from income before they
apply the low-income standard or they permit excess income to be diverted
to a “Miller trust.” The rule of thumb is that income below the cost of a
nursing home, easily $8,000 or $9,000 per month, is not disqualifying. Nor
do assets stand in the way of Medicaid LTC eligibility in most cases,
because the largest assets seniors possess are exempt, such as a home,
car, personal belongings, etc. and any countable liquid wealth is easily
made non-countable by purchasing exempt assets. Even far more affluent
people qualify for Medicaid LTC benefits by retaining elder law attorneys
to impoverish them artificially with special trusts, annuities and other
sophisticated strategies.
Key Money: LTC Racism’s Motor
Why would people who could afford private LTC
manipulate eligibility rules to qualify for Medicaid which has such a poor
reputation for access and quality? Some Medicaid facilities are better
than others. They may serve mostly Medicare or private residents, receive
much higher reimbursement rates, enjoy philanthropic support, and have
only a few Medicaid beds. Savvy seniors, their families, and legal
advisors learn to use “key money” to access those better facilities.
Medicaid planners tell their affluent clients to hold back enough liquid
capital from the artificial impoverishment process to enable them to pay
privately for a while. Because LTC providers are desperate for private
payers who contribute half again as much as Medicaid to their bottom line,
they roll out the red carpet for new private-pay admissions. Once in a
good facility, the advisor flips a legal switch converting the client to
Medicaid. By law the provider cannot expel a resident simply because the
funding source changes from private to Medicaid.
This is how Medicaid, commonly considered a LTC
safety net for the poor, came to be the dominant LTC funding source for
nearly everyone, even the affluent, stricken by catastrophic LTC costs. By
covering the “medically needy”—people with too much income to qualify
categorically, but too little income to pay their health and LTC expenses
privately—Medicaid’s limited resources were overwhelmed. The program tried
to do too much for too many and ended up doing too little for most. Worse,
Medicaid allowed privileged majorities to coopt its better facilities and
services while diverting the less advantaged, who lack key money, to the
program’s least desirable facilities and services. This is how structural
racism, deficient public LTC services for those most in need, came to
predominate. Nothing will change until this cause is removed.
LTC racism: Treatment
The most common remedy for LTC racism proposed in the
academic literature is to allocate more resources to Medicaid so it can
pay caregivers more, provide better services, offer more home- and
community-based care, and relieve family caregivers. For example, one
source calls for a multi-prong effort to add “disproportionate-share
payment adjustments to nursing homes with a higher proportion of Medicaid
residents” and to equalize “Medicaid and private-pay payments.” (“Separate
And Unequal: Racial Segregation And Disparities In Quality Across U.S.
Nursing,” 2007, Abstract) Another source suggests “increase Medicaid
and Medicare reimbursement rates, especially for providers serving high
proportions of Medicaid-eligible and BIPOC older adults” and “expand
access to Medicaid-waivered HCBS services,” “increase promotion of
integrated HCBS programs that can be targeted to BIPOC consumers.”
(“Evidence
for Action: Addressing Systemic Racism across Long-Term Services and
Supports,” 2022, Abstract) All have proven to be politically
unachievable goals.
But simply spending more on Medicaid would only mean
increased resources going disproportionately to the over-privileged with
relatively less reaching the underprivileged. The only way to eliminate
LTC racism once and for all is to remove from Medicaid dependency the
people who rely on the program now, but who could, should and would have
prepared to pay privately otherwise. The easy availability of Medicaid LTC
late in life while preserving wealth created a moral hazard that
discouraged early planning for LTC. The middle class and affluent who
crowd out the poor from Medicaid’s best services, could have saved,
invested or insured for LTC and avoided reliance on Medicaid. Bottom line,
it is they who must be incentivized to take personal responsibility early
in life so that later, when they need LTC, they can pay privately, access
the best possible care in the most desirable venues, and free up Medicaid
to do a better job for those most in need. Relieved of the burden to cover
everyone, Medicaid will have the resources to pay private rates, afford
top-quality professional caregivers thus eliminating their shortage, offer
more HCBS, and move everyone on the program into the top-tier of LTC
services.
Long-Term Care: Cure
The solution to LTC racism is to move privileged
groups into the private LTC market in order to save and improve Medicaid
for the less fortunate. That is a big ask. How can we possibly do it?
Government tried unsuccessfully for decades (1) to reduce excess Medicaid
dependency (employing income and asset limits, transfer of assets
penalties, estate recoveries, even “Throw Granny in Jail”) and (2) to
encourage private LTC insurance. Nothing worked. People struggling in
mid-life with house and car payments, child care, elder care, retirement
and education savings, etc. would not think, plan or prepare for the
potential risk and cost of LTC in the distant future. The fact that
Medicaid paid for the vast bulk of catastrophic LTC expenses probably
didn’t enter their awareness but it influenced their financial planning
nonetheless, enabling their denial.
These conditions are the dam obstructing progress
toward a solution of LTC racism. I propose a way to break that dam and
improve both private and Medicaid LTC in a new paper, titled “Long-Term
Care: The Solution,” for the
Paragon Health Institute. It is due for publication on October 2 and
follows a paper, “Long-Term
Care: The Problem” that Paragon published last fall. We’ll bring you
more analysis and answers soon.
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Updated, Monday, September 11, 2023,
9:32 AM (Pacific)
Seattle—
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LTC
E-ALERT #23-025:
LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Damon at 206-283-7036
or
damon@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members
also receive our weekly LTC Bullet op-ed. To join the Center and receive
all these benefits and more, contact Damon at 206-283-7036 or
damon@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and comments on
the following articles, reports, or data:
-
State veterans home rife with deficiencies,
inaccurate COVID death reports: federal report
-
Biden’s Proposal to Restrict Affordable Health
Options
-
Fitch Downgrade Could Mean Medicaid Cuts
-
Could legacy long-term care (LTC) blocks be the
next wave of M&A deals?
-
Understanding the Stages of Dementia: A
Compassionate Guide for Families and Caregivers
-
Fixing Medicaid rolls doesn’t mean leaving people
without coverage
-
Biden unloads on nursing home operators
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, September 8, 2023,
10:40 AM (Pacific)
Seattle—
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LTC BULLET: LONG-TERM
CARE RACISM
LTC Comment: What is LTC
racism? How does it manifest? What should be done? Excerpts from the
scholarly literature follow the ***news.***
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LTC BULLET: LONG-TERM
CARE RACISM
LTC Comment: We know
America’s LTC service delivery and financing system is fraught with
problems. These problems include dubious access and quality, nursing home
bias, too little home- and community-based care, inadequate provider
revenue, reduced private financing from insurance, savings or home equity,
caregiver shortages, and excessive emotional and financial strain on
family caregivers. We also know that these problems impact
socioeconomically marginalized groups disproportionately.
A large and growing
scholarly literature attributes this LTC status quo to systemic,
structural or institutionalized racism. Examples of unfair and inequitable
LTC conditions and outcomes abound. So do ideas and recommendations about
how to fix or improve LTC services and financing by eliminating or
reducing LTC racism. Today’s LTC Bullet offers a selection of
quotes about LTC racism from many peer-reviewed journal articles. For now,
let’s reflect on this material and its meaning before we turn soon to
analysis and recommendations.
Definition: “[I]nstitutionalized
racism is defined as differential access to the goods, services, and
opportunities of society by race. Institutionalized racism is normative,
sometimes legalized, and often manifests as inherited disadvantage. It is
structural, having been codified in our institutions of custom, practice,
and law, so there need not be an identifiable perpetrator.”
Levels of Racism: A Theoretic Framework and a Gardener’s Tale, 2000,
p. 1212
Examples: “The
long-term services and supports (LTSS) sector is a microcosm of systemic
racism that exists in our society. Nationally, half of frontline
professional caregivers are nonwhite, while mid- and executive-level
managers and board members are predominately white.”
The Value Proposition for Diversity: Creating A Pipeline of Diversity in
The LTSS Sector, 2022, Abstract
“Long-term services and
supports (LTSS), including care received at home and in residential
settings such as nursing homes, are highly racially segregated; Black,
Indigenous, and persons of color (BIPOC) users have less access to quality
care and report poorer quality
of life compared to their White counterparts. Systemic racism lies at
the root of these disparities,
manifesting via racially segregated care, low Medicaid reimbursement, and
lack of livable wages for staff, along with other policies and processes
that exacerbate disparities.” Evidence
for Action: Addressing Systemic Racism Across Long-Term Services and
Supports, 2022, p. 1
“Long-term services and
supports for older persons in the United States are provided in a complex,
racially segregated system, with striking racial disparities in access,
process, and outcomes of care for residents, which have been magnified
during the Coronavirus Disease 2019 pandemic. These disparities are in
large measure the result of longstanding patterns of structural,
interpersonal, and cultural racism in US society, which in aggregate
represent an underpinning of systemic racism that permeates the long-term
care system's organization, administration, regulations, and human
services. … Additional foundational drivers include a fragmented payment
system that advantages persons with financial resources, and reimbursement
policies that systematically undervalue long-term care workers.”
Addressing Systemic Racism in Nursing Homes: A Time for Action, 2021,
Abstract
“In this study, nursing
homes with the highest proportions of non-White residents experienced
COVID-19 death counts that were 3.3-fold higher than those of facilities
with the highest proportions of White residents.”
Factors Associated With Racial Differences in Deaths Among Nursing Home
Residents With COVID-19 Infection in the US, 2021, p. 1/10.
“We found that a larger
share of Hispanic Medicare residents that are admitted to nursing homes
have ADRD [Alzheimer’s disease and related dementias] compared with
African American and White beneficiaries. Both Hispanics and African
Americans with ADRD received care in segregated nursing homes with fewer
resources and lower quality of care compared with White residents.”
Disparities in Nursing Home Use and Quality Among African American,
Hispanic, and White Medicare Residents With Alzheimer's Disease and
Related Dementias, 2019, p.1
“Using Medicaid claims
data for a national cohort of dual eligibles with MS, we find state HCBS
priority is associated with disparities in utilization-blacks and
Hispanics receiving HCBS more often do so in low-priority states compared
with whites.”
Racial Disparities in Medicaid Home and Community-Based Service
Utilization among White, Black, and Hispanic Adults with Multiple
Sclerosis: Implications of State Policy, 2019, Abstract
“Disparities between
vaccination coverage among racial/ethnic minorities versus Whites ranged
from 2% to 20% for influenza and 6% to 15% for pneumococcal vaccination.
Researchers reported racial/ethnic minorities were more likely to refuse
vaccinations and less likely to have vaccinations offered and their
vaccination status tracked compared to Whites.”
Racial/Ethnic Disparities in Influenza and Pneumococcal Vaccinations Among
Nursing Home Residents: A Systematic Review, 2018, p. e205
“Despite the increased
use of nursing homes by minority residents, nursing home care remains
highly segregated. Compared to whites, racial/ethnic minorities tend to be
cared for in facilities with limited clinical and financial resources, low
nurse staffing levels, and a relatively high number of care deficiency
citations. … We also found that increasing the Medicaid payment rate might
help improve both overall quality and disparities, but state case-mix
payment approaches might worsen both.”
Deficiencies In Care At Nursing Homes And Racial & Ethnic Disparities
Across Homes Declined, 2006–11, 2015, p. 1
“Highlights
- Patients of
each race prefer nursing homes with higher prevalence of patients of
their own race.
- Preference
for distance and quality of care are same for patients of both the
races.
- Both
preference for distance and preference for racial homogeneity contribute
to racial disparity in nursing home quality of care.
- Results are
robust among subgroup of patients with same Medicaid eligibility and
similar likelihood of becoming long-stay resident.
- Simulations
based on estimated sorting model suggest that interventions targeting
nursing homes serving minority population would yield a greater
reduction in racial quality disparities than interventions targeting low
quality nursing homes.”
Racial Segregation and Quality of Care Disparity in US Nursing Homes,
2014, p. 28
“Findings revealed that
black residents are more likely than white residents to be restrained with
bed rails, side rails, and trunk restraints. Findings suggest that racial
disparities exist in the use of physical restraints. Implications for
practice, policy, and research are discussed.”
Racial disparities in the use of physical restraints in U.S. nursing homes,
2013, Abstract
“Racial disparities in
nursing homes have been reported for a number of outcomes, including
pressure ulcers, influenza vaccination rates, pain management, hospice use
and in-hospital death.(16–19, 22) Our findings confirm that compared to
Whites, Black residents experience more aggressive EOL[End of Life] care
with higher rates of in-hospital deaths and lower rates of hospice use.”
Racial Disparities in In-Hospital Death and Hospice Use Among Nursing Home
Residents at the End-of-life, 2012, p. 6
“Between 1999 and 2008,
the number of elderly Hispanics and Asians living in US nursing homes grew
by 54.9 percent and 54.1 percent, respectively, while the number of
elderly black residents increased 10.8 percent. During the same period,
the number of white nursing home residents declined 10.2 percent. These
shifts have been driven in part by changing demographics, especially the
fast growth of older minority populations. However, the numbers of
minority residents in nursing homes increased more rapidly than the
minority population overall, even in areas with high concentrations of
minority populations. Thus, these results may indicate unequal minority
access to home and community-based alternatives, which are generally
preferred for long-term care. When designing initiatives to balance
institutional and noninstitutional long-term care, policy makers should
take steps to reduce racial and ethnic disparities.”
Growth of Racial and Ethnic Minorities in US Nursing Homes Driven by
Demographics and Possible Disparities in Options, 2011, p.1358
“Greater PU [pressure
ulcer] occurrence among Blacks may not result from differential
within-facility treatment of Blacks versus Whites. Rather, Blacks are more
likely to reside in facilities with poorer care quality. To improve PU
care for Blacks, efforts should focus on improving the overall quality of
care for facilities with high proportion of Black residents.”
Pressure ulcer prevalence among Black and White nursing home residents in
New York State: Evidence of racial disparity?, 2010, p. 1
“Although segregation in
nursing homes seems to have declined slightly, elderly Hispanics are more
likely than their non-Hispanic white peers to reside in nursing homes that
are characterized by severe deficiencies in performance, understaffing,
and poor care.”
Elderly Hispanics More Likely To Reside In Poor-Quality Nursing Homes,
2010, p. 65
“Disparities in quality
of care are more consistently documented and appear to be related to
racial and socioeconomic segregation of long-term care facilities as
opposed to within-provider discrimination. Market-based incentives
policies should explicitly incorporate the goal of mitigating the
potential unintended consequence of increased disparities.”
Disparities in long-term care: building equity into market-based reforms,
2009, Abstract
“Compared to Whites,
African Americans were less likely to have completed an advance directive
(35.5% vs. 67.4%, P<.001) and had less favorable beliefs about
hospice care (Hospice Beliefs and Attitudes Scale score, P<.001).
African Americans were more likely to express discomfort discussing death,
want aggressive care at the end of life, have spiritual beliefs which
conflict with the goals of palliative care, and distrust the healthcare
system.”
What explains racial differences in the use of advance directives and
attitudes toward hospice care?, 2008, p. 1
“Average nursing-home
case-mix acuity for African Americans and Caucasians were essentially
identical, suggesting that shifts in payment incentives have eliminated
the selective admission of easy-care private-pay (predominantly Caucasian)
patients and helped fuel the growth of private pay home care and assisted
living for this segment of the population. While these shifts in
incentives helped increase the use of nursing homes by African Americans,
a high degree of segregation and disparity in the quality of the nursing
homes used by African Americans persists. Parity in use is an illusive
benchmark for measuring progress in assuring equity in treatment.”
Racial disparities in access to long-term care: the illusive pursuit of
equity, 2008, Abstract
“Nursing homes remain
relatively segregated, roughly mirroring the residential segregation
within metropolitan areas. As a result, blacks are much more likely than
whites to be located in nursing homes that have serious deficiencies,
lower staffing ratios, and greater financial vulnerability. Changing
health care providers’ behavior will not be sufficient to eliminate
disparities in medical treatment in nursing homes.” p. 1448
“A tiered system of
nursing home care that concentrates blacks in marginal-quality nursing
homes also appears to exist.5” (p. 1449) “We found that nursing home care
was relatively segregated in 2000, with two thirds of all black residents
living in just 10 percent of all facilities.” (p. 1453) “Disparities in
payment between Medicaid and private payers make the financial viability
of a nursing home dependent on the proportion of private-pay patients it
is able to attract. Homes unable to attract sufficient private-pay
patients will tend to have lower nurse staffing levels and more-serious
inspection deficiencies.”18 (p, 1456) “Nursing home operators might also
try to control admissions to their facilities, limiting the number of
first-day-eligible Medicaid admissions and expanding as much as possible
admissions of those with sufficient resources that are unlikely to spend
down and become eligible for Medicaid.” (p. 1456) “It [discrimination]
might also play a role in shaping the decisions of white private-pay
nursing home patients and their families about where to get care,
including whether to opt for non–nursing home alternatives altogether.”
(p. 1456)
Separate And Unequal: Racial Segregation And Disparities In Quality Across
U.S. Nursing Homes, 2007
“Non-Hispanic Whites
(Whites) experienced substantially better functional outcomes than did
home health care recipients of other racial/ethnic backgrounds. The
disparity in outcomes was most pronounced between Whites and African
Americans.”
Racial and ethnic disparities in the outcomes of elderly home care
recipients, 2005, Abstract
“Nursing home care is
currently a two-tiered system. The lower tier consists of facilities
housing mainly Medicaid residents and, as a result, has very limited
resources. The nearly 15 percent of U.S. nonhospital-based nursing homes
that serve predominantly Medicaid residents have fewer nurses, lower
occupancy rates, and more health-related deficiencies. They are more
likely to be terminated from the Medicaid/Medicare program, are
disproportionately located in the poorest counties, and are more likely to
serve African-American residents than are other facilities. The public
reporting of quality indicators, intended to improve quality through
market mechanisms, may result in driving poor homes out of business and
will disproportionately affect nonwhite residents living in poor
communities. This article recommends a proactive policy stance to mitigate
these consequences of quality competition.”
Driven to Tiers: Socioeconomic and Racial Disparities in the Quality of
Nursing Home Care, 2004, Abstract
“African Americans are
about one-third as likely as Caucasians to have living wills and one-fifth
as likely as Caucasians to have DNR orders; Hispanics are about one-third
as likely as Caucasians to have DNR orders and just as likely as
Caucasians to have living wills. In conclusion, we found that the presence
of advance care plans is related to race, even after controlling for
health and other demographic factors.”
Persistence of racial disparities in advance care plan documents among
nursing home residents, 2002, Abstract
“Results: Most
African Americans resided in nursing homes and smaller RC/AL facilities
and tended to be concentrated in a few predominantly African American
facilities, whereas the vast majority of Whites resided in predominantly
White facilities. Facilities housing African Americans tended to be
located in rural, nonpoor, African American communities, to admit
individuals with mental retardation and difficulty in ambulating, and to
have lower ratings of cleanliness/maintenance and lighting.
“Conclusions: These
racial disparities may result from economic factors, exclusionary
practices, or resident choice. Whether separation relates to inequities in
care is undetermined.”
Distribution of African Americans in Residential Care/Assisted Living and
Nursing Homes: More Evidence of Racial Disparity?, 2002, p. 1272
Solutions: “We
developed a set of recommendations for LTSS based on existing evidence,
including (1) increase Medicaid and Medicare reimbursement rates,
especially for providers serving high proportions of Medicaid-eligible and
BIPOC older adults; (2) reconsider the design of pay-for-performance
programs as they relate to providers who serve underserved groups; (3)
include culturally sensitive measures, such as quality
of life, in public reporting of quality of care, and develop and
report health equity measures in outcomes of care for BIPOC individuals;
(4) implement culture change so services are more person-centered and
homelike, alongside improvements in staff wages and benefits in
high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered
HCBS services; (6) adopt culturally appropriate HCBS practices, with
special attention to family caregivers; (7) and increase promotion of
integrated HCBS programs that can be targeted to BIPOC consumers, and
implement models that value community
health workers.”
Evidence for Action: Addressing Systemic Racism Across Long-Term Services
and Supports, 2022, p. 1
“Focusing limited
available resources on facilities with high proportions of non-White
residents is needed to support nursing homes during potential future
[Covid-19] outbreaks.”
Factors Associated With Racial Differences in Deaths Among Nursing Home
Residents With COVID-19 Infection in the US, 2021, pp. 1-2/10.
“The solution to racial
health inequities is to address
racism and its attendant harms and erect a new health care
infrastructure that no longer profits from the persistence of inequitable
disease.”
On Racism: A New Standard For Publishing On Racial Health Inequities,
2020
“Ten-dollar increments
in Medicaid rates reduced the odds of hospitalization by 4 percent (95
percent CI=0.93–1.00) for white residents and 22 percent (95 percent
CI=0.69–0.87) for black residents.” (p. 869)
“Quality NH care is dependent on the availability of resources (Mor et al.
2004; Miller et al. 2006) but NHs that are largely Medicaid-reliant are
often disadvantaged because Medicaid rates are generally below private pay
rates and sometimes below actual costs of care (Seidman 2002). Such
facilities disproportionately serve black residents (Mor et al. 2004).”
(p. 870)
“That higher Medicaid payment rates reduced the risk of hospitalization
substantially more for black than for white residents suggests that
efforts to reduce racial disparities in NH care must include strategies to
better support Medicaid-reliant NHs.” (p. 879)
Relationship between State Medicaid Policies, Nursing Home Racial
Composition, and the Risk of Hospitalization for Black and White Residents,
2008
“What can be done to cut
this knot? A multi-prong effort in four areas could help: (1)
disproportionate-share payment adjustments to nursing homes with a higher
proportion of Medicaid residents; (2) equalization of Medicaid and
private-pay payments; (3) certificate-of-need and broader regional
planning responsive to racial-disparity concerns; and (4) ongoing
monitoring and more rigorous enforcement of Title VI in admission
practices. Indeed, some of the MSA variations on these measures of
disparities may reflect variations in effort in these areas. These
findings are not very different for the nursing home sector than for other
parts of the health system in terms of the characteristics of this knot or
in the possible approaches to cutting it.”
Separate And Unequal: Racial Segregation And Disparities In Quality Across
U.S. Nursing Homes, 2007, pp. 1456-7
#############################
Updated,
Tuesday, September 5, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-024:
LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to
the original, and our analysis in a sentence or two. To inquire or
subscribe, contact Damon at 206-283-7036 or
damon@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more,
contact Damon at 206-283-7036 or
damon@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
BREAKING: CMS issues first-ever nursing home
staffing mandate
-
BREAKING: CMS nursing home staffing mandate in
question after study leaks
-
Proposed mandatory long-term care insurance: A
closer look at the potential negatives
-
Short-Term Plans: The Battle for Health Insurance
Choice
-
Can the Left and Right Agree on Health Reform?
-
As forecast price of federal staffing mandate
climbs to $11.7B, analysts offer alternatives
-
Researchers identify lifestyle factors that predict
nursing home needs later in life
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Monday, August 28, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-023 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
·
Dementia Risk From Midlife Onward Predicted With New Tool
·
California Warns Against Dishonest Marketing Tied to
Long-Term Care Proposal
·
AHCA offers ‘wake-up call’ on bed and facility counts:
446,000 residents may be displaced
·
New research uncovers racial inequities in home health
patients’ health outcomes
·
The Upheaval at America’s Disappearing Nursing Homes, in
Charts
·
Alarming reality: One in four Americans with cognitive
impairment lives alone
·
China population: 100 million more senior citizens expected
in next decade as ageing crisis enters ‘crucial juncture’
·
Here's the Size of Social Security Cuts if Congress Doesn't
Act Soon: CRFB
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Friday, August 25, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: YOU PAY FOR CALIFORNIA’S LTC PROFLIGACY AND STRUCTURAL RACISM
LTC
Comment: California’s Medicaid program (Medi-Cal)
says come one, come all for free LTC, sends the bill to federal taxpayers,
and institutionalizes structural LTC racism. What’s happening, after the
***news.***
***
HELP us change LTC financing policy for the better. Whenever you see an
article or report that says something like:
“Only low-income people qualify for Medicaid.”
“Medicaid only pays for long-term care after you spend down into
impoverishment.”
“Millions across America are losing their life savings to long-term care.”
“LTC insurance costs too much and will never be a major payer.”
“The best way to fix LTC is to add it to Medicare.”
Forward the source to me (smoses@centerltc.com)
or to Damon (damon@centerltc.com).
We will contact the author, explain why those commonplace beliefs are
false, provide evidence to back up our conclusion, offer correct
information, recommend public policy solutions, and propose to become a
source for the author’s future publications on LTC.
With
the
Paragon Health Institute’s
publication of our monographs “Long-Term
Care: The Problem”
and (soon) “Long-Term Care: The Solution,” the time is right again to
address and correct misconceptions about LTC financing among reporters,
analysts, and policy makers.
Let’s fix long-term care once and for all.
***
LTC
BULLET: YOU PAY FOR CALIFORNIA’S LTC PROFLIGACY AND STRUCTURAL RACISM
LTC
Comment: California is eliminating one of the last remaining reasons
people have to plan privately for long-term care risk and cost. The state
already lifted Medi-Cal’s countable asset limit from $2,000 to $130,000 in
2022. Effective January 1, 2024, the Golden State will eliminate the asset
limit entirely. This change applies to people receiving LTC benefits in
the community or nursing homes. It will add 18,000 new recipients without
their having to spend down or prove their wealth. (McKnight’s
Senior Living).
Why
should you care? After all, California is notorious for crazy public
policies. (Have you been to San Francisco lately?) You may not have to pay
for most of their well-intentioned, unintended consequences. But you are
paying for this one. The way Medicaid (including Medi-Cal) works, the
state puts up part of the program’s cost and the federal government pays
the rest. For California this
match rate
is 50/50. So, for every wealthy Californian newly eligible for Medi-Cal
LTC benefits, we federal taxpayers in New Mexico, Illinois, New York,
etc., etc. are paying half.
Surely the federal government will not stand for this fiscal inequity.
But, no, the Centers for Medicare and Medicaid Services (CMS)
approved the state plan amendment
removing the asset limit, calling it a “first
of its kind.” Will
other states follow in California’s footsteps? Will yours?
Maybe you’re thinking “Oh well, at least people have to be ‘low income’
before California can make me pay for their long-term care.” But, no
again, the state has
“no
income limit” for “institutional / Nursing Home Medicaid,”
although: “All of a beneficiary’s monthly income, with the exception of a Personal
Needs Allowance of
$35 / month, Medicare premiums, and a Spousal
Income Allowance (if
applicable), must be paid to the nursing home as a Share of Cost.” (American
Council on Aging).
Think of income as kind of a “deductible,” a small price for the asset
rich to access government-funded LTC.
Playing fast and loose with welfare-financed LTC benefits is nothing new
for California. I documented many examples 12 years ago in Medi-Cal
LTC: Safety Net or Hammock?
On pages 25-28 of that report, check out the ways California ignored
federal mandates from the Omnibus Budget Reconciliation Act of 1993 and
the Deficit Reduction Act of 2005. You paid for all this “generosity”
also.
Medi-Cal’s Structural LTC Racism
On
average, Medicaid pays LTC providers less than the cost of care, roughly
70 percent of what private payers must contribute. Consequently, Medicaid
often provides deficient care access and quality compared to what affluent
private payers command. Financially underprivileged minorities tend to end
up on Medicaid and in nursing homes that are more dependent on Medicaid
than nicer, mostly private-pay skilled facilities or assisted living.
Thus, Medi-Cal’s more favorable treatment of affluent people in terms of
eligibility and access has led to charges of structural racism. According
to an open access article in
Health Affairs*:
Structural racism in coverage and financing has created a two-tier system
of racially segregated care in which minority people receive
poorer-quality care.… Inequities in nursing home care provide a
particularly vivid example.… Stark racial segregation in nursing homes
persists today.
Awful as that sounds, the full story is even worse. If Medicaid and Medi-Cal
care is so poor, why would people who can afford to pay privately want to
qualify for it? Elder law attorneys who specialize in “Medicaid planning,”
the legal practice of artificially impoverishing affluent clients to
qualify them for publicly funded LTC benefits, have a ready answer.
Nursing homes are desperate for revenue because Medicaid (Medi-Cal) pays
them so little. They will roll out the red carpet for anyone who can pay
privately at rates half again as much as Medicaid pays. So lawyers advise
clients to hold back enough “key money” to pay privately for a while.
That’s how their upscale clients can get into the nicer facilities that
accept only a few Medicaid recipients. Then after a short period paying
privately, the attorney implements a plan to impoverish the client on
paper by means of common legal steps, such as: to purchase unlimited
exempt assets; set up a Medicaid Asset Protection Trust; buy a
Medicaid-compliant annuity; or use other methods described
here,
while legally avoiding estate recovery. Voila. Another well-to-do person
enters a rare, top-quality facility paid for by Medicaid. Once in, the
placement is permanent:
Keep
in mind that, once you have been admitted to a Medi-Cal certified
facility, you cannot be transferred or evicted simply because of a change
from private pay to Medi-Cal payment status even when a (illegal) duration
of stay contract has been signed. This applies while the Medi-Cal
application is pending, as well. (CANHR,
pps. 6-7)
Unfortunately, poor people don’t have the key money to buy their way into
the nicer nursing homes in this way. That’s why they end up in the less
desirable places that are more likely to be featured in tabloid exposes of
deficient care. Worse, the poor on Medi-Cal may be unable to access care
in California at all. According to the California Advocates for Nursing
Home Reform (CANHR):
Over
the past 5 years, one of the most disturbing violations of state and
federal laws has been the increase in discrimination against Medi-Cal
beneficiaries who need nursing home care. Call a nursing home and tell
them that your mother, a Medi-Cal beneficiary, has dementia along with
other medical issues and that her doctor has recommended a nursing home–
good luck in finding a placement within 200 miles – or at all! … Nursing
home discrimination against Medi-Cal beneficiaries and residents has
become epidemic in California, and the state regulatory agencies do
nothing to contain it. (Source:
Medi-Cal
Discrimination In Nursing Homes – Getting In Is Half The Battle)
By
making it even easier than it was already for affluent people to crowd out
the poor from better LTC, Medi-Cal has exacerbated the problem of
structural LTC racism which in fact afflicts Medicaid nationwide.
If
you want to know why these problems persist, read the
Paragon Health Institute’s
paper “Long-Term
Care: The Problem.”
If you want to know what to do about it, watch for “Long-Term Care: The
Solution,” coming soon from Paragon and the
Center for Long-Term Care Reform.
*
Ruqaiijah Yearby, Brietta Clark, and José Figueroa, “Structural Racism in
Historical and Modern US Health Care Policy,” Health Affairs, vol.
41, no. 2 (2022).
#############################
Updated,
Monday, August 21, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-022 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
HealthyLife.net
(Moses podcast interview)
-
Nine out of 10
seniors concerned about senior living cost, care and quality: report
-
State becomes
first to strip Medicaid asset limit
-
8 Big Things
Clients Don't Know About Estate Planning, Long-Term Care and Probate
-
Japan:
Long-term care insurance system under funding pressure
-
Minnesota
studies a Medicare companion product for LTC coverage
-
‘Old Age’
Enters a New Age: Dramatic shifts in demography and Americans' views of
aging revealed in new Harris Poll study conducted by Age Wave
-
The Long View:
Six reasons to start retirement planning in your 20s
-
Brains of
people with Alzheimer’s are low on some antioxidants, study finds
-
How Do You Hide
Money From Nursing Homes
-
Medicaid
spending up for seniors but who will bankroll coming growth
-
Got Insurance?
You May Be on Medicaid Too
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated, Monday, August 14, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-021 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Nursing homes
and adult care costs surged by largest amount in July
-
Life
Settlements Can Pay for Long-Term Care
-
What Happens to
the Items I Bought to Qualify for Medicaid?
-
Genworth Set to
Offer Long-Term Care Services in Texas
-
Painful and
Getting Worse: Rise of Medicare Advantage Drains Vast Revenue from SNF
Sector, Worsens Workforce Instability
-
Transforming
health care for older adults
-
Providers must
confront radical change in shifting competitive landscape: experts
-
Minority groups
comprise more than 25 percent of MA beneficiaries, study finds
-
Many Americans
Believe AI Will Provide Their In-Home Care As They Age
-
More Baby
Boomers are living alone. One reason why: ‘gray divorce’
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, August 11, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LET’S FIX LONG-TERM CARE ONCE AND FOR ALL
LTC
Comment: If you had to diagnose and cure what ails LTC in a single page,
what would you say? Steve’s answer follows.
LTC
BULLET: LET’S FIX LONG-TERM CARE ONCE AND FOR ALL
LTC
Comment: Policymakers’ attention spans are extremely short. So one pagers
are grist for the policy mill in DC and state capitals. But writing short
is much harder than writing long.
Mark
Twain said
“I didn't have time to write a short letter, so I wrote a long one
instead.” These LTC Bullets aim to say what they want to say in
less than 1000 words. But we often blow through that target. So let’s take
the time today to keep it short. Here’s everything you need to know about
what’s wrong with LTC, why, and what to do about it in one page. But if
this précis leaves you wanting more, read “Long-Term
Care: The Problem”
and await “Long-Term Care: The Solution,” coming soon.
Let’s Fix Long-Term Care Once and for All
Step
One:
Understand the Cause. People who ignore LTC planning but end up needing
catastrophically expensive care later in life routinely transfer that
liability and cost to taxpayers via Medicaid.
Step
Two:
Understand the Problem. As the dominant LTC payer, Medicaid caused most of
LTC’s deficiencies including nursing home bias, access and quality
problems, inadequate reimbursement, caregiver shortages, and excessive
reliance on “free” care by friends and family.
Step
Three:
Understand the Solution. As long as most people can ignore LTC risk and
cost, wait to see if they ever need expensive care, and shift the cost to
Medicaid, few will plan early to save, invest or insure for LTC. That must
change for more private revenue to fix long-term care.
Step
Four:
Understand the Plan. Medicaid allows people who failed to prepare
privately for LTC to shelter unlimited wealth in trusts, annuities,
five-year asset transfers and exempt assets including, over $1 million in
home equity. This must end for consumers to take LTC seriously.
Step
Five:
Understand the Reasoning. If we remove those major loopholes by which
people qualify for Medicaid LTC benefits late in life, consumers will have
no choice but to plan for LTC earlier. WA Cares proved that by threatening
a LTC tax that unleashed a LTCI fire sale.
Step
Six:
Understand the Practicality. It is unrealistic to expect younger people
and families to plan for LTC at a time in their lives when they’re also
saving for retirement and children’s education, making house and car
payments, etc. So we must offer a way to ease that burden.
Step
Seven:
Understand the Research. The LTC financing burden may be more manageable
than we previously believed. $70,000 invested by a 65-year-old now will
cover his/her average LTC cost of $138,000 later. Aging Americans have
enough saved already to cover two years of LTC.
Step
Eight:
Understand the Potential. If people only had to cover their individual
average LTC risk by setting aside or earmarking resources they already
have or are in the process of saving, they could do so more easily and
while simultaneously covering their other financial needs.
Step
Nine:
Understand the Options. Purchase less LTC insurance at lower premiums to
cover average LTC risk instead of catastrophic potential as now. Carve out
enough home equity, life insurance, Individual Retirement Account balances
or estate wealth to cover average risk.
Step
Ten:
Retain Medicaid as the payer of last resort for anyone who cannot or will
not prepare privately for LTC and to cover catastrophic costs. But make
this resource available only after all personal income and assets of
applicants/recipients are consumed by private LTC costs.
Summary and Conclusion:
If we recognize these facts and implement these measures, America’s
failing LTC service delivery and financing system can be saved and
improved. There is ample wealth to ensure access to quality long-term care
for all Americans. Simply replace perverse incentives to ignore LTC that
prevail now with positive incentives to plan for LTC.
#############################
Updated, Monday, August 7, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-020 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Nationwide Maps
Consumers' Long-Term Care Insurance Confusion
-
Tracking The
Elusive Medicaid Workforce To Improve Access
-
National
Advisory Commission for long-term care proposed — without providers
-
In a rapidly
aging America, Medicaid can be a lifeline for long-term care
-
Introducing
OmniFlex™: A Revolutionary Short-Term Care Plan Redefining the Industry,
offered by ManhattanLife
-
In policy
break, Medicare to pay for respite services under new dementia care
model
-
CNA hourly pay
nears $19 average, while admins score major gains of their own: salary
survey
-
Long-term care:
Insurance innovation can’t come soon enough
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, July 31, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-019 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
California to
eliminate asset tests for Medicaid
-
Comedy Video:
D.C.'s Premier Elder Care Community
-
New OIG Report
Examines Prior Authorization Denials in Medicaid MCOs
-
The Forgotten
Generation: Generation X Approaches Retirement
-
Pandemic loans
showed dollars will move the staffing shortage needle: study
-
8 facts about
Americans with disabilities
-
Medicare
Advantage Plans Face More Budget Pressure
-
At-home,
finger-prick blood test for Alzheimer’s is latest touted stab at early
diagnoses
-
Healthcare
bankruptcy filings set to triple
-
What Is
Transfer Trauma?
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, July 28, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC BULLET:
CASSANDRA’S CURRENT QUANDARY
LTC Comment: Apollo
granted Cassandra the ability to predict the future accurately, but cursed
her to be disbelieved. That’s a familiar quandary for anyone warning today
about LTC jeopardy. Details after the ***news.***
*** 7/20/2023, “The
CLTC Digest Quarter 3,” Certification for Long-Term Care
Quote: “We are
pleased to share the 2023 3rd Quarter edition of the CLTC Digest. As
always, you will find highly educational and insightful articles, and a
case study, to expand your knowledge and skills when it comes to helping
clients plan for extended care.”
LTC Comment: I
discovered an earlier issue of the CLTC Digest and was very
impressed. I asked if they would consider an article by me. They did and
it became the cover story in this latest issue. If you have the CLTC
certification, you can access this new journal issue online. Non-CLTCs can
purchase it for $9.95. Go to
https://www.ltc-cltc.com/ and click on Store, and then on Marketing
Materials. What’s more, CLTC is offering a special deal on their eCLTC (self-study)
program. It's $200 off the street rate. That’s a convenient and easy way
to get the CLTC designation. But don’t wait; the special ends July 31.
That deadline is this coming Monday! ***
LTC BULLET: CASSANDRA’S
CURRENT QUANDARY
LTC Comment: In 2015 the
Center for Long-Term Care Reform published
Cassandra’s Quandary. That paper proposed and provided
an example of a tool to measure long-term care vulnerability. What, we
asked, are the national and state-level risks to the provision and
financing of long-term care services? We closely examined these seven
variables.
Aging Demographics:
How many older people are coming in the next few decades?
Morbidity: How sick will they be?
Public Funding: How viable is Medicaid as the dominant
long-term care payer?
Economy, Federal: How reliable is federal revenue on which
Medicaid mostly depends?
Economy, State: How reliable is state revenue on which
Medicaid secondarily depends?
Private Financing Alternatives: How much private-pay revenue
is available to relieve LTC financing pressure on Medicaid?
Entitlement Mentality: How strong has cradle-to-grave
dependency on public programs become?
It is high time to ask
those questions again. Our recent paper for the
Paragon Health Institute, titled
Long-Term Care: The Problem, updates the LTC service
delivery and financing challenge.
Our new paper
forthcoming soon, titled Long-Term Care: The Solution, will propose
a radically new approach to the LTC challenge. In the meantime, following
are some excerpts to consider from the original
Cassandra’s Quandary:
Executive Summary
It may already be too
late to save America’s long-term care safety net. But it is not too late
to examine its problems and to propose policy changes to relieve or
eliminate them. That is this report’s objective.
Long-term care service
delivery and financing face enormous challenges. Risk and cost are very
high, yet few Americans plan early to save, invest or insure for long-term
care (LTC). Consequently most people who need expensive LTC end up
depending on Medicaid, an under-funded, means-tested, public welfare
program.
Originally conceived as
a last resort for people in dire need, Medicaid has become the dominant
funder of long-term care for middle class and even affluent people, not
only the poor. By trying to do too much for too many, Medicaid has hurt
the poor. Decades of institutional bias and questionable access and
quality resulted from dismally low reimbursement rates. Programs for the
poor, as the adage goes, are poor programs.
Nor have more prosperous
people truly benefited from easy access to Medicaid LTC benefits. Lenient
and elastic eligibility rules mandated by the federal government enabled
them to dodge high LTC costs, but only at the expense of losing their
ability to choose their LTC providers, select their preferred level and
venue of care, and demand high quality care as private payers who can
change providers.
Today, on the cusp of an
unprecedented increase in older Americans most likely to need long-term
care, the United States faces exceptionally high debt and unfunded
entitlement liabilities, a weak economy despite years of fiscal and
monetary pump priming, and a populace more dependent on social insurance
and welfare programs than ever before.
But health and long-term
care expenditures have not yet exploded despite long and frequent warnings
they would. Public program cost and utilization projections within the
usual ten-year outlook window appear manageable. Deficit spending, enabled
by artificially induced low interest rates, defers short-term worries.
Complacency prevails. [No longer. Irresponsible fiscal and monetary
policies finally created excessive debt, higher interest rates and spiking
inflation.]
Lift your sights to
2050, only 35 years from now [27 years now], and all confidence about the
existing long-term care system should dissolve. But we face a dilemma like
the mythical Cassandra’s. She was blessed with accurate prognostication
but cursed to be disbelieved. The primary purpose of this report is to
take the longer view, enumerate the coming challenges, estimate the
current LTC system’s survivability, awaken greater concern and propose
corrective actions.
New Hampshire is an apt
harbinger of the country’s long-term care challenges. The state’s age 85
plus population will nearly quadruple in the next three and a half
decades. If its Medicaid long-term care expenditures for the elderly keep
pace they’ll increase from $282 million per year to $1,047 million, more
than one billion dollars every year. Sustainability at that level is
highly dubious.
What exactly are America
and the Granite State up against? To answer that question, we offer an
“Index of Long-Term Care Vulnerability” that lists the major challenges
and provides a way to measure, analyze and score their impact. We break
out aging demographics, future morbidity, Medicaid’s viability, federal
and state revenue sustainability, private financing potential, and
entitlement mentality as the key subjects for review.
We conclude that
America’s and New Hampshire’s long-term care service delivery and
financing systems - as currently operating and as they are most likely to
evolve - will not survive the coming demographic age wave and that radical
changes in federal and state laws and regulations are needed to align
consumer incentives with the need to finance future long-term care
adequately.
We recommend (1)
changing the system by which the federal government funds state long-term
care systems; (2) empowering states to experiment with different
approaches to long-term care financing; (3) reducing dependency on
government funding of long-term care by re-targeting scarce public
resources to the genuinely needy; and (4) incentivizing private long-term
care financing to encourage early planning, saving, investing and
insuring. …
We have plenty of
reasons to worry:
• The boomers start
coming of heavy-LTC-usage age 85 in 2031.
• Social Security and
Medicare run out of “trust funds” in the early 2030s, less than 20 years
from now. [Only a decade away now.]
• Gallup pollsters
report “51% of non-retirees doubt they will receive Social Security” and
“[t]wo-thirds say Social Security is in crisis or has major problems.”
• U.S. tax-generated
general funds will have to make up the entitlements’ annual shortfalls as
well as pay off the trust funds’ bonds (IOUs).
• Federal debt is $18.9
trillion and rising rapidly. [Now 72 percent higher at $32.6 trillion and
rising even faster.]
• Heavy taxation impedes
the economic activity necessary to generate needed tax revenue.
• The Federal Reserve
domestically and central banks internationally are pushing the limits of
their ability to expand credit in order to conceal economic malaise.
• Fiscal walls are
closing on the U.S. and world economies.
• Promiscuous spending
leads to impoverishment for individuals or families (sooner) and national
economies (later, because of their ability to manipulate currency).
• These lessons are
legion throughout history and around the world.
But there are “none so
blind as those who will not see,” so this report takes a wide-eyed look at
an expansive range of indicators in order to identify and score the LTC
system’s risk between now and 2050.
LTC Comment: The
analysis and warning presented in
Cassandra’s Quandary is more relevant and worrisome than
ever. That’s why we encourage you to consider it again and revisit the
“Index of Long-Term Care Vulnerability” it proposed as a tool to help wake
up doubters and resolve the quandary of LTC denial. The Center applied the
“Index of LTC Vulnerability” in three additional states in the mid-2010s.
Check out:
We are reviving the
Index of Long-Term Care Vulnerability as a tool to arouse interest and
concern about LTC again as we prepare to propose a new approach to a
solution. Stay tuned.
NB: If you try to open
the
Index of Long-Term Care Vulnerability and get this message as I do:
“Website blocked due to suspicious content,” just disregard it and click
“Continue to this website.” Rest assured, it is safe to do so.
#############################
Updated,
Monday, July 24, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-018 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
For Home Care
Providers, There’s Untapped Potential In Long-Term Care Insurance
-
The CLTC Digest
Quarter 3
-
Nursing care
has fastest-growing prices of healthcare sectors
-
Family
caregivers have fewer assets, more debt issues than non-caregivers
-
For some
Washington residents, the new WA Cares Fund may seem appealing. But
sticking with a private long-term care insurance plan might still be the
better option. Our expert has the details.
-
Alzheimer’s
among seniors is most common in these parts of the US, first-of-its-kind
data shows
-
Dementia
patients fared better in LTC facilities, not home, during pandemic, new
study shows
-
New Paragon
Study: The Harm of Delaying the Disenrollment of Medicaid Ineligibles
-
KFF: Only 29%
of Nursing Homes Would Meet 4-Hour Federal Staffing Mandate
-
Tax Advantaged
Strategies to Help Clients Plan for Long-Term Care
-
AHCA to White
House: Nursing home staffing mandate spells ‘disaster’
-
Republicans
want to make state's long-term care tax optional
-
Biden’s
long-term care agenda faces headwinds Workforce shortages: Medicaid
reimbursement rates make it hard to hire staff for long-term, home and
community-based care facilities
-
Is Work From
Home to Blame for Senior Housing’s Muted Recovery?
-
Independent
living program to aid hundreds of aging, disabled adults
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Friday, July 14, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTC BLOCK GRANT OR WAIVER POTENTIAL
LTC Comment: Consider
how a Medicaid block grant or waiver could improve long-term care, after
the ***news.***
*** 2023 MILLIMAN LONG
TERM CARE INSURANCE SURVEY: This 25th consecutive annual review of
stand-alone long-term care insurance (LTCI) authored by Claude Thau,
Nicole Gaspar, and Chris Giese, and published by Broker World
magazine is
available in the insurance trade journal’s July 2023 issue. More
discussion of worksite sales, including a comparison of worksite sales
distributions vs. non-worksite sales distributions will be in Broker
World magazine’s August issue. If you don’t subscribe to this
important industry source, fix that problem now
here. ***
LTC BULLET: LTC BLOCK
GRANT OR WAIVER POTENTIAL
LTC Comment: Medicaid
law encourages excessive federal and state spending and increases public
welfare dependency. These problems manifest in long-term care due to
federal financial participation (FFP) match rates that reward increasing
state expenditures and through generous financial eligibility policies
that discourage early, private LTC planning and subsidize reliance on
Medicaid when LTC is needed late in life.
Decades of federal and
state efforts to discourage Medicaid LTC expenditure growth by making
benefits harder to get, such as lower income and asset eligibility limits,
asset transfer restrictions, property liens and estate recoveries, failed
to achieve the objective of controlling costs. The rules were weak and
full of loopholes. The federal government did not enforce them. The states
did not implement them effectively. The media did not publicize them. So
the public continued to ignore LTC planning and rely on Medicaid when care
was needed driving costs higher and impairing care access and quality,
especially for the needy Medicaid is supposed to serve.
As long as these federal
rules prevail, nothing is likely to change. If new, worsening economic
conditions, including rising debt, deficits, interest rates and inflation
compel change, there are very limited options available politically.
Doubling down on earlier failed efforts to scare the public straight about
LTC by insisting on, but not enforcing, the risk that their life savings
are at stake, is futile. Completely eliminating Medicaid as a LTC safety
net that preserves middle class and affluent wealth could save the program
for the poor, but would prove difficult to implement politically unless
and until budgetary pressures compel its adoption. What might work
instead?
Over the years, two
ideas have received serious consideration that would allow experimentation
toward finding a solution to the LTC conundrum just described. One idea is
to “block grant” Medicaid, give states a limited amount of money to pursue
the program’s objectives, but allow them much more flexibility to set and
enforce eligibility controls. Another idea, long an option under federal
law, is to allow states to request and receive “waivers” of federal law
and regulations enabling them to experiment with new ideas and methods not
otherwise permissible. Neither approach has been tried in the endeavor to
control costs, preserve Medicaid LTC benefits for the needy, and encourage
personal LTC planning by the financially comfortable. But what if an
oncoming recession or depression compels more creative measures than in
the past? How could states configure LTC benefits under a block grant or
waiver?
Following is a proposal
I offered in “The
Long-Term Care Financing Crisis:
Danger or Opportunity?: A Case Study in Maryland”
(1995). It refers explicitly to using a block grant to achieve the
objective, but could as effectively be applied using a waiver as I
proposed in “Doing
LTC RIght” (2010). The waiver option is based on and inspired by Rhode
Island’s ingenious “global Medicaid waiver” designed, obtained and
administered by
Gary D. Alexander, then Secretary of the Rhode Island Executive Office
of Health and Human Services and currently head of the Medicaid and Health
Safety Net Initiative at the
Paragon Health Institute.
Note that the following
proposal refers mostly to nursing home care as that was the dominant venue
of care at the time, but it also explains how and why the plan will
encourage transition from institutional to home and community-based care.
See what you think of this approach and feel free to share your feedback
or questions with me at smoses@centerltc.com.
Long-Term Care Financing Under a
Medicaid Block Grant
Notes Toward a Model State Statute[1]
by
Stephen A. Moses
1.
Introduction
Medicaid is
known as the "pac-man" of state budgets and the "800-pound gorilla" of
long-term care. We all know something has to be done to control this
fiscally hemorrhaging giant.
On the
positive side, if Medicaid block grants pass this year [block granting
Medicaid received serious consideration in 1995], states will have the
authority for the first time to implement the proper corrective actions.
That is a tremendous incentive to prepare now to meet the risks and
opportunities that lie immediately ahead.
The big
questions public policy makers face are what to do and how to do it. We
cannot plot a course of corrective action until we understand completely
the mess we are in and how we got into it. The purpose of this paper is to
explain the problem, show how it developed and propose a solution.
Medicaid
nursing home expenditures nearly doubled between Federal Fiscal Year (FFY)
1988 and FFY 1993. Today, Medicaid pays for 73.7 percent of all nursing
home patient days in the United States. At least 85 to 90 percent of all
nursing home payments come from Medicaid, Social Security benefits
contributed by Medicaid patients toward their cost of care, Medicare, or
private patient income (not assets). Dozens of recent empirical studies
indicate that Medicaid "spenddown" is much lower than previously believed.
In fact, there is no evidence whatsoever of the much-touted, widespread
catastrophic spenddown.
Although
Medicaid is ostensibly a means-tested public assistance program, i.e.
welfare, evidence abounds that middle-class Americans and even the
well-to-do qualify easily for the program's nursing home benefits.
Congressional actions (in OBRA '93) to close Medicaid eligibility
loopholes and mandate estate recovery have had little effect because of
unforeseen weaknesses in the law, sluggish implementation by the states,
lukewarm enforcement by the Health Care Financing Administration, and
creative end-running by public and private Medicaid estate planning
attorneys.
Finally,
Medicaid has developed a dismal reputation for problems of access,
quality, reimbursement, discrimination, institutional bias, and welfare
stigma. How did America come to provide for the long-term care needs of
its proud, self-reliant World War II generation by consigning them to a
welfare program that is going bankrupt?
II.
Background
In 1965,
America was just starting to have a problem with long-term care. People
were living longer, but dying slower of chronic illnesses that caused
frailty and cognitive impairment. That was when a prosperous private
market in low-cost home and community-based services and long-term care
insurance might have developed in the United States. It did not.
Instead,
with every good intention, the new Medicaid program offered publicly
financed nursing home care. This subsidy confronted families with a very
difficult choice. They could pay out-of-pocket for the home care and
assisted living services seniors prefer or they could accept nursing home
care paid for by the government. Most people chose the safety and
financial benefits of the Medicaid option. Therefore, the market for home
care withered, private long-term care insurance expired stillborn, and
Medicaid-financed nursing home care flourished.
The nursing
home industry took full advantage of this situation. As fast as the
industry could build them, nursing home beds filled with Medicaid
residents. Stunned by the cost, Medicaid attempted to control the
construction of new beds with Certificate of Need (CON) programs on the
principle that "we cannot pay for a bed that does not exist." By the
mid-1970's, health planning for nursing homes was in full swing.
Capping
supply, however, only spurred the nursing home industry to drive up rates.
Government costs grew faster than ever. So Medicaid capped reimbursement
rates too. This compelled the nursing home industry to increase private
pay reimbursement rates to compensate. So began the highly problematical
differential between Medicaid rates and private pay rates. Today, Medicaid
pays only 80 percent of private pay rates on average nationally.
Higher
private rates made Medicaid more attractive to private payers and this led
to pressure on legislators to liberalize Medicaid eligibility. A long
process of eligibility bracket creep gradually made Medicaid nursing home
benefits available even to upper middle class people who had or could
obtain the expertise to manipulate eligibility rules. A whole sub-practice
of law--Medicaid estate planning--developed to take advantage of this new
opportunity.
With the
supply and price of nursing home beds capped by government fiat and with
Medicaid eligibility increasingly generous, nursing home occupancy
skyrocketed to 95 percent nationally. Nursing home operators realized they
could fill their beds easily with low-paying Medicaid patients no matter
what kind of care they offered. To achieve adequate operating margins,
however, nursing homes had to attract a sufficient supply of full-paying
private patients or they had to cut costs drastically.
If they
tried to attract more lucrative private payers with preferred treatment,
however, the nursing homes were deemed guilty of discrimination against
Medicaid patients. If they tried to cut costs instead, they came under
fire for technical violations or quality problems. In response, Congress
and state governments pressured the industry to provide higher quality
care without discriminating against low-paying Medicaid recipients. Given
its fiscal duress, however, Medicaid could not offer higher reimbursement
rates to achieve these goals.
Caught
between the proverbial rock and a hard place, the nursing home industry
put up a strong fight. Armed with the Boren Amendment, a law that requires
Medicaid to provide reimbursement adequate to operate an efficient nursing
facility, many state nursing home associations took the battle to court.
By now, however, state and federal Medicaid expenditures were rising so
fast and taxpayers were so reluctant to pay for growing public spending
that large increases in nursing home reimbursement were out of the
question.
In the
meantime, a wave of academic speculation in the late 1970's indicated that
paying for home and community-based services (HCBS) instead of nursing
home care could save a lot of money. For years, therefore, Medicaid
experimented with HCBS waivers as a cost-saving measure. In time, however,
hard empirical research showed that (desirable as they may be) home and
community-based services do not save money overall. Today, institutional
bias remains Medicaid's strongest cost containment tool and one of its
gravest deficiencies.
In a
nutshell, just as heavy demand was building for a private seniors housing
market in the 1960's, Medicaid co-opted the trend by providing easy access
to subsidized nursing home care. Confronted with a choice between paying
out-of-pocket for a lower level of care or receiving a higher level of
care at much less expense, seniors and their families made the predictable
economic choice. Not surprisingly, Medicaid nursing home caseloads and
expenditures increased rapidly and drastically. In response, Medicaid
capped bed supply and reimbursement rates, which led inevitably to
excessively high occupancy, private-pay rate inflation, discrimination
against low-paying Medicaid patients, and increasingly serious quality
problems. In time, Medicaid nursing home care acquired its reputation for
impeded access, doubtful quality, inadequate reimbursement, widespread
discrimination, pervasive institutional bias, and excessive cost. Medicaid
remains, however, the only way the middle class can pay for long-term care
without spending their savings. That is why so many otherwise independent
and responsible Americans end up dying in nursing homes on welfare.
III.
The Challenge
If the
foregoing analysis of the Medicaid malaise is accurate, a sensible
solution comes easily into focus. To facilitate universal access to top
quality long-term care for all Americans, a new, cost-effective,
block-granted, publicly financed, long-term care program should have the
following characteristics.
-
It should save
taxpayers money while improving access to quality long-term care for all
citizens;
-
It should encourage,
instead of discouraging, private financing of home and community-based
services and assisted living;
-
It should encourage,
instead of discouraging, the purchase of private long-term care
insurance to pay for all levels of extended care;
-
It should combine
generous eligibility criteria to protect the unprotected with strong
incentives for everyone to plan ahead for self-protection;
-
It should pay
market-based reimbursement rates to assure access to quality care for
all participants and to eliminate discrimination;
-
It should promote
strong market competition between providers of all levels of care;
-
It should maximize the
number of consumers in the marketplace who have a pecuniary interest in
getting the best possible care at the lowest possible price.
Is a single program that
combines all these features possible? Yes, but only if it is based on a
common understanding and agreement as to its goals and objectives. In the
course of numerous research studies over the past 12 years, I have found
almost universal consensus on the following ethical foundation.
IV.
The Moral High Ground
We
have very limited dollars available for public assistance. We must take
care of the truly poor and disadvantaged first. The middle class and
well-to-do should pay privately for long-term care to the extent they are
able without suffering financial devastation. Prosperous people who rely
on public assistance for long-term care should reimburse the taxpayers
before giving away their wealth to heirs. Seniors and their heirs who wish
to avoid such recovery from the estate should plan ahead, purchase private
long-term care insurance, and pay privately for the care of their choice
when the time comes.
What would a publicly
financed long-term care program based on this philosophical underpinning
look like?
V.
Model State Statute for a Senior Financial Security Program (SFSP)
(Rough draft state
statutory language is presented below in highlighted italics.)
The following are the key components of the program.
A.
Preserve generous eligibility
1.
Status Quo
Despite the
conventional wisdom that seniors must spend down their life savings to
receive Medicaid nursing home benefits, the truth is that most seniors
qualify easily regardless of income or assets.
Most state Medicaid
programs place no limit on how much income someone can have and still
qualify for nursing home benefits. If your total medical costs, including
nursing home care, approximate or exceed your income, you are eligible.
The well known $2,000
limit on assets is meaningless. Medicaid recipients can also keep exempt
assets of unlimited value, such as a home, a business, and a car. Married
folks have it even easier than single people. They can shelter an
additional $74,820 in assets and $1,870.50 per month in income. [These
figures are $148.620 and $3,715.50 respectively as of 2023 having nearly
doubled since 1995 due to inflation.]
For the truly
well-to-do, even these generous limits are easily overcome. Any competent
Medicaid planner can deliver Medicaid eligibility almost overnight to
practically anyone for less than the cost of one month in a private
nursing home.
Given Medicaid's
generous nursing home eligibility criteria, there is little wonder why
most Americans (1) fail to plan ahead for long-term care risk, (2) neglect
to purchase private long-term care insurance, (3) hesitate to spend their
own money on home care or assisted living, and (4) end up in nursing homes
subsidized by Medicaid.
2.
Senior Financial Security Program
Drastically cutting
Medicaid nursing home eligibility and coverage for the middle class is not
politically feasible. Strong senior interest groups would fight such cuts
aggressively and both private and legal services attorneys would tie such
a system in knots of litigation. Fortunately, it is not necessary to burn
the village in order to save it. The Senior Financial Security Program
preserves Medicaid's generous eligibility and coverage. This is the
program’s biggest political selling point.
3.
Model State Statute
"Seniors who
need nursing home care may qualify for the Senior Financial Security
Program if their income is inadequate to pay for such care and if their
assets do not exceed $2,000 plus certain exempt resources enumerated
below.
"To qualify for
assistance, however, every participant must provide a net worth statement
confirmed by a certified public accountant. This net worth statement
constitutes security offered by program participants to assure repayment
of benefits received. As the participant receives benefits, the cost to
the SFSP will be deducted from the participant's net worth ledger. As long
as the ledger has a positive balance, the program participant is in
receipt of a government-sponsored loan. When the ledger's balance turns
negative, the participant converts to 'public assistance.'
"Exempt assets
that SFSP participants may retain are similar to those permitted by the
traditional Medicaid program with a few additional limitations.
"Home: no limit
on value for one single-family residence, however, expensive homes
purchased (or additions constructed) within eight years of applying for
benefits will be treated as a transfer of assets to qualify (see transfer
of assets restrictions below).
"Automobile:
one car of any value provided it is actually used for the benefit of the
program participant. Transfer of an automobile, even though exempt, will
be deemed a transfer of assets subject to penalty. Program participants
may not give away exempt assets and replace them with new exempt assets as
a means to qualify for assistance or avoid estate recovery.
"Funeral plan:
one prepaid funeral plan, not to exceed the average cost in the state of a
simple service and disposal of remains (perhaps $2,500). Program
participants may not shelter tens of thousands of dollars in burial plans
as a means to qualify for assistance.
"Other exempt
resources and limitations to be delineated."
B.
Prohibit divestiture
1.
Status Quo
Under the existing
Medicaid program, anyone who transfers assets three years [now five years]
before applying for assistance can give away any amount of money and
qualify with no questions asked. Unfortunately, the average period of time
from onset to death in Alzheimer's Disease is eight years. If the family
transfers her assets the first time Grandma forgets to turn off the stove,
they guarantee her unlimited Medicaid nursing home benefits three years
later with no expense or inconvenience.
Today, many Medicaid
estate planning attorneys advise their clients and colleagues to initiate
a "gifting strategy" years in advance in order to assure easy Medicaid
eligibility. Such a strategy may include many tactics including outright
gifts, establishment of trusts, retention of life estates, purchase of a
partial interest in adult children's homes, and conversion of non-exempt
into exempt assets. The options are limited only by the imagination of the
Medicaid planner.
2.
Senior Financial Security Program
The SFSP cannot
protect generous eligibility and survive without eliminating divestiture
planning altogether. Seniors and their heirs must get the message very
clearly that long-term care is an enormous financial risk, that people
should save and insure throughout their lives to protect against this
risk, and that giving away assets for any reason at a time when the
long-term care risk is at its peak is a very dangerous proposition.
Of course, by
birthright, any American is free to dispose of his assets in any way he
wishes and at any time. One must no longer be allowed, however, to give
away one's wealth in order to compel other Americans to provide oneself
with expensive long-term care benefits.
Adult children, other
relatives, friends and charities to whom older people give away income or
assets must realize that if such a gift leaves seniors unable to pay for
their own care and dependent on the public dole, that the state will seek
restitution.
3.
Model State Statute
"Any assets
transferred for less than fair market value within eight years of applying
for assistance constitute a debt owing the state (up to the total public
benefits paid) and such debt is payable by the transferees who received
the assets and/or by the estate of the program participant or by such
persons who may have received the assets by means other than a formal
probated estate. Any asset transferred in contemplation of qualifying for
the SFSP or of avoiding estate recovery shall be considered a fraudulent
conveyance.
"A transfer of
assets is any divestiture of purchasing power including but not limited to
gifts, purchase of exempt assets, divorce, purchase of unsalable or
undividable property, divestment into trusts, converting assets into joint
tenancy, etc.
"The intent of
this provision is to assure that no purchasing power possessed within
eight years of application by anyone who later depends on the SFSP shall
be used for any other purpose than the care and maintenance of the owner
or reimbursement to the SFSP for providing such care and maintenance.
"If any
purchasing power shall have been taken from an SFSP participant improperly
or illegally, the program shall petition the appropriate court to appoint
a private attorney as the participant's conservator (reimbursed on
contingency) to recoup the misappropriated assets on behalf of the
participant and the program. Such recoupment may include relitigating
abusive divorce decrees, reversing improper asset transfers, invading
inappropriate trusts, and partitioning undivided property."
C.
Require legal security as a condition of eligibility
1.
Status Quo
Exempt assets
divested legally or illegally while on Medicaid are lost forever as a
source of long-term care financing for seniors. Nor can such divested
resources serve as a non-tax revenue source to the program. Under the
existing Medicaid program, states are permitted but not required to place
liens on the homes of recipients under certain highly restrictive
circumstances. Very few states use the lien authority to secure assets for
later recovery. Even states that utilize liens have limited success
enforcing and collecting on them because of extensive exclusions in the
federal law. Consequently, exempt and non-exempt assets held openly or
concealed by Medicaid recipients routinely disappear during the period of
eligibility either legally or illegally as relatives, friends and others
take advantage of the senior's incapacity to relieve them of their
resources.
2.
Senior Financial Security Program
No competent
financial institution will extend a loan of hundreds of thousands of
dollars to anyone without requiring security. The government can no longer
afford to do so either. People who expect to depend on the SFSP while
preserving substantial income and assets for the support of their
dependents must realize and agree that they lose some measure of control
over these resources in the process.
Of course, all
citizens have the option to use their income and assets as they see fit.
For example, they can sell their homes and cars to pay privately for
long-term care if they choose. But if they prefer to use a public program
to pay for their care, they must recognize the obligation to encumber
their resources for later recovery, after the resources are no longer
needed by their legitimate surviving dependents.
3.
Model State Statute
"As a condition
of eligibility for the SFSP, all participants must allow the state to
place a lien on their exempt property. The lien shall apply to all real
and personal property retained by the participant with the exception of
the $2,000 liquid asset exclusion and certain highly private personal
property such as original wedding rings.
"Such liens
shall be officially recorded in the appropriate legal manner and shall be
enforceable upon sale of the asset or upon the death of a program
participant, or if the participant is survived by a legitimate dependent,
upon the death of the last surviving exempt dependent relative (to be
defined).
"Nothing in
this statute shall be construed in any way to prohibit or prevent an SFSP
participant from disposing of his property in any way he sees fit. The
sole purpose is to assure that his creditor, i.e. the state in the form of
the SFSP, knows of the transaction, can recover benefits paid as
appropriate, and can terminate eligibility if appropriate."
D.
Require estate recoveries
1.
Status Quo
For most of the
history of the existing Medicaid program, nursing home recipients could
preserve unlimited exempt assets in the form of homes, cars and personal
property and pass this wealth to their heirs completely unencumbered. It
was not until the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA
'82) that Congress gave state Medicaid programs the authority to recover
from recipients’ estates. It was not until the Omnibus Budget
Reconciliation Act of 1993 that Congress required estate recoveries.
Consequently, few states have so far implemented strong, cost-effective
estate recovery programs.
2.
Senior Financial Security Progra
As long as Americans
can ignore the risk of long-term care, avoid the premiums for private
insurance, wait to see if they ever need to go to a nursing home, and if
so, get the government to pay while still passing all their wealth to
heirs, most people will not pay for their own care and public costs will
continue to explode. Extensive research indicates that states can save
five percent or more of the cost of their nursing home programs by
recovering benefits paid from the estates of deceased recipients. The
potential liability of estate recovery provides a huge incentive for
future generations to insure privately or pay for less expensive, lower
levels of care in the private marketplace in order to avoid or postpone
exorbitant nursing home costs. By requiring and strictly enforcing estate
recovery, the SFSP assures that those participants, who are able, pay
their own way thus preserving their dignity. It is not welfare if you pay
it back.
3.
Model State Statute
"Every
participant in the Senior Financial Security Program must agree in writing
to pay back the entire cost of care from his or her estate or from the
proceeds of sale of real or personal property during program eligibility
up to the total value of the estate or sale. If the program participant
should predecease a spouse or other legitimate, dependent heir or joint
tenant, the participant's share of any jointly owned property or
purchasing power shall be recovered from such third party as soon as it is
no longer needed for the maintenance of the dependent, and in any case, no
later than upon the death of the dependent third party.
"It is
expressly understood that the term 'estate' is not limited to the formal
probated estate, but includes all purchasing power held by the program
participant within eight years of applying for the SFSP in whatever form
it passes to another before or after program participation and later
death.
"The intent of
this rule is to assure that people pay for their own long-term care,
either directly by retaining providers in the private marketplace or
indirectly by reimbursing the Senior Financial Security Program. The
financial viability of the SFSP and its ability to provide care to less
fortunate participants depends on strong estate recovery enforcement."
E.
Encourage home and community-based services and long-term care insurance
1.
Status Quo
As explained in the
background section of this paper, Medicaid extinguished the private
markets for home and community-based services (HCBS) and long-term care
insurance when it began providing subsidized nursing home care in 1965.
Later efforts to retrofit HCBS and encourage private insurance, i.e.,
Medicaid waivers and public/private partnerships respectively, have proven
to be too little too late. With all its resources sucked into the black
hole of institutional long-term care, state Medicaid programs have been
unable to fund the HCBS waivers adequately. With regard to long-term care
insurance: people do not buy apples on one side of the street when they
can get them for free on the other.
2.
Senior Financial Security Program
By prohibiting
divestiture of assets to qualify, by requiring liens on all property as a
condition of eligibility, and by mandating recovery from estates of every
program participant who retains exempt assets, the SFSP creates an
enormous incentive for future generations to plan ahead, buy insurance,
pay privately for home care or assisted living, and avoid as long as
possible starting the meter running for publicly financed nursing home
care. Nevertheless, the SFSP should make this goal explicit in the
program's statutory language.
3.
Model State Statute
"The purpose of
the Senior Financial Security Program is to protect those who are unable
to take care of themselves. The program does not replace any individuals'
responsibility to provide for their own long-term care. Program
requirements that prohibit divestiture of assets, require security for
benefits paid, and mandate recovery from estates are expressly intended to
encourage all citizens to plan ahead, purchase quality long-term care
insurance, pay privately for appropriate, cost-effective levels of care,
and rely on the Senior Financial Security Program only as a last resort."
F.
Educate the public
1.
Status Quo
The main reason
that Medicaid nursing home costs have grown explosively for 30 years is
that the program desensitized the public to the risk and cost of long-term
care. Most people today do not know who pays for long-term care. Medicare,
Medicaid or Santa Claus, why should it matter? All the public knows for
sure is that someone must pay, because they hear few genuine anecdotes of
catastrophic spenddown and they never see Alzheimer's patients wandering
the streets with nowhere to go and no one to take care of them. Until
Americans understand and internalize the risk of long-term care, they will
not plan ahead to protect themselves against it and they will continue to
end up in nursing homes on Medicaid.
Extensive research
over the past 12 years suggests that Medicaid nursing home expenditures
could be reduced by as much as 15 to 20 percent by persuading the public
to pay privately for long-term care either out-of-pocket or by means of
insurance coverage.
2.
Senior Financial Security Program
The big challenge to
public policy is to provide a long-term care safety net that protects the
frail and vulnerable without discouraging the hale and able from planning
ahead to take care of themselves. The SFSP achieves this objective by
building a downside risk into reliance on public financing of long-term
care, i.e. the lien and estate recovery liability, and by
aggressively promulgating information about the probability, cost, and
personal responsibility of long-term care. To assure that this critical
feature of the program is not neglected, the SFSP model statute expressly
incorporates a non-tax revenue source to support it.
3.
Model State Statute
"Ten percent
(or such proportion as shall be necessary to achieve the objective) of the
revenue generated by Senior Financial Security Program's lien and estate
recovery efforts shall be used exclusively to support a public education
initiative on long-term care. The purpose of this initiative is to educate
the public, the medical profession, the bar, the judiciary, financial
advisors, and all other individuals in the community who influence the
lives of older people, concerning the importance of long-term care
planning. Such education and training will include but not be limited to
(1) the probability of requiring long-term care, (2) the average
incidence, duration and cost of nursing home care, (3) the principles of
how to identify and select a reliable long-term care insurance policy, (4)
the kinds of free and fee-for-service assistance available to postpone
institutionalization (e.g., meals on wheels, chore services, adult day
care, congregate care, assisted living, etc.), and (5) the eligibility,
lien and estate recovery requirements associated with dependency on the
Senior Financial Security Program.
"The purpose of
this education program is to assure that no one in the state turns 50
years of age without having received complete information on long-term
care risk and on all of the private options available to plan for it."
VI.
Conclusion
Fully
implemented and aggressively enforced, the Senior Financial Security
Program will empower any state to assure universal access to top quality
long-term care for rich and poor citizens alike across the entire
continuum from home and community-based services to sub-acute nursing home
care while simultaneously saving the taxpayers money and enhancing the
private market for all long-term care providers and insurers.
The goal of
the program should be to provide eligibility and coverage equal to or
better than conventional Medicaid nursing home benefits at no more than 80
percent of the former cost. In 1993 dollars, this constitutes a savings to
taxpayers of approximately $5 billion per year nationally.
Stephen A. Moses is
Director of Research for LTC, Incorporated, a private firm in Seattle,
Washington specializing in long-term care financing and insurance. He
served as a career federal employee for 18 years, mostly with the Health
Care Financing Administration which administers Medicaid and Medicare.
#############################
Updated,
Monday, July 10, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-017 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Alzheimer’s
drug Leqembi has full FDA approval now and that means Medicare will pay
for it
-
State factsheet
not helpful for long-term-care crisis
-
A Closer Look
at the Five Largest Publicly Traded Companies Operating Medicaid Managed
Care Plans
-
‘Astronomical’
Medicare Advantage Denials, Pre-Auth Issues Cause Outcry from Nursing
Homes
-
Retirees are
underestimating how long they will live
-
Medicare
Advantage retaining sicker patients with more complex health needs:
study
-
Ages 55-Plus
Control Three Quarters Of U.S. Investable Assets, But Assets Aren’t Main
Driver For Retirement: Net equity in real estate jumps; taxable now
outpaces retirement assets
-
Dollars spent
on HCBS go further than those spent on nursing homes, study finds
-
Nursing home,
home health fast-growing health spending categories
-
Washington
State Long-Term Care Insurance Program to Launch Saturday
-
Majority Of
Americans Have Taken A Financial Hit Due To Rising Interest Rates
-
LTC workers
need higher wages, better training now that society’s applause has
ended: report
-
TOMORROW:
Medicaid Redeterminations: Setting the Record Straight
-
Medicaid Long
Term Care Update
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Friday, June 30, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: THE LTC NARRATIVE
LTC
Comment: The dominant long-term care narrative crowds out inquiry,
critical reasoning and creativity leaving conformity and groupthink. We
explain after the ***news.***
***
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LTC
BULLET: THE LTC NARRATIVE
“A
dominant narrative is an explanation or story that is told in service of
the dominant social group’s interests and ideologies. It usually achieves
dominance through repetition, the apparent authority of the speaker (often
accorded to speakers who represent the dominant social groups), and the
silencing of alternative accounts. Because dominant narratives are so
normalized through their repetition and authority, they have the illusion
of being objective and apolitical, when in fact they are neither.”
College of Literature, Science and Arts, University of Michigan
LTC
Comment: Most LTC researchers remind me of the fish who asked “What is
water?” They are so steeped in the “LTC narrative” that they don’t see,
consider or question anything else. What is the LTC narrative? It goes
something like this:
Long-term care is a huge risk and cost that can and does wipe out the life
savings of huge numbers of aging Americans. Medicaid is the only option
that helps people who need expensive, extended, custodial care. But
Medicaid requires impoverishment and has a dubious reputation for care
access and quality. So, therefore, America needs a new compulsory,
payroll-funded social insurance program similar to Medicare to pay for
long-term care.
Nothing in the LTC narrative is true. There is no evidence that LTC
frequently wipes out life savings and researchers cite none. Medicaid is
not the only option for long-term care; people could save, invest or
insure for LTC risk, but few do. Why not? Medicaid does not require
impoverishment. That is a myth. Medicaid allows recipients to have income
up to the monthly cost of a nursing home and to retain practically
unlimited exempt assets. No new LTC entitlement program is needed nor
desirable. Rather, we should fix the one, Medicaid, we already have.
Although nothing in the LTC narrative is true, most LTC researchers take
it for granted. Why? It fits their ideological prejudice against free
markets and in favor of government financing and control. How? They affirm
the LTC narrative by ignoring or misrepresenting all evidence to the
contrary, by redefining or misinterpreting data to fit the narrative, and
by equivocating on key terms such as impoverishment, spend down,
out-of-pocket expenses and Medicaid planning.
How
do LTC researchers ignore or misrepresent evidence that contradicts the
LTC narrative? They pretend that Medicaid financial eligibility rules
require impoverishment when the truth is that income rarely stands in the
way of qualification for LTC benefits and applicant/recipients may retain
virtually unlimited non-countable assets, including very large home
equity, one vehicle, a business, personal belongings and home furnishings,
even retirement savings accounts. LTC researchers rarely acknowledge the
vast legal literature on methods to circumvent Medicaid financial limits
and qualify the affluent who possess even much greater wealth. If they do
concede that Medicaid planning occurs, they disingenuously pretend it is
limited to asset transfers, a method far less common and significant than
other, more frequent and important techniques of artificial
self-impoverishment, such as the purchase of exempt assets.
How
do LTC researchers redefine or misinterpret data to fit the LTC narrative?
To promote the misconception that elders all across the country are
spending down into impoverishment for LTC, it helps if out-of-pocket LTC
expenditures appear high and Medicaid expenditures appear low. That
supports the LTC narrative that long-term care is wiping out people’s
savings, that Medicaid does not do enough to help, and that, therefore, a
big new government program is needed. So LTC researchers try to make
out-of-pocket LTC costs appear higher than they actually are, as high as
50 percent, by including room and board expenses in assisted living or
residential care facilities’ LTC spending tallies. But people incur room
and board costs whether or not they need or receive LTC.
The
Centers for Medicare and Medicaid Services (CMS) are also complicit. The
agency changed the definition of nursing home services to include
Continuing Care Retirement Communities in 2011. That change deceptively
made Medicaid expenditures look lower and out-of-pocket costs appear
higher because CCRCs are almost entirely private-pay. In fact, Medicaid’s
share of nursing home expenditures has been going up and out-of-pocket
expenditures, down for decades. Full price out-of-pocket private pay SNF
revenue has collapsed to only seven percent leaving nursing homes heavily
dependent on Medicaid’s notoriously inadequate reimbursements. But you
wouldn’t discern that in CMS’s biased reporting.
How
do LTC researchers equivocate on key terms of art to validate the LTC
narrative?
(1)
They insist Medicaid requires “impoverishment” when the truth is that
people need only a cash flow problem, e.g., too little income to afford
long-term care privately, to qualify. Medicaid’s role in long-term care
financing is that it reduces the risk and cost of long-term care
substantially, not that it impoverishes people.
(2)
The LTC researchers equivocate on the meaning of “spend down.” They often
imply and sometimes assert incorrectly that Medicaid requires applicants
to spend down countable resources for health or LTC expenses to qualify.
But Medicaid has no such requirement. People may spend down countable
assets to purchase and retain exempt assets, thus qualifying for LTC
benefits while preserving wealth. Purchase of exempt assets is the single
most common method of Medicaid planning and is almost universally
practiced by applicants with excess countable assets.
(3)
LTC researchers prevaricate on terms like “out of pocket,” spend down and
impoverishment, when they misrepresent data from their main data sources,
the Health and Retirement Study (HRS) and its auxiliary, the Asset and
Health Dynamics among the Oldest Old (AHEAD) study. The HRS and AHEAD
studies are often cited as proof older Americans spend down for long-term
care until impoverished and thus become eligible for Medicaid LTC
benefits. But neither of those data sources provides any information about
how elders’ decumulate wealth. They only show that wealth declined and a
transition to Medicaid eligibility occurred. Such transitions could as
well and as likely have occurred due to purchase of exempt assets as to
LTC spend down.
In
conclusion, the LTC narrative reflects the dominant scholarly social
group’s ideological bias in favor of compulsory government social
insurance and against free market competition. The narrative prevails due
to constant repetition, the unchallenged authority of its “experts,” and
by silencing other accounts. Because no other analyses or evidence can
penetrate the LTC narrative’s peer-review barricade, it has the illusion
of being objective and apolitical, when it is neither. Unless and until
critics deconstruct the LTC narrative and replace it with consistent,
principled analysis and recommendations, little success in the
decades-long effort to improve LTC services and financing will occur.
#############################
Updated, Monday, June 26, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-016 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Russian hackers
expose information of 2.5 million Genworth customers
-
A blow to CMS’s
credibility … thank goodness
-
ChatGPT and
Beyond: How Artificial Intelligence is Shaping the Future of Nursing
Home Operations
-
Americans pay
$17.5 billion to support parents in a year
-
Should State
Long-Term Care Insurance Funds Invest In Stocks?
-
Ben Veghte: As
long-term care needs grow, WA Cares offers long-term solution for
working Washingtonians
-
Medicaid
changes could help assisted living help more older adults
-
‘Harmful Yet
Largely Invisible:’ Resident Fear of Staff Highlighted in Recent Report
-
Workers in
Germany will soon pay more for long-term care insurance
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, June 19, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-015 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Medicare spending expected to top $1
trillion this year, CMS says
-
What to Know About Buying Long-Term Care
Insurance
-
Long Term Care Insurance & Inflation
-
White House asks states to pump the brakes
on Medicaid disenrollment
-
UC Davis Health launches new geriatric
division
-
New tool detects falls 32 days before they
happen
-
It’s no better in 16 years of long-term
care study in SD
-
Public Long Term Care Insurance Programs
-
Social Security COLA Estimated at 2.7% for
2024 as Inflation Cools
-
New long-term care solution for couples
eliminates the guesswork of who will need care: Nationwide CareMatters
Together is the first cash-indemnity, linked benefit solution designed
for two lives
-
Researchers identify home health fraud
patterns across U.S.
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, June 16, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC BULLET:
THE MEDICAID SPEND DOWN BULLETS
LTC Comment:
Does it matter whether Medicaid spend down actually occurs? We’ve explored
and answered that question and covered related issues in 25 years of
LTC Bullets. Find them all archived chronologically and by subject
here.
LTC BULLET:
THE MEDICAID SPEND DOWN BULLETS
LTC Comment: The fallacy
that eligibility for Medicaid LTC benefits requires catastrophic spend
down of life savings is endemic in the academic and popular literature on
long-term care financing. Most of the Center for Long-Term Care Reform's
1,358 LTC Bullets published since 1998 bear on identifying and
correcting that error in one way or another. Following is a small sample
of Bullets that debunk and/or explain the consequences of assuming
falsely that Medicaid forces LTC spend down. Bottom line, if Medicaid
really did require asset spend down, the public would not be so blasé
about LTC risk and cost; more people would plan ahead for LTC by saving,
investing or insuring; much more private revenue at market rates would
flow through to LTC providers who could then provide better care access
and quality; fewer people would need public welfare as a last resort LTC
payer; and families would feel the burden of caregiving less with far more
elders prepared to receive paid home care. For our long series of LTC
Bullets correcting errors about LTC financing made by financially
well-endowed think tanks, advocacy organizations, government agencies and
the media that broadcast their messages, see
LTC Bullet: Still Standing Guard.
The Medicaid Spend
Down Bullets
LTC Bullet: How to Unleash Long-Term Care Insurance and Assisted Living,
June 15, 1999
LTC Comment: We highlighted the importance of Medicaid spend down
in this early Bullet. “A public financing system should be
implemented that guarantees every American access to quality care at the
appropriate level in the private marketplace, but requires the quid pro
quo that financial assistance in obtaining such care constitutes a
dollar-for-dollar spend down of one’s estate assets payable after death.
Only with this kind of system can an incentive be created that is strong
enough to persuade the financially able to take responsibility for
themselves so that publicly financed programs can be saved to serve those
who cannot provide for themselves.”
LTC Bullet: HCFA Data Easily Misconstrued, February 23, 2000
LTC Comment: This LTC Bullet disproved the common notion
“that out-of-pocket nursing home expenditures are destroying the life
savings of huge numbers of older Americans.” It became the model for our
2004 to 2022 series titled “So What if the Government Pays for Most
Long-Term Care?” Find those 19 annual updates of newly reported CMS data
here by searching for “So What?”
LTC Bullet:
"Nursing Home Care Virtually Free For Life," May 7, 2002
LTC Comment: While researchers claimed LTC costs wiped out life
savings across the U.S, this Bullet showed how easy that tragic
spend down outcome was to avoid. “What follows is a transcription of
excerpts from a professionally produced and mass-distributed videotape.
The tape is an advertisement for a man and his company who promise
‘nursing home care virtually free for life.’ This financial miracle worker
proudly proclaims that he is not an attorney, a financial planner, nor,
perish the thought, an insurance agent.”
LTC Bullet:
New LTC Expenditure Data Provide Clues to Low LTCI Sales and LTC
Facilities' Financial Woes, January 14, 2003
LTC Comment: This is another precursor of what became the “So
What?” series described above. It explains how the lack of real Medicaid
LTC spend down accounts for dysfunctions in the LTC service delivery and
financing system. “Heads up! We're about to explain why long-term care
insurance sales have been disappointing and why the nursing home and
assisted living industries are in such a woeful financial condition. The
explanation is complicated, but hey, if it were simple, everyone else
would have figured it out already.”
LTC Bullet: GAO on TOA Underwhelms, October 5, 2005
LTC Comment: We observed that the Government Accountability
Office's "letter report" titled "Medicaid:
Transfers of Assets by Elderly Individuals to Obtain Long-Term Care
Coverage" “disappoints in many ways. It asked the wrong questions. It
used the wrong methods. It searched the wrong data. And, consequently, it
provides little new information of value.” For example, its “trite
observation that people ‘can’ quickly spend down for nursing home care
begs the question ‘Do they?’ Answer: there is no evidence of widespread
nursing home spend down. All but 10 to b15 percent of total nursing home
costs are accounted for by direct or indirect government financing and
personal income, not assets.”
LTC Bullet: Who Still Gets Medicaid LTC Without Spending Down?,
April 20, 2006
LTC Comment: Even after the Deficit Reduction Act, the vast
majority of seniors who need long-term care can get it from Medicaid
without spending down their own assets for care. The DRA limited home
equity for the first time and extended the lookback period for asset
transfers to five years. But the home equity limit it imposed ($500,000 to
$750,000) excludes almost no one; the five year lookback is too short to
make a difference given the slow onset of Alzheimer’s Disease; and most
people qualify for Medicaid LTC benefits without spending down wealth
anyway based on the program’s generous and elastic financial eligibility
rules.
LTC Bullet: Spousal Refusal Robs Taxpayers and the Poor,
December 14, 2010
LTC Comment: Medicaid financial eligibility rules are so generous
that most people qualify without using Medicaid planning techniques to
avoid spending down their savings. But some married couples with even
higher income and assets dodge even those lenient rules to shelter much
more wealth. This Bullet describes the “squalid practice” of
“spousal refusal” used mostly in New York and Florida.
LTC Bullet: Nursing Home Spend Down Misunderstood and Late-Breaking
LTCI Industry News, July 20, 2012
LTC Comment: A recent Employee Benefit Research Institute (EBRI)
study that claims nursing home stays are wiping out Americans’ savings is
based on a fallacy and mistaken. Author Sudipto Banerjee assumes without
evidence that people must and do spend down their life savings for
long-term care before they become eligible for Medicaid LTC benefits. We
explain that (1) Medicaid does not require such spend down, (2) there is
no evidence in the source cited that it occurs, and (3) how people can and
do qualify for Medicaid LTC benefits without spending down their wealth
for care.
LTC Bullet: Medicaid Spend Down that Isn’t and Why it Matters,
July 19, 2013
LTC Comment: Claiming “transitions” to Medicaid are evidence of
catastrophic LTC asset “spend down” misrepresents the truth and should be
publicly recanted. This Bullet explains who, what, when, where and
why. It reviews two articles titled “Medicaid Spend Down: New Estimates
and Implications for Long-Term Services and Supports Financing Reform” and
“Medicaid Spend Down: Implications for Long-Term Services and Supports and
Aging Policy,” and concludes “What these papers call ‘spend down’ is
nothing more than ‘transition’ from non-Medicaid status to Medicaid
eligibility. Neither the articles nor the research they report contain any
measurement whatever of money actually spent for health care, long-term
care or anything else.”
LTC Bullet: Is it Spend Down or Medicaid Planning?, July 14,
2017
LTC Comment: A lot of what passes for Medicaid “spend down” in the
scholarly literature is really Medicaid planning. We explain, give
examples, and critically review an often-cited article that argues the
opposite by economist Norma B. Coe titled “Financing
Nursing Home Care: New Evidence from Spend Down Behavior,” Tilburg
University, 2007.
LTC Bullet: Retirement Confidence and Asset Spend Down, April
27, 2018
LTC Comment: We review “Asset
Decumulation or Asset Preservation? What Guides Retirement Spending?,”
by Sudipto Banerjee, in which he challenges the assumption “that retirees
will spend down their accumulated assets to fund their retirement needs”
and concludes there are several complicated reasons why people decumulate
assets slowly in retirement or not at all. We offer a simpler explanation:
“[C]atastrophic spend down for long-term care is a myth because Medicaid
pays for most expensive LTC, exempts most assets, is easy to get after
care is needed without spending down assets significantly and only
requires income as the patient’s contribution to the cost of care.
Consequently, after decades living in retirement, most people at most
levels of wealth, spend down very little.”
LTC Bullet: LTC Bankruptcy, March 4, 2022
LTC Comment: Clare Ansberry describes
a heartrending case of long-term care spending unto impoverishment in “Caring
for Older Relatives Is So Expensive That Even AARP’s Expert Filed for
Bankruptcy” (Wall Street Journal,
2/20/22). We explain that tragic stories like that are very uncommon,
because catastrophic spend down to qualify for Medicaid LTC is
unnecessary. It is common, although unwise, to extrapolate from such
anecdotes to the conclusion that a new government entitlement for LTC is
needed.
LTC Bullet: Biased LTC Scholarship Misinforms Policymakers,
September 2, 2022
LTC Comment: Many “progressive” analysts equivocate on terms like
“impoverishment,” “spend down,” “Medicaid planning,” and “out of pocket.”
They do not interview the right people to learn how individuals qualify
for Medicaid without spending down personal wealth and they rely on widely
accepted data sources that are actually highly dubious in this regard (HRS
and AHEAD). Such analysts ignore or misrepresent important facts and
emphasize only information that confirms their biases. We analyze a case
in point: Richard W. Johnson and Melissa M. Favreault, “Economic
Hardship and Medicaid Enrollment in Later Life: Assessing the Impact of
Disability, Health, and Marital Status Shocks.”
LTC Bullet: LTC Strawman, September 30, 2022
LTC Comment: Critics claim self-impoverishment by high net worth
people to qualify for Medicaid is uncommon. But disproving a claim no one
has ever made contributes nothing to a crucial conversation about who
should qualify for Medicaid LTC benefits, when and under what
circumstances. The right question the same critics ignore is “Do most
people need to spend down their life’s savings for long-term care before
they can get help from Medicaid?” The answer to that question is “No.”
LTC Bullet: What if Most People Don’t Spend Down for Medicaid LTC?,
June 2, 2023
LTC Comment: This Bullet (1) shows how people through and
including the fourth wealth quintile qualify for Medicaid LTC benefits
without spending down for care, (2) debunks the idea that people don’t
know how to qualify for Medicaid without spending down or don’t take
advantage of Medicaid due to a sense of responsibility or shame, (3)
argues that if we take into account wealth people already have that goes
unused for LTC, the need to save, invest or insure for this risk would be
vastly reduced, and (4) concludes that we do not need a huge new payroll
funded compulsory social insurance program for LTC.
#############################
Updated,
Monday, June 12, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-014 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
New York
Regrets How It Regulated Long-Term Care Insurance Rates
-
My Child Helps
Pay My Bills. Do I Need to Tell Medicaid?
-
The Nation's
Fiscal Health: Action Needed to Address Projected Unsustainable Debt
Levels
-
Setting the
Record Straight on Medicaid Redeterminations
-
‘New retirement
reality’ undermines planning, survey finds
-
WA Cares
investment meeting talks money, mentions renewed website
-
What Should We
Do About Medicare?
-
The Future of
Assisted Living: AI in Elderly Care
-
‘Impetus’
ignored: LeadingAge CEO calls on Congress, White House to act on broader
threats to long-term care
-
Social Security
and Medicare Are Ticking Time Bombs
-
Americans
refocusing on future amid decline in financial readiness for retirement:
analysis
-
Ensuring
Resident Coverage During the Medicaid Unwinding
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Friday, June 2, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: WHAT IF MOST PEOPLE DON’T SPEND DOWN FOR MEDICAID LTC?
LTC
Comment: Analysts make long-term care financing look very bleak—and
therefore in need of a big, new government program—by ignoring Medicaid’s
huge, damaging role. Why, how, and what to do about it, after the
***news.***
***
2023
SPOUSAL IMPOVERISHMENT NUMBERS
are out. Center members can find them for this year and every other year
back to 1991 in our “members
only zone.”
You’ll need your user name and password to access The Zone. Contact
damon@centerltc.com
for a reminder or to join and get a UN/PW. These new numbers reflect a
8.2% cost of living increase. Here are some highlights: The Medicaid home
equity exemption is now at least $688,000 and as high as $1,033,000 in
some states. The Community Spouse Resource Allowance that started at
$60,000 in 1988 is now $148,620. The Maximum Monthly Maintenance Needs
Allowance that began at $1,500 when the Medicare Catastrophic Coverage Act
of 1988 ended Medicaid spousal impoverishment is now $3,715.50. For
insights on what these numbers mean for LTC financing policy and Medicaid
spend down risk, read the rest of today’s LTC Bullet. ***
LTC
BULLET: WHAT IF MOST PEOPLE DON’T SPEND DOWN FOR MEDICAID LTC?
LTC
Comment: The
National Council on Aging
(NCOA) and
The
LeadingAge LTSS Center @UMass Boston
published an Issue Brief titled “The
Continued Toll of Financial Insecurity in Retirement”
in February. Its authors include Rocki Basel, PhD and Susan Silberman, PhD
of NCOA; and Jane Tavares, PhD, Marc Cohen, PhD, and Molly Wylie, MS of
the LeadingAge LTSS Center.
One
of the authors, Marc Cohen, is a longtime friend and fellow LTC analyst.
NPR interviewed him about the new report in a piece titled “The
cost of long-term care in the U.S. is outpacing the income and savings of
older adults.”
Marc summarized the Issue Brief’s dismal findings and concluded “that
middle-income Americans are particularly vulnerable due to a lack of
affordable care options. And for those earning too much to qualify for
Medicaid — but not enough to cover the growing cost of care — there are
few options. … There's a private insurance market that provides private
insurance for long-term care, but those policies are pretty much out of
the financial reach of middle-income Americans. To fill this gap in care,
… some states have considered an employer-provided social insurance
program for long-term care that’s modeled off Social Security.”
Let’s quickly review the Issue Brief’s discouraging results and then ask
these questions: Are people’s incomes and assets really preventing their
eligibility for Medicaid LTC benefits? Is private LTC insurance hopelessly
overpriced for the middle class and so nevermore a part of the solution?
To make up the LTC financing shortfall, do we really have to have another
state or federal social insurance program? What if there were a better way
to finance LTC for rich and poor alike, revitalize private LTC insurance,
and do it all without a big, new, compulsory, payroll-funded, government
Ponzi scheme? Wouldn’t that be great? Read on. We quote the Issue Brief
and then comment.
Issue Brief:
“Over a 20-year period,
more than 25% of adults age 50 and over will experience a shock resulting
in a 75% or more drop in net wealth.
Among adults age 70 and older, more than two-thirds will experience at
least one negative shock with financial consequences over a nine-year
period.” (Emphasis in the original.)
LTC
Comment:
Ouch! At least there is a social safety net in place and some private
charity remaining to help those most in need. But it gets worse …
Issue Brief:
“One of the most significant costs burdening older adults is long-term
care services and supports (LTSS), ranging from non-medical assistance
with activities of daily living to medical care in a skilled nursing
facility. While many Americans underestimate the need for LTSS,
over half of adults 65 and older will need LTSS
for
less than two years, and about one in seven will require care for more
than five years. Financing even one year of care can prove unwieldy for
most Americans. In 2018,
the average yearly cost of a private room in a nursing home was $105,485,
and that of a home health care aide was $37,440.”
LTC
Comment:
More
recent data
are somewhat less daunting: “While individuals on average will need 0.8
years of paid LTSS, 55% of older adults will not use any paid LTSS. About
24% of older adults (or about half of paid LTSS users) will receive less
than a year of paid LTSS (measured in service days), and about 4% of older
adults will use five years or more.” On the other hand,
more
recent (2021) data
show higher costs: $108,405 for a year in a private nursing home room and
$61,776 for a home health aide ($27 per hour, 44 hours per week, 52 weeks
per year). Definitely, not a pretty picture.
Issue Brief:
“As Medicare does not absorb the shock of LTSS costs, this financial risk
is often faced directly by older adults and their families or by social
safety net programs such as Medicaid.”
LTC
Comment:
OK, but what is the balance between the risk “faced directly by older
adults and their families or by social safety net programs such as
Medicaid.” We’re expected to presume that wide swaths of aging Americans
are forced into poverty by high LTC costs resulting in their becoming
impoverished and on Medicaid eventually. Is there any evidence that
occurs? Not in this Issue Brief. In fact, the Health and Retirement Study
(HRS) on which the Issue Brief is based provides zero evidence of asset
spend down for LTC incidental to Medicaid LTC eligibility. The HRS
documents only “transitions” to Medicaid, which could occur due to
Medicaid planning, i.e., artificial self-impoverishment, conducted years
before LTC is needed and Medicaid eligibility occurs. So, what does the
Issue Brief tell us about aging Americans’ ability to purchase LTC with
their own resources?
Issue Brief:
“Though the value of financial assets marginally increased or stayed the
same for 80% of older adults from 2016 to 2018, the bottom 20%,
approximately 11 million households, have no assets. This group has a 2018
median income of $16,989 and would be unable to rely on personal finances
to pay for LTSS, especially with rising costs of care. The next three
quintiles (21– 40%, 41–60%, and 61–80%) of older adults saw modest
increases in their financial assets between 2016 and 2018, but these
individuals would still be unable to afford more than two years of
nursing home care in a semi-private room or four years in an assisted
living community if their median income and household value of financial
assets were added together. Despite adults’ preference to age in place,
60% of adults would be unable to afford two years of in-home long-term
services and supports. Therefore, although the need for services both
in the short- and long-term remains a reality for many older Americans,
most do not have the financial resources to afford either.”
LTC
Comment:
So, the bottom quintile has no assets and very low income. That’s
practically the definition of someone who qualifies for Medicaid LTC. But
what about the next three higher quintiles? According to the Issue Brief,
these folks can afford two years of nursing home care, four years in an
assisted living facility, and 40% of them could manage two years of
in-home LTC. Sounds like they’re in pretty could shape since the Issue
Brief says “over
half of adults 65 and older will need LTSS
for
less than two years.”
But,
here’s the kicker. If these middle-income people are spending their money
on LTC, where is the evidence? Nursing home private-pay revenue has
plummeted to about 7 percent so that’s not where it’s going. Maybe these
folks are spending their substantial savings on home care. But no,
Medicare (37.2%) and Medicaid (34.2%) paid
71.4% of the $125.2
billion Americans spent on home health care in 2021. Private health
insurance (not LTC insurance) paid another 12.7%. Only 10.3% of home
health care costs were paid out of pocket. So that’s not where all this
wealth is being spent. Maybe people are spending down for assisted living.
Some surely do but “Almost 1
in 5 [ALF] residents relies on Medicaid to pay for daily services
(18%),”
“48%
of ALFs are Medicaid certified”
and only “a
small minority of state Medicaid programs do not cover services in
assisted living.”
(Find these quotes under the source’s “Finance” tab.) Bottom line: there
is no evidence that private-pay LTC spend down is consuming significant
amounts of middle class savings. What’s happening instead?
Let’s consider those questions we raised earlier.
Are
people’s incomes and assets really preventing their eligibility for
Medicaid LTC benefits?
Click through to the
Issue Brief
and scroll down to “FIGURE 1. Older Adult Households Divided into
Financial Quintiles based on Net Value of Total Wealth.” Look at the
income, savings and home equity amounts for the fourth wealth quintile,
representing 61-80% of older adults. Their total household income is
$52,229. Would that disqualify them for Medicaid LTC benefits? Would that
force them to spend down into impoverishment before getting help? No. The
rule of thumb is that income below the cost of a nursing home is not
disqualifying. That’s because private health and LTC expenditures are
deducted from income before comparing it to Medicaid’s allowable limit. A
well spouse, if there is one, would keep a spousal impoverishment
protection “maximum monthly maintenance needs allowance” of $2,465 or
$29,580 per year. Only the remaining income balance in the recipient’s
name would go to offset Medicaid’s cost for his/her care. Thus, while some
private income goes for care, this out-of-pocket cost, mostly Social
Security income, merely reduces Medicaid’s share of the dismally low
reimbursement, often less than the cost of care, that the LTC provider
receives. Although the recipient is paying out of pocket, he/she is not
commanding the better access and higher quality care associated with
paying privately. He/she is trapped in the lower Medicaid level of
America’s two-tier LTC system.
Well, what about assets? The “net value of primary residence,” i.e. home
equity, of folks in the fourth wealth quintile is $220,000. Would that
interfere with Medicaid LTC eligibility compelling asset spend down? Well,
no. Medicaid exempts a minimum of $688,000 of home equity and up to
$1,033,000 in some states. Even the richest people, in the 91-100% decile
of the Issue Brief’s Figure 1, would qualify for Medicaid based on their
home equity of $400,000.
But,
as everyone knows, you can’t have more than $2,000 in “countable” assets
and still qualify for Medicaid LTC. So, what is the fourth quintile’s
“Household Value of Financial Assets (non-housing, median)” and
would that disqualify them for Medicaid? That total is $130,000. Way more
than $2,000. But, we’re just getting started. First, if there is a spouse,
compute the couple’s jointly owned assets, and set aside half, not to
exceed $148, 620 but never less than $29,724, for the “community spouse.”
Back out the non-countable assets people own such as “pre-paid
burial and funeral expenses, an automobile, term life insurance, life
insurance policies with a combined cash value limited to $1,500, household
furnishings / appliances, and personal items, such as clothing and
engagement / wedding rings.”
Very few people in the fourth quintile of wealth will have much left, but
whatever remains can easily be converted to non-countable status by
investing more money in the home or purchasing any of the items just
listed.
Do
you think that people confronting high LTC costs ignore those generous
Medicaid financial eligibility limits and pay out-of-pocket? Do they
plunge themselves into real impoverishment from a sense of personal
responsibility or shame at depending on public assistance? Some do. More
used to do. But nowadays information on how to qualify for Medicaid
without spending down for care is universally available in magazine
articles, self-help books, and on the internet. Google “Medicaid planning
in [your state],” if you have any doubt. Even state Medicaid eligibility
workers routinely explain to middle class applicants how to speed up or
entirely eliminate their “spend down” process by purchasing exempt assets.
Workers report that people now think of Medicaid (welfare) as though it
were an entitlement like Medicare. They ask themselves, as Jane Bryant
Quinn did in her 12/18/89 Newsweek column, “Do Only the Suckers
Pay?” So, no, ignoring easy access to Medicaid LTC benefits and paying out
of pocket, is not the rule. It is the exception.
Is
private LTC insurance hopelessly overpriced for the middle class and so
nevermore a part of the solution?
It
is so disappointing and disheartening to see former supporter of private
LTC insurance, not to mention potential buyers and current owners,
abandoning the product in favor of more government dependency. We need
instead to reconceptualize LTC risk based on new data, some of which is
recounted in the Issue Brief, but much more of which is at our fingertips
in the recent research on LTC risk and cost. For example, if most people
can afford a couple years of LTC as the Issue Brief acknowledges, but they
have no reason to spend their own money for LTC because even the folks in
the fourth wealth quintile are immediately eligible for Medicaid without
spending down, why not change the rules and realign the incentives. Let’s
say we eliminate all the ways people qualify for Medicaid while preserving
wealth for people under 65 today. Then we tell younger folks they only
need to insure for their average LTC risk, not for the whole potential
catastrophic risk. That would collapse the premiums they would need to pay
to a level affordable even by the middle class at a time in their lives
when they’re also coping with house and car payments, retirement and
education savings. They’d buy this coverage because they could no longer
ignore LTC risk, wait to see if they ever need expensive care and, if they
do, go on Medicaid and still preserve most of their wealth. What about
that remaining catastrophic risk? Medicaid can handle it if most people
are protected for those first couple years of LTC need and because the
eligibility loopholes that allow wealth preservation are gone, the assets
that are no longer sheltered or divested will go to fund LTC in the
private market for anyone who failed to insure.
To
make up the LTC financing shortfall, do we really have to have another
state or federal social insurance program?
No.
People respond to incentives. Stop giving them an easy way to avoid LTC
risk and cost while preserving their wealth and they’ll look creatively
for ways to cover that risk. They will find many possibilities such as
tapping home equity, life insurance, retirement savings and many other
sources of wealth that currently dodge LTC responsibility. All that’s
needed is a real incentive in public policy for people to take personal
responsibility and prepare, putting to use some of the wealth that
Medicaid diverts from private LTC spending now.
What
if there were a better way to finance LTC for rich and poor alike,
revitalize private LTC insurance, and do it all without a big, new,
compulsory, payroll-funded, government Ponzi scheme?
Wouldn’t that be great?
Yes,
and the proposal to achieve that is on its way. Stay tuned!
#############################
Updated,
Tuesday, May 30, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-013 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Gary D.
Alexander and Elizabeth Stelle: Medicaid eligibility matters
-
America aged
rapidly in the last decade as baby boomers grew older and births dropped
-
U.S. Nursing
Homes Fail to Report Many Serious Falls, Bedsores: Study
-
Washington’s
long-term care program still flawed as new tax looms
-
Wearable AI
patch monitors multiple health factors for seniors
-
3 nursing homes
closing quickly as Ohio leaders plead for Medicaid adjustment
-
Is The Next
Wave Of Life Expectancy Gains On The Horizon?
-
People with
disabilities need more access to HCBS, researchers say
-
Senior-Living
Debt Defaults Far Outpace the Rest of Government Debt Market
-
The History of
Medicare Advantage: From Inception to Growing Popularity
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Monday, May 22, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-012 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
The Home Care
Workforce Has Not Kept Pace With Growth In Home And Community-Based
Services
-
Don't let
caregiving sabotage retirement planning
-
Senators
probing largest Medicare Advantage plans over how algorithms factor in
care denials
-
Complete
Debacle’: US House Hearing on Nursing Home Covid Deaths Blames Political
Acrimony, Policies, Staffing
-
Western Diet
Identified as Risk Factor For Alzheimer's Disease, Scientists Warn
-
Medicaid and
leadership challenges, as state takes over nursing home
-
What to know
about Washington Cares payroll tax as premiums are set to resume
-
Medicare,
Medicaid Spending Similar Among Dual Eligible Beneficiaries
-
Sorry kids if I
need long-term care, I’m spending your inheritance
-
40 percent of
healthcare working hours can be augmented by AI, study finds
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated,
Friday, May 19, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: WHO NEEDS LTC? HOW MUCH? SO WHAT?
LTC Comment: Do 70% need LTC or half?
For one year or three? Who pays? What’s it going to cost me? Medicaid?
Medicare? Based on sum-of-expenditures or present discounted value? The
key LTC numbers are shifting again, after the ***news.***
*** GET YOUR free article from the
CLTC Digest. CLTC, the people behind “Certification
for Long-Term Care” publish this thought-provoking quarterly journal.
They’re offering a free download of an article in the latest issue: “Your
Clients are Running Out of Money. (You just don’t know it” by Leigh
Maynard. Get it
here. Just scroll down and fill out the simple form. Heads up! I’ll be
in the next issue of CLTC Digest with a piece on “The Elephant, The Blind
Men, and Long-Term Care.” ***
*** LTC CLIPPINGS keep you
apprised of important industry news so you know what’s happening before
clients or prospects blindside you. Steve Moses reads everything online or
in print about long-term care, sends you one or two items each day like
the ones that follow, and welcomes your questions or comments. If you
haven’t subscribed to LTC Clippings yet or if you aren’t a member
of the Center, fix that now
here. Thanks for your consideration.
5/17/2023,
“Senators
probing largest Medicare Advantage plans over how algorithms factor in
care denials,” by Bob Herman and Casey Ross, STAT
Quote: “Senators warned the country’s largest Medicare
Advantage insurers at a hearing on Wednesday that they must abide by
Medicare’s coverage rules and cannot rely on algorithms to deny care that
patients need. … The hearing comes on the heels of a STAT investigation
that found Medicare
Advantage insurers are routinely relying on proprietary algorithms as a
basis for denying care. Instead of using the technology as a guide for
a Medicare patient’s care in a nursing home or rehab facility, many
Medicare Advantage plans are using it as a hard-and-fast rule to avoid
paying for care and to discharge patients home as soon as possible — even
if patients are not ready.”
LTC Comment: Are AI robots replacing human claims adjusters? How
will patients fare?
5/17/2023,
“Medicaid
and leadership challenges, as state takes over nursing home,” by
Jessica R. Towhey, McKnight’s LTC News
Quote: “A Rhode Island nursing home with more than 30 citations for
deficiencies and whose administrator’s license was suspended last month
has been put into state receivership. … ‘Rhode Island Medicaid has been
chronically underfunded for more than a decade,’ said John Gage, president
and CEO of the Rhode Island Health Care Association. The state’s Medicaid
rates are based on 2011 actual costs inflated by approximately 1% per year
since 2012, Gage said. The estimated shortfall is $50 million to $60
million per year, and the pre-pandemic gap between reimbursement and the
cost of care was approximately $30 per patient per day. Both Gage and his
counterpart at LeadingAge Rhode Island, which represents nonprofit
facilities, said the gap is likely much higher now.”
LTC Comment: If only Rhode Island officials had listened when we
warned them this was coming and how to avoid it in
Doing LTC RIght (2010) and
The Age Wave, the Ocean State, and Long-Term Care (2009).
5/8/2023,
“TCARE
Welcomes Long-Term Care Executive Vince Bodnar as Chief Actuary,” by
Julia Pitlyk, Technology Today
Quote: “TCARE,
the industry-leading, evidence-based caregiver support platform designed
to prevent family caregiver burnout, welcomes Vince Bodnar as its Chief
Actuary. With nearly 40 years of experience, Bodnar is recognized as one
of the country’s leading long-term care financing experts.”
LTC Comment: Vince Bodnar is one of the most creative and impactful
thinkers in the LTC insurance space. Maybe that’s why he’s in such demand,
changing jobs so often. Congratulations, Vince, do keep us posted on where
to send your LTC Clippings and LTC Bullets.
5/8/2023,
“Provider
payments could be at ‘catastrophic’ risk if federal debt limit breached,”
by Jessica R. Towhey, McKnight’s LTC News
Quote: “Without a legislative solution from warring political
parties in Congress and the White House, the US is in danger of breaching
its debt limit, which would have serious repercussions for the long-term
care sector, advocates and experts warned. … If the US defaults on its
debt, which it has never done, those payments would halt, at least
temporarily. Even a short-term cessation could be ‘catastrophic,’ said
Katie Smith Sloan, president and CEO of LeadingAge, in an email to McKnight’s
Long-Term Care News on Friday.”
LTC Comment: Live by government funding and regulation, die by
them. Politicians say we have to raise the debt ceiling because the U.S.
always pays its bills? That’s a phony argument. If the U.S. paid its
bills, it wouldn’t be $32 trillion in debt and in need of a debt ceiling
increase. No, they want to raise the debt limit so they can go on
borrowing, spending and not paying the bills. ***
LTC BULLET: WHO NEEDS LTC? HOW MUCH?
SO WHAT?
LTC Comment: Those are important
questions. But the answers are a moving target. The experts used to say
that 70 percent of the elderly will require some LTC and 20 percent will
need five years or more. We critiqued the study that produced those
estimates in
LTC Bullet: Microsimulate This!, March 28, 2006. We were not
impressed. It was full of misleading, ideologically biased statements.
Garbage in, garbage out, we concluded.
Then in 2015, new and better data
became available. Roughly half—not 70 percent—of elderly Americans will
need long-term care. One in seven—not one in five—will require five years
or more. We critiqued the study (Favreault and Dey, 2016) that produced
these new estimates in
LTC Bullet: New Data on LTC Incidence, Duration, Cost and Financing
Sources, July 24, 2015. We concluded the new data was a “vast
improvement over what we had before,” but this report was also fraught
with political and ideological bias.
If those two opening paragraphs tweak
your interest, by all means click through, read the source documents and
our analysis in those LTC Bullets from 17 and eight years ago,
respectively. But right now, let’s consider the latest in this series of
LTC risk and cost estimates. The U.S. Department of Health and Human
Services’ Assistant Secretary for Planning and Evaluation (ASPE) published
“Long-Term
Services and Supports for Older Americans: Risks and Financing, 2022,”
by Richard W. Johnson and Judith Dey on September 27, 2022.
Based on this new study’s Abstract,
the key numbers have moved around again, but not so drastically this time.
Now “over half (56%)” will need some LTC and about “one in five” (22%)
will need more than five years. Is the
Urban Institute’s Dynasim microsimulation model finally homing in on
less variable, more stable estimates? Let’s take a closer look at how the
newest data varies from what preceded it in 2015. We’ll proceed from here
with quotes from the new paper followed by our “LTC Comments.”
Johnson/Dey:
“The results presented here differ from those reported in Favreault and
Dey (2016) … our updated model projects longer average durations of LTSS
needs (3.1 years versus 2.0 years) … The updated model also projects lower
average LTSS expenditures ($120,900 versus $138,100), especially for
family out-of-pocket payments. These differences result from some
definitional changes between the two analyses and numerous technical
changes and updates. … An important substantive change between this brief
and Favreault and Dey (2016) is that we removed from our expected cost
tables the incidental LTSS that Medicare covers. … Medicare generally does
not pay for long-term care when it is the only service a person needs.”
(p. 10)
LTC Comment:
Those are very big changes! LTC duration is up by more than 50 percent
from two years to 3.1 years. Average LTC expenditures plummeted 12.5
percent from $138,100 to $120,900. What’s more, these authors are no
longer counting Medicare as a contributor to LTC costs. That makes sense
from the standpoint that Title 20 doesn’t pay for LTC, but it distorts
financial analysis substantially by ignoring the role Medicare profits
play in propping up LTC providers’ ability to survive losses from
Medicaid’s meager reimbursement rates.
The paper goes on for two more
paragraphs explaining the tweaks to their model that caused the big
changes. Maybe we better not assume these important estimates of LTC risk
and cost are settling into a more consistent pattern. Be that as it may,
let’s consider what the new estimates would mean if they are correct and
do remain stable.
(Note that we prefer the traditional
designation “long-term care” (LTC) instead of the awkward neologism
“long-term services and supports” (LTSS) used in the Johnson/Dey report.
To their credit, they do at least acknowledge in an end note that “LTSS is
also sometimes called long-term care.” p. 11)
Johnson/Dey:
“Although most people with LTSS needs will spend relatively little on
their care, 14% will spend at least $100,000 out of pocket for future LTSS.”
(p. 1)
LTC Comment:
That sounds like a small risk of a substantial loss that could be replaced
by an affordable premium, which is the role of private insurance in our
economy. But, the report downplays that potential.
Johnson/Dey:
“A private market for LTSS insurance exists, but less than 8% of Americans
have purchased coverage (Freundlich 2014), partly because of high and
rising premiums and the exit of insurers from the market (Scism 2015).
Sales figures from recent years suggest the market has stagnated or even
shrunk (Cohen 2016; Schmitz and Giese 2019; Ujvari 2018).” (p. 2)
LTC Comment:
Why so little demand for private insurance in the face of such a clearly
insurable risk? The obvious answer is that someone or something else pays
for LTC obviating the public’s need to worry about it and deflating demand
for the product. But Johnson/Dey also downplay that possibility.
Johnson/Dey:
“Although Medicaid provides LTSS to those with chronic disabling
conditions (Komisar 2013; Tompson et al. 2013), it is available only for
individuals who meet income and other eligibility requirements (U.S.
Department of Health and Human Services 2015).” (p. 1)
LTC Comment:
So, Medicaid pays for LTC but only for people who meet its eligibility
requirements? That makes Medicaid sound somewhat insignificant. What are
Medicaid’s financial eligibility requirements? How hard are they to
satisfy? Is it possible for people with substantial wealth to qualify for
Medicaid LTC benefits without spending down their wealth to qualify? The
paper blanks out on these crucial topics. But it does elsewhere
acknowledge Medicaid’s very large LTC financing role.
Johnson/Dey:
“Medicaid is the largest payer of LTSS, averaging $51,800 after age 65 and
accounting for 43% of the total [$120,900].” (p. 6)
“Most Americans who receive paid LTSS
pay some share out of pocket. Those with longer spells may pay out of
pocket until they qualify for Medicaid. Reliance on Medicaid for those who
cannot afford the full cost of LTSS may increase federal and state
spending for LTSS.” (p. 2)
LTC Comment:
So, Medicaid is a huge LTC payor but it doesn’t desensitize the public to
LTC risk or impede demand for private LTC insurance because it has
financial eligibility limits to which people must spend down over “longer
spells” of paying privately until they finally become eligible. That’s the
hidden narrative the report fails to make explicit. Where is the proof for
their assumption that people must pay out of pocket before Medicaid
starts? Scholars of this stature should know and acknowledge that there is
no evidence in the HRS or AHEAD data bases on which they rely of Medicaid
“spend down.” Those sources only show that “transitions” to Medicaid occur
for whatever reason. On that subject, we offer these observations:
LTC Bullet: Medicaid Spend Down that Isn’t and Why it
Matters, July 19, 2013
LTC Bullet: Behind AHEAD, September 2, 2016
LTC Bullet: Is it Spend Down or Medicaid Planning?, July 14, 2017
The truth is that Medicaid exempts
virtually unlimited resources, including home equity, personal belongings,
a car and many others. People receive Medicaid benefits despite having
large incomes if their health and LTC expenses are high enough, as they
usually are for people in need of LTC. This report, like its predecessors,
simply presumes without evidence that people “spend down” before
qualifying for Medicaid. To its credit, this report does not make the
explicit, preposterous, unsubstantiated claims of its predecessors that
wide swaths of the American public spend down for LTC into total
impoverishment. Still it, like they, ignore how Medicaid financial
eligibility actually works as explained in ubiquitous legal tomes,
magazine articles and internet ads for Medicaid estate planning.
Nevertheless, they do give some lip service to the fact that Medicaid
covers more than the poor.
Johnson/Dey:
“The DYNASIM4 projections suggest that although Medicaid is used by older
adults throughout the age-65 income distribution, it primarily serves
those in the bottom two income quintiles (Table 8).” (p. 9)
LTC Comment:
Medicaid is mostly for the poor? That should be no surprise. It is a
welfare program, after all. What’s really important is their admission
that “Medicaid is used by older adults throughout the age-65 income
distribution.” These authors recognize that fact, but make no effort to
explain how or why it can happen if people must spend down wealth to
qualify as they believe, assume and imply without giving a shred of
evidence. But let’s look again at the basic facts.
Johnson/Dey:
“About 15% of older adults can expect their total LTSS expenses from age
65 onward to amount to more than $250,000, whereas about 8% will have
positive but low costs (less than $10,000). A smaller percentage (about
6%) will spend $250,000 or more out of pocket on LTSS. Fourteen percent
will spend at least $100,000 out of pocket on LTSS after turning 65.” (p.
8)
LTC Comment:
Sounds pretty daunting, doesn’t it? But their Table 7 breaks it down.
Turns out that of that “15 percent,” actually 14.7 percent, who spend more
than $250,000 only 6.4 percent, shown as “6 percent” in the paper, are
paying out of pocket. The rest comes from Medicaid, “other public,” or
private insurance. In other words, long-term care financing is very
complicated, constitutes a heavy burden both on taxpayers and individuals,
and is going to get much worse given the current demographics of aging,
before it gets better. But even with all the public and private money
poured into the current system, it still fails friends and families who
are left with the need to provide care themselves without pay.
Johnson/Dey:
“Many older adults with care needs receive substantial amounts of unpaid
care from family members and friends. Our projections indicate that the
value of unpaid family care received by adults born between 2021 and 2025
with significant disabilities averages $91,900 (Table 10). Among people
receiving unpaid family care, the average value of care reaches $204,000,
more than the value of all paid LTSS. Women receive more unpaid care than
men.” (p. 9)
LTC Comment:
Bottom line: America’s long-term care service delivery and financing
system is a huge, expensive, unproductive, debilitating failure. It traps
people on public welfare, discourages personal responsibility and early
planning, subsidizes institutional care, inhibits the home care people
prefer, and still leaves much of the direct caregiving duties for stressed
out, untrained, unpaid family and friends to provide. The whole mess seems
hopeless.
But what if different incentives
prevailed? What if the rules that allow people to ignore LTC until they
need it and qualify for Medicaid without spending down their wealth
disappeared? What if people had to save, invest or insure for long-term
care or actually face impoverishment if confronted with catastrophic LTC
costs? What if we told everyone below a certain age—65, 50, 40,
whatever—that the Medicaid planning techniques used in the past to qualify
for LTC benefits will no longer exist for them in the future?
I submit that people would worry much
more about LTC risk and cost. They would seek ways to save, invest or
insure for that risk. But how could they come up with the funds to save or
buy private insurance while they are in their prime earning years, but
still making house and car payments, saving for their own retirement, and
setting aside funds for their children’s education? I find a clue to the
answer in this report that is otherwise sterile of policy ideas.
Johnson/Dey:
“These estimates differ from a present discounted value (PDV) of
expenditures at age 65, the amount that an individual would need to set
aside at age 65 to cover future LTSS expenses. The PDV is lower than the
sum-of-expenditures measure because it accounts for the investment returns
that could be earned on funds set aside at age 65 until LTSS expenses
begin, often after age 80. We show PDV projections in the appendix.” (p.
6)
LTC Comment:
Say what? What does that even mean? The cost estimates provided in the
main body of this report represent what people or programs could be
expected to pay for long-term care over time in today’s dollars. But how
much would they need to set aside at age 65, assuming a reasonable rate of
return, to cover their expected future expenses? We find the answer to
that question in the PDV tables of the report’s Appendix. For example:
To cover the $120,900 “projected sum
of LTSS expenditures from age 65 through death for adults who turn 65 in
2021-2025” would require that an individual set aside only the “projected
PDV of expenditures from age 65 through death for adults who turn 65 in
2021-2025” of $69,800. Still a big number but much less onerous.
Likewise, to cover the $245,400 sum of
expenditures liability for people who actually experience LTC costs, would
require only $141,700 in PDV set aside. Still big, but more manageable.
How do they figure that?
Johnson/Dey:
“PDV estimates, which are reported in Tables A1-A9, use the Social
Security trustees' ultimate real interest rate of 2.5%. Because the
trustees assume long-range price growth averages 2.6%, this real discount
rate is equivalent to a nominal long-run discount rate of about 5.1%.” (p.
13)
LTC Comment:
In other words, much less money set aside at age 65 in an investment
earning 5.1 percent per annum would cover future average or catastrophic
LTC costs. Now imagine, if those funds were earmarked for LTC at even
younger ages, how much easier the average or catastrophic risk would be to
meet.
Of course the numbers are very
different for men and women, and that needs to be considered and accounted
for, but let’s stick with the averages for purposes of the argument now.
Here’s my point: what if instead of
expecting people to shoulder the entire burden of potentially catastrophic
LTC costs and then giving them easy access to Medicaid later if they
ignored that risk as happens now, we rather created a new expectation that
everyone is responsible by a specified age for the present discounted
value of their average LTC risk? That would still leave the catastrophic
risk for Medicaid to cover, but it would relieve the welfare program of
supporting the middle class and affluent who could, should, and would
save, invest or insure at least for their average LTC risk.
How could people save, invest or
insure for even that smaller LTC responsibility while still keeping up
with their other financial liabilities? Don’t expect any help from
Johnson/Dey.
Johnson/Dey:
“Conclusion Most Americans who survive to age 65 can expect to need
and use LTSS. … Average long-term care costs can be out of reach for many
Americans. Medicaid is an important payer of LTSS, but because it serves
only those who meet strict income and asset criteria many families pay for
LTSS out of pocket. Private LTSS insurance has only a modest reach, and it
predominantly covers costs for those high in the income distribution.
Other public expenditures, such as U.S. Department of Veterans Affairs
(VA) care, only help cover small shares of the population with LTSS needs.
The value of unpaid care provided by family members and friends to people
with significant disabilities exceeds the value of paid care, and unpaid
care is even more important when people have less severe disability. Our
results highlight the need for better planning for LTSS to accommodate
both average and catastrophic financial risks associated with chronic
disability.” (p. 10)
LTC Comment:
Shall we conclude that nothing works and the situation is hopeless? Or
shall we accept the reality that “average long-term care costs can be out
of reach for many Americans” and everyone needs “better planning for LTSS”
and do something about it? If you lean toward taking action, then what? We
have a plan, but it’s under development and we cannot share it yet. But
here’s a hint. Our plan involves persuading and enabling
middle-aged and younger Americans to save or set aside enough to cover the
average present discounted value of their LTC liability. Maybe they’ll
also insure for their catastrophic risk if the insurance industry can come
up with a new product to cover and secure the smaller average catastrophic
PDV. Stay tuned to LTC Bullets for details in the coming months.
#############################
Updated, Monday, May 15, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-011 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Argentum Releases New Report Outlining
Policy Solutions to Increase Access to Assisted Living
-
How to Use a Trust to Plan for Long-Term
Care
-
Social Security COLA Estimated at 3.1% for
2024
-
AHCA’s CEO: Nursing Homes Must Prepare for
‘Massive’ Staffing Mandate Battle, Adapt to Managed Care ‘Mega-Trend’
-
TCARE Welcomes Long-Term Care Executive
Vince Bodnar as Chief Actuary
-
The Nation's Fiscal Health: Road Map Needed
to Address Projected Unsustainable Debt Levels
-
Provider payments could be at
‘catastrophic’ risk if federal debt limit breached
-
AARP poll: Majority of voters want more
support for family caregivers
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, May 8, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-010 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
The Hidden
Costs Home Health Providers Face When Taking On More MA Patients
-
Genworth
Creates Discounted LTC Provider Network
-
Biden Moves To
Increase Pay For Medicaid Home Care Aides. Will It Work?
-
‘Big Trouble’:
Medicare Advantage Rates Strain SNF Margins, Deepen Sector’s Pain
-
Regular
internet use may be linked to lower dementia risk in older adults, study
says
-
A Clever
Strategy to Get Your Long-Term Care Costs Covered by Medicaid
-
ChatGPT’s blind
spots can compromise caregiving, authors warn
-
Life Estates:
Helpful or Problematic? (Part 3: Medicaid)
-
The Super SNF
Comes of Age: Advanced Care Programs Expand, Yield Results
-
Retirement
Confidence Hits Lowest Point Since 2008: EBRI
-
AI chats could
be more empathetic than doctors’ responses to patient questions, study
finds
-
Half of All
Eligible Medicare Beneficiaries Are Now Enrolled in Private Medicare
Advantage Plans
-
How Can I
Protect My IRA From Medicaid?
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, May 5, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC Bullet: AI on LTC
LTC Comment: Artificial intelligence (AI) is all the
rage these days. Does it help or hurt long-term care planning? We ask; AI
answers; and we respond after the ***news.***
*** TODAY'S LTC BULLET is
sponsored by Claude Thau with BackNine Insurance. Back9 gives you a
free personalized website at no cost. Your clients (& family &
friends) can, with as little or as much of your involvement as you or
they want, buy life insurance and LTCi, and schedule parameds and
upload their medical records to speed the process. We quote
stand-alone LTCi, linked-benefit and life with a LTC rider
side-by-side and provide a sales track with video support. Claude is
the lead author of Milliman’s annual Broker World LTCi Survey & a past
Chair of the Center for Long-Term Care Financing. Contact him at
913-707-8863 or
claude@back9ins.com discuss how he might
help you. *** |
LTC BULLET: AI ON LTC
LTC Comment: “Artificial
intelligence is the simulation of human intelligence processes by
machines, especially computer systems.” Click the link for details,
but bottom line, among other features: AI makes it possible for us to ask
questions online and get plausible narrative answers almost
instantaneously. Leaving aside for now that some experts’ worry AI
technology could threaten human survival, we decided to
Ask AI some important questions about LTC financing policy. What
follows are our questions, AI’s answers, and our comments in response.
Especially, don’t miss
iAskAI’s answer to my final question at the very end: “If you were to
write an ‘LTC Bullet,’ what would it say?” Here’s an excerpt from the
chatbot’s answer: “The LTC Bullet is known for its in-depth analysis and
comprehensive coverage of long-term care issues. It is highly regarded by
policymakers, industry professionals, and academics alike. The publication
is available to subscribers only and is distributed via email. In
conclusion, the LTC Bullet is a valuable resource for those interested in
long-term care policy and financing. It provides insightful analysis on a
range of topics related to long-term care and is highly regarded by
industry professionals and policymakers.” Gosh, thanks.
Should I buy LTC insurance or wait to see if I
ever need long-term care and if I do use Medicaid planning?
According to iAsk.AI Answer Engine: Long-term
care (LTC) insurance is a type of insurance that covers the cost of
long-term care services, such as home health care, nursing home care, and
assisted living facilities. It is designed to help individuals pay for
these services without depleting their savings or relying on Medicaid.
However, whether or not to buy LTC insurance depends on several factors.
One factor to consider is your age and health status.
LTC insurance premiums increase with age, so if you are young and healthy,
it may be more affordable to purchase LTC insurance now than to wait until
you are older and at a higher risk of needing long-term care. On the other
hand, if you have pre-existing health conditions, you may not be able to
qualify for LTC insurance or may have to pay higher premiums.
Another factor to consider is your financial
situation. If you have significant assets and income, you may be able to
afford the cost of long-term care without depleting your savings or
relying on Medicaid. However, if you have limited assets and income, LTC
insurance may be a good option to help protect your financial security.
It is also important to consider the potential
benefits of Medicaid planning. Medicaid is a government program that
provides health coverage for low-income individuals and families. It also
covers the cost of long-term care for those who meet certain eligibility
requirements. However, Medicaid planning can be complex and requires
careful consideration of your financial situation and goals.
In summary, whether or not to buy LTC insurance
depends on several factors, including your age and health status,
financial situation, and goals for long-term care. It is important to
carefully weigh the potential benefits and costs of LTC insurance and
Medicaid planning before making a decision.
LTC Comment: Not a lot of help. Pretty
wishy-washy. Doesn’t define Medicaid planning, acknowledge it involves
artificial self-impoverishment to qualify for public welfare, nor disclose
Medicaid’s serious access and quality deficiencies. On the other hand, the
answer emphasizes LTCI’s downsides such as age-based premiums and
pre-existing conditions without developing the product’s substantial
benefits. So we homed in on Medicaid planning with this question …
What are the main techniques Medicaid planning
attorneys use to qualify their clients for Medicaid LTC benefits while
preserving their wealth?
According to iAsk.AI Answer Engine: Medicaid
planning attorneys use several techniques to qualify for Medicaid
long-term care benefits while preserving their clients' wealth. These
techniques include:
1. Asset Protection Trusts: Attorneys can create irrevocable trusts that
protect assets from being counted towards Medicaid's asset limit. These
trusts can be set up so that the client and their spouse can still receive
income generated by the assets in the trust, but the assets themselves are
protected.
2. Medicaid Compliant Annuities: Attorneys can also use annuities to
convert countable assets into income streams that are not counted towards
Medicaid's asset limit. These annuities must meet certain criteria to be
considered Medicaid compliant.
3. Spend Down Strategies: Attorneys can help clients spend down their
assets in a way that maximizes their eligibility for Medicaid benefits.
This might involve paying off debts, making home modifications, or
prepaying funeral expenses.
It's important to note that Medicaid planning strategies can be complex
and should only be undertaken with the guidance of an experienced
attorney. Additionally, there are strict rules governing Medicaid
eligibility, and any attempts to hide or transfer assets could result in
penalties or disqualification from benefits.
LTC Comment: What struck me most about this
answer is how it differs from what LTC researchers say about Medicaid
planning. They rarely refer to any artificial self-impoverishment
techniques other than asset transfers, which AI doesn’t even mention and
are relatively uncommon methods. Note that AI does mention “spend down
strategies” which are more accurately described as reducing countable
resources by purchasing exempt assets. That is the Medicaid planning
method used the most. So, let’s ask about it.
Can people with large assets qualify for Medicaid
LTC benefits by purchasing "exempt" resources?
According to iAsk.AI Answer Engine: Yes,
people with large assets may be able to qualify for Medicaid long-term
care (LTC) benefits by purchasing "exempt" resources. Medicaid is a joint
federal and state program that provides healthcare coverage to eligible
individuals with low income and limited assets. Medicaid can also cover
the cost of long-term care services, such as nursing home care, for those
who meet certain eligibility requirements.
To qualify for Medicaid LTC benefits, an individual must meet both
financial and medical eligibility criteria. Financial eligibility is
determined by the individual's income and assets. In most states, an
individual cannot have more than $2,000 in countable assets to be eligible
for Medicaid LTC benefits. However, some assets are considered exempt and
are not counted towards this limit.
Exempt assets may include a primary residence (up to a certain equity
value), one vehicle, personal belongings, and certain types of prepaid
funeral arrangements. Some states may also allow individuals to purchase
exempt resources, such as annuities or trusts, in order to reduce their
countable assets and meet the eligibility criteria for Medicaid LTC
benefits.
It is important to note that purchasing exempt resources can be a complex
process and may have legal and financial implications. It is recommended
that individuals consult with a qualified attorney or financial advisor
before making any decisions regarding the purchase of exempt resources.
In summary, people with large assets may be able to qualify for Medicaid
LTC benefits by purchasing "exempt" resources. However, this strategy
should only be pursued after careful consideration and consultation with a
qualified professional.
LTC Comment: So, purchasing exempt assets is a
“complex process” and people should consult a “qualified attorney” before
using it? Nonsense. This technique of self-impoverishment is very easy,
completely unlimited, and involves no special legal knowledge. State
Medicaid eligibility workers routinely advise applicants and their
families to speed up their “spend down” process by purchasing exempt
assets, especially prepaid burial funds. Of course, people who do consult
Medicaid planning lawyers will get the extra help of receiving long lists
of exempt assets they are advised to buy in order to reduce their
countable wealth. What does this easy access to Medicaid LTC benefits
after people need care mean for the marketability of private LTC
insurance? Let’s ask.
Does Medicaid Planning for LTC benefits impede the
private LTC insurance market?
According to iAsk.AI Answer
Engine: Medicaid planning for long-term care (LTC) benefits can
potentially impede the private LTC insurance market. Medicaid is a
government-funded program that provides healthcare coverage to low-income
individuals, including coverage for long-term care services. Medicaid
planning involves legally restructuring an individual's finances to
qualify for Medicaid benefits, which can include transferring assets or
income to a spouse or trust.
One potential way that Medicaid planning can impede the private LTC
insurance market is by reducing the demand for private insurance. Since
Medicaid provides coverage for long-term care services, individuals may
choose not to purchase private insurance policies, especially if they
believe they can qualify for Medicaid benefits through planning. This
reduction in demand could lead to higher premiums and reduced
profitability for private insurers, which could ultimately discourage
insurers from offering LTC policies.
Another way that Medicaid planning can impact the private LTC insurance
market is by creating adverse selection. Adverse selection occurs when
individuals who are more likely to use LTC services are more likely to
purchase private insurance policies, while those who are less likely to
need LTC services opt-out of purchasing insurance. This can lead to higher
premiums and reduced profitability for insurers, which again could
discourage insurers from offering LTC policies.
However, it is important to note that there are also arguments against the
idea that Medicaid planning impedes the private LTC insurance market. For
example, some experts argue that Medicaid planning actually increases
awareness of the need for long-term care services and encourages
individuals to consider their options for financing these services,
including private insurance.
In conclusion, while there are arguments both for and against the idea
that Medicaid planning impedes the private LTC insurance market, it is
clear that there is a complex relationship between these two factors that
requires further research and analysis.
LTC Comment: Pretty good answer except on a
couple points. AI says Medicaid planning might discourage LTC insurance if
people “believe they can qualify for Medicaid benefits through planning.”
Such belief is not necessary. Nor is it common. Most people don’t know who
pays for LTC. But because Medicaid does pay and has paid since 1965, it
enables consumers’ denial resulting in their skipping LTCI while they’re
still young, healthy, and affluent enough to buy it. Of course, the idea
that easy access to free LTC if it’s ever needed by means of Medicaid
planning somehow increases awareness and encourages LTC planning is
preposterous. How can free care at the point of need funded by the
government not crowd out planning decades ahead, paying high premiums for
many years and maybe getting nothing from your coverage in the end if you
never need LTC? Count on AI to stretch every point to present a “balanced”
view. But does any of this really matter?
How common is it for people to artificially
impoverish themselves to become eligible for Medicaid LTC benefits?
According to iAsk.AI Answer
Engine: It is difficult to determine the exact number of people who
artificially impoverish themselves to become eligible for Medicaid LTC
benefits. However, it is a known practice that some individuals engage in
to qualify for government-funded long-term care benefits.
To be eligible for Medicaid LTC benefits, an individual must meet certain
income and asset requirements. These requirements vary by state but
generally require that an individual's income and assets fall below a
certain threshold. Some individuals may artificially lower their income or
transfer assets to family members in order to meet these requirements.
This practice of artificially impoverishing oneself is not illegal, but it
may be considered unethical by some. Additionally, it can have negative
consequences for the individual and their family members. For example,
transferring assets can result in gift taxes and can also disqualify the
individual from receiving Medicaid benefits for a period of time.
It is important to note that there are legal ways to plan for Medicaid
eligibility without resorting to artificial impoverishment. Consulting
with a qualified elder law attorney or financial planner can help
individuals and families navigate the complex rules surrounding Medicaid
eligibility.
In conclusion, while there is no exact number on how common it is for
people to artificially impoverish themselves to become eligible for
Medicaid LTC benefits, it is a known practice that some individuals engage
in.
LTC Comment: This answer is a good example of
the double talk you get from attorneys and most LTC researchers when you
ask them about Medicaid planning. They downplay its frequency and
whitewash its morality to divert attention and avoid regulation. So, is
there no “exact number” of how many people ignore the risk of long-term
care, avoid saving or insuring for the need, and take advantage of the
Medicaid poverty program if necessary? Don’t you think that is something
policy makers ought to know? Why are there no academic studies to measure
this problem?
What is the "two Mercedes strategy" to gain
Medicaid LTC eligibility?
According to iAsk.AI Answer
Engine: The "two Mercedes strategy" is a planning technique used to
gain Medicaid long-term care (LTC) eligibility by spending down assets.
Essentially, the strategy involves purchasing exempt assets, such as two
Mercedes-Benz cars, in order to reduce the countable assets of an
individual seeking Medicaid LTC coverage.
In order to qualify for Medicaid LTC coverage, an
individual must meet certain asset and income requirements. Generally, an
individual's countable assets cannot exceed a certain amount (varies by
state), and their income must be below a certain level. However, there are
certain assets that are considered exempt and do not count towards the
asset limit. These can include a primary residence, personal belongings,
and one vehicle.
The "two Mercedes strategy" takes advantage of this
exemption by purchasing two high-value vehicles that are exempt from the
asset limit. By doing so, the individual can reduce their countable assets
and potentially qualify for Medicaid LTC coverage.
It is important to note that this strategy may not
work in all cases and should only be used after consulting with a
qualified elder law attorney or financial planner. Additionally, it is
important to consider the ongoing costs associated with owning two luxury
vehicles.
In conclusion, the "two Mercedes strategy" is a
planning technique used to gain Medicaid LTC eligibility by spending down
assets on exempt assets such as two high-value vehicles. However, it is
important to consult with a professional before implementing this
strategy.
LTC Comment: Well, iAskAI finally got an
answer clearly wrong. The “two Mercedes” method does not involve buying
two cars. Two cars would make one ineligible for Medicaid. Rather, one
purchases a single luxury vehicle, which is exempt in any dollar amount,
and gives it away. That gift is not a transfer of assets for less than
fair market value for the purpose of qualifying for Medicaid which would
trigger a penalty because owning the car was not disqualifying in the
first place and giving it away therefore is not done for the purpose of
qualifying for Medicaid. But maybe I’m splitting hairs. AskAI got the
basic idea right that people can qualify for Medicaid LTC benefits by
purchasing an expensive car and giving it away, though only one at a time.
Does it hurt the poor when Medicaid planning
attorneys qualify affluent clients for Medicaid LTC benefits?
According to iAsk.AI Answer
Engine: Medicaid planning attorneys qualifying affluent clients for
Medicaid LTC benefits can potentially hurt the poor by diverting resources
from those who truly need it. When affluent clients are qualified for
Medicaid, they are essentially taking advantage of a system that is meant
to help those who are unable to afford long-term care. This can lead to a
strain on resources and funding, which can ultimately harm the poor who
rely on Medicaid for their healthcare needs.
However, it is important to note that not all
Medicaid planning attorneys engage in this practice. Some attorneys may
work within the legal framework to help their clients qualify for Medicaid
benefits while also ensuring that resources are not diverted away from
those who truly need it.
Furthermore, there are also other factors that
contribute to the strain on Medicaid resources, such as an aging
population and rising healthcare costs. Addressing these issues would
require a comprehensive approach that goes beyond just targeting Medicaid
planning attorneys.
Overall, while there may be instances where Medicaid
planning attorneys qualifying affluent clients for Medicaid LTC benefits
can hurt the poor, it is not a black and white issue and requires careful
consideration of various factors.
LTC Comment: Not black and white? Some
Medicaid planners ensure resources are not diverted from the poor? Name
one. How would they do that even if they wanted to? I think iAskAI must
have an algorithm that searches for arguments to balance any potential
disagreement, but often fails to come up with plausible counterpoints.
What percentage of Medicaid LTC applicants
purchase prepaid burial funds to spend down to asset limits?
According to iAsk.AI Answer
Engine: I'm sorry, but I cannot provide a comprehensive answer to this
question as there is no available data or statistics on the percentage of
Medicaid Long-Term Care (LTC) applicants who purchase prepaid burial funds
to spend down to asset limits. The Medicaid program is administered by
individual states, and each state has its own rules and regulations
regarding eligibility requirements and asset limits. While some states may
allow the purchase of prepaid burial funds as a way to spend down assets,
it is not a universal practice across all states.
Additionally, there is no centralized database or reporting system that
tracks the specific financial strategies used by Medicaid LTC applicants
to meet asset limits. Therefore, it is impossible to provide an accurate
percentage or estimate of how many individuals use prepaid burial funds
for this purpose.
It is worth noting, however, that Medicaid planning and asset protection
strategies are complex and often require the assistance of an experienced
elder law attorney or financial advisor. These professionals can help
individuals navigate the rules and regulations surrounding Medicaid
eligibility and develop a customized plan to protect their assets while
still qualifying for benefits.
LTC Comment: I’ve conducted many state-level
studies of Medicaid eligibility and planning. State Medicaid eligibility
workers told me that between two-third and 80 percent of Medicaid LTC
applicant/recipients shelter assets in prepaid burial funds averaging
around $7,000 or $8,000 each. If that is true nationwide, it amounts to
many billions of dollars diverted from personal LTC responsibility to
public liability, constituting a huge subsidy for the funeral industry at
taxpayers’ expense. Again, this is an aspect of poor public policy that
researchers should study, analyze, and report, but don’t.
Is it ethical to self-impoverish oneself by
transferring wealth five years in advance, purchasing exempt assets, or
putting money into special annuities or trusts in order to qualify for
Medicaid's welfare LTC benefits?
According to iAsk.AI Answer
Engine: It is a controversial topic whether it is ethical to
self-impoverish oneself by transferring wealth five years in advance,
purchasing exempt assets, or putting money into special annuities or
trusts in order to qualify for Medicaid's welfare LTC benefits.
On one hand, some argue that it is unethical to take advantage of a
government program intended for those who are truly in need. They argue
that individuals who engage in these practices are essentially gaming the
system and taking resources away from those who may not have any other
means of support. Additionally, some argue that these practices may be
considered fraudulent and could result in legal consequences.
On the other hand, others argue that it is not unethical to engage in
these practices as they are simply taking advantage of legal loopholes
within the system. They argue that individuals have a right to protect
their assets and ensure that they are able to receive the care they need
without depleting their life savings. Additionally, some argue that these
practices can actually benefit society as a whole by reducing the burden
on government-funded programs.
Ultimately, whether or not it is ethical to self-impoverish oneself in
order to qualify for Medicaid's welfare LTC benefits is a matter of
personal opinion and values.
LTC Comment: Exactly how can using Medicaid
planning to get the government to pay for one’s long-term care “actually
benefit society as a whole by reducing the burden on government-funded
programs.” That is just more double talk in groundless justification of
practices that hurt taxpayers, the poor, and even the affluent who end up
in nursing homes on public welfare but could have purchased quality home
care instead.
Should people who shelter wealth in exempt assets,
such as a home, car or business, in order to qualify for Medicaid LTC
benefits, be required to repay Medicaid after they die?
According to iAsk.AI Answer
Engine: Yes, people who shelter wealth in exempt assets such as a
home, car, or business in order to qualify for Medicaid long-term care (LTC)
benefits should be required to repay Medicaid after they die. This is
because Medicaid is a needs-based program that provides healthcare
assistance to those who cannot afford it. It is not intended to provide a
way for individuals to pass on their wealth to their heirs while still
receiving government assistance.
The practice of sheltering assets in order to qualify for Medicaid LTC
benefits is known as Medicaid planning. While it is legal, it can be seen
as unethical by some. Medicaid planning involves transferring assets out
of an individual's name in order to meet the program's asset and income
limits. Exempt assets, such as a primary residence, are not counted
towards these limits.
However, when an individual who has received Medicaid LTC benefits passes
away, their estate may be subject to estate recovery. This means that
Medicaid can recover the cost of the benefits paid out from the
individual's estate after they die. This includes any assets that were
transferred out of the individual's name during the Medicaid planning
process.
The National Academy of Elder Law Attorneys (NAELA) explains that
estate recovery is required by federal law and applies to all states that
receive Medicaid funds. However, each state has its own rules regarding
how and when estate recovery can occur.
The Centers for Medicare & Medicaid Services (CMS) provides
guidance on estate recovery and states that it can only be applied to
individuals who are over 55 years old, permanently institutionalized, or
who receive home and community-based services through a waiver program.
The Kaiser Family Foundation notes that estate recovery is
controversial because it can create a burden for heirs who may not have
been aware of the Medicaid planning their loved one engaged in. However,
the foundation also notes that estate recovery helps ensure that Medicaid
funds are used appropriately and can help offset the cost of the program.
In conclusion, individuals who shelter wealth in exempt assets in order to
qualify for Medicaid LTC benefits should be required to repay Medicaid
after they die. This is because Medicaid is a needs-based program, not an
inheritance planning tool. Estate recovery is a legal requirement and
helps ensure that Medicaid funds are used appropriately.
LTC Comment: OK, so we don’t need to worry
about Medicaid planning because Medicaid “can recover the cost” from “the
individual’s estate.” That would be a valid point if states actually
enforced estate recoveries and the federal government compelled them to do
so in compliance with the law. But that rarely happens. Nor do the media
publicize the estate recovery liability. Consequently, estate recovery
risk does not incentivize the public to plan privately for LTC and leaves
them relying on Medicaid in the end despite the welfare program’s
downsides. Is Medicaid really “a needs-based program, not an inheritance
planning tool” when eligibility is so easy to obtain and estate recovery
is so easy to avoid?
How easy is it to avoid Medicaid estate recovery?
According to iAsk.AI Answer
Engine: Avoiding Medicaid estate recovery can be a complex and
challenging process. However, there are some legal strategies that can
help individuals protect their assets from Medicaid estate recovery. One
of the most effective ways to avoid Medicaid estate recovery is by
transferring assets out of the individual's name before they apply for
Medicaid benefits. This can be done through various legal mechanisms, such
as irrevocable trusts, gifting, or purchasing exempt assets.
Another approach to avoiding Medicaid estate recovery is by using
annuities. By purchasing an annuity, the individual can convert their
countable assets into an income stream that is not subject to Medicaid
estate recovery. However, it is important to note that annuities must meet
certain criteria to be considered exempt from Medicaid estate recovery.
Additionally, some states have implemented laws that allow individuals to
protect their homes from Medicaid estate recovery by transferring
ownership to a spouse or child. However, these laws vary by state and may
have limitations on the amount of equity that can be protected.
It is important to note that attempting to avoid Medicaid estate recovery
through fraudulent means, such as hiding assets or providing false
information on a Medicaid application, can result in serious legal
consequences.
In summary, while there are legal strategies available for avoiding
Medicaid estate recovery, it is important to consult with a qualified
attorney who specializes in elder law and Medicaid planning to determine
the best approach for your individual situation.
LTC Comment: All in all, AI does a pretty good
job of summarizing the facts and arguments on both sides of the Medicaid
planning debate. Unfortunately, AI grants equal credibility to specious
arguments in favor of Medicaid planning and to common sense objections to
the practice. What I take away from this is that we need more and better
research and analysis on this topic to avoid the errors of thought and
ethics that AI does such an effective job of summarizing and justifying.
Anybody out there want to fund such a study? I’m ready to conduct it.
One last question for
iAsk.AI: “If you were to write an ‘LTC Bullet,’ what would it
say?”
According to iAsk.AI Answer
Engine: As an AI Search Engine, I am not capable of writing an "LTC
Bullet" as it is a publication produced by the Center for Long-Term Care
Reform. However, I can provide information on what an LTC Bullet is and
its purpose.
An LTC Bullet is a publication produced by the Center for Long-Term Care
Reform (CLTCR), which is a private institute that aims to ensure quality
long-term care for all Americans. The purpose of an LTC Bullet is to
provide analysis and commentary on issues related to long-term care
policy, financing, and delivery. The publication covers a range of topics
such as Medicaid, Medicare, long-term care insurance, and the aging
population.
The LTC Bullet is known for its in-depth analysis and comprehensive
coverage of long-term care issues. It is highly regarded by policymakers,
industry professionals, and academics alike. The publication is available
to subscribers only and is distributed via email.
In conclusion, the LTC Bullet is a valuable resource for those interested
in long-term care policy and financing. It provides insightful analysis on
a range of topics related to long-term care and is highly regarded by
industry professionals and policymakers.
LTC Comment: No argument there from us. Thanks, iAsk.AI. Good luck
as you pursue your wide-ranging interests. Please don’t destroy humankind.
#############################
Updated, Monday, May 1, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-009 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
- CMS proposes that 80 percent of Medicaid payments for home care go
to direct care workers
- Feds to crack down on harmful uses of AI
- What is Medicaid and why should you and your farm care?
- Rising interest rates helping to stabilize long-term care insurance
policies
- Startup to Sell Life-LTC Hybrid at the Worksite
- Older adults’ housing equity dips to $12.39 trillion in fourth
quarter
- Washington nursing homes get 13.6 percent Medicaid boost — no
strings attached
- The Future is Here. Watch Ken Dychtwald’s keynote at NextMed and be
ready to embrace healthy longevity
- Poll: 40% of clinicians thinking of quitting
- Most older patients embrace move toward deprescribing, poll finds
#############################
"LTC E-Alerts" are a feature offered by the
Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The Center for Long-Term Care Reform,
Inc. is a private institute dedicated to ensuring quality LTC for all
Americans (www.centerltc.com).
#############################
Updated, Monday, April 24, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-008 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
How Assured Allies Is Helping People Thrive
As Long As Possible Without Long-Term Care
-
Why Medicaid is for the middle class
-
The Home Care Workforce Has Not Kept Pace
With Growth In Home And Community-Based Services
-
80% of Older Americans Cannot Pay for
Long-Term Care or Withstand a Financial Shock, New Study Shows
-
Biden Order Could Create Federal Long-Term
Care Benefits Demand
-
BREAKING: New Biden executive order would
tie Medicare rates to turnover
-
CVS report finds more seniors facing
chronic conditions
-
Life Insurance Is Profitable Again, but Too
Late for Many Insurers
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, April 21, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LONG-TERM CARE AND THE SOCIAL COMPACT
LTC
Comment: When governments promise their citizens less risk through
pay-as-you-go entitlement programs, they reduce the public’s sense of
personal responsibility leaving people unprotected by either public
programs or private savings when their ability to tax and borrow runs out.
More after the ***news.***
***
AS THE CENTER FOR LONG-TERM CARE REFORM, founded April 1, 1998, begins its
second quarter century we seek your support for our pursuit of public
policy aimed to improve long-term care financing and service delivery in
the United States. Over the years, we’ve had some success influencing
federal policy (OBRA ’93 and DRA ’05) but much more remains to be done.
Ask about those laws and our role in passing them. In the meantime, we’ve
published dozens of state and federal level studies
here;
authored scores of articles
here;
delivered speeches all across the country for decades
here;
published to date 1,354 LTC Bullets (our now bi-weekly op-ed like
columns, archived by date and topic
here;
and we’ve sent thousands of daily LTC Clippings to keep our members
apprised of new events, reports, developments and potential professional
vulnerabilities so they are ready for anything prospects or clients may
hit them with. Most recently we are working with the
Paragon Health Institute
to clarify the long-term care problem (Long-Term
Care: The Problem)
so we can present a radically new, market-based approach to solve it (Long-Term
Care: The Solution, due this fall.) Won’t you help us keep this noble
mission vibrant and successful? To join the Center, support our efforts,
become part of our team, and receive the
benefits of membership,
contact Damon at 206-283-7036 or
Damon@centerltc.com.
Or join and contribute online
here.
Thank you for your time and consideration. Let’s do this! ***
LTC
BULLET: LONG-TERM CARE AND THE SOCIAL COMPACT
LTC
Comment: America and Americans have strayed from the binding
principles—balancing personal freedom and individual responsibility—that
made the country great. No social issue illustrates this problem better
than long-term care (LTC).
To
need LTC is a high risk: seventy percent of people who reach age 65 will
eventually develop severe need. Forty-eight percent will receive paid care
averaging $138,000. Among those who need paid care, about half will
require less than a year, and a little more than 10 percent will need five
years or more at an average cost of $266,000.
Thus, LTC represents a high probability of significant cost, but a
relatively small risk of ruinously high expense. That is precisely the
condition for which private insurance is best suited. That is, to replace
the small risk of catastrophic loss with the certainty of an affordable
premium.
Yet,
most people do not buy private insurance for LTC risk. Why?
Since its founding in 1965, Medicaid has paid for most catastrophically
high LTC costs. Although it is ostensibly a means-tested public assistance
program, Medicaid’s financial eligibility rules allow its LTC benefits
recipients to retain substantial exempt assets and to have high incomes as
long as their personal health and LTC expenses were comparably high.
By
offsetting the public’s catastrophic LTC risk, Medicaid desensitized
consumers to the need to plan, save, invest or insure when they were still
young, healthy and affluent enough to do so. This “moral hazard” left most
aging Americans, including the Greatest Generation, unprotected for LTC
risk and dependent on Medicaid nursing home care.
As
the dominant LTC funder, Medicaid paid too little to ensure access to
quality care, created “institutional bias” by paying only for nursing
homes, caused caregiver shortages due to low wages, crowded out private
financing from insurance or home equity conversion, and left too great a
direct caregiving burden on financially and emotionally stressed friends
and families.
In
other words, by attempting to solve the problem of financing LTC, Medicaid
had the opposite effect of reducing the public’s perception of the risk
resulting in too many people in need of LTC dependent on public welfare
and too few prepared to pay privately for the type, quality and venue of
care they prefer.
That
is how Medicaid LTC violated the social compact. Instead of protecting
their freedom to take care of themselves, Medicaid undercut their sense of
personal responsibility leaving them dependent on a public welfare program
unable to meet their needs.
LTC
is only one example. Social Security and Medicare are two more programs
that told citizens they are protected for income and health security in
old age, but are now facing massive unfunded liabilities and the high
probability of insolvency in the short term.
Government promises should never replace personal freedom and individual
responsibility.
For
full development of this argument and its conclusion, including citations
to scholarly sources, read
How to Fix Long-Term Care Financing
(2017),
Medicaid and Long-Term Care
(2020), and
Long-Term Care: The Problem
(2022). Expect Long-Term Care: The Solution this fall.
#############################
Updated, Monday, April 17, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-007 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Social Security and Medicare Reform
-
Fast Facts about Medicare and Social
Security
-
The Growing Opportunity For Wealth
Transfer; Not Only For The Wealthy
-
Falling Inflation May Be Too Late for
Retirees. Here’s Where It’s Still Hitting Hardest
-
Hourly wage growth slowing across long-term
care, Fitch Ratings says
-
BREAKING: CMS failed to publicly post
deficiencies for two-thirds of nursing homes, OIG finds
-
Weight loss linked to 10 percent higher
mortality in elders, particularly men
-
Anxiety Abounds as Americans Contemplate
Social Security, Market Risks
-
Study finds frailty prevalent in
middle-aged and older adults
-
Feds broaden nursing home quality campaign
with new discharge, satisfaction and vaccination measures
-
Nursing Homes Profited Off Pandemic,
Reports Kaiser
#############################
"LTC
E-Alerts" are a feature offered by the Center for Long-Term Care Reform,
Inc. to members at the $150 per year level or higher. We'll track and
report to you news and analysis regarding long-term care financing,
service delivery, and research. We hope The LTC E-Alerts will help you
attain and maintain a high level of knowledge and competency in this
complex field. The Center for Long-Term Care Reform, Inc. is a private
institute dedicated to ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Monday, April 10, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-006 LTC
NEWS AND COMMENT
LTC Comment: Do you
spend hours searching the internet for useful articles, key data, and
relevant reports to keep you on the forefront of professional knowledge?
Do you lose business because you’re blindsided by clients or competitors
who learn critical information before you do? Here’s an antidote:
LTC Clippings: The
Center for Long-Term Care Reform notifies subscribers to our LTC Clippings
service daily of information you need to know. Each message contains only
the critical facts about new publications: a title, representative quote,
a link to the original, and our analysis in a sentence or two. To inquire
or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials by satisfied subscribers
here. To subscribe online,
please click
here.
LTC E-Alerts: Once a
week, we compile our daily LTC Clippings into a summary, email it to
Center for Long-Term Care Reform members, and archive it in The Zone, our
password-protected members-only website. Center members also receive our
weekly LTC Bullet op-ed. To join the Center and receive all these benefits
and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our
LTC E-Alerts on the Center’s public access website, but here’s what
today’s LTC E-Alert contained: links, quotes and comments on the
following articles, reports, or data:
-
Lawmaker again
tries to rid workers of a payroll tax that begins in July
-
10 State-Level
Long-Term Care Bills to Track Now
-
Assisted-living
homes are rejecting Medicaid and evicting seniors
-
Government
forecast predicts steep climb in nursing home costs for next two years
-
Continental
General Agrees to Acquire Elevance LTCI Policies
-
Solving today’s
enigma of the state long-term care tax mandates of tomorrow
-
Exclusive: US to
build $300 mln database to fuel Alzheimer's research
-
My Wacky Idea to
Save Social Security
-
Study: Burnout
high among all healthcare professionals
-
Long-term care
insurance could create huge fiscal burden for adult children of aging
boomers
-
Medicare, Social
Security financial shortfalls would ‘further cripple’ long-term care,
advocates say
#############################
"LTC E-Alerts" are a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The Center
for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, April 7, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTC TANSTAAFL
LTC
Comment: Free lunches are the most expensive after the ***news.***
***
CENTER’S 25TH ANNIVERSARY: On April 1, 1998 attorney David
Rosenfeld and I founded the Center for Long-Term Care Financing (now
Reform). A quarter century later, the Center is still going strong. David
moved on to play a major role as a Congressional staffer in passing our
proposals as part of the Deficit Reduction Act of 2005. Damon joined as VP
for Administration in 2002 and he’s kept us in business ever since. We
thank our corporate and individual members for your many years of support,
encouragement, collegiality and friendship. The most promising
opportunities to improve LTC financing public policy are immediately
ahead. Stay committed with us. ***
LTC
BULLET: LTC TANSTAAFL
LTC
Comment: TANSTAAFL: There Ain’t No Such Thing
As A Free Lunch. That immortal verity pertains
today more than ever. But equally true is its corollary that everyone
wants a free lunch and many will fall for the promise of one when offered.
Government is the worst purveyor of free lunches that turn out to be very
expensive indeed. Pay a little now and get a lot later. That’s the formula
employed by Social Security, Medicare, Ponzi, and Bankman-Fried. The
outcome is always the same. Sooner or later there aren’t enough new
suckers to keep the game going.
Medicaid LTC’s free lunch isn’t as obvious. You don’t have to pay in to
get the bonanza later. You only have to be broke. Medicaid even says that
if you aren’t broke and you need expensive LTC, you have to become broke
by paying for your own care first to qualify.
Not
much of a free lunch if you put it that way. But here’s the twist. When
the time comes that you need high-cost LTC, you don’t have to impoverish
yourself. Reaching “low income” is easy. Medicaid subtracts your private
health and LTC costs. Most big assets are exempt so uncounted.
Here’s how Medicaid LTC offers a free lunch. It turns the typical Ponzi
entitlement scheme on its head. It says “ignore the risk of LTC and if you
need it you’ll lose your life’s savings paying for it before you get any
help from the government.” Then, when you need care, government pays
anyway, ignoring the draconian warnings.
Medicaid LTC’s free lunch is the worst of both worlds. People ignore the
impoverishment warnings with impunity. They don’t plan, save, invest or
insure for LTC. The fact that government always paid in the end enabled
their denial of the risk.
There are two ways to eliminate Medicaid LTC’s upside down free lunch. You
can force everyone to pay a tax to fund a new entitlement for LTC. That’s
WA Cares. It turns LTC into a conventional social insurance free lunch
scheme.
A
better approach is to establish a LTC planning responsibility, offer many
ways to meet it, monitor compliance, but only enforce responsibility when
it’s unmet voluntarily. Instead of threatening catastrophic spend down
maybe someday without following through, incentivize responsible early
planning as a way to avoid any government compulsion.
That’s the plan that I’m working on now, details of which are being
formulated every day. So stay tuned.
#############################
Updated, Monday, April 3, 2023, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-005 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
How to Get Your Long-Term Care Planning on
the Right Track
-
Why the U.S. Health Care System Must
Address the Shortage of Geriatricians Now
-
100 Must-Know Statistics About Long-Term
Care: 2023 Edition
-
Medicaid a major challenge to providing
affordable assisted living, NCAL says
-
Retirement plan contribution rate decreases
-
The Looming Collapse of a Long-Term Care
Insurer Raises Questions for DFS
-
Study: Older adults spending billions on
home repairs to age in place
-
Life expectancy confusion may be
jeopardizing retirement planning: study
-
Long-Term Care Planning vs. Taxes: Finding
a Healthy Balance
-
CalPERS to pay $800 million settlement over
claims it misled retirees on costs of long-term care insurance
############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, March 24, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: VIRTUAL VISIT TO ILTCI 2023
LTC Comment: Last week’s
ILTCI conference in Denver had a hopeful theme and a promising new
focus. Read on for a virtual visit to the program for those of you who
were not there, but may wish to consider attending next year.
*** TODAY'S LTC
BULLET is sponsored by Claude Thau with BackNine Insurance. Back9
gives you a free personalized website at no cost. Your clients
(& family & friends) can, with as little or as much of your
involvement as you or they want, buy life insurance and LTCi, and
schedule parameds and upload their medical records to speed the
process. We quote stand-alone LTCi, linked-benefit and life with a LTC
rider side-by-side and provide a sales track with video
support. Claude is the lead author of Milliman’s annual Broker World
LTCi Survey & a past Chair of the Center for Long-Term Care Financing.
Contact him at 913-707-8863 or
claude@back9ins.com discuss
how he might help you. *** |
LTC BULLET:
VIRTUAL VISIT TO ILTCI 2023
LTC Comment:
Steve Schoonveld chaired the 2023 ILTCI conference in Denver. He opened
the program with a brief retrospective of its past iterations. The first
was January 2001 in Miami with 500 attendees. Florida, Texas and Nevada
accounted for 13 of the 21 total locations. The latest Denver conference
had over 950 in attendance; 270 unique companies were represented
including 66 exhibitors, 34 sponsors, and over 200 presenters and
moderators. If you’re interested in the history of these meetings, have a
look at our
History of LTC Insurance Conferences (2021). It covers all of
the major LTCI meetings for the previous two decades and contains pictures
of LTCI’s leading lights over the years. (They’ve aged, but most are still
going strong.)
This year’s
planning and education committee focused on bringing in new speakers and
topics and it showed. The meeting’s theme “Take the Lead” was evident
throughout with a constant focus on innovation. Most evident was a special
emphasis on wellness and finding ways to meet the needs of prospects and
clients, especially people at risk or already in claim. It’s not just
about selling policies and managing books of business anymore. It is more
than ever about helping people age well and stay healthy. More on that as
we describe some of the sessions below.
As usual, this
ILTCI conference was ideal for networking. The exhibit hall offered free
drinks and excellent food. Special thanks are due to the sponsors.
Exhibitors included many who represented the meeting’s “Take the Lead”
theme and its special focus on wellness and healthy aging. Check out lists
of the
exhibitors and
sponsors so you can thank them. With this year’s conference in the
rear view mirror, it’s not too soon to begin planning for next year’s
ILTCI program in San Diego, CA – March 17-20, 2024 – at the newly
renovated Town & Country resort.
Tracks
Here is the
distribution of this year’s attendees based on their self-reported tracks:
Track Title |
101% |
Actuarial & Finance |
25% |
Advisors, Agents, & Agencies |
19% |
Aging in Place Solutions |
7% |
Claims & Underwriting |
12% |
Legal, Compliance, & Regulatory |
9% |
Management & Operations |
17% |
Marketing & Research |
7% |
Technology & Eldercare Services |
5% |
Behaviorist and
humorist
Jeff Kreisler delivered this year’s opening keynote address focusing
on “why we do what we do.” He describes himself as just another typical
Princeton educated lawyer turned award-winning comedian, best-selling
author and champion for behavioral science. Kreisler is author of
Dollars and Sense: How We Misthink Money and How To Spend Smarter and
Head of Behavioral Science for JP Morgan Chase. The presentation was
interesting, humorous and thought provoking. Margie Barrie, who covered
the conference for ThinkAdvisor, reviewed the keynote in “What
Can Help Clients See the Long-Term Care Cost Threat? Science.”
The App
This year’s
conference smart phone app was excellent, the best so far. One could find
all the attendees, plan a schedule based on searching all available
sessions in each block, and review the handouts. The downside was that
this detailed information was not included in the online version of the
program. That makes it much more difficult to share session details as we
were unable to cut and paste. Another problem was that the sound system in
several of the meeting rooms was very poor making it impossible to capture
some of the content. What follows nevertheless is a little information on
each of several sessions. Hopefully, this will give you a good idea of
what the conference was like and what you might expect if you come next
year.
Some
sessions:
3/13/23
10:30am
Title: “The Impact of State Legislative Activity on our Industry -
Friend or Foe?”
Producer: Melissa Bova
Speakers: Moench, Stephanie; Veghte, Ben; Bova, Melissa; Gugig,
Mike; Simonson, Dawn
Topic: “How can public sector activity targeted at LTC services and
supports help or hurt activity in the private sector?”
Much is
happening in this realm in several states including California and
Minnesota, but of course the biggest development is WA Cares in Washington
State. Ben Veghte, WA Cares’ Director made the case for that program,
about to start withholding payroll taxes in the Evergreen State July 1. He
is an articulate advocate for a program that, at the least, has had its
ups and downs. Claude Thau brought some balance to the conversation by
pointing out that WA Cares’ website claims people no longer have to worry
about LTC risk. Claude observed that such a statement is false and should
be removed. Veghte said he’d look into it.
3/13/23 2pm
Title: “How are consumer needs influencing product development?”
Producer: Josh Falco
Speakers: Nisenson, Larry; Tell, Eileen; Falco, Josh; Walbrun,
Dave; Haas, Mike
Topic: Discuss the new and innovative ways consumers are getting
help with long-term care.
This was the
first of several sessions I attended focused on the mission to serve
prospects and clients better, to understand their needs, and meet them.
Eileen Tell offered examples of what consumers think they know about LTC
that is wrong. When researchers ask what people want in a product and what
they would be willing to pay, they get untenable answers. There’s a
disconnect between reality and expectations. Larry Nisenson spoke about
Assured Allies’ quantitative approach to discern what people really
want, healthy aging in place, and to help them achieve it with
NeverStop.
3/13/23
3:45pm
Title: “The New Trend in Integrating Caregiving Benefits with LTCI
Benefits”
Producer: Larry Nisenson
Speakers: Nisenson, Larry; McInerney, Thomas; Sikorski, Cathy;
Martin, Todd
Topic: How are caregiving and LTCI linked and how can we leverage
relationships with HR representatives to tighten the connection further?
This was
another session aimed at better integrating long-term care insurance
benefits with caregiving needs. Genworth CEO Thomas McInerney mentioned
his company’s largest claim ($1.3 million) on an original premium of
$1,500. Todd Martin asked how many in the audience have caregiving
experience. Answer, 90%. He observed there is involuntary employee
turnover due to LTC with serious ramifications for the organizations
affecting their ability to acquire and retain top talent. Cathy Sikorski
emphasized the importance of bringing LTCI into the workplace.
3/14/23 9am
Title: “Leveraging Public & Private Insurances & Resources to Improve
Health Outcomes”
Producer: Colleen Dennis
Speakers: O'Leary, John; Plaskon, Todd; Lillis, Maureen; Ludden,
Beth; Dennis, Colleen
Topic: Join this session to learn how to leverage public and
private insurances and companies like Medicare, Medicare Advantage,
non-profits, and AAA’s to improve health outcomes and lower costs. We’ll
specifically talk about what we can learn/utilize from Medicare (equipment
coverage, use of the OASIS data for homecare claimants, use of the MDS
data for facility claimants) and Medicare Advantage (meal delivered
programs, transportation). Panelists will also discuss how to find
resources in the area (e.g. life alerts, Meals on Wheels) to complement
wellness programs and/or to reduce reliance on caregivers.
This was a
fascinating session with its focus on integrating services, less so on
financing. Beth Ludden of Genworth observed there are many critical
organizations that elders who need them do not know about, including the
Area Agencies on Aging. She observed we work in our insurance bubbles too
much, unaware of services that are out there. Medicare and Medicaid are
ahead of the LTC insurance industry in focusing on hands-on or supervisory
care. Other panelists shared many examples of organizations that can help
and ideas to enhance the cooperation and mutual effectiveness of public
and private insurance sources.
3/14/23
10:45am
Title: “Teamwork Makes the (LTC) Dream Work: Public/Private
Collaboration”
Producer: Stephanie Moench
Speakers: Cain, Steve; Moench, Stephanie; Arland, Jamala; Mueller,
Jamie
Topic: This session explores opportunities for the private LTC
market to collaborate with state programs, e.g., through the development
of supplemental insurance products, to meet consumers' evolving LTC needs.
During this interactive discussion, panelists will delve into key
considerations related to public/private collaboration with the goal of
expanding industry awareness and sparking product innovation, such as:
• What
challenges are impeding public/private collaboration?
• How will
publicly funded LTC programs impact private LTC market dynamics and
product designs?
• How can we
proactively promote public/private collaboration while mitigating consumer
confusion?
• What are some
of the key supplemental (and substitutive) LTC product opportunities for
insurers given the range public programs designs being discussed? What are
the primary actuarial considerations that could impact the consumer’s
decision? Providing consumers with a range of options (public and private)
should better enable them to holistically plan for their future LTC
needs--teamwork makes the (LTC) dream work!
This was yet
another session aimed at making the collaboration between public and
private insurance work better. Stephanie Moench, for Oliver Wyman, spoke
of the landscape of public LTC programs, showing a map with 14 or 15
states highlighted that are in creative phases. Steve Cain observed the
need to meet people where they are, the workplace.
3/14/23, 2pm
Title: “The Results Are In: Aging in Place/Wellness Programs Seem
Promising for the LTCI Industry”
Producer: Jodi Anatole and Vince Bodnar
Speakers: Jacobs, Dave; Anatole, Jodi; Moore, Nate; Gal, Afik; Hu,
Char; Henderson, James
Topic: One of the greatest reasons LTCI carriers hesitate to
implement an Aging in Place/Wellness program is lack of actual results.
While these programs are still new, results are beginning to emerge that
seem very promising. After a rigorous selection process, we have
assembled a panel of vendors who will share their strategies and results
- with a focus on the bottom line. This session should give you a deeper
understanding on why these programs are worth the investment and how they
can help you manage your block.
Each speaker
had 10 minutes to share their company’s approach and results. All were
impressive. Afik Gal of Assured Allies went first reporting that they
work with people before they become claimants with an evidence based
approach. They help people get their confidence back. Return on investment
of 167%. Other speakers discussed their unique approaches and report
similarly impressive results.
Bonus
session reviews prepared by Damon Moses:
Session:
“Modernizing The LTC Customer Experience Using Technology”
Track: Management & Operations
Moderator/Producer: Jennifer Jones
Speakers: Jim DuEst, Duane Anderson, Kim Poulopoulos, Jennifer
Jones
Description: “Please join this panel to hear more about how
companies are leveraging technology to modernize the long term care
customer experience throughout the policy lifecycle from underwriting to
rate increases to claims. Hear from carriers, reinsurers, and
administrators on their strategies, success stories, and challenges, as
well as learn about emerging trends in technology in our industry.”
Key messages:
- Investment
in technology to increase efficiency and automation is necessary for
improving the LTC Customer experience.
- Improve
customer experience by employing technology such as Chat GPT.
- Improve
health outcomes by collecting personalized data through wearables such
as Fitbit.
- Some of the
biggest challenges preventing technological progression are: resources,
organizational issues and overcoming legacy systems.
Session:
”The LTC Renaissance: New Product and Market Opportunities”
Track: Actuarial & Finance
Moderator/Producer: Erik Wenzel
Speakers: Brian Vestergaard, MacKenzie Madsen, Erik Wenzel, Tom
Riekse
Description: “This is an exciting time for the LTC industry—the
confluence of rising interest rates, proposed public financing solutions,
demographic shifts, post-pandemic focus on health and wellness, and
technological advancement gives the industry an opportunity for an "LTC
Renaissance”. This session is presented by those on the frontlines of the
imminent renaissance and will cover:
- New market
opportunities presented by state-sponsored LTC programs
- The growth
of group and worksite distribution channels
-
Middle-market solutions
- New market
entrants and innovative features
- Wellness
programs on new business”
Key messages:
- LTC is
currently in a period of renaissance of renewed interest and product
innovation.
-
State-sponsored programs are increasing interest in LTCi as a tax
avoidance measure.
-
Accessibility, affordability and ease of premium payments are important
to LTCi consumers.
- Hybrid
products linked to the market and products with variable benefits will
be important.
- Consumers
should look at an LTCi policy as a valid component of a holistic
financial portfolio and should be able to view the value of their policy
easily online.
Session:
“Caregivers need help too!”
Track: Aging in Place Solutions
Moderator/Producer: Robin Devine
Speakers: Ali Ahmadi, Karen Brown, Tracey Gendron, Timothy Peck,
Robin Devine
Description: “Caregivers take care of us, we need to take care of
them. A Discussion on raising the level of awareness of the needs and
wants of older adult and their caregivers.
“Caregiver burnout doesn’t need to be inevitable. So, why do we so often
associate caregiving with burnout? The caring relationship is one that has
both joy and frustration - just like all other relationships. Join our
panel discussion where leaders in Caregiving, Gerontology, and Innovation
share methods, ideas and best practices to support care partners by
breaking through their misconceptions and helping them increase choice,
control, and independence. We will have a conversation around preventative
vs reactive caregiver support concepts.”
Key messages:
- Women tend
to be default primary caregivers, often as a spouse or eldest daughter.
- 24% of
caregivers provide care for 5 years or more.
- $470 billion
is the economic value provided by informal caregivers.
- LTC as
ecosystem of care. Caregiving is a natural and normal part of everyone’s
lifecycle and should be destigmatized. People fall into two categories:
current caregivers or future caregivers.
- Further
support caregivers by improving care infrastructure and examining the
health consequences of ageism.
3/14/23,
3:30 Closing General Session
Title: “Taking the Lead: Building Towards 2030”
The closing
session was comprised of three panels and a poll.
The first
panel, titled “The Future of Caregiving and Care Management,” engaged
Karen Brown of the Colorado Commission on Aging; Noreen Guanci, co-founder
CEO of Long-Term Solutions in Massachusetts; Maureen Lillis, COO of
Independent Living Systems; and Robert Eaton, principal at Milliman in
Tampa. They discussed caregiver shortages, poor caregiver compensation,
and the importance of valuing caregivers. One idea: Train high school
students to do caregiving so they have jobs when they graduate. The ILTCI
conference has come a long way toward understanding and supporting
caregiving since its Aging in Place track 10 years ago.
The second
panel, titled “The Future of Care Financing,” engaged moderator Vince
Bodnar of FTI Consulting; John O’Leary, president of O’Leary Marketing;
Anna Frankowska, CEO of Graceful Finance; Shannen Logue, Deputy Insurance
Commissioner in Pennsylvania; and Liz Christopher, COO of Home Care Genie.
They discussed the public and private realms of LTC financing, how both
involve many different aspects, and often do not understand each other.
But all are trying to do the same thing, which is to find adequate
financing to support the country’s caregiving needs. Shannen asked, “why
are so many people qualified for Medicaid?” Vince asked “what is the best
way to reach the middle market?” Both good questions the answers to which
would wisely begin with a careful study of how Medicaid LTC eligibility
determination actually works, enabling potential middle market prospects
to access Medicaid when they need LTC late in life without significant
spend down. A sense of optimism is growing as the profession is starting
to focus on our customers and policy holders.
The third
panel, engaged industry veterans Ron Hagelman, author of the
long-running monthly column “The Last Word on LTCI” in Broker World
and his long-time business partner Barry Fisher of Blaze ‘n Bear Insurance
Services, Inc., in amusing, and informational back and forth banter about
their perspectives on long-term care services and financing. Barry
observed “people who need to be here aren’t” and that Medicaid crowds out
private products due to the “elder law industrial complex.” He compared
the moral hazard of letting Medicaid co-opt private insurance with the
current travail in the banking system where government bailouts ensure
even more irresponsible banking behavior in the future. He said “private
insurance should be the first line of defense; public, second.” I’ll have
more to say along those lines in my closing LTC Comment. Ron observed LTC
is “all about control,” what can I do to assure best quality of care for
loved ones and clients. As a fellow old-timer, this session was my
favorite of the conference.”
Director’s
Pitch: Conference director Steve Schoonveld closed the meeting with
his “Pitch.” He said “So we have health insurance that protects or
maintains your health. It’s called dental insurance and not tooth decay
insurance. Vision insurance and not blindness insurance. Auto insurance
and not crash insurance. Life Insurance covers the value of your life in
case of death.
So, does LTC
insurance and extended care insurance cover your care or should it insure
your wellness? I offer that this conference will be called the
Intercompany Wellness Insurance Conference, or the IWIC by 2030.”
Finally, he posed these questions to the audience:
- In 23 years
of ILTCI conference, what has surprised you the most?
- What are the
likely trends you expect in the next 7 years?
- Predict the
theme of the 2030 conference and explain why.
- Rename
Long-Term Care Insurance.
- “Punt the
pitch” and make the case for your preferred 2030 conference location.
Several
audience members approached the microphone to share their answers.
A final
electronic poll asked “How many ILTCI conferences audience members had
attended.”
1. First, 34%
2. 2-5 times, 38%
3. 10 times, 14%
4. 11-15 times, 7%
5. 16-20 times, 5%
6. All 21 times, 1%
Supplemental
content before and after the conference
CLTC delivered
two classes the weekend before the conference - a Master Class and a pilot
for their new Product Insider class. “Both were a hit!”
SOA Section
Council Meeting (Open to All), Sunday, March 12
SOA
Professionalism Course, Wednesday, March 15th
Alzheimer's
Association Session, Wednesday, March 15th
Closing LTC
Comment: I was moved and heartened by this ILTCI conference’s “Take
the Lead” theme and its overwhelming focus on wellness and serving
clients’ needs. Both were encouraging and inspiring. But as an attendee of
nearly all of the meeting’s earlier iterations, I missed some of the
former sessions’ broader content and fiery interactions. To my mind the
biggest missing pieces are the absence of policy and provider tracks. It’s
as though the LTCI industry has given up the battle, succumbing to
Medicaid’s crowd out effect without further effort. It’s stuck in its silo
lacking the former invitation to nursing homes, home health agencies,
assisted living facilities to come, share, argue, and conceive together. I
remember debates and challenging questions, that are less evident now.
Harley Gordon and George Sherman, where are you when we need you? I hope
the LTCI business does not subside into a go-along-to-get-along truce with
government, ironically just as LTCI’s prospects are looking up and
government’s, especially its entitlement programs, are going down.
#############################
Updated, Monday, March 20, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-004 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Some
State Regulators Frown on Life-Long-Term Care Combo Products
-
High
concentration of dually eligible older adults in assisted living
warrants study of care quality, researchers say
-
OIG:
Personal care providers accounted for most Medicaid fraud convictions
again in 2022
-
Costs
for linked-benefit long-term care insurance policies drop up to 15
percent from last year
-
Medicare costs could soar with availability of new obesity drugs,
experts say
-
What
Can Help Clients See the Long-Term Care Cost Threat? Science
-
Denied
by AI: How Medicare Advantage plans use algorithms to cut off care for
seniors in need
-
How
Life and Annuity Issuers Could Get Silicon Valley Bank Flu
-
The
Role Of Medicaid In Addressing Climate Change And Climate-Related
Inequity
-
Exclusive: Biden administration warns states to minimize coverage loss
as they restart Medicaid eligibility reviews
-
Biden
pledges $150B for HCBS in new budget
-
Long
term care insurance in the UK: What's going on?
-
New
evidence of four distinct pain trajectories in nursing home residents
-
Family
caregivers’ unpaid work valued at $600 billion: report
-
AARP:
Paid caregivers are key to relieving family caregiver burden
-
Assured
Allies secures $42.5M Series B to help Americans ‘successfully age’
-
A
tax-advantaged solution for long-term care needs
-
GoldenCare Long-Term Care Insurance
-
7
Long-Term Care Program Ideas for Taxphobic Times
-
Aggressive Medicare Advantage marketing floods TV and mailboxes with
misleading ads. The Biden administration is cracking down
-
Argentum’s Workforce Projections for Senior Care Report Sees a Need to
Fill 20 Million Job Openings Through 2040
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Monday, March 6, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-003 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Terry Savage and
Brian Gordon on long-term care insurance
-
Social Security
Checks Got a Historic Boost This Year. Retirees Say It’s Not Enough
-
The High Cost of
Waiting to Plan for Long Care
-
As States Prepare
to Resume Disenrollments, Medicaid/CHIP Enrollment Will Reach Nearly 95
million in March, and the Pandemic-Era Enrollment Growth of 23 million
Accounts for 1 in 4 Enrollees
-
They could lose
the house — to Medicaid
-
As Debate Heats Up
in Washington Over Possible Entitlement Cuts, A New KFF Analysis Details
the 30% of Federal Spending That Goes to Health Care Programs
-
A Hidden Source of
Wealth Many Retirees Overlook
-
The problematic
politics of Japan’s ageing electorate
-
Long-term care
insurance costs in Germany to increase from July
-
Better
cardiovascular health may explain declining dementia rates: study
-
Older adults
fearful they could outlive savings: survey
-
Skilled Nursing
Operators Protest ‘Insane Amount’ of Administration Needed as Medicare
Advantage Expands
-
The Real Federal
Deficit: Social Security And Medicare
-
New Life Policy
Can Protect Against Disability and Long-Term Care Risk
-
Brian Blase and
Frederick Isasi on Medicare and Medicaid
-
7.7% Increase in
Long-Term Care Benefits Payouts
-
CMS Officials
Confirm End of PHE Nursing Home Waivers, Barring Congressional Action,
-
What Long-Term
Care Insurance Policyholders Need to Know
-
They offer to help
nursing home residents get Medicaid. Too often, say legislators, they
cheat them
-
States, other
countries offer insights into making long-term care more affordable:
report
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, March 3, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTCI AND INNOVATIVE FINANCIAL PLANNING
LTC
Comment: “Adapt or die,” capitalism demands. Consider how long-term care
insurance evolves and survives after the ***news.***
***
ILTCI CONFERENCE themed “Take the Lead” convenes in Denver March 12-15,
only days away. Register
here.
Find lodging
here.
Click
here
for the conference app and how to reach the hotel from the airport. This
is the big one, folks. Be there if you can. If you can’t, watch for our
virtual visit to the conference, summarizing its highlights, shortly after
it ends. In the meantime, check out our “History
of LTC Insurance Conferences (2021).
It has narrative and pictures covering twenty years of LTCI professional
meetings. What a gauntlet we’ve run! ***
***
CERTIFICATION FOR LONG TERM CARE
will be in Denver for the
ILTCIconf
offering a new
Product Insider
class that provides “an impartial deep dive” into all the LTCi product
types on the market, who offers them, their pros and cons and client
applications. CLTC reports: “Because we are excited about our new class
and want your participation in our roll out event in Denver on March 12th,
8:00 – 2:00, we have a very special (and limited) offer. ILTCI Price: Only
$500 (current street rate: $899); CLTC Training Pre-Requisite: Waived.”
Register
here.
***
***
CLTCR APPEAL. Every so often, we need to appeal for your support of the
Center for Long-Term Care Reform. This is one of those times. Please
review our “Membership
Levels and Benefits Schedule.”
It explains all the ways individuals, companies and organizations can work
together with us to improve long-term care financing policy. We are on the
verge of an opportunity for statutory LTC policy reform the likes of which
we have not seen in decades. I know because I’ve been in the thick of the
fight for 40 years, as my
bio
recounts. The
Paragon Health Institute
recently published my assessment of what’s wrong with long-term care in
America: “Long-Term
Care: The Problem.”
Watch for our radical proposal to fix LTC policy coming in the fall titled
Long-Term Care: The Solution. Center members can follow our
progress and contribute their own ideas and recommendations by reading our
biweekly LTC Bullets, our weekly LTC E-Alerts, and our daily
LTC Clippings (for premium members).
Join
our campaign!
***
LTC
BULLET: LTCI AND FINANCIAL PLANNING INNOVATION
LTC
Comment: Financing long-term care is a critical part of ensuring that all
Americans have access to quality extended care when they need it. But so
is preventing and delaying the need for paid long-term care by promoting
wellness and well-being.
Assured Allies
is a company dedicated to combining data science, personalized technology,
and human touch to unlock the benefits of healthy aging for individuals,
families, and insurers. It should come as no surprise that when they
succeed in that mission it benefits the people they help and their
LTC insurers. The Center for Long-Term Care Reform is proud to count
Assured Allies among our corporate members.
I
was so impressed with Assured Allies’ creative strategy to integrate
wellness, retirement planning, and long-term care financing that I asked
the company to prepare a “Guest Bullet” sharing their approach. The result
follows in a piece authored by the company’s Chief Growth Officer, Larry
Nisenson. He has committed to share more about Assured Allies’ mission and
approach in the future. In the meantime, he suggests this
video.
But for now, here’s …
“The
Role of Long-Term Care Insurance and Innovation in Financial Planning”
by
Larry Nisenson
Retirement financing in America was revolutionized when Congress passed
the Revenue Act of 1978, which allowed employees to set aside a portion of
their salary in a tax-deferred retirement account or 401K. As the defined
benefit plans of our parents’ generation shrank, the modern world of
retirement investing flourished. Today, almost 50 years later, Americans
have socked away over five trillion dollars in these retirement
juggernauts. In reaction to this sea change, a new retirement planning
industry boomed to help individuals save and invest enough for their
futures. The industry focused on three main areas of retirement planning:
accumulation of assets, income generation and wealth transfer.
While these phases are critical to retirement planning, there is a key
risk that is often overlooked by even the most astute financial planners:
the impact of a long-term care event. According to an ASPE Research Brief
presented to the HHS in August of 2020, over 50 percent of people over age
65 will require long-term care at some point, making this a huge oversight
for half the population. Long-term care may be brief for some, but the
average statistics—a length of three years, and a cost of over
$120,000—are sobering indeed.
Despite the urgent need for long-term care insurance (LTCI) to cover this
potential liability, the industry has sold only about 7 million LTCI
policies in the last 40+ years, an incredible decline from the 2003 peak,
when sales exceeded $2 billion in premium. In 2020, according to Milliman,
the industry only sold $150 million of stand-alone LTCI, over a 90 percent
drop from its high two decades ago. Hybrid products have picked up some of
that slack, but consumers are hardly rushing to purchase any of those
choices in droves. Why not?
There are several reasons for the gap in coverage, including fewer
carriers who write LTCI, lack of consumer awareness of the risk, and
negative agent and consumer sentiments due to rising premiums and a
general misunderstanding of health care insurance. Many consumers believe
that Medicare will cover long-term services and support (LTSS), but in
most cases, that isn’t accurate. Since the vast majority of LTC claims are
non-medical in nature, Medicare isn’t the answer.
The
aging demographics of the U.S. today render this problem even more dire.
According to the U.S. Census Bureau, there will be over 80 million
Americans over the age of 65 by 2030 as the last of the Baby Boomers head
into retirement. With so many of them financially unprepared, it becomes
even more critical that the retirement industry steps up to provide
products that meet people’s needs and show them a workable path toward
financial security in retirement.
To accomplish this, the industry must continue to embrace change and
innovation from every angle. The participants need to include incumbent
carriers, agents and distributors and, of course, regulators. Innovation
can happen on many fronts, but I’d like to focus on three areas:
annuities, underwriting and wellness incentives.
First, let’s look at annuities. The fixed index annuity space is a
familiar one for many agents and consumers and, according to LIMRA, is
experiencing a recent boom—2022 was a record sales year with almost $80
billion in sales. Deferred annuities have been used by consumers during
all three phases of their retirement planning, but to date have not been
considered as a long-term care solution, as evidenced by the somewhat
anemic sales of less than $500 million in 2021. In addition to the
overlooked potential of deferred annuities, the
Pension Protection Act
(PPA) has opened the door to incredibly powerful new annuity hybrid
product opportunities in the LTCI space.
The
PPA was enacted by Congress in 2006 and generally allows consumers to
enjoy both tax-deferred growth of their annuity contract and tax-free
distributions for qualified long-term care expenses. This only applies to
non-qualified annuities with true LTC benefits, not acceleration riders
attached to the policy. There are other rules of course, but this
incredibly efficient tax policy should be on every consumer's mind and in
every advisor’s playbook. Even so, demand for hybrid LTC annuities
probably won’t accelerate without innovations on the consumer front.
Underwriting continues to be a friction point for consumers. Given the
advancements in electronic medical records (EMRs), data science and
clinical understanding of morbidity drivers, there's no reason we can’t
offer a more streamlined experience.
At
my company,
Assured Allies,
we’ve developed and brought to market an all-digital underwriting
experience that takes less than 30 minutes and provides objective
underwriting decisions that achieve as good if not better risk assessment
than traditional morbidity underwriting. A single 30-minute video
assessment allows us to assess the physical and cognitive abilities of the
applicant and then feed the scores into an algorithm that determines which
class is appropriate for the applicant. Our approach is much more in line
with the immediacy that consumers expect and reflects the trend lines of
other companies in today’s underwriting space as well.
The
final innovation I’d like to address is wellness incentives. Wellness
programs offer opportunities to enhance LTC products for both the consumer
and the carrier. John Hancock’s Vitality program has done a wonderful job
of incentivizing policyholders to participate in healthy living, but to
date, this type of innovation has been missing on the annuity side.
Assured Allies introduced the
NeverStop
wellness program on
Bridge,
our first annuity product, launched in partnership with EquiTrust in Q4 of
2022. Policyholders who participate in NeverStop wellness take an active
role in their aging journey and can earn additional long-term care dollars
if they need to access their benefits.
There are many other examples of innovation that are surfacing for
consumers in the caregiving space, the voluntary benefit world and the
insurance product world. Assured Allies is proud to be part of this wave
of innovation; we must continue to push these efforts forward to make
successful aging accessible to all. An important consideration for all
these enhancements is the regulatory front and the push by the NAIC for
more innovation. The task force has done a great job of advancing their
thinking and being open to new ideas, and we need to see more states
embracing these innovations. This is key to private enterprises’ ability
to meet consumers where they are with modern solutions that answer their
needs.
Larry Nisenson is Chief Growth Officer for Assured Allies. Reach him at
908-500-0770 or larry.nisenson@assuredallies.com
#############################
Updated,
Monday, February 20, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #23-002 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Are Payments To Medicare Advantage Plans Inflated?
-
More than 1 in 6 Americans now 65 or older as U.S.
continues graying
-
Bridging the Gap: A Discussion of Short-Term and
Long-Term Care
-
Is Applying for Medicaid for Do-It-Yourselfers?
-
Researchers ID 8 social factors that lead to early
death in seniors
-
Medicare Recipients Face Significantly Higher
Projected Costs: EBRI
-
Death, Finances and How Many of Us Get Our Money
Needs Wrong
-
Genworth to Launch Senior Care Provider Network
Business
-
FACTSHEET: State of the Nursing Home Sector
-
Study: Prevalence of disabilities among older
Americans is much lower than a decade earlier
############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Monday, February 17, 2023, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTCI EDUCATION
LTC
Comment:
CLTC
exemplifies certified excellence in LTC education. More on what that means
after the ***news.***
***
2022 LTCI PAID CLAIMS: Jesse Slome,
Director,
American Association for Long-Term Care Insurance
reports “Long-term
care insurance companies paid out a record $13.25 billion in 2022. Claim
benefit payouts for policyholders with traditional long-term care
insurance coverage grew from $12.3 billion in 2021. The increase in
benefit payouts is expected as policyholders age and start to require
care. For calendar year 2018 the Association reported that long-term care
insurers paid out $10.3 billion. Link to the reported info
here.
***
***
CLTC, the subject of today’s Guest LTC Bullet is sponsoring some
special programs. One, titled “The Rise of LTC-Annuities: What’s New? Why
Now? What Lies Ahead?, is scheduled for February 22, 2023 (Wednesday) at
2:00 P.M. EST. Another, called the
CLTC Product Insider
class will be offered March 12 at the ILTCI conference in Denver. Check
out these programs
here.
***
***
THE 2023 ILTCI CONFERENCE is less than a month away. Check out the Denver
March 12-15 program
here.
Register
here.
The 2023 ILTCI Mobile App, sponsored by Nationwide, is already available
to registrants. Themed “Take the Lead,” the conference will convene at
the Sheraton
Downtown Denver.
Comedian lawyer (evidently not an oxymoron)
Jeff Kreisler,
is slated to keynote the program. Organizers say “Last year’s conference
was a huge success! Over 750 attendees from across the US attended. We
look forward to bringing you another amazing conference in 2023.” For a
history of this and other LTC insurance conferences over the years, check
out our
History of LTC Insurance Conferences (2021).
You’ll find summaries of each conference and many pictures of much younger
LTCI luminaries, who are older and wiser now. Don’t miss this opportunity
to get the latest industry news, scuttlebutt and networking. ***
LTC
BULLET: LTCI EDUCATION
LTC
Comment: The Certification for Long-Term Care company and training have
been around for a long time. They are highly regarded and deeply
appreciated by people who care about LTC insurance excellence. That
includes myself and the Center for Long-Term Care Reform, which is proud
to have CLTC as a corporate member.
Our
appreciation for CLTC got an extra boost when I saw the latest issue of
their
CLTC Digest.
It contains serious articles by thoughtful experts bearing on issues of
concern to anyone serious about improving the delivery and financing of
long-term care. In fact, the Digest’s “new year and fresh look”
spurred me to email this to CLTC’s Executive Director Amber Pate: “I’m so
impressed with CLTC’s program and development, especially the CLTC
Digest. The industry has had nothing like that since George Sherman
published LTC News & Comment in the 1990s.” Old timers like me
remember how that monthly newsletter kept us all at the forefront of LTCI
news and analysis at a time when anything and everything still seemed
possible, in fact more than likely, to happen. If the CLTC Digest
can help rekindle that sense of mission and hope, it will be a valuable
part of our common objective, to improve long-term care for all Americans.
So I added “I’d very much like to publish a guest LTC Bullet about
CLTC and the Digest.”
Steve Moses
LTC
Comment: Now here’s today’s Guest Bullet column by CLTC’s Director of
Education.
The
Value of Education in the Long-Term Care Insurance Industry
by
Celeste Cobb
The
impact of an unexpected need for extended care has serious, if not
irreversible consequences for families and for their ability to keep
future financial commitments. Long-term care planning is a critical
component of risk management and retirement planning and is considered the
most overlooked aspect of insurance and financial planning in our country.
A long-term care event and associated expenses pose the greatest threat to
an aging client’s financial security.
Long-term care insurance is a complex product. Long term care planning is
a complex process. Back in 1997 elder law attorney Harley Gordon, Esq.
created the Certification for Long-Term Care (CLTC®) because he believed
long-term care planning was an essential component of comprehensive
financial, retirement and estate planning. He also did not support the
common practice of educating a client about the risk of needing care for
the purpose of purchasing an insurance product. Such tactics serve only to
create an adversarial environment because most people believe that the
worst will happen to someone else. Attempting to convince the client
otherwise will only provoke an argument that leads to frustration for the
advisor and the client.
As a
result, Harley developed a program built on the concept of “consultative
engagement.” Its goal is to educate a client about the consequences,
emotionally, physically and financially, to those he or she loves, if an
unexpected extended care event happens. When it is done correctly, the
individual is persuaded to decide to plan for such an event, and to fund
it.
The
16-hour CLTC Master Class is the hallmark of Harley’s vision and awards
the CLTC designation to those who pass the 100-question exam. Over the
past 26 years, tens of thousands of planning professionals have completed
this training, and carry the CLTC (Certified in Long-Term Care)
designation.
CLTC
has many industry thought leaders among its alumni. Becoming a CLTC
graduate grants instant access to this elite group of long-term care
planning specialists. It also provides objective credibility for the
advisor about his or her intent, commitment, and skills in extended care
planning. With the advance of technology and the changing work
environment, advisors have a choice of how they complete the Master Class
today. There is the traditional live classroom option, or a student can
join a virtual classroom, or pursue a self-study program via eCLTC.
CLTC
leaders recognize the need to adapt and continually increase the value of
CLTC because much has changed since 1997. New training programs have been
introduced including a shortened, 4-hour continuing-education-approved
“Foundations” class developed for advisors who want to know the basics,
but don’t wish to specialize.
Most
recently, a new “Product Insider” class was developed to answer the ever
present questions about LTC insurance products. There are many ways to
fund an extended care plan today, and this new class provides in depth and
impartial training on the features, client applicability, pros and cons of
each.
CLTC
recognizes that education extends well beyond the class room. Therefore,
it provides tools and “news” members can use to advance their knowledge
and practice. Industry experts join our monthly webinars and contribute to
our quarterly CLTC Digest. Monthly newsletters give quick updates
on CLTC and industry happenings. A variety of planning and education tools
are developed, updated and shared regularly, some targeted for use with a
client, and others for advisors only. All materials are impartial,
carrying only the CLTC logo. While it is true that all of the leading
insurance carriers and distributors endorse CLTC, it is not aligned with
any one organization.
CLTC’s mission is to educate financial, legal, accounting and other
professionals about the need to discuss proactively with their
clients the consequences of not having a plan will have on them and their
families during retirement. As a former First Lady said, “There are only
four types of people in the world: those who have been caregivers, those
who are currently caregivers, those who will be caregivers, and those who
will need caregivers.”
Celeste Cobb is CLTC’s Director of Education. Reach her at
celeste@ltc-cltc.com
or 203-770-2438.
#############################
Updated, Monday, February 6, 2023,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #23-001 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Fight to Rename 'Medicare Advantage' Gets New Push
-
Report: Medicaid Falls Short on Costs of Care in
Nursing Homes
-
Most long-term care doesn’t qualify for insurance
benefit
-
Feds to Cut Medicare Advantage Plan Pay Over Health
Score Creep
-
Two KFF Analyses Explore the Demographics of People
Jointly Enrolled in Medicare and Medicaid As Well As Program Enrollment
and Spending for This Population
-
Debate: Will Secure 2.0 Act Help Americans Pay for
Long-Term Care?
-
Can I Apply for Medicaid Home Care If I Left
Long-Term Care?
-
Human Freedom Index: 2022
-
Look To The States, Not Congress, For Long-Term
Care Financing Reform
-
CMS Proposal Marks Shift After Years of Skilled
Nursing Frustration with Medicare Advantage Diversions
-
Small-town nursing homes closing amid staffing
crunch
-
Millions of Medicaid beneficiaries may lose
coverage as disenrollments resume in April
-
Older adults’ housing wealth hits new record at
$11.81 trillion
-
Can My Mom Pay Me Rent If She Will Be Applying for
Medicaid?
-
Top 5 States for Long-Term Care Planning Increases
-
Medicaid HCBS study shows ‘we still know very
little’ about COVID in senior living
-
Impact of Secure Act and Long-Term Care Insurance
Provisions Discussed
-
10 Things to Know About the Unwinding of the
Medicaid Continuous Enrollment Provision
-
Will Secure 2.0 Increase Long-Term Care Insurance
Sales?
-
Congratulations to the McKnight’s Pinnacle Career
Achievement Award winner
-
Public, private partnerships key to New York state
Master Plan for Aging
-
Nursing home staff shortage a ‘crisis’ in Clark
County, Washington
-
81 percent of nursing homes receive less than cost
of care for Medicaid patients: analysis
-
CMS releases new Medicaid guidance for states to
tackle unmet social needs
-
California to Reality-Check $144K Public Long-Term
Care Benefits Package
-
Nursing Homes Need $11.3b Annually To Meet Proposed
Staffing Minimum
-
Spiraling costs threaten growing optimism for
skilled nursing in 2023 Outlook Survey
-
2023: The Year Medicare Advantage Begins To
Dominate Traditional Medicare
-
CVD Benefits of Activity Seen Below Widely Quoted
Step Goal in Older Adults
-
US life expectancy falls to lowest levels since
1996 due to COVID, drug overdoses: CDC
-
House Passes Secure 2.0 Act in $1.7T Spending Bill
############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, December 30, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: MAKE LTC SIMPLE AGAIN
LTC
Comment: There must be a better way to do LTC. There is. Read on after the
***news.***
***
HAPPY NEW YEAR ***
***
RON HAGELMAN deserves our special thanks and a shout out. Here’s how we
covered his latest column for Broker World in a recent LTC
Clipping. ***
12/1/2022,
“Enemies,”
by Ronald R. Hagelman, Broker World
Quote:
“In my humble opinion no one has been a more consistent hard headed
advocate of exposing the corrosive relationship between the public
response to custodial care for the aged and the lack of success in private
responses to reduce and return control of individual claims destiny than
Stephen Moses. His most recent manifesto ‘Long-Term Care: The Problem’
recently released from the Paragon Health Institute once again provides
conclusive irrefutable evidence that the still mushrooming consequence of
current market conditions is the fault of existing misguided public
response to the problem. The truth is we have always been fighting
ourselves. It is the incestuous relationship between the holy trinity of
Social Security, Medicaid and Medicare that has made it virtually
impossible for us to adequately blunt this risk from the private sector.
Private funding solutions including insurance, reverse mortgages and life
settlements have had no room to breathe free when all the oxygen has
already been sucked out of the room by State and Federal mandated,
frequently capped and therefore underfunded, politically loose footballs.
This exceptional white paper provides more than a sufficient arsenal of
hard statistic ammunition to defeat any spurious attempt to defend the
expansion of public taxpayer funded strategies. More of the same will not
help. It will however most certainly exacerbate the problem.”
LTC
Comment:
Ron Hagelman’s monthly column for Broker World is a mainstay of
thoughtful analysis and hopeful optimism in a struggling market. Ron is a
friend and ally in our common mission to improve long-term care for all. I
thank him for this recognition and urge his readers to take his advice:
read
Long-Term Care: The Problem
and look forward to Long-Term Care: The Solution, forthcoming next
year from
Paragon Health Institute.
To borrow Mr. Hagelman’s well-known tagline: “Other than that I have no
opinion on the subject.”
***
OFF TO COLOMBIA. Honestly, I can’t remember a time in its almost 25 years
that the Center for Long-Term Care Reform fully closed down for a holiday
from our 24/7 mission to improve LTC public policy. But now we’re going to
do just that. January 2 Damon joins Steve on a flight to Panama, followed
by speedboats through the San Blas Islands to Colombia, with more boats
and busses to Cartagena, and finally on through the Andes, to Bogota,
Medellin and other points of interest. So please enjoy a respite from
LTC Bullets and LTC E-Alerts until Steve returns February 8.
He’ll keep the LTC Clippings coming to premium members though
perhaps with a little less frequency. Hasta luego. ***
LTC
BULLET: MAKE LTC SIMPLE AGAIN
America’s long-term care system is complicated, confusing and
counterproductive. People want to receive care at home, but the system
shunts them into nursing homes. They want qualified caregivers they choose
for themselves, but they get whatever Medicaid offers at minimum wages.
They don’t want to burden their families, but the financial and emotional
strain of LTC on friends and families is worse today than ever. What
happened?
This
part is not complicated. Since Medicaid began in 1965, government has paid
the cost of catastrophic LTC. No matter how often analysts, politicians or
the media told them they could lose their life’s savings to LTC, consumers
would not save, invest or insure against that risk. They didn’t believe
the scary warnings, but most importantly, the warnings were untrue. Most
people never ended up needing prohibitively expensive extended care and
those who did got it paid for by Medicaid without catastrophic spend down.
Never mind for now all the complicating details such as “doesn’t Medicaid
require impoverishment?” Why do people ignore the risk and cost of LTC?
Are they stupid? Or just “in denial?” Don’t we have to take care of them
if they can’t or won’t take care of themselves? Isn’t government the only
solution? If not Medicaid, then what? Don’t we need a new compulsory,
payroll-funded, social insurance entitlement for LTC? That’s the course
most analysts’ reasoning and their argument usually takes.
Don’t go down that rabbit hole. I can refute that argument and
I
have done many times.
For now, keep it simple, just consider the basic fact. That is, few people
worry about or do anything to prepare for LTC until they need it. Then
when the costs mount, they slip onto Medicaid. We’ll make no progress
solving the LTC challenge until we confront that reality and change it.
How can we get people to deal with LTC risk and cost while they are still
young, healthy and affluent enough to prepare and avoid public assistance
in the future?
We
saw one way to do it when Washington State confronted its citizens with
the threat of a .58 percent payroll tax for a lifetime benefit of $36,500,
but gave them a way out by purchasing private LTC insurance. Almost half a
million Washingtonians jumped at that chance overwhelming the insurance
carriers with demand for minimal policies the industry feared would be
quickly dropped. Clearly people don’t want more government compulsion or
taxes and they’re willing to buy private insurance to avoid them.
There’s no denying that confronting people with the need to deal with LTC
risk now, not later, worked. So, how could we get people to plan for LTC
now without forcing them into a big new government entitlement program?
Here’s a way.
Establish by law the responsibility to fund a certain limited amount of
LTC by age 50. Let a private organization or agency determine the amount,
which should be somewhere between a person’s actuarial probability of
needing paid care someday and the higher amount that would be required if
the worst happens, such as high cost need for an extended time.
People could meet their personal responsibility in any of many ways. They
could buy private LTC insurance. They could tap their home equity, $11.1
trillion for people 62 or older. They could use life insurance, over $20
trillion in effect. They could apply a portion of current or newly created
retirement accounts to prefund for LTC. They could pledge some of their
future estate toward LTC, legally secured to avoid the failure of
Medicaid’s estate recovery program.
Clearly, there is plenty of money available in the U.S. economy to fund
top quality LTC for all Americans. All we need to do is get people to plan
for LTC before it’s too late for them to avoid anything but Medicaid.
Government’s role should be limited to establishing the individual LTC
responsibility in general which the private sector would then price out
actuarially for each citizen.
Most
people would act responsibly as they do when they protect themselves
against other risks such as early death, fire, accident, or health risk.
For those who don’t, let the usual measures when people don’t meet their
legal responsibilities suffice, such as tax collection, grant reductions,
or LTC avoidance fees. In other words, government would enforce LTC
responsibility only in cases where people have not fulfilled their
responsibility voluntarily. Not in all cases against everyone as in the WA
Cares program.
#############################
Updated,
Monday, December 19, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-037 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Maine Has A Plan
To Help Family Caregivers. Other States Should Follow
-
Parkinson’s
disease strikes many more older adults than previously estimated:
research
-
Regulators End
Effort to Develop Long-Term Care Hybrid Rules
-
Enemies
-
The 10 Fastest
Rising Costs for Seniors
-
Caring for Aging
Relatives is Draining, Both Financially and Emotionally
-
Viagra Lowers the
Risk of Alzheimer’s by Almost 70%, Study Says
-
Welcome to the
December e-Brief
-
How to Talk to
Your Parents About Long-Term Care
-
How Medicare
Advantage plans dodged auditors and overcharged taxpayers by millions
-
Entering the
Winter Season, How Many Nursing Facility Residents and Staff Were
Up-To-Date With Their COVID-19 Vaccines?
-
Growing Older with
Enthusiasm
-
Defiant Sloan to
nursing home critics: Address funding to tackle staffing challenge
-
Lawmakers can help
workers with this WA Cares repeal bill
-
Am I Allowed to
Have Two Cheap Cars With Medicaid?
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, December 16, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: SO WHAT IF THE GOVERNMENT PAYS FOR MOST LTC, 2021 DATA UPDATE
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, 2021 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 2021 statistics on its website at
NHE
Tables (ZIP).
Click on that link to download the tables, unzip them, then click on the
data tables of interest, Tables 14 and 15 for our purposes.
Health Affairs
has
published a summary and analysis of the new data titled “National Health
Care Spending In 2021: Decline In Federal Spending Outweighs Greater Use
Of Health Care." Health Affairs subscribers can access the full
text of that article
here.
Others can purchase it. The “Abstract” is available free. Unfortunately,
the Health Affairs summary has little to say about long-term care,
so read on to get that story.
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 twenty-first in a row we’ve done annually to analyze 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.” You’ll find our yearly analyses of the data
going all the way back to "So
What If the Government Pays for Most LTC, 2002 Data Update."
------------------
"So
What If the Government Pays for Most LTC, 2021 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 $181.3 billion on nursing facilities and continuing care
retirement communities in 2021, a 7.9% decrease compared to 2020 due to
pandemic disruptions. The percentage of these costs paid by Medicaid and
Medicare has gone up over the past half century (from 26.8% in 1970 to
52.3% in 2021, up 25.5 % of the total) while out-of-pocket costs have
declined in the same period (from 49.2% in 1970 to 24.5% in 2021, down
24.7% 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 1970-2021.
So
What? Consumers' liability for nursing home and CCRC costs has declined by
over half, down 50.2% in the past five decades while the share paid by
Medicaid and Medicare has nearly doubled, up 95.1%.
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 $688,000 and in some states up to $1,033,000 of home equity (as of
1/1/23). 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 (and CCRC) care (29.9% of the dollars in 2021), it covers
nearly two-thirds (65.1%)
of all nursing home patient days.
So
What? Medicaid pays in full or subsidizes nearly two-thirds 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. “Medicaid, the primary payer for nursing homes, covers
more than 60 percent of all nursing home residents and approximately 50
percent of costs for long term care services. Medicaid reimbursements, on
the other hand, only cover 70 to 80 percent of the actual cost of care.”
(Source: AHCA/NCAL, “Financial
Challenges Continue To Affect Nursing Homes, Emphasizing Need For Higher
Medicaid Reimbursement Rates,”
October 14, 2020)
Private Health Insurance
Don't be fooled by the 9.0% of nursing home costs that CMS reports as
having been paid by "private health insurance" in 2021. 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 providers. 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? According to the
Genworth Cost of Care Survey for 2021,
ALFs cost an average of $54,000 per year, up 4.7% from 2020.
Although assisted living facilities remain mostly private pay, “48%
of ALFs are Medicaid certified”
and only “a
small minority of state Medicaid programs do not cover services in
assisted living.”
(Find these quotes under the source’s “Finance” tab.) Over time assisted
living facilities have followed nursing homes down the
primrose path
of accepting more and more revenue from Medicaid.
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 $688,000 or $1,033,000 depending on the state),
plus—in unlimited dollar 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 $125.2 billion on home health
care in 2021, nearly the same as in 2020 ($125.0). Medicare (37.2%) and
Medicaid (34.2%) paid 71.4% of this total and private health insurance
(not LTC insurance) paid 12.7%. Only 10.3% 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
1970-2021.
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.
Note
especially:
Long-Term Care: The Problem
(2022) with the
Paragon Health Institute
at
https://paragoninstitute.org/long-term-care-the-problem/
Medicaid and Long-Term Care
(2020) at
http://www.centerltc.com/pubs/Medicaid_and_Long-Term_Care.pdf
“How
to Fix Long-Term Care Financing” (2017), at
http://www.centerltc.com/pubs/How-To-Fix-Long-Term-Care-Financing.pdf
“CASSANDRA’S QUANDARY: The Future of Long-Term Care” (2016), at
http://www.centerltc.com/pubs/FIA-Cbassandra-Quandry.pdf.
“How
to Fix Long-Term Care,” a series of briefing papers, at
http://www.centerltc.com/BriefingPapers/Overview.htm;
"Medi-Cal
Long-Term Care: Safety Net or Hammock?" at
http://www.centerltc.com/pubs/Medi-Cal_LTC--Safety_Net_or_Hammock.pdf;
"The
LTC Graduate Seminar Transcript" at
http://www.centerltc.com/members/LTCGraduateSeminarTranscription112712.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 significant steps
toward addressing these problems. A cap was placed for the first time 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 cresting and threatening to crash over the next two
decades, we can only hope it isn't too late already.
*
Note that CMS changed the definition of National Health Expenditure
Accounts (NHEA) categories in 2011, adding for example Continuing Care
Retirement Communities (CCRCs) to Nursing Care Facilities. This change had
the effect of reducing Medicaid's reported contribution to the cost of
nursing home care from over 40% in 2008 to under one-third (32.8%) in
2009. CMS also created a new category called "Other Third Party Payers"
(7.1%) which includes "worksite health care, other private revenues,
Indian Health Service, workers' compensation, general assistance, maternal
and child health, vocational rehabilitation, other federal programs,
Substance Abuse and Mental Health Services Administration, other state and
local programs, and school health." For definitions of all NHEA
categories, see
http://www.cms.gov/NationalHealthExpendData/downloads/quickref.pdf.
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. Learn more at
www.centerltc.com
or email
smoses@centerltc.com.
#############################
Updated, Monday, December 5, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-036 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
How Medicaid mission creep undermines real
health care
-
Medicare Advantage Coverage is Rising for
the Declining Share of Medicare Beneficiaries with Retiree Health
Benefits
-
Study: 70% Want To Age At Home, But Only
10% Have Long-Term Insurance
-
COVID mortality trending older, with 9 in
10 deaths in adults aged 65 and older
-
More Families Depend on Medicaid to Pay for
Long-Term Care
-
Ongoing Impacts of the Pandemic on Medicaid
Home & Community-Based Services (HCBS) Programs: Findings from a
50-State Survey
-
A Look at Waiting lists for Home and
Community-Based Services from 2016 to 2021
-
Congressional Research Service Issues In
Focus White Paper on Overview of Long-Term Care Insurance
-
People are still getting out of a coming
payroll tax for long-term-care program
-
Federal Government Suspends Sale Of
Long-Term Care Insurance To Its Employees
-
Magic Johnson's Firm Powers New Long-Term
Care Effort
-
Private Equity Trying Harder to Keep People
Out of Nursing Homes, Not Invest in Them
-
Hidden audits reveal millions in
overcharges by Medicare Advantage plans
-
Notice of Federal Long Term Care Insurance
Program (FLTCIP)–Suspension of Applications for FLTCIP Coverage
############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, December 2, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LAST UNTIL LTC
LTC
Comment: The question of how to obtain and pay for LTC is moot unless you
survive long enough to need it. A guide follows the ***news.***
***
STEVE MOSES FEATURED IN HEALTH CARE NEWS:
11/18/2022,
“More
Families Depend on Medicaid to Pay for Long-Term Care,”
by AnneMarie Schieber, Health Care News
Quote:
“Medicaid is the government’s health care safety net, but for LTC, it has
become a hammock, says Stephen Moses, president of the Center for
Long-Term Care Reform and author of the Paragon report, titled ‘Long-Term
Care: The Problem.’ ‘The common wisdom is you have to become impoverished
before the government helps you with long-term care, but the truth is very
different,’ Moses told The
Heartland Daily Podcast on
November 1. ‘I call it “the fallacy of impoverishment.’” The 40-page
report shows how liberal enrollment policies disincentivize families from
saving for LTC and how dependence on Medicaid and Medicare has compromised
care and driven out more innovative, cost-efficient options. … It is
critical for Congress to start pushing for private options now, says Brian
Blase, president of the Paragon Health Institute. … Moses is working on a
second report on solutions.”
LTC
Comment:
Check out the article and the podcast. Then keep an eye out for “Long-Term
Care: The Solution,” forthcoming from the
Paragon Health Institute.
***
LTC
BULLET: LAST UNTIL LTC
LTC
Comment: Hospitals and long-term care are joined at the hip. One of the
reasons America has a big nursing home industry is that policy makers
sought to moderate Medicare expenditures at the outset in 1965. Paying for
sub-acute and rehabilitation in skilled nursing facilities through
Medicaid reduced higher Medicare hospitalization costs. But making the
transition from acute to long-term care has always been a challenge. Often
families are left with an urgent, high-pressure need to find a suitable
nursing home placement when Medicare coverage runs out, private funding is
unavailable, Medicaid beds are scarce and eligibility uncertain. But
before you even get to cope with those issues, you must survive the
hospital.
So,
when I read the following essay by LTCI author, trainer, producer and all
around industry maven Margie Barrie, I thought it’s something all LTC
Bullets readers should see. Margie’s story is all the more poignant
given her and her husband-patient Bernie’s long active involvement in the
LTC insurance business. Too much of what she says and warns is familiar to
me as one who has managed hospitalizations for late parents and wife. In
today’s government funded and regulated health care system, the funder
(Medicare or Medicaid) becomes the providers’ customer, getting most of
their attention, instead of the patient who needs care. Lesson learned.
Don’t surrender to medical or bureaucratic authority. Demand clarity,
reason and respect.
A
much abbreviated version of the following piece was published by
ThinkAdvisor. We offer this unabridged account with the author’s
permission.
“8
Steps to Maneuver Through a Medical Crisis with a Loved One”
by
Margie Barrie
I
started writing this article while sitting by my husband’s bedside in the
hospital. The last few weeks have been a medical nightmare.
My
purpose is to share what I have learned the hard way – strategies needed
to successfully maneuver through a medical crisis with a loved one.
Here’s what happened:
Week
1 - My husband Bernie had emergency gall bladder surgery. It was very
badly infected, and he had sepsis. With the hospitalist system now in
place in many hospitals, you’re assigned a surgeon in the emergency room.
I will call him Dr. S.
Week
3 - We had a 9 a.m. follow-up appointment with Dr. S. Bernie was still
having pain and very weak.
LESSON 1 – Be assertive. If you think there is a problem that is not being
addressed by the doctor, don’t take no for an answer. Speak up and listen
to your gut feelings.
Dr.
S. found that the incision was badly infected. He drained it and said
Bernie should return home and a home health care nurse would visit daily
to check it.
I
replied: “There is something really wrong here. Please do additional
tests.”
Dr.
S. disagreed. I insisted. And finally he replied – in a very aggravated
tone - that I should take him to the emergency room if I was worried.
That’s what I did. After numerous tests, we were informed that the sepsis
was worse, and that Dr. S. would do emergency surgery the next morning.
If I
had taken him home - like originally advised – my husband probably would
have died.
LESSON 2 – Take copious notes. If possible, record the conversation.
The
following morning, a surgery that was supposed to take one hour lasted
three. When Dr. S. found me in the waiting room to discuss the surgery
results, I was anticipating good news. I was shocked to hear what he had
to say . . . that he had to do another emergency surgery in two days.
I
did take some notes but was so horrified that I missed a lot of what he
was explaining. After Dr. S. left, the woman who had been sitting nearby
came over and hugged me. She had overheard the conversation. Then I asked
her to help me recall what Dr. S had said so I could take more notes.
Keep
a notebook. Write down the name of every person providing medical updates
and what they said and when. If they know you have their name, they
immediately feel accountable and will be more likely to provide the
attention you want and need to stay on top of the medical crisis.
LESSON 3 – Doctors and other medical personnel seem to sugarcoat the
patient’s condition.
Probe to get the hard facts. The following day, I called ICU for an update
and was told he was doing fantastically. Meanwhile, he was on a breathing
tube and heavily sedated.
I
wanted to know the truth. I finally drove to my primary care doctor’s
office to ask him in person for more details. I then asked: “Could my
husband die from this and should I have my sons fly in.” He hesitated and
then said yes.
Also, I learned that there were a number of small blood clots in his left
leg. That could result in a stroke. Ask why various medications and IVs
are being used.
LESSON 4 – Be aware of the limitations of the hospitalist system.
Many
hospitals are now using the hospitalist system – where every doctor seeing
a patient is a specialist in a certain area. From a management
perspective, it is touted as providing continuity of care for an
in-patient.
However, from a spouse’s vantage point, it’s frustrating. I never could
get in touch with any doctor who could provide a comprehensive picture of
all the problems. My primary care doctor is not allowed to see inpatients,
because he is with an outside group practice. But he was able to access
the hospital records and keep me updated.
LESSON 5 – Take control when needed.
When
Bernie was improving and moved to a regular hospital room, I quickly
realized that the doctors were only talking to him. He was also
sugarcoating the facts so I wouldn’t worry. I needed to know all the
facts. I have continually reminded my husband of that – and have now been
calling the Case Manager and other key people to make sure I’m in the
loop. That is very important.
LESSON 6 – Memorize these two magic words - Unsafe Discharge.
Even
if a hospital wants to discharge a patient – primarily because of the
revised Medicare payment system - you can protest and insist that the
patient stay longer. The words to use are “Unsafe Discharge.” And then the
hospital needs to keep the person for the longer period of time while the
appeal is underway.
It
was important that my husband be admitted to the hospital’s rehab area
rather than going to an outside facility. First, the care is excellent;
and two, Dr. S. wanted to continue to monitor his progress. A friend
advised me to protest a discharge until my husband was strong enough to
get three hours of physical therapy a day, which is the admission
requirement. I called the Case Manager to introduce myself and told her
upfront that I would appeal any discharge plans until my husband was
approved to go to their rehab facility. And it worked - he has now been
moved there.
LESSON 7 – Use the CaringBridge website to provide updates.
It’s
wonderful to have family and friends concerned about my husband’s
progress, but it’s overwhelming to be fielding numerous calls, emails and
texts in addition to working and going to the hospital every day. This
free website enables you to provide a journal entry and people can then
comment. I read it every morning – all this support and love are so
appreciated.
LESSON 8 – Take time for yourself.
You
will need it to survive this. Many days when I leave the hospital I am
exhausted and stressed. My solution right now – gourmet chocolate ice
cream. It does help.
Margie Barrie, an agent with ACSIA Partners, has been writing the
ThinkAdvisor LTCI Insider column since 2000. She is the author of two
books and a frequent conference speaker.
LTC
Comment: Get well soon, Bernie!
#############################
Updated, Monday, November 21, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-035 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Changes In The LTC Industry Call For
Advance Planning By Seniors Who Intend To Age In Place
-
Long-term-care law might be changing again,
and solvency is sought
-
Long-Term Crisis: The Case for Reforming
Medicaid ‘Personal Care’ in New York
-
Can Returning Assets Eliminate a Medicaid
Transfer Penalty?
-
Millennials Are Asking About Long-Term Care
-
VA Nursing Home Care: Opportunities Exist
to Enhance Oversight of State Veterans Homes
-
Nursing Home Operators Brace For the Threat
of a Tripledemic
-
White House to extend PHE designation
through April, reports say
-
Medicare Advantage 2023 Spotlight: First
Look
-
Turkey, Pumpkin Pie and the Long-Term Care
Conversation: LTCI Insider
-
Report backs immigration as a way to
improve long-term care
-
Pandemic Drives Federal Share of State
Revenue to Record High
-
‘Substantial’ decline in dementia rates due
in part to higher education levels: study
-
States’ use of LTSS varies widely for
dual-eligible adults with dementia
-
A SCOTUS nursing home case could limit the
rights of millions of patients
############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, November 11, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: WHAT HAVE YOU DONE FOR ME LATELY?
LTC Comment: The Center for Long-Term Care Reform is
a membership organization. Thank you for your support. Here’s an update on
our recent LTC research and advocacy on your behalf, after the ***news.***
*** HONOR VETERANS TODAY ***
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little or as much of your involvement as you or they want. Claude is
the lead author of Milliman’s annual Broker World LTCi Survey & a past
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here to register and book your hotel. ***
LTC BULLET: WHAT HAVE YOU DONE FOR ME LATELY?
LTC Comment: Step one to solve a problem is to
recognize you have one. For long-term care services and financing, we’re
long past step one. Everyone recognizes America’s LTC system is broken.
Step two is to define the problem. We have lots of
published content on that as well. The Center for Long-Term Care Reform
recently collaborated with the
Paragon Health Institute to offer our definition:
Long-Term Care: The Problem.
Step three is to explain what caused the problem.
It’s step three where we part company with most analysts. In the face of
LTC’s many challenges, they throw up their analytical hands in despair and
turn immediately to recommend more government spending, central planning
and regulation to save the day. We argue that those “solutions” are
actually what caused the problems in the first place. Doing more of what
you’ve been doing and expecting a different result defines insanity.
So, what caused LTC’s many dysfunctions? Here’s how
we explained it in
Long-Term Care: The Problem:
Providing and funding long-term care (LTC) for the elderly is a large and
growing challenge. Baby boomers start turning 85—the age at which health
and LTC costs spike—in 2031, as Social Security and Medicare face
insolvency. The government, mostly through Medicare and Medicaid, finances
almost three-fourths of LTC expenditures (72.3 percent in 2020). Central
planning, public funding, heavy regulation, and easy access to welfare
benefits have caused most of LTC’s problems, such as nursing home bias,
poor access and quality, inadequate revenue for care providers, caregiver
shortages, and the terrible emotional and financial distress for
caregiving families. Medicaid especially is responsible because, despite
the conventional wisdom that it requires impoverishment, the program’s LTC
benefits are routinely available not only to the poor but to the middle
class and affluent as well. …
Access to publicly financed LTC [late in life] creates a moral hazard that
discourages responsible LTC planning when people are still young, healthy,
and affluent enough to save, invest, or insure for the risk. Policymakers
should consider how public financing created and worsened LTC’s problems
before proposing more of the same to address those problems.
Step four to solve a problem is to eliminate its
cause. For long-term care, that means removing the perverse incentives in
Medicaid that have (1) discouraged early and responsible LTC planning and
(2) rewarded ignorance and complacency about LTC risk and cost with
windfall welfare benefits for patients and their families if and when
catastrophic care costs occur.
How to achieve the objective of retargeting Medicaid
to the genuinely needy and persuading everyone else to plan early to save,
invest or insure for LTC is the subject of our forthcoming paper, again
with the Paragon Health Institute, titled “Long-Term Care: The Solution.”
Watch for it in the new year.
What else have we been up to at the Center for
Long-Term Care Reform? Today’s LTC Bullet is our 1,346th.
They’re all archived chronologically and by topic
here. Check them out. So far this year, we’ve published 34 LTC
E-Alerts, our weekly collection (for all members) of our daily LTC
Clippings (for premium members). In the Clippings and the
LTC E-Alerts, Steve Moses scans the news and research to keep members
apprised of what they need to know to stay on the professional forefront.
On November 1, AnneMarie Schieber of the Heartland
Daily Podcast interviewed Center president Stephen Moses about
“How Medicaid Compromised Long-Term Care”. She summarized: “In the
interview, Moses discusses:
1. How easy is it to get Medicaid to pay for
long-term care?
2. How has this compromised the quality of long-term
care over the decades?
3. Who will need long term care? Can any of us live
independently until we die?
4. Baby boomers…most are now 65…what kind of pressure
will that put on long-term care and Medicaid in 10, 20, and 30 years from
now?
5. What about counting on family members to care for
you? How about covering your care with your own wealth and investments?”
Click
here to listen to this 20-minute podcast.
On November 2, RealClearPolicy published
Steve’s article “What’s
Wrong With Long-Term Care.” He concluded:
The only solution to this compendium of complications is to eliminate the
moral hazard created when people can ignore the risk and cost of LTC until
they need it and transfer the liability to taxpayers. To do that, we must:
change Medicaid financial eligibility rules so they no longer desensitize
the public to LTC risk and cost; front load the need to plan, save, invest
or insure for LTC so most people deal with it when they’re still young,
healthy and affluent enough to manage such financial decisions; and remove
Medicaid as an eventual LTC safety net for people who fail to plan but
retain wealth.
Here are a few more of our published contributions to
the long-term care conversation in the past year.
“What
works for long-term care and what doesn’t,” by Stephen A. Moses,
McKnight’s Long-Term Care News, November 17, 2021
“Long
Term Care Irony,” by Stephen A. Moses, Broker World, December
1, 2021
“The
irony of long-term care advocacy,” by Stephen A. Moses, McKnight’s
Long-Term Care News, December 17, 2021
“The
Great Long-Term Care Compromise,” by Stephen A. Moses, Broker World,
January 1, 2022
“Trappings
of LTC system leave operators trapped,” by Stephen A. Moses,
McKnight’s Long-Term Care News, February 23, 2022.
“Long-Term
Care Epiphany,” by Stephen A. Moses, Broker World, June 2022
“Long-term
care’s mortal risk,” by Stephen A. Moses, McKnight’s LTC News,
June 6, 2022
“LTC
insurance sales suddenly surge,” by Stephen A. Moses, McKnight’s
LTC News, August 10, 2022
Won’t you join us in the Center for Long-Term Care
Reform’s noble mission to “ensure quality long-term care for all
Americans?” To join, contact Damon at 206-283-7036 or
damon@centerltc.com. Sign up online at
http://www.centerltc.com/support/index.htm. With your help, we can do
this!
#############################
Updated,
Monday, November 7, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-034 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
OneAmerica®
Long-Term Care Survey Shares Consumers' Perspectives
-
Genworth
Executives Review Long-Term Care Rate Hike Settlements
-
Medi-Cal’s
long-term care services reach only a small portion of seniors, disabled
adults
-
WA Cares suddenly
solvent? Hopefully, but it depends — and the long-term-care law still
isn’t good
-
What’s Wrong With
Long-Term Care?
-
How Medicaid
Compromised Long-Term Care (Guest: Stephen Moses), with AnneMarie
Schieber
-
54% of Consumers
Have Cut Retirement Savings Due to Inflation: Allianz Life
-
Soaring dementia
treatment costs leave care providers with task of finding solutions:
report
-
Team Biden’s
latest welfare expansion: Medicaid payments for housing, food, even
furniture
-
California study
holds lessons for middle-market providers nationwide: NIC
############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, October 31, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-033 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Another Facility Shuttered as Montana
Nursing Home Closures Continue
-
Don't Miss LTC Impact Day This Monday!
-
WA Cares Fund projected to be solvent
through 2098 in new analysis
-
GE to End $2.5B Long-Term Care
Insurance Reinsurance Arrangement
-
Home health spending outpacing rate of
national healthcare spending
-
In the U.S., Income and Wealth are
Concentrated at the Top. Where Does This Leave Older Americans?
-
Annual nursing home, home healthcare
spending more than double the recent rate of healthcare overall
-
One in 10 older U.S. adults has
dementia, new national data show
-
Nursing homes becoming ‘loss leaders’
as they struggle with funds, staffing, sector leaders say
-
Pandemic-delayed move-ins mean
residents come to senior living with greater needs: NIC
-
Millions at risk of losing health
insurance if U.S. ends Covid public health emergency in January
-
Why long-term care advocates are
holding their breath over likely Congress power shift
-
Older Households: Comparison of Income,
Wealth, and Survival in the United States with Selected Countries
-
Inside the Social Security COLA
Calculations
-
U.S. extends public health emergency,
buying LTC a bit more time
#############################
"LTC E-Alerts" are
a feature offered by
the Center for Long-Term Care Reform, Inc. to members at the $150 per year
level or higher. We'll track and report to you news and analysis regarding
long-term care financing, service delivery, and research. We hope The LTC
E-Alerts will help you attain and maintain a high level of knowledge and
competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, October 28, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: WA CARES REPERCUSSIONS
LTC
Comment: Washington State politicians and bureaucrats think they can do
LTC insurance better than private sector professionals. What could
possibly go wrong?, 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 sight unseen. You’ll get trenchant analysis and valuable ideas on how
to address objections and complaints. Contact Damon at 206-283-7036 or
damon@centerltc.com
for details or subscribe directly here:
http://www.centerltc.com/newonlinepaymentspage.htm.
Choose “Premium Membership” to receive our LTC Clippings. For
example, here are some recent LTC Clippings:
10/24/2022,
“WA
Cares Fund projected to be solvent through 2098 in new analysis,”
by King 5 Staff, King5 News
Quote:
“Washington state’s long-term care program - known
as the WA Cares Fund -
is projected to be solvent through June 2098, according to a new study
published by the Office
of the State Actuary.
…
Click here to read the full report.”
LTC
Comment:
Milliman is the actuarial gold standard and it produced this report. But
didn’t other actuaries give us similar assurances in 1935 (Social
Security) and 1965 (Medicare)? Now look at their prognoses: insolvency by
2035 and 2028, respectively. What will WA Cares look like after a few
years of high inflation, rising interest rates, and increasing government
budget deficits? Can actuaries factor in those considerations?
10/26/2022,
“Home
health spending outpacing rate of national healthcare spending,”
by Diane Eastabrook, McKnight’s Home Care
Quote:
“Spending on home healthcare rose by 10.5% in August, more than double the
4.9% increase in healthcare spending overall, according to a
new report by
research and consulting firm Altarum. Spending on skilled nursing care
wasn’t far behind, expanding by 10.2%. … Demand for home health services
have outpaced those for skilled nursing over the past two years. A report
last spring found
discharges to home health between the second quarter of 2020 and the third
quarter of 2021 increased by 2.5% to 24.1% of total inpatient discharges,
while the number of patients released to SNFs declined by 2.4% to 18.6% of
total discharges.”
LTC
Comment:
Experts thought rebalancing from nursing homes to home care would save
money. That prospect isn’t panning out as I’ve always predicted. Research
shows that home care delays, but doesn’t necessarily replace institutional
care over a lifetime or across society. People want home care and they
should have it, but when government pays for most of it, shortages and
quality problems predominate. They’re worsening as inflation from
excessive public spending and money printing increases.
10/26/2022,
“Don't
Miss LTC Impact Day This Monday!”
by NAIFA’s Limited
& Extended Care Planning Center
Quote:
“Long-Term Care Awareness Month starts in November, and NAIFA's Limited
& Extended Care Planning Center is
kicking it off one day early with ‘Don't Be Scared of Long-Term Care’ this
Monday, October 31 from 9 am to 5 pm. Join industry experts at the top of
each hour to hear the latest insights on long-term care! Each session will
last 30 minutes, with 15 minutes left for questions and answers so you can
get the information that's most beneficial to you. Registration is free
and you are welcome to hop in and out of the sessions throughout the day.
All you need to do is register and one link gets you full access.”
LTC
Comment:
Click through to check out the sessions on offer.
LTC
BULLET: WA CARES REPERCUSSIONS
LTC
Comment: In my estimation, no one knows more about private long-term care
insurance than
Claude Thau.
He’s run a carrier, been a broker/dealer, and guided hundreds of producers
up the steep ladder of success in LTCi sales. Claude is the lead author of
Milliman’s annual Broker World LTCi Survey and a past Chair of the
Center for Long-Term Care Financing (1998-2005). He knows whereof he
speaks.
In
the current month’s issue of Broker World, he addressed future
prospects for the WA Cares Fund (WCF), Washington State’s foray into
compulsory, payroll-funded, social insurance for long-term care. Following
are some key points from Claude’s article, but definitely go to the source
itself for all the interesting context and details. (If you don’t yet
subscribe to Broker World, you can correct that oversight
here.)
“What
May Be The Repercussions of The Washington Cares Fund?,”
by
Claude Thau,
Broker World,
October 1, 2022
Thau:
“When working to get the law passed, proponents expressed confidence that
WCF would stimulate a significantly increased future market for private
LTCI because WCF would educate consumers regarding their need for LTCI.”
He
points out several reasons why such a positive outcome is doubtful:
Confusion:
“WCF uses different triggers than the HIPAA-defined triggers used by
private LTCI and pays different providers. To the degree that it is hard
to remember trigger definitions and provider qualifications, it becomes
much more difficult when faced with conflicting definitions.”
Dried-Up Stream of Sales:
“Because Washingtonians wanted to be exempt from the WCF tax, the industry
sold more than 90 times as many WA policies with LTCI features in 2021
than in 2020. Because of the avalanche of 2021 sales, demand is likely to
be greatly muted for the next several years. … Rather than devoting
disproportionate attention to WA’s small, unattractive LTCI market,
insurers, brokers, employers, and others might sit on the sidelines for an
extended period.”
Lack
of Perceived Need: “Many
Washingtonians seem likely to think they need no additional coverage.
Unfortunately, rather than educate Washingtonians regarding the value of
supplemental coverage, the state promotes WCF with messages such as ‘We no
longer have to worry about how we will afford long term care as we age.’”
Denigration of the Private LTCI industry: “In
addition to suggesting that WCF is all the coverage Washingtonians need,
WA officials spread inaccurate and misleading comments denigrating private
LTCI.”
Financial advisor hesitance: “Because
of the complications introduced by WCF, financial advisors seem more
likely to be hesitant to raise the issue of LTCI with their clients. The
reduced likelihood of a sale also discourages what may be fruitless
discussion, and more work for less compensation is not very motivating. …
Employers and employee benefit managers also seem less likely to be
interested. Thus, much of the private LTCI industry might sit on the
sidelines for at least several years.”
Increased Total Cost:
“The combined cost for LTCI (WCF plus private insurance) will increase
significantly compared to prior to WCF for two reasons:
-
Buyers are forced to have a zero-day elimination period which increases
the price (but provides additional value).
-
People who can afford private LTCI tend to be healthy high-earners, who
are overcharged for WCF coverage to subsidize less affluent and less
healthy Washingtonians.
“The
market is not likely to respond favorably to the high combined cost.”
Future Impact:
“For the above reasons, WCF seems likely to shrink future LTCI sales
significantly, particularly stand-alone LTCI sales. Future sales may
migrate heavily toward life insurance or annuities with LTCI features. The
life insurance or annuity side of the contract is less confusing and
guarantees a pay-out.”
“The
2021 private LTCI sales in WA were less likely to include automatic
compound benefit increases. In addition to providing less coverage
up-front, the shortfall is likely to increase over time.”
“In
addition to its impact on future LTCI sales in WA, WCF has encouraged
other states to consider state-run LTCI programs. In California, a task
force is exploring creation of a state LTCI program. Most observers think
a CA-run program is nearly certain.”
LTC
Comment:
Next Claude opines about how this shotgun spread of state LTC programs
might differ in terms of exemptions and “triggers, total coverage,
compounding, benefits, vesting, etc.” He asks:
“Will insurers be interested in complementing state programs if those
programs vary by jurisdiction? Will financial advisors consider such
complexity worth their effort? Will employers and employee benefit
advisors consider LTCI programs if they must vary by employee resident
state? What will happen to individuals who move from one state to another?
Will inconsistencies increase pressure for a uniform national program?
Will consumers, employers, advisors and insurers sit on the sidelines in
what they might view as a turbulent market with a questionable future?”
In
sum: “Hopefully, other jurisdictions will involve the insurance industry
in discussions about all aspects of a state-run LTCI program throughout
the development process. Such involvement should include front-end
salespeople as well as insurance company home office personnel. It should
include careful consideration of the insurance industry’s comments, not
just token participation.”
LTC
Comment:
Left unsaid is the fact that the WA Cares Fund designers did not consult
the insurance industry in any meaningful way which may account for many of
that plan’s problems.
#############################
Updated,
Monday, October 17, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-032 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Washington State
Issues New Rules for Long-Term Care Fund
-
Slowing home sales
could delay recovery for independent living, CCRCs: Fitch
-
Social Security
COLA for 2023 Set at 8.7%
-
The US Needs To
Help Seniors And Their Families Navigate Long-Term Care
-
Research Centers
Post Long-Term Care Policy Papers
-
Fiscal Policy
Report Card on America’s Governors 2022
-
Parkinson: Nursing
home sector pinning hopes on ‘Medicaid adequacy’ rule
-
One quarter of
clinicians say they want to switch careers, survey finds
-
Providers demand
tax credit to help New Yorkers fund home care
-
Paper analyzes
government policy’s role in creating LTC problems
-
Study: Most
Pre-Retirees Unprepared to Retire by Age 65
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, October 14, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC BULLET: LTC
REFLECTIONS
LTC Comment: America
made great strides toward fixing long-term care until 2006. Then, nothing
since. What happened? When will progress resume? We explain after the
***news.***
*** TODAY'S LTC BULLET is sponsored by Claude
Thau with BackNine Insurance. In addition to many
unique services to advisors relative to individual, worksite and
affinity LTCi (including his revolutionary “Range of Exposure” tool
that protects FPs from risks most don’t recognize). New service: your
own free insurance website allowing clients to buy insurance with as
little or as much of your involvement as you or they want. Claude is
the lead author of Milliman’s annual Broker World LTCi Survey & a past
Chair of the Center for Long-Term Care Financing. Contact him at
913-707-8863 or
claude@back9ins.com to kick his tires &
discuss how he might help you. *** |
*** THE
PARAGON HEALTH INSTITUTE published my new study last week titled “Long-Term
Care: The Problem.” PHI president
Brian Blase summarized the paper and stated: “You can find ‘Long-Term
Care: The Problem’ and an executive summary here.”
He also announced: “The next paper, ‘Long-Term Care: The Solution,’ will
be published early next year and will provide a set of reforms to address
the problems caused by misguided government policies.” McKnight’s
Senior Living covered the study in
“Paper
analyzes government policy’s role in creating LTC problems” by
Kathleen Steele Galvin. ***
LTC BULLET: LTC
REFLECTIONS
LTC Comment: Long-term
care in the USA is fraught with problems. To name a few: dubious access
and quality, institutional bias, excessive dependency on inadequate
government financing, caregiver shortages, and worn out, financially
distressed families struggling to support loved ones in need of help. What
went wrong?
I argue in a new paper
titled “Long-Term
Care: The Problem,” that Medicaid is the primary cause of those
dysfunctions. Specifically, availability of Medicaid LTC benefits when
care is needed late in life created a moral hazard that discouraged
responsible LTC planning while consumers were still young, health and
affluent enough save, invest or insure for the risk. Easy access to
Medicaid late in life enabled consumers’ denial of LTC risk and cost
leaving them nowhere to turn when catastrophic LTC costs ensued except to
Medicaid. Too many people dependent on inadequate Medicaid funding led
directly to all the other problems cited above. Enough here about that;
see
the paper for details.
What I want to cover
today is a certain mystery. Congresses and presidents from both political
parties worked for decades to fix what’s wrong with long-term care and
Medicaid. When Medicaid LTC expenditures vastly exceeded original
expectations, they set about controlling costs. They imposed financial
eligibility restrictions. They required penalties to discourage
artificially self-impoverishing asset transfers. They made estate
recoveries mandatory. They encouraged private LTC insurance with limited
tax deductibility; offered the LTC Partnership program to forgive estate
recoveries; and urged the public to “Own Your Future” by preparing for the
likely eventuality of needing long-term care one day. All this was done to
wean the public off Medicaid and prepare them to pay privately for top
quality long-term care in the most appropriate venue if and when they
needed it.
Nothing worked fully,
but progress was being made until 2006. After that, nothing. What
happened? That’s the mystery. Here’s my explanation.
From Medicaid’s early
days legislative efforts to control its spending on long-term care and to
focus the public on early LTC planning coincided with economic recessions.
The economy would tank; politicians couldn’t make budget ends meet;
deficits and the national debt grew; pressure mounted to curb spending;
and statutory changes were passed to control costs by ensuring Medicaid
LTC benefits went only to the truly needy. Consider these examples of
recessions that led directly to legislative reforms:
Recessions |
Legislation |
January to July 1980 |
Omnibus Reconciliation Act of
1980 imposed the first ever restriction on asset transfers to
qualify for Medicaid. |
July 1981 to November 1982 |
Tax Equity and Fiscal
Responsibility Act of 1982 authorized state
Medicaid programs to penalize asset transfers, place liens on real
property, and recover benefits from the estates of deceased recipients
Consolidated
Omnibus Budget Reconciliation Act of 1985
attempted unsuccessfully to prohibit "Medicaid qualifying trusts."
Medicare
Catastrophic Coverage Act of 1988
required Medicaid asset transfer penalties, mandated a 30-month look
back, and capped maximum asset transfer penalties at 30 months. |
July 1990 to March 1991 |
Omnibus Budget Reconciliation
Act of 1993 made estate recovery mandatory, expanded the look back
period to five years, eliminated the cap on asset transfer penalties,
and prohibited “pyramid divestment.”
Health Insurance Portability
Act of 1996 made it a crime to transfer assets to qualify for
Medicaid (Throw Granny in Jail Act) and Balanced Budget Act of 1997
repealed Throw Granny in Jail and replaced it with Throw Granny’s
Lawyer in Jail. |
March 2001 to November 2001 |
Deficit Reduction Act of 2005
placed the first cap on Medicaid’s home equity exemption, limited the
half-a-loaf loophole, amended the annuity rules, and unencumbered the
Long-Term Care Partnership Program. |
After 2000, the linkage between
recessions and legislative reform was broken. |
A sea change in economic policy
around the turn of the century unleashed Medicaid spending. The
Federal Reserve forced interest rates down artificially. The U.S.
Treasury spent beyond its means. The Federal Reserve monetized the
resulting debt. Inflation occurred but it was disguised by rising real
estate, stock and bond values. Consumers didn’t feel the pinch. The
rest of the world bought our debt, sending the USA valuable goods in
exchange for bonds we sold and they bought relying on our promises to
repay them.
Modern Monetary Theory prevailed. |
December 2007 to June 2009 (The
Great Recession)
and
February 2020 to April 2020 (Covid
19 Recession) |
These recessions spurred no
legislation to control Medicaid LTC spending by targeting benefits
away from the middle class and toward the truly needy. In fact, they
led to ever more generous funding of all Medicaid programs including
long-term care. The Covid 19 recession created a tsunami of spending.
The federal government prevented state Medicaid programs from culling
even ineligible people from the rolls. Enhanced federal matching funds
were conditioned upon keeping everyone on Medicaid until the national
health emergency (NHE) ended. The pandemic subsided but the NHE has
been extended out of fear that millions would be forced off Medicaid
when it ends. |
What is going on? As
long as politicians were under budgetary pressure to control expenditures,
they responded with legislation intended to target scarce Medicaid
resources to people most in need. Eligibility controls, rules against
asset divestiture, and mandatory estate recoveries sent the message that
people should plan early and responsibly to save, invest or insure against
their personal LTC risk. But after 2006, with the government money spigots
wide open and the Federal Reserve liberally monetizing whatever debt the
federal government created while forcing interest rates to near zero,
pressure to control costs disappeared. Consequently, no further progress
was made to ensure Medicaid LTC benefits went only to the genuinely needy.
More and more Medicaid became the primary LTC payer for catastrophic costs
not only of the poor but of the middle class and affluent as well.
What is changing?
We are now experiencing a regression to the mean of economic and political
policy making. Excessive government spending during the pandemic created
an economic bubble. Too low interest rates caused excessive optimism,
malinvestment, booming stock markets, and engorged real estate values. Too
much money chased too few goods as the government channeled unearned funds
to non-working people and non-producing businesses. The bill for that and
for earlier decades of careless spending and irresponsible monetary policy
is finally coming due. The price of payment is consumer inflation. All the
“generous” government spending over the years that created a national debt
currently
exceeding $31 trillion is now in collection status. Consumers make the
payments for their government’s profligacy at the grocery store, at the
gas station, in their monthly rent or mortgage payments, in literally
everything they buy.
What does this mean
going forward? Careless fiscal and monetary policies unleashed debt and
inflation. High inflation makes servicing the huge national debt
unsustainable. All of a sudden, politicians at both the state and federal
levels are being forced to deal again with budget shortfalls. It’s harder
than ever for them to raise taxes, because the pressure of inflation has
tapped out tax payers. The pols can no longer get away with printing money
and monetizing the debt, because that only increases inflation and
tightens the fiscal vise. A long-delayed rendezvous with economic reality
is underway.
So here is what I
predict. This new economic and political reality will once again force
politicians to control Medicaid LTC expenditures. They will need either to
revisit the kinds of interventions tried before and reinstate them with
stronger enforcement. Or they will have to try something different. I
think we’ve learned what does not work. Telling people they could lose
their life savings to catastrophic LTC costs when it wasn’t true, did not
work. Because the federal and state governments did not adequately enforce
income and asset eligibility rules, including asset transfer restrictions,
and mandatory estate recoveries, the public was desensitized to LTC risk
and remains so.
What are the odds that
will change in the future? Nil. When the current recession finally ends
and the economy improves, the politicians will return to their usual ways.
As soon as the budget pressure is off, they’ll lose interest in
controlling Medicaid LTC expenditure. Benefits will continue to flow to
the middle class and affluent. States won’t enforce strict eligibility
rules or estate recoveries. Moral hazard will reign as before with few
people worrying about LTC risk and cost until they need high cost care.
Then they’ll turn as they always have to Medicaid and around we’ll go
again in this endless negative cycle.
No, we have to do
something different. What to do and how to do it is the subject of my next
paper for the Paragon Health Institute titled “Long-Term Care: The
Solution.” Watch for it early in the next year, but expect clues to its
direction in these LTC Bullets, both past and future.
#############################
Updated, Monday, October 10, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-031 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
- Legal
Ease: Medicaid Asset Protection Planning — what is it?
- Elder
Care: Nursing homes, Medicaid and the middle class
-
Exercise caution with zero-premium Medicare Advantage plans
- As
seniors’ presence in nursing homes drops, young people with disabilities
stuck with few alternatives: study
-
Medicaid Long-Term Care’s Real Problem Is Insufficient Resources, Not
Abuse By Wealthy Seniors
- Pick
Up the Phone: Older Clients Want to Hear From You
- After
a Dementia Diagnosis: Preparing for the Future
-
Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time
Than Medicare Covers
- ‘Tens
of thousands’ of nursing home caregivers could lose their jobs this
week: AHCA
-
Dementia Diagnosis Linked to Suicide
- 10
Things to Know About the Unwinding of the Medicaid Continuous Enrollment
Requirement
-
‘They’ve been an afterthought’: millions of elderly Americans still
vulnerable as pandemic caution wanes
- Beer
is GOOD for you! Scientists claim two pints a day may slash your risk of
dementia
- The
Walmart, UnitedHealth Group deal: Another big retail, health care
partnership
- Sages
of Aging hosted by Ken Dychtwald, PhD
- Census
finds more than 3 million older adults on the move each year
- ‘The
Forgotten Middle’: Seniors Facing Housing, Care Crisis
-
Seniors are stuck home alone as health aides flee for higher-paying jobs
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, September 30, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTC STRAWMAN
LTC
Comment: Disproving a claim no one has ever made contributes nothing to a
crucial conversation about who should qualify for Medicaid LTC benefits,
when and under what circumstances. What this means and why it matters
after the ***news.***
***
9/14/2022, “Family
Caregivers Confront Considerable Challenges,”
by
The
Certification for Long-Term Care,
Cision PR Newswire
Quote:
“Nearly all family caregivers say they are ‘always’ or ‘often’ providing
emotional support (80%) to a loved one needing long-term care. That
can levy a heavy toll on caregivers' well-being and relationships in their
lives. In our survey, burn out, lack of expertise and concerns about their
ability to focus on their jobs were cited as the most important reasons
why family caregivers sought paid home care. … Among the survey's other
findings:
-
33% of family caregivers find getting the emotional support they
need one of their biggest challenges
-
32% of family caregivers worry about juggling caregiving and their job
-
27% of those who decided not to bring in paid home care did so because
they felt it was their duty to provide care
-
44% felt using paid home care could have helped reduce the emotional and
physical strain of being a caregiver”
LTC
Comment:
Everyone knows long-term caregiving is demanding, stressful, and
expensive. But this study puts some empirical flesh on those observational
bones. Despite a small sample (200 who used paid care and 200 who didn’t),
the reported numbers are credible and do comport, I think, with many of
our personal caregiving experiences.
Eileen J. Tell,
CEO of ET Consulting, LLC, conducted the study and presented findings this
week at the
CLTC
Leadership Summit
in Minneapolis. For a pdf copy of the full report, contact Celeste Cobb at
celeste@ltc-cltc.com.
Kudos to CLTC for supporting this research. ***
LTC
BULLET: LTC STRAWMAN
LTC
Comment: Marc Cohen, a distinguished LTC scholar I consider my friend,
insists Medicaid forces people to spend down into impoverishment before
they qualify for Medicaid LTC benefits. I maintain that accessing Medicaid
LTC benefits without spending down significantly is easy, commonplace and
recommended by thousands of lawyers and financial advisors. Who’s right?
Marc
has published a new article he says supports his point of view. Does it?
Let’s see. Definitely consider what he and co-author Jane Tavares have to
say. Then read on for my response. Here’s their article:
Marc
A. Cohen & Jane Tavares (2022): Are Wealthy Older Adults who use Medicaid
Opportunistically Accessing the Program?, Journal of Aging & Social
Policy, DOI: 10.1080/08959420.2022.2127597
To
link to this article:
https://doi.org/10.1080/08959420.2022.2127597
The
article’s “Abstract” says it all:
There has been longstanding concern that wealthy older adults may be
accessing the program by opportunistically divesting assets in order to
qualify for coverage rather than by having high medical or LTSS expenses
on which they spend down their resources to eligibility levels. … Our
findings demonstrate that this may occur among a relatively small
proportion of wealthy people, and that tightening Medicaid eligibility
criteria would likely have only a very modest impact on program
expenditures.
What
are we to make of that problem statement and those findings? Is it true
there has been a “longstanding concern that wealthy older adults may be
accessing” Medicaid “by opportunistically divesting assets”? Maybe, but
I’m not aware of anyone having claimed such behavior is widespread.
Certainly I have not and I am the only author cited in the article as
having made the claim. My 1990 piece in The Gerontologist titled “The
Fallacy of Impoverishment,”
the one Cohen and Tavares reference, says nothing about asset divestiture
by the wealthy.
My
position is much more modest and nuanced. It is that qualifying for
Medicaid long-term care benefits does not require impoverishment, that
Medicaid’s income and asset limits allow middle class and moderately
affluent people to qualify without spending down their savings
significantly, and that in some cases even more wealthy people can qualify
without spending down appreciably, with the help of lawyers who specialize
in “artificial impoverishment.” In fact, when I searched my
dozens of national and state-level reports about Medicaid planning
I found not a single use of the term “opportunistic.” When I used the term
“wealthy” it was either to quote a state Medicaid eligibility official
complaining about the abuse or to point out that rich people can
qualify for Medicaid LTC benefits, which Cohen and Tavares acknowledge is
true, not that they do so in large numbers.
So
why all the hyperventilating about wealthy people accessing Medicaid by
opportunistically divesting assets? It is to divert attention from the
real problem which is that Medicaid has become the dominant long-term care
funding source for most Americans and that it is available without
significant asset spend down after care is needed and long after it is too
late for people to plan early and responsibly to handle the high risk and
cost of long-term care privately. It is that reality that has caused most
of the long-term care system’s problems including excessive dependency on
welfare-financed nursing home care, insufficient supply of home and
community-based services, meager public funding resulting in serious
access and quality problems, as well as severe caregiver shortages, and
the lack of demand for private insurance to spread the risk.
Why
do scholars like Cohen and Tavares, and nearly all of their “peers” choose
to focus exclusively on minor problems like the wealthy capturing Medicaid
instead of the big problem, that Medicaid crowds out personal LTC
responsibility and planning? Why do they fail to mention, much less
explain, the
many
Medicaid planning techniques that are far more common and costly to
Medicaid than asset divestiture?
Why is there no mention of the
National Academy of Elder Law Attorneys,
the Medicaid planners’ professional association nor the
vast
formal legal literature on Medicaid planning?
How do they manage such intellectual sleight of hand when the real problem
is so much more obvious and compelling?
The
answer is that the real problem violates the dominant ideological
narrative to which most academics subscribe. That narrative is that
Medicaid requires impoverishment and that aging Americans in the millions
are being wiped out financially by high and rising long-term care costs.
It isn’t true. There is no empirical evidence that it is true and these
authors provide none. In fact, Medicaid does pay for most catastrophic LTC
expenses and its financial eligibility rules are very generous and
elastic. But the impoverishment narrative is necessary to garner support
for these experts’ preferred “solution,”
a
new, compulsory, payroll-tax-funded social insurance program to fund
long-term care.
Why is it that we only hear this narrative and almost nothing about how
Medicaid actually works? Because very little information to the contrary
can penetrate the “peer review” wall that protects the dominant narrative
from critical scrutiny.
In a
2017 report titled “How
to Fix Long-Term Care Financing”
for the
Foundation for Government Accountability
I answered the question “Why Do Analysts Wrongly Claim Medicaid Long-Term
Care Eligibility Requires Impoverishment?” Here’s my answer in a nutshell,
but do go to the source for the full six-page explanation.
First, analysts wrongly claim Medicaid requires impoverishment because
they equivocate on the meaning of “impoverishment.” … Second, … they
equivocate on the meaning of “spend down.” … Third, … they equivocate on
the meaning of “Medicaid planning.” … Fourth, … they equivocate on the
meaning of “out-of-pocket” expenditures for long-term care by claiming
they are higher than they really are. … Fifth, … they rely on data, much
of it faulty, from HRS and AHEAD surveys. Sixth, … they do not ask the
people who know the truth.
Until analysts come to grips with the real reasons long-term care service
delivery and financing are so dysfunctional by confronting each of those
issues honestly, there will be little hope for improvement. Focusing
instead on asset divestiture by the wealthy is a
Strawman
argument: “an intentionally misrepresented proposition that is set up
because it is easier to defeat than an opponent's real argument.”
Marc, I challenge you, as I have done before, to debate the real issue in
a public forum. To wit: What is Medicaid’s role in the long-term care
system and how can we repair the damage it has caused? You can pitch
socializing the LTC risk by partnering with government and I’ll defend a
freer market relying more on individual initiative and responsibility.
#############################
Updated,
Monday, September 26, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-030 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
What Are Medicaid Asset Protection Trusts?
-
Information campaign on aging and long-term care is
wise; taking more earnings from workers isn’t
-
Industry Leaders Split on Whether Skilled Nursing’s
Future Should Include Separate Short, Long-Term Care
-
U.S. Retirement Income Imbalance
-
Alzheimer’s might not be primarily a brain disease.
A new theory suggests it’s an autoimmune condition
-
America’s age tipping point is approaching — we’re
totally unprepared
-
BREAKING: Congressional study eviscerates
for-profit nursing homes
-
Over 7 Million U.S. Seniors Have Mental Declines
That Threaten Financial Skills
-
A Review of 62 Studies Finds Few Big Differences
Between Traditional Medicare and Medicare Advantage on a Variety of
Measures
-
4 tips for selling long-term-care insurance
-
10 Things About Long-Term Services and Supports (LTSS)
-
Risk of Alzheimer’s nearly doubles in seniors with
COVID, analysis shows
-
Northwestern Mutual Adds a Long-Term Care Hybrid
-
Family Caregivers Confront Considerable Challenges
-
Medicare Advantage Is A Diamond In The Government
Healthcare Rough
-
‘It’s Becoming Too Expensive to Live’: Anxious
Older Adults Try to Cope With Limited Budgets
-
Support for greater government role in health care
for older adults
-
While Inflation Takes a Toll on Seniors, Billions
of Dollars in Benefits Go Unused
-
Nursing homes fire back after CMS warning about
‘exploitative’ debt-collection practices
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, September 16, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: LTC STUDIES SHARE FLAWS
LTC
Comment: Three new LTC studies don’t ask “what went wrong?” before
prescribing more of what caused LTC’s problems in the first place. We
explain after the ***news.***
*** TODAY'S LTC BULLET is sponsored by Claude
Thau with BackNine Insurance. In addition to many
unique services to advisors relative to individual, worksite and
affinity LTCi (including his revolutionary “Range of Exposure” tool
that protects FPs from risks most don’t recognize). New service: your
own free insurance website allowing clients to buy insurance with as
little or as much of your involvement as you or they want. Claude is
the lead author of Milliman’s annual Broker World LTCi Survey & a past
Chair of the Center for Long-Term Care Financing. Contact him at
913-707-8863 or
claude@back9ins.com to kick his tires &
discuss how he might help you. *** |
***
ROMEO RAABE, LUTCF, LTCP is
The
Long-Term Care Guy
of Wisconsin, a proactive advocate for better LTC financing policy, and a
long-time Regional Representative of the Center for LTC Reform. Contact
him at (920) 884-3030 or
rraabe@thelongtermcareguy.com.
He offers this comment:
“Are
We Selling Appropriate LTCi?”
by
Romeo Raabe
There are a multitude of different products sold to help pay for the cost
of LTC. There are also many choices as to how much money is needed, for
how long, with or without inflation, various deductibles, and choices of
facility coverage, home care coverage or both. Everyone has an opinion on
these options but the important part is for our clients to have sufficient
cash flow to pay for the care they need - when they need it. That is the
point, isn't it?
One
type of comment I often hear is “This can turn $100,000 into $300,000 for
LTC.” Sounds pretty good to many, but let’s ask how much the client can
get out each month and is that enough along with other cash flow to pay
the bills? If not, and they spend down to Medicaid, have we done any good
other than earn a commission? If the plan, which the client understands,
is just to have enough to cover some home care, then it’s fine. But if the
client expects to be able to afford a nursing home, it’s not.
Something is not always better than nothing if it does not do what the
client expects. First, do no harm. ***
LTC
BULLET: LTC STUDIES SHARE FLAWS
LTC
Comment: America has an abundance of dedicated, well-intentioned analysts
who lament the state of long-term care and want to fix it. I could list (and
have listed)
dozens of studies these scholars conducted which share two fatal flaws.
First, none of them ask—much less answer— what caused the long-term care
system’s current dysfunctional state before recommending more government
funding and regulation to fix it. Second, they all founder on the shoals
of inadequate financing.
Add
these three recently released studies to that list:
Study # One:
“Improving
Care for Older Adults: Convergence Dialogue on Reimagining Care for Older
Adults Project Staff and Consultants: Final Report”
tells us what’s wrong with long-term care and prescribes:
1.
“Establish a broad constellation of financially sound and adaptable
care settings that reflect the desires and needs of older adults.
2.
“Ensure There Are Enough Caregivers
3.
“Finance the Future Care System”
Why
are these measures necessary? What caused the problems they’re supposedly
needed to resolve? Why is it government’s job to fix a broken system
already dominated by government spending and regulation? Blank out.
Study # Two:
“The
National Imperative to Improve Nursing Home Quality: Honoring Our
Commitment to Residents, Families, and Staff (2022)”
devotes 600 pages to lamenting the sorry state of nursing home care in the
USA …
“First, the way in which the United States finances, delivers, and
regulates care in nursing home settings is ineffective, inefficient,
fragmented, and unsustainable. …
“Second, immediate action to initiate fundamental change is necessary. …
“Third, federal and state governments, nursing homes, health care and
social care providers, payers, regulators, researchers, and others need to
make clear a shared commitment to the care of nursing home residents. …
“Fourth, extreme care needs to be taken to ensure that quality-improvement
initiatives are implemented using strategies that do not exacerbate
disparities in resource allocation, quality of care, or resident outcomes
(including racial and ethnic disparities), which are all too common in
nursing home settings.
“Fifth, high-quality research is needed to advance the quality of care in
nursing homes.
“Sixth, the nursing home sector has suffered for many decades from both
underinvestment in ensuring the quality of care and a lack of
accountability for how resources are allocated. …
“Finally, key partners, such as the Centers for Medicare & Medicaid
Services (CMS) and other federal agencies, may not currently have the full
authority or resources to carry out the actions recommended.”
So,
what’s the bottom line?
“Therefore, as a final overarching conclusion, the committee notes that
all relevant federal agencies need to be granted the authority and
resources from the U.S. Congress to implement the recommendations of this
report.”
In
other words, everything wrong with nursing home care in the United States
is directly related to public financing and regulation, but the National
Academies of Sciences, Engineering, and Medicine can think of nothing
better to do about it than to pile on more of the same.
Study # Three:
“Where
Am I, Where Do I Go: The Missing Entry Point to Long-Term Care Solutions
for Older Adults and Their Caregivers”
explains how America’s LTC system leaves people in crisis floundering,
under extreme financial pressure, lacking guidance, not knowing what to
do, but having to do something fast. It paints a beautiful picture of an
improved system that points everyone in need of long-term care to the best
possible solution.
But
here again: “Although this paper does not specifically recommend a funding
model for the hubs, we recognize that funding will be a barrier to
achieving our vision. Historically,
policy options
for long-term care have focused on creating a financing system to fund
services, which is critically important for supporting families and
funding a long-term care workforce. However, policy must also focus on the
navigational needs of older adults and their families.”
In
other words, the need is so great we just have to find a way to do this
and pay for it. Can’t somebody do something?!
LTC
Comment:
The only way we’ll ever confront long-term care’s problems successfully
and actually solve them is to begin by asking: what caused the problems in
the first place? I’ve answered that question already in two reports—Medicaid_and_Long-Term_Care
and
How to Fix Long-Term Care Financing—with
two more forthcoming: “The Long-Term Care Problem” and “The Long-Term Care
Solution.” Bottom line, government financing and regulation caused LTC’s
problems. Medicaid paid for expensive LTC after care is needed resulting
in a moral hazard that prevented most people from planning ahead for the
LTC risk and left them dependent on public assistance when the need arose
later. To solve LTC’s problems,
Frontload LTC
so most people save, invest, or insure for the risk and cost while they’re
still young, healthy and affluent enough to do so and thus dramatically
reduce the number of people who end up dependent on Medicaid. The free
market will do the rest, directing creative entrepreneurial energy toward
finding the best ways to meet consumers’ LTC preferences and needs.
#############################
Updated,
Monday, September 12, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-029 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Cracks in the foundation: The experience of care
aides in long-term care homes during the COVID-19 pandemic
-
Study: 72% of middle-class seniors may not be able
to afford assisted living by 2033
-
Helping prospects navigate long-term care system an
‘enormous opportunity’ for senior living: report
-
A Valuable New Framework For Improving The Care Of
Older Adults
-
‘Red-hot inflation’ drives senior living asking
rates to record high
-
Envisioning new financing models to mitigate the
crisis in long-term care
-
Why Medicare Advantage is the basis for Medicare
reform
-
What Is Community Medicaid?
-
A 2022 Introduction to Ken Dychtwald, PhD
-
Almost half of eligible Medicare beneficiaries use
Medicare Advantage, analysis shows
-
‘Death spiral’ for SNFs as Medicare Advantage pay
decreases
############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Tuesday, September 6, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-027 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Other states have proposed long-term-care
laws that could sneak up on workers
-
Rising Interest Rates Will Crush the
Federal Budget
-
MedPAC Members Concerned About Medicare's
Finances
-
Simple musical test predicts cognitive
decline in older adults, study shows
-
Study: More middle-income seniors to tax
home care, housing resources in coming years
-
Birth of LTCi: Fatal miscalculations spur
decades of angst
-
Inflation drives long-term care costs even
higher. Here’s how planning ahead can help families afford it
-
5 Reasons Affluent Clients Might Need
Long-Term Care Insurance
-
Single Seniors Are Struggling to Retire
-
Life Settlement Firm Plans to Go Public
Through $619M SPAC Deal
-
Watch Out! RMDs Can Trigger Massive
Medicare Means Testing Surcharges
-
The rich are using long-term care funds
meant for the poor
-
9 Lessons From John Hancock's $26M LTCI
Settlement
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, September 2, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: BIASED LTC SCHOLARSHIP MISINFORMS POLICYMAKERS
LTC
Comment: Government-funded, ideologically biased research causes bad
policy decisions, as we explain 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 sight unseen. You’ll get trenchant analysis and valuable
ideas on how to address objections and complaints. Contact Damon at
206-283-7036 or
damon@centerltc.com
for details or subscribe directly here:
http://www.centerltc.com/newonlinepaymentspage.htm.
Choose “Premium Membership” to receive our LTC Clippings. For
example, here are some recent LTC Clippings:
8/31/2022,
“Birth
of LTCi: Fatal miscalculations spur decades of angst,” by John Hilton,
InsuranceNewsNet
Quote:
“In fact, the assumptions stood on a quite reasonable foundation, Slome
explained. But two things did not play out as insurance executives and
actuaries expected: the changing dynamics of long-term care, and the lapse
rates. Fast forward a few decades, and LTCi is a perplexing product
landscape. The need for the product is overwhelming, yet, insurers are
busier trying to maintain old blocks of business that are actuarially
unsound. That means repeated rate requests in states across the country.
It means reduced benefits. It means denying coverage to nearly half of
applicants who most need it. Finally, it means some insurers have gone
insolvent. Many others have left the LTCi business entirely. Meanwhile,
state insurance regulators struggle to weigh the needs of policyholders
against the needs of insurers. It has pitted state against state in some
instances.”
LTC
Comment:
“The
best laid schemes o’ mice an’ men. Gang aft a-gley”--Robert
Burns. But there’s even more to it than my friend Jesse Slome points out.
The Federal Reserve forced interest rates to near zero which made
obtaining reasonably expected returns on reserves impossible. That forced
carriers to raise premiums which alienated prospects and angered insureds.
Those same artificially low interest rates enticed politicians to spend
with abandon resulting in the inflation we’re experiencing now. Likewise
Medicare and Social Security face insolvency in a decade or so. When will
those government programs acknowledge they cannot pay promised benefits
and take action as LTCI carriers already have? If rate increases upset
LTCI insureds, what do you think the reaction will be from voters when
Medicare and Social Security cut benefits or raise payroll taxes?
8/30/2022,
“5
Reasons Affluent Clients Might Need Long-Term Care Insurance,”
by Margie Barrie, ThinkAdvisor
Quote:
“Here’s a common question from financial planners: Should they be
recommending long-term care insurance to high-net-worth clients, or should
their clients self-fund long-term care risk?
The decision to consider long-term care protection is often based on the
value of the client’s assets. However, there are other risk factors that
need to be considered, because those factors will affect the client’s
portfolio and may have tax implications. In many situations, long-term
care protection may provide a solution for portfolio risk management and
legacy planning issues in the most cost-effective and efficient manner
currently available.”
LTC
Comment:
These are five of the best, but least recognized, reasons to own LTCI
protection.
8/29/2022,
“The
rich are using long-term care funds meant for the poor,”
by Mark Warshawsky, The Hill
Quote:
“Unfortunately, several studies show
that many older people with significant real estate and financial asset
holdings get long-term care from Medicaid for free or at subsidized rates.
These findings should not be surprising because, in many states, the rules
and administration of the program are loose and porous, and little effort
is made to recover assets from the estates of deceased Medicaid users,
despite this being required by federal law. By my estimate every year
almost $6 billion of Medicaid funds are inappropriately used for the
long-term care of individuals with significant asset holdings. Breaking
this amount down, almost $3 billion could be recuperated from enhanced
estate recoveries and more than $3 billion from retirement assets.”
LTC
Comment:
It’s good to see someone else pointing out this problem as we have done
frequently since
1988
in many
national and state level studies.
Unfortunately, the author’s solution has proved inadequate and
unenforceable. That’s why we’re proposing a better approach:
LTC
Bullet: Frontload LTC.
***
READ STEVE MOSES’s latest published articles:
“LTC
insurance sales suddenly surge,”
by Stephen A. Moses, McKnight’s LTC News, August 10, 2022
“Long-term
care’s mortal risk,”
by Stephen A. Moses, McKnight’s LTC News, June 6, 2022
“Long-Term
Care Epiphany,”
by Stephen A. Moses, Broker World, June 2022
“Trappings
of LTC system leave operators trapped,”
by Stephen A. Moses, McKnight’s Long-Term Care News, February 23,
2022.
“The
Great Long-Term Care Compromise,”
by Stephen A. Moses, Broker World, January 1, 2022
“The
irony of long-term care advocacy,”
by Stephen A. Moses, McKnight’s Long-Term Care News, December 17,
2021
“What
works for long-term care and what doesn’t,”
by Stephen A. Moses, McKnight’s Long-Term Care News, November 17,
2021
“What’s
better for senior living and care — the market or government?,”
by Stephen A. Moses, McKnight’s Senior Living, October 25, 2021
“Long-term
care’s problems are bad and getting worse — but fixable,”
by Stephen A Moses,
McKnight’s LTC News,
October 4, 2021 ***
LTC
BULLET: BIASED LTC SCHOLARSHIP MISINFORMS POLICYMAKERS
LTC
Comment: It’s no wonder so many policymakers want a new, compulsory,
centrally planned, taxpayer-funded, budget-busting, LTC entitlement
program when the researchers they pay for advice blank out or misrepresent
information critical to good decision making. When policymakers believe
falsely that Medicaid requires impoverishment and that wide swaths of the
American public are being wiped out financially by private LTC
expenditures, of course they’re tempted to impose a government solution
from on high.
I
explained what I mean by that and gave examples in
How to Fix Long-Term Care Financing (pages
13-18). In a nutshell, many “progressive” analysts equivocate on terms
like “impoverishment,” “spend down,” “Medicaid planning,” and “out of
pocket.” They do not interview the right people to learn how individuals
qualify for Medicaid without spending down personal wealth and they rely
on widely accepted data sources that are actually highly dubious in this
regard (HRS and AHEAD). Such analysts ignore or misrepresent important
facts and emphasize only information that confirms their biases.
In “LTC Bullet:
LTC Center Standing Guard,”
I listed and linked to 100 LTC Bullets in which we analyzed and
critiqued biased scholarship tending to promote public LTC funding and to
discourage private financing alternatives. Today we add another example to
that list. To wit:
Richard W. Johnson and Melissa M. Favreault, “Economic Hardship and
Medicaid Enrollment in Later Life: Assessing the Impact of Disability,
Health, and Marital Status Shocks,” published by the U.S. Department of
Health and Human Services Office of the Assistant Secretary for Planning
and Evaluation, January 31, 2021,
https://aspe.hhs.gov/reports/economic-hardship-medicaid-enrollment-later-life#results.
What
follows are quotes from that study Johnson & Favreault and our
LTC Comments in reply:
Johnson & Favreault:
“This report assesses the financial security of older adults and examines
the role that disability, health, and marital shocks play in economic
hardship in later life. … We also focus on enrollment in Medicaid, which
is available only to people with very limited financial resources.” (p. 2)
LTC
Comment:
J&F have a lot of interesting things to say about “economic hardship in
later life,” but we’ll focus on their comments regarding Medicaid LTC
eligibility, especially the idea that it is “available only to people with
very limited financial resources.”
Johnson & Favreault:
“Many older adults have amassed significant wealth over their working
years that can supplement their income. Wealth holdings at older ages are
becoming increasingly common as employers replace traditional
defined-benefit pensions, which provide retirees with a steady income
stream that lasts until death, with retirement plans that provide workers
with retirement savings accounts to which both employees and employers
contribute.” (p. 4)
LTC
Comment:
Good point. There’s a lot of wealth held by aging Americans in IRAs and
401Ks, and far more residing in home equity. But how much of this
financial wherewithal finds its way into paying for long-term care?
Johnson & Favreault:
“About 70 percent of adults develop serious LTSS needs after age 65
(Johnson 2019). …The onset of nursing home care and cognitive impairment
has the largest impacts on household wealth.” (p. 6)
LTC
Comment:
OK, now we know that aging people possess huge amounts of liquid and
illiquid financial resources and they have a high risk of very expensive
long-term care. Again, are they actually spending that money on long-term
care? Is there any evidence?
Johnson & Favreault:
“Relatively few older adults with significant wealth deplete their
holdings before they die, and those who spend their savings usually
experience significant health shocks (Table 3).” (p. 6)
LTC
Comment:
Interesting, but more of the same. Most older adults don’t deplete their
wealth but those who do experience health shocks. So does that latter
group spend their money on health and LTC? Are we supposed to presume so?
Apparently, but empirical evidence that such spend down is actually
happening would be very helpful. But none is offered.
Johnson & Favreault:
“Another indicator of economic hardship is Medicaid enrollment. Because
people qualify for Medicaid only if they have virtually no assets, except
for a home, and very little income, receipt of Medicaid benefits is a
strong indicator of financial vulnerability.” (p. 7)
“Medicaid enrollment is a reliable indicator of economic hardship because
people qualify only if they have very low income (after covering health
care costs) and few assets.” (p. 10)
LTC
Comment:
Wait a minute. Eligibility for Medicaid proves economic hardship? That’s a
circular argument as I explained in “LTC Bullet:
Begging the LTC Question.”
Turn it around and you have: there’s no hardship if people can qualify for
Medicaid while preserving wealth. Is that what these analysts really
believe? Evidently so as it follows logically. Read on.
Johnson & Favreault:
“Adults ages 65 and older may qualify for Medicaid if they have virtually
no assets, except for a home, and very little income. The program’s asset
test limits Medicaid eligibility to people with no more than $2,000 in
countable assets if single and no more than $3,000 in countable assets if
married. Countable assets exclude the value of the home and such things as
automobiles, household goods, the surrender value of life insurance, and
burial funds.” (p. 7)
LTC
Comment:
What’s wrong with this picture of Medicaid LTC eligibility? J&F want us to
believe that Medicaid LTC financial eligibility rules force people to
spend down their wealth even though they provide no evidence that actually
happens and they acknowledge “countable assets exclude” practically all
wealth seniors hold. Those excluded assets include up to between $635,000
and $955,000 of home equity depending on the state and, with no dollar
limit at all, one business, individual retirement accounts, term life
insurance, burial funds for the immediate family, household goods and
personal effects including heirlooms. Does Medicaid require people to
spend any remaining countable assets for LTC as J&F imply? No. People can
spend their countable assets on anything they want, including
non-countable assets. So anyone with too much countable wealth can qualify
quickly and easily by purchasing exempt assets such a house, car, or
diamond ring (represented to be a family heirloom). Converting countable
into non-countable assets in this way is the easiest and single most
common technique of Medicaid planning.
Johnson & Favreault:
“A single SSI beneficiary without earnings who does not receive Social
Security or other income, like a state supplement could receive no more
than $771 in monthly income in 2019 (equivalent to $9,252 per year), well
below the FPL. Many states extend Medicaid eligibility to people with
income up to 138 percent of the FPL.” (p. 7)
LTC
Comment:
Oh, so you must be desperately income-poor to qualify for Medicaid LTC
benefits? Not so fast. They admit there’s more to it.
Johnson & Favreault:
“Many states account for individuals’ health care spending when
determining Medicaid eligibility by subtracting applicants’ out-of-pocket
costs for medically necessary services and supplies from their countable
income. This adjustment essentially allows people to ‘spenddown’ their
income until they qualify for Medicaid. Other states achieve similar
outcomes by allowing applicants to assign that portion of their income
that exceeds the Medicaid income threshold to a special trust used to help
cover service costs. The state receives any funds remaining in these
trusts after a Medicaid enrollee’s death, up to the amount the state paid
in Medicaid benefits.” (p. 7)
LTC
Comment:
Oh, Medicaid income eligibility rules are not so draconian after all. In
fact, in the real world, unconfused by academic obfuscation, the rule of
thumb is that anyone with income below the cost of a nursing home—easily
$8,000 per month—qualifies based on income assuming their private health
and LTC expenditures are high enough, as they usually are for aged people
in need of expensive health and long-term care. Bottom line, neither the
possession of substantial assets nor high income interferes with Medicaid
LTC eligibility for people who know and take advantage of the rules or
seek professional legal assistance to help them qualify.
Johnson & Favreault:
“Despite concern that some older adults game the system by transferring
wealth to their children to qualify for Medicaid, there is little evidence
that this practice is widespread, especially after the 2005 Deficit
Reduction Act tightened Medicaid eligibility rules (Baird, Hurd and
Rohwedder 2016).” (p. 8)
LTC
Comment:
Here J&F give lip service to the possibility that people can qualify for
Medicaid LTC benefits without spending down. But lip service is all it is.
Asset transfers are only a minor form of Medicaid planning, the tip of the
iceberg. J&F focus on asset transfers to divert attention from far more
common methods. Purchase of exempt assets is by far the most frequently
used and costly (to taxpayers) technique. But there are dozens of ways to
shelter wealth. See this list for example:
https://www.medicaidplanningassistance.org/medicaid-planning-techniques/.
What exposes these researchers’ intellectual dishonesty is their total
failure to acknowledge the widespread practice and methods of Medicaid
planning as well as the vast professional legal literature on how to do
it. For a history and bibliography of Medicaid planning over the past four
decades see pages 34-65 in
How to Fix Long-Term Care Financing.
Johnson & Favreault:
“Older adults who develop serious LTSS needs account for 77 percent of
Medicaid enrollees in the bottom lifetime earnings quintile, 79 percent in
the second quintile, 87 percent in the middle quintile, 91 percent in the
fourth quintile, and 90 percent in the top quintile (numbers not shown in
the table). Serious LTSS need is a relatively weak predictor of Medicaid
enrollment for older adults with limited lifetime earnings because their
limited financial resources often qualifies them for benefits even without
receiving paid LTSS and spending down some of their wealth.” (p. 18)
LTC
Comment:
So, poor people qualify for Medicaid? Not exactly news. But people who
need LTC account for 91% of Medicaid enrollees in the fourth income
quintile and 90% in the top quintile? That’s more believable. But how can
it be so if Medicaid financial eligibility restrictions are as severely
limiting as these analysts insist? Simple. It isn’t true and the
researchers are wrong about Medicaid LTC eligibility.
Johnson & Favreault:
“Although many middle-income older adults have savings they can use to
supplement their incomes and help make ends meet, they run the risk of
depleting their wealth if out-of-pocket health care costs persist, which
could force them to turn to Medicaid. We project that 25 percent of older
adults in the middle lifetime earnings quintile enroll in Medicaid after
age 65. Nearly nine in ten of these older middle-class Medicaid enrollees
have serious LTSS needs.” (p. 20)
LTC
Comment:
Thus, Johnson & Favreault conclude their paper. They say middle class
people run the risk of depleting their wealth due to high health and LTC
expenses. But they provide no empirical evidence whatsoever that this
actually happens. They fail to recognize the simple reality that Medicaid
financial eligibility rules are generous and elastic allowing people who
choose that course to qualify for Medicaid without spending down assets
significantly for care and despite having substantial incomes. There’s
little wonder remaining why government, in this case USDHHS-ASPE, finances
such research. To gain power and control, to promote more public financing
and regulation of the LTC market, it helps to have research reports that
say the public is devastated by catastrophic costs and existing programs
like Medicaid aren’t doing enough. The opposite is true. Medicaid does too
much and does it after care is needed when it is too late for people to
save, invest or insure responsibly against the LTC risk. The only true
solution to this real problem is to move LTC risk and cost forward in time
so responsible people can prepare. See
Frontload LTC
for details.
#############################
Updated,
Monday, August 29, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-027 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
3 Reasons Not to Tap Your Home Equity Right Now
-
Fears grow over controversial long-term care bill
-
Inflation replaces staffing as top concern for many
operators: survey
-
Congress Considers Strategies To Improve Medicare
And Medicaid Integration For Dual-Eligible Individuals
-
World Insurance: Inflation Risks Front And Center
-
Long-term care accounts for 54 percent of
healthcare bankruptcies this year
-
U.S. life expectancy dropped by average of 2 years
in 2020, new data reveal
-
What older adults do while they sit affects
dementia risk, study indicates
-
7 Reasons New York’s $26M John Hancock LTCI Action
Matters for Advisors
-
BREAKING: CMS bulletin presses states on Medicaid
nursing home spending
#############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Monday, August 22, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC E-ALERT #22-026 LTC NEWS AND COMMENT
LTC Comment: Do you spend hours searching
the internet for useful articles, key data, and relevant reports to keep
you on the forefront of professional knowledge? Do you lose business
because you’re blindsided by clients or competitors who learn critical
information before you do? Here’s an antidote:
LTC Clippings: The Center for Long-Term
Care Reform notifies subscribers to our LTC Clippings service daily of
information you need to know. Each message contains only the critical
facts about new publications: a title, representative quote, a link to the
original, and our analysis in a sentence or two. To inquire or subscribe,
contact Steve at 425-891-3640 or
smoses@centerltc.com. Read testimonials
by satisfied subscribers
here.
To subscribe online, please click
here.
LTC E-Alerts: Once a week, we compile our
daily LTC Clippings into a summary, email it to Center for Long-Term Care
Reform members, and archive it in The Zone, our password-protected
members-only website. Center members also receive our weekly LTC Bullet
op-ed. To join the Center and receive all these benefits and more, contact
Steve at 425-891-3640 or
smoses@centerltc.com.
We no longer post our LTC E-Alerts on the
Center’s public access website, but here’s what today’s LTC E-Alert
contained: links, quotes and comments on the following articles, reports,
or data:
-
Opting out of the long-term-care payroll
tax is more complicated than necessary, suggesting it’s just a nice
gesture
-
Updated numbers on people exempted from
state’s long-term-care program and payroll tax
-
Long Term Care Insurance — The Latest
-
Value-Based Care Series: Anne Tumlinson,
CEO, ATI Advisory
-
Consumer Reps Say Advisors Need Clients'
LTC Insurance Rate-Hike Info
-
40 states now cover around-the-clock
Medicaid HCBS as provided in assisted living
-
Over 50% Of Generation X Can't Afford To
Help Their Senior Parents
-
With new acquisition, Humana carves out
larger slice of Medicaid pie
-
Federal Staffing Minimums Won’t Solve
Labor Woes For Nursing Homes in Disadvantaged Neighborhoods
-
Law in the Marketplace: Do you need
Medicaid planning?
############################
"LTC E-Alerts" are
a
feature offered by the Center for Long-Term Care Reform, Inc. to members
at the $150 per year level or higher. We'll track and report to you news
and analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, August 15, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-025 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Miller Trusts Can Help You Qualify for
Medicaid
-
Problems persist at Washington hospitals
due to lack of long-term care options
-
LTC insurance sales suddenly surge
-
Will a Medicaid Recipient Lose His Benefits
If He Sends His Incarcerated Son Money Every Month?
-
What You Need to Know About Medicaid’s
Personal Needs Allowance
-
Social Security: 3 Reasons Why Record COLA
Increase in 2023 Could Backfire on Seniors
-
59 percent of adult children cannot afford
assisted living, home care for parents: survey
-
Major nursing home association urges COVID
emergency extension, revised guidance
-
Amazon Could Roll Into Home Care
-
We Have a Short Time to Fix Long-Term Care
-
Socioeconomic deprivation associated with
increased dementia risk and faster memory decline
-
Filling The Gaps: The Role And Value Of
Supplemental Benefits In Medicare Advantage·
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, August 12, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC BULLET: LTC
ALMANAC UPDATE
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
damon@centerltc.com for details or subscribe directly here:
http://www.centerltc.com/newonlinepaymentspage.htm. Choose “Premium
Membership” to receive our LTC Clippings. For example, here are
some recent LTC Clippings.
8/4/2022, “Facing
stagnant Medicaid rates, this state has lost 10 percent of SNF beds in
2022,” by John Hall, McKnight’s LTC News
Quote: “The loss of seven nursing homes and hundreds of beds in a
short period of time has set healthcare officials in Montana reeling, even
as the state is trying to regain its footing following the brunt of the
COVID pandemic. It’s part of a trend that has seen more than 1,000 nursing
homes close since 2015, industry officials said. In just the past six
months, Montana has lost approximately 10% of its nursing home beds.
Operators of the closed facilities said they could no longer absorb losses
in excess of $100 per resident per day.”
LTC Comment: If only Montana had listened when we explained what
was wrong with long-term care and what to do about it:
LONG-TERM CARE IN MONTANA: A Blueprint for Cost-Effective Reform
(1993).
8/2/2022, “As
new Alzheimer’s drugs have failed, scientists are shifting focus to other
potential causes,” by Berkeley Lovelace, Jr., NBC News
Quote: “As yet another Alzheimer's drug targeting plaque buildup in
the brain fails to improve cognition in patients, leading scientists said
a significant shift is underway in the search for effective treatments for
the disease. The new direction in Alzheimer’s research — away from
focusing solely on beta-amyloid plaques to other potential causes,
including brain
inflammation and conditions related to diabetes — comes from growing
evidence that multiple factors contribute to the development of the
disease.”
LTC Comment: “If at first you don’t succeed, try, try again” but
doing the same thing over and over again is the definition of insanity.
So, it’s about time science looks more closely at the idea of Alzheimer’s
as “Type 3 Diabetes,” the result of unhealthy lifestyles.
7/28/2022, “Funding,
unionization needed to improve wages, working conditions in long-term
care: report,” by Kimberly Bonvissuto, McKnight’s Senior Living
Quote: “Expanding public funding, increasing the minimum wage and
unionizing workers are the first steps toward improving wages and working
conditions in the residential long-term care industry, according to the
authors of a new report.
'The state of the residential long-term care industry,' from
Washington, DC-based think tank Economic Policy Institute, covers
employment trends in the industry and suggests interventions to try to
ensure that long-term care services are accessible, affordable, safe and
enriching for those who need them.”
LTC Comment: Public financing and government control dominate
long-term care now. Instead of recommending more of the same, shouldn’t we
first ask why the system is such a mess already? That is the more
promising analytical approach in
Medicaid_and_Long-Term_Care (2020) and
How to Fix Long-Term Care Financing (2017). ***
LTC BULLET: LTC
ALMANAC UPDATE
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, August 26, 2022. To access this
introductory peek into The Zone, go to
http://www.centerltc.com/members/index.htm 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
damon@centerltc.com. ***
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
International
Unfunded Liabilities--Social Security, Medicare, and Budgets
Long-Term Care
Caregiving
Long-Term Care Financing
Long-Term Care Insurance
Reverse Mortgages
Long-Term Care Providers
Medicaid
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:
http://www.centerltc.com/support/index.htm. Call or email Damon at
206-283-7036 or
damon@centerltc.com. 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
2020 Older Americans,
Key Indicators of Wellbeing URL:
https://agingstats.gov/docs/LatestReport/OA20_508_10142020.pdf
10/29/2020,
“Older Americans 2020: Key Indicators of Well-Being,” AgingStats.gov
Quote: “This report provides the latest data on the 40 key
indicators selected by the Forum to portray aspects of the lives of older
Americans and their families. It is divided into six subject areas:
population, economics, health status, health risks and behaviors, health
care, and environment.
Download the Full 2020 Report (PDF)”
LTC Comment: Generally a good source for aging stats, but this
quote from page 52 is false: “In 2017, about 44 percent of long-term care
facility costs for Medicare beneficiaries age 65 and over were covered by
Medicaid; another 51 percent of these costs were paid out of pocket.”
Private out-of-pocket LTC facility costs are much lower than half, closer
to 10%. See “LTC Bullet:
So What If the Government Pays for Most LTC, 2018 Data Update” and
Medicaid and Long-Term Care, p.49ff.
2019 Profile of Older
Americans:
LINK
7/21/2020, “Now
Available: 2019 Profile of Older Americans,” Administration for Community
Living
Quote: “The Profile of Older Americans is an annual summary of the
available statistics related to the older population in the United States.
Principal sources of data are the U.S. Census Bureau, the National Center
for Health Statistics, and the Bureau of Labor Statistics. The Profile
illustrates the shifting demographics of Americans age 65 and older. It
includes key topic areas such as income, living arrangements, education,
health, and caregiving. This year's report includes special sections on
obesity as well as aerobic activity and muscle-strengthening activities.”
LTC Comment: This is your annual go-to
source for demographic data on the aging.
Chapter 2: International
General
Weiner, Coe, Hoffman
and Werner, 0420:
LINK
POLICY OPTIONS FOR
FINANCING LONG-TERM CARE IN THE U.S. Janet Weiner, Norma B. Coe, Allison
K. Hoffman, and Rachel M. Werner
Abstract: Unlike many
other developed nations, the U.S. has no system that protects its
residents against the high costs of long-term care, which many people will
need as they age. Medicaid coverage kicks in only after families have
exhausted their resources. Until then, families bear the financial and
caregiving burden of LTC themselves. In the absence of a national system,
several states have considered or passed programs that offer some support
for LTC. Many peer nations have more comprehensive systems to spread the
risk for LTC costs across their population, through social insurance or
other mechanisms. This Issue Brief reviews international models of
financing LTC, as well as recent state efforts, to help U.S. policymakers
design a program that can meet the LTC challenges of an aging population.
LTC Comment: This papers
makes the false assumption that “Medicaid coverage kicks in only after
families have exhausted their resources” and concludes that “the U.S. has
no system that protects its residents against the high costs of long-term
care.” It is exactly the U.S. system that prevents early and responsible
personal long-term care planning by indemnifying elders and their heirs
with public LTC financing after care is needed and with generous financial
eligibility rules riven with loopholes that allow families to retain
substantial assets. This “moral hazard” is what ails U.S. long-term care,
not the lack of government imposed regulations and funding.
Chapter 4: Long-Term
Care
Covid
COVID-19 and the
Future of Long-Term Care: The Urgency of Enhanced Federal Financing
Feder, Judy.
J Aging Soc Policy ; 32(4-5): 350-357, 2020.
Article in English | MEDLINE | ID: covidwho-343189
https://search.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/en/covidwho-343189
ABSTRACT The economic
threat posed by responses to COVID 19 endangers financing for long-term
care across the states that is already inadequate and inequitable.
Increasing the federal share of Medicaid spending as unemployment rises
would mitigate fiscal pressure on states and preserve public services. But
unlike the demand for Medicaid’s health care protections, which rises when
economic activity declines, the demand for long-term care protections will
grow even in a healthy economy as the population ages. Enhanced federal
support is urgent not only to cope with the virus today but also to meet
the long-term care needs of the nation’s aging population in the years to
come. Long-term care financing policy should be modified to either adjust
federal matching funds by the age of each state’s population, or fully
federalize the funding of LTC expenses of Medicaid beneficiaries who are
also eligible for Medicare.
Chapter 6: Long-Term
Care Financing
LTC Approaches and
Studies
New Approaches to Long-Term Care Access for Middle-Income Households
by the Milken Institute
LTC Bullet: Milken Groupthink Fumbles LTC Financing
Friday, April 16, 2021
Seattle—
LTC Comment: You might
expect innovative ideas from the Milken Institute, but when it comes to
long-term care financing, all you get is ideological retreads. We explain
below.
LTC BULLET: MILKEN
GROUPTHINK FUMBLES LTC FINANCING
LTC Comment: The
Milken Institute, chaired by former junk-bond king, now philanthropist
Michael Milken, modestly bills itself as a “catalyst for practical,
scalable solutions to global challenges.” Toward that end they “conduct
research and analysis and convene top experts, innovators, and influencers
from different backgrounds and competing viewpoints.” Lately, the Milken
Institute tackled the problem of providing and financing long-term care
for the broad American middle class. Last week it published “New
Approaches to Long-Term Care Access for Middle-Income Households,” a
timely look at a critical topic that begs for fresh analysis and ideas.
Did the Milken Institute
deliver? Yes and no. The report does a yeoman’s job of describing the
problem. It offers creative ideas to address service delivery problems,
proposing for example a “Medicare Advantage Demonstration Project” and
that the country should “Scale Up Integrated Care Programs.” But when it
comes to how to pay for long-term care, the report founders as its many
predecessors have done. It makes no attempt to understand why long-term
care financing is so inadequate in the United States. It parrots the
prevailing academic shibboleths, ignores critical facts, and proposes
nothing new or promising. We get no original analysis or ideas. We’re
asked to hang our hopes on a fatally flawed exercise in political
futility, the LTC Trust Act in Washington State.
What went wrong?
Following are quotes from the Milken Institute’s “New
Approaches to Long-Term Care Access for Middle-Income Households”
followed by our comments.
Read the rest of this LTC Bullet
here.
Nursing Home and Home
Care Expenditure Data from CMS and Health Affairs
National Health
Expenditure Projections, 2021–30: Growth To Moderate As COVID-19
Impacts Wane: https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00113
ABSTRACT Although
considerable uncertainty remains, the COVID-19 pandemic and public health
emergency are expected to continue to influence the near-term outlook for
national health spending and enrollment. National health spending growth
is expected to have decelerated from 9.7 percent in 2020 to 4.2 percent in
2021 as federal supplemental funding was expected to decline substantially
relative to 2020. Through 2024 health care use is expected to normalize
after the declines observed in 2020, health insurance enrollments are
assumed to evolve toward their prepandemic distributions, and the
remaining federal supplemental funding is expected to wane. Economic
growth is expected to outpace health spending growth for much of this
period, leading the projected health share of gross domestic product (GDP)
to decline from 19.7 percent in 2020 to just over 18 percent over the
course of 2022–24. For 2025–30, factors that typically drive changes in
health spending and enrollment, such as economic, demographic, and
health-specific factors, are again expected to primarily influence trends
in the health sector. By 2030 the health spending share of GDP is
projected to reach 19.6 percent.
National Health Care
Spending In 2018: Growth Driven By Accelerations In Medicare And
Private Insurance Spending:
https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01451
ABSTRACT US health care
spending increased 4.6 percent to reach $3.6 trillion in 2018, a faster
growth rate than the rate of 4.2 percent in 2017 but the same rate as in
2016. The share of the economy devoted to health care spending declined to
17.7 percent in 2018, compared to 17.9 percent in 2017. The
0.4-percentage-point acceleration in overall growth in 2018 was driven by
faster growth in both private health insurance and Medicare, which were
influenced by the reinstatement of the health insurance tax. For personal
health care spending (which accounted for 84 percent of national health
care spending), growth in 2018 remained unchanged from 2017 at 4.1
percent. The total number of uninsured people increased by 1.0 million for
the second year in a row, to reach 30.7 million in 2018.
Who Will Pay for LTC?
(includes "Not the VA")
“The middle ground for fixing long-term care
costs: the WISH act”
https://www.healthaffairs.org/do/10.1377/forefront.20210729.585743/
Marc A. Cohen, Stuart M. Butler
August 9, 2021
Health Affairs
article with details on the WISH Act
Roughly one week
before Americans celebrated the July 4 holiday, Representative Thomas
Suozzi (D-NY) introduced a revolutionary bill (H.R.
4289) designed to repair our broken system
for financing long-term services and supports (LTSS). The “WISH
Act”—Well-Being Insurance for Seniors to be at Home—is based on an idea
first put forward by a group of long-term care experts known as the Long-Term
Care Financing Collaborative, which was
convened in 2012 by the Convergence Center for Policy Resolution and
included the authors of this blog post. The idea was developed further in
a 2018 paper presented
at the Bipartisan
Policy Center. If enacted, the WISH Act
could significantly transform our LTSS financing system by harnessing the
best of what the public and private sectors can jointly do to solve a
problem that neither sector seems able to solve on its own. And it does
this in a fiscally responsible way.
LTC Comment: This
dream come true for advocates of government funding petered out when
Thomas Suozzi (D-NY) decided to run for New York Governor.
State LTC Initiatives
Cohen, Tell on State
Initiatives 0720:
https://www.ltsscenter.org/wp-content/uploads/2020/07/State-LTSS-Financing-Executive-Summary-July-2020.pdf
7/27/2020, “New
Report: Exploring LTSS Social Insurance Strategies in 6 States,” by Marc
Cohen, et al., LeadingAge LTSS Center @UMass Boston and the Center
for Consumer Engagement in Health Innovation
Quote: “A new
analysis from the LeadingAge LTSS Center @UMass Boston and the Center for
Consumer Engagement in Health Innovation examines activity across 6 states
that are exploring social insurance initiatives to help finance long-term
services and supports (LTSS). The Robert Wood Johnson Foundation supported
the study.
Learning from New State Initiatives in Financing Long-Term Services and
Supports, a 48-page report detailing findings from the
analysis, was developed in partnership with Community Catalyst’s Center
for Consumer Engagement in Health Innovation. A 12-page Executive
Summary is also available. The study was led by Marc Cohen, LTSS
Center co-director; Ann Hwang, director of the Center for Consumer
Engagement in Health Innovation; and Michael Miller, director of strategy
policy at Community Catalyst.”
LTC Comment: Can
more government regulation and compulsion improve a long-term care system
ruined by excessive government interference and financing? How will the
epidemiological, monetary and fiscal consequences of the pandemic affect
the answer? Are bankrupt states reliant on overextended federal largesse
and driven by anti-market ideology part of the solution or much of the
problem? Hopefully, this report, written by two distinguished LTC
insurance scholars (Cohen, Tell plus others) will give us some answers.
I’m eager to dig into it and will share my perspective in a future LTC
Bullet. [LTC
Bullet: Umpteenth Long-Term Care Study Disappoints. Friday, August 14,
2020]
Chapter 7: Long-Term
Care Insurance
Criticism
Esworthy, Tumlinson
and Cohen on LTC insurance, 0620:
https://atiadvisory.com/wp-content/uploads/2020/06/Protecting-Consumers-and-Medicaid-from-Catastrophic-Long-Term-Care-Costs_June-2020.pdf
“Protecting Consumers
and Medicaid from Catastrophic Long-Term Care Costs:
How financial challenges in the long-term care insurance industry may
shift costs to policyholders and Medicaid.”
“The long-term care
insurance (LTCi) market has been on a twenty year downward spiral, driven
by an unfavorable (i.e., declining) interest rate environment, higher than
expected benefit costs, and lower than expected voluntary lapse rates.1
Some carriers have exited the
industry entirely, whether voluntarily or via insolvency. Those carriers
who have remained in the market have turned to premium increases in order
to remain viable.2
LTCi is a financial product
that promises over 7 million policyholders.”
LTC Comment:
Kicking LTC insurance when it’s down.
Chapter 9: Long-Term
Care Providers
Assisted Living
Suggested citation:
Sengupta M, Lendon JP, Caffrey C, Melekin A, Singh P. Post-acute and
long-term care providers and services users in the United States,
2017–2018. National Center for Health Statistics. Vital Health Stat 3(47).
2022. DOI:
https://dx.doi.org/10.15620/cdc:115346.
6/13/2022, “Assisted
living’s place in the long-term care continuum,” by Lois A. Bowers,
McKnight’s Senior Living
Quote: “According to the report, assisted living is the
long-term and post-acute care service provider with the most settings in
the United States, with 31,400 assisted living and similar residential
care communities providing such services. By comparison, 15,600 nursing
homes, 11,500 home health agencies, 4,700 hospices, 4,200 adult day
centers, 1,200 inpatient rehabilitation facilities and 400 long-term care
hospitals provide long-term and post-acute care services. Home care
agencies, however, had approximately 4,940,300 discharges in 2017, and
1,562,500 patients received services from hospices that year. By
comparison, in 2018, 1,321,200 people were current residents in nursing
homes and 918,700 current residents were living in assisted living
communities; also in 2018, 251,100 current participants were enrolled in
adult day services center, and in 2017, 380,400 patients received services
from inpatient rehabilitation facilities and 115,800 patients received
services from long-term care hospitals. … Want to take a deeper dive into
the information? The report is available on the CDC
website.”
LTC Comment: Fascinating facts about the LTC continuum very hard to
find anywhere else.
Chapter 10: Medicaid
Medicaid Financing
and Burwell Data
Medicaid Long Term
Services and Supports Annual Expenditures Report
Federal Fiscal Year 2019
December 9, 2021
Burwell Data
Executive Summary
Long-term services and supports (LTSS) encompass a wide range of
medical and nonmedical services and supports for people with physical,
intellectual, mental, or other disabilities or conditions. These can
include institutional care, such as that provided in nursing facilities,
intermediate care facilities for individuals with intellectual or
developmental disabilities (ICF/IDD), and mental health facilities,1 and
home and community-based services (HCBS), such as personal care and home
health, among other services. Medicaid is the primary payer of LTSS,
covering slightly more than half of all spending for such services and
supports in the United States (Centers for Medicare & Medicaid Services
n.d.; O’Malley Watts et al. 2020). Over the past several decades, federal
and state initiatives and consumer preferences have led to shifts in
Medicaid LTSS expenditure patterns across settings and service types,
including increases in HCBS expenditures.
This report is the latest in a series of reports, sponsored by Centers for
Medicare & Medicaid Services (CMS), on Medicaid LTSS expenditures.
Medicaid Eligibility
KFF on Medicaid
Financial Eligibility
https://www.kff.org/report-section/medicaid-financial-eligibility-in-pathways-based-on-old-age-or-disability-in-2022-findings-from-a-50-state-survey-issue-brief/
7/11/2022, “Medicaid Financial Eligibility in Pathways Based on Old
Age or Disability in 2022: Findings from a 50-State Survey,” by MaryBeth
Musumeci, Molly O'Malley Watts, and Meghana Ammula, KFF
Quote: “This issue brief presents state-level data on Medicaid
financial eligibility criteria and adoption of the major non-MAGI pathways
as of January 2022. It includes mandatory and optional pathways to full
Medicaid eligibility as well as state options to expand Medicaid financial
eligibility for people who need long-term services and supports (LTSS) in
nursing homes or other institutions or in the community.”
LTC Comment: I’m often asked about state-level Medicaid financial
eligibility rules. Today I have good news and bad news. The good news is
that this publication by the Kaiser Family Foundation has tons of that
information. The bad news is that Medicaid eligibility is so complicated—a
Serbonian bog according to one jurist—that you may not be able to make
much sense out of it. Still, this is a very valuable resource for those of
us who can’t just shake our heads in dismay and ignore the subject. For
the rest of you, here’s a useful, and much simpler, rule of thumb. Anyone
with income less than the cost of a nursing home can qualify for Medicaid
LTC benefits. Assets don’t matter because the big ones are exempt and the
rest can easily be converted to exempt status. Is it any wonder people
don’t worry about paying for LTC until they need it?
Hest, Alarcon and
Blewitt on Modeling Financial Eligibility for Medicaid Longterm
Services and Supports
Robert Hest, Giovaan Alarcon & Lynn A. Blewett
To cite this article: Robert Hest, Giovaan Alarcon & Lynn A. Blewett
(2020): Modeling Financial
Eligibility for Medicaid Long-term Services and Supports, Journal of Aging
& Social Policy, DOI:
10.1080/08959420.2020.1740638
To link to this article:
https://doi.org/10.1080/08959420.2020.1740638
ABSTRACT Medicaid plays
a significant role in financing long-term services and supports (LTSS) for
low-income elderly (65+) in the United States. We modeled the impact of
changing income, home equity, and asset limitations on Medicaid
eligibility across states. We found that one in five elderly adults (10
million individuals) meet all three tests and would be financially
eligible for Medicaid LTSS. Imposing additional restrictions on income
allowances and eligibility thresholds had greatest impact on financial
eligibility for Medicaid LTSS. Few states have opted to restrict financial
eligibility and are instead looking for ways to keep people living
independently in the community.
LTC Comment: I
analyzed this article in
LTC Bullet: Rethink LTC Financing. Friday, February 19, 2021
Blewitt and Hest,
0520
https://doi.org/10.1080/08959420.2020.1774312
“Emergency Flexibility
for States to Increase and Maintain Medicaid Eligibility for LTSS under
COVID-19”b Lynn A. Blewett & Robert Hest To cite this article: Lynn A.
Blewett & Robert Hest (2020) Emergency Flexibility for States to Increase
and Maintain Medicaid Eligibility for LTSS under COVID-19, Journal of
Aging & Social Policy, 32:4-5, 343-349, DOI: 10.1080/08959420.2020.1774312
To link to this article:
https://doi.org/10.1080/08959420.2020.1774312
Medicaid Managed LTSS
GAO on Medicaid
Managed Care 1220 URL: https://www.gao.gov/assets/720/710680.pdf
12/16/2020,
“Medicaid Long-Term Services and Supports: Access and Quality Problems in
Managed Care Demand Improved Oversight,” Government Accountability Office,
GAO-21-49
Quote: “Medicaid
spends about a third of its budget on long-term services and supports for
adults and children with disabilities and chronic conditions. Over half of
states contract with managed care organizations to provide those services.
We examined 6 states, each of which reported finding significant problems
with the quality of care provided through these contracts. In some cases,
the problems led to patient injury or neglect. This suggests that problems
may be widespread, raising concerns given gaps we found in monitoring and
oversight. Our
recommendations include drafting a national oversight strategy.”
LTC Comment: This
was never going to end well as we observed in this “LTC Bullet:
How the Government Ruined LTC (and We’ll Fix It)” on June 10, 2016:
What about long-term care specifically? The big change there is that
Medicaid, the dominant LTC payer, has shirked its responsibility for
providing and paying for quality community and institutional care. How so?
Instead of paying home care and nursing facility providers directly
(however inadequately), state Medicaid programs all across the country are
shifting to “managed long-term care.” That means they contract with
private companies to (1) find and sign up providers, (2) direct Medicaid
recipients to this limited range of locked in providers, and (3) pay the
providers after taking a cut for themselves--all for less than it would
have cost Medicaid to pay the providers itself. Traditional direct-care
LTC providers wonder how adding an extra payee and a new level of
bureaucracy will lower costs and improve quality. But for now, that’s the
Holy Grail of managed long-term care.
Medicaid Estate
Recovery (and Liens)
MACPAC, “Medicaid
and CHIP Payment and Access Commission” recommended curtailing Medicaid
estate recoveries in its
March 2021 Report to Congress on Medicaid and CHIP
We analyzed and
critiqued their proposal in two LTC Bullets:
040221
LTC Bullet #1302--MACPAC Captured
030521
LTC Bullet #1300--MACPAC Misfires
Little has been heard of
this misguided proposal since.
#############################
Updated, Monday, August 8, 2022,
10:40 AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-024 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Webinars aim to gather more support for
long-term-care law and tax
-
Facing stagnant Medicaid rates, this state has lost
10 percent of SNF beds in 2022
-
As new Alzheimer’s drugs have failed, scientists
are shifting focus to other potential causes
-
Want to improve Medicare Advantage? Deliver some
real advantages
-
American Caregivers: The Time To Plan Is Now
-
Funding, unionization needed to improve wages,
working conditions in long-term care: report
-
Mega Millions sales boost senior citizen programs
-
Asset Limit Changes for Non-MAGI Medi-Cal
-
Low pay, poor working conditions common for
long-term care workers: report
-
Older adults’ home equity exceeds $11.12 trillion
in first quarter: report
-
Unique New Mexico program turns immigrants into
caregivers
-
True Cost of Aging’ Index Shows Many Seniors Can’t
Afford Basic Necessities
-
CMS offering new tool to transition more people
away from SNFs
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, July 29, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC BULLET:
LTCI SALES SURGE
LTC Comment: All of a
sudden LTCI sales exploded to the upside last year. What happened? Could
it happen again? How? Some thoughts after the ***news.***
*** LTC CLIPPINGS
are notifications we send to Center Premium Members daily with news, data,
reports, and information they need to know to stay at the professional
forefront. Steve Moses scans the popular and scholarly media, condenses
vital information, and forwards to you a message with the title, author, a
link, a representative quote and his “LTC Comment” analyzing the
significance. Don’t miss any more LTC Clippings. To subscribe
contact Damon at 206-283-7036 or
damon@centerltc.com. Here are two examples of need-to-know LTC
clippings we sent recently:
7/27/2022, “Older
adults’ home equity exceeds $11.12 trillion in first quarter: report,”
by Kathleen Steele Galvin, McKnight’s Senior Living
Quote:
“Homeowners aged 62 or more years increased their home equity by the first
quarter of 2022 by 4.9%, to a record $11.12 trillion, from the fourth
quarter of 2021, according to the latest quarterly
release from the National Reverse Mortgage Lenders Association,
published Tuesday. That’s a difference of $520 billion. … Some older
adults are using reverse mortgages to finance their moves to senior living
communities.”
LTC Comment:
Expect senior home equity to decline as the housing recession continues
but to remain a critical source of LTC financing when the broader economic
recession takes its toll on public LTC funding programs.
7/28/2022, “Low
pay, poor working conditions common for long-term care workers: report,”
by Kathleen Steele Galvin, McKnight’s Senior Living
Quote: “Low pay
and poor working conditions are the norm for workers in long-term care,
according to a report published
Wednesday by the think tank Economic Policy Institute. … Their key
findings:
- 80.9% of
long-term care workers are women.
- 22.4% are
Black women, and 12.8% are immigrant women.
- $15.22 is
the median hourly pay rate, below the US median hourly wage of $20.07.
- 7.2% live in
poverty, a higher percentage than the poverty rate for all workers
(5.3%).
- 6.9% are
covered by a union contract, a lower rate than the overall workforce
(11.9%). …
Increased public funding
is an answer to ensuring higher pay, better staffing levels and improved
working conditions for workers, according to the researchers. They also
called upon policymakers to raise the minimum wage and strengthen
protections for workers seeking to organize a union.”
LTC Comment: The
kneejerk answer is always to throw more money at the problems. But
shouldn’t the first step be to ask why LTC has these problems? The market
is dominated by public funding and government regulation. If it is such a
mess, do we really believe more public funding and regulation will make it
better? To understand what’s wrong and what can fix it, try these studies:
Medicaid_and_Long-Term_Care (2020) and
How to Fix Long-Term Care Financing (2017). ***
LTC BULLET: LTCI SALES
SURGE
LTC Comment: In the
1980s and ‘90s long-term care insurance sales moved gradually upwards. We
had every reason to believe that trend would continue. After all, the
undesirable alternative was to pay out of pocket for long-term care if
needed or to rely on public welfare. But by the early 2000s, LTCI sales
took a downward turn. Analysts and policy makers wrote the product off as
a way to offset public funding from Medicaid. The private long-term care
insurance market languished. Until now!
What happened? To find
out, read the “2022
Milliman Long Term Care Insurance Survey” in Broker World’s
July 2022 issue. (Subscribe
here.) This is the magazine’s 24th consecutive annual review of
stand-alone long-term care insurance (LTCI). Kudos to authors Claude Thau,
Allen Schmitz, and Chris Giese. Here are some pull quotes (footnotes
omitted, but emphasis added) from the article followed by our comments.
We estimate
total stand-alone LTCI annualized new premium sales of nearly
$200 million in 2021 … , almost 1/3 more than our 2020 estimate
of $150 million. However, premium outside the state of Washington
decreased 6.0 percent, based on the insurers that reported sales.
We estimate
that 140,000 to 150,000 people purchased stand-alone LTCI coverage in
2021, more than triple the 2020 numbers. Outside of WA,
the number of new insureds dropped 9.4 percent based on the
insurers that reported sales.
Worksite sales
soared. We estimate that new annualized premium from worksite sales
tripled in 2021, while non-work-site premium increased by 6.0
percent. We estimate that there were about 9.3 times as many worksite
sales in 2021 compared to 2020, while non-worksite sales increased
47 percent.
For the first
time ever in our survey, more males purchased LTCI than females,
which appears to have been driven by the WCF exemption.
Reflecting
nine companies’ data, the inforce
number of cases increased for
the first time since 2014, by 3.6 percent, because of WA sales.
MARKET
PERSPECTIVE … Washington State’s
“Washington Cares Fund” (WCF) stimulated a tremendous demand for
private LTCI from individuals and businesses within WA. WCF imposes a
0.58 percent payroll tax to fund a $36,500 lifetime pool (intended
to inflate according to the Washington consumer price index) for care
received in WA as defined in the Revised Code of Washington 50B.04.
However, people who purchased qualifying private stand-alone or
combination LTCI by November 1, 2021 could file to be exempt from the
tax. … WA accounted for 60 percent of reported stand-alone LTCI
policies sold and 60 percent of combination life/LTCI on-going
premium (i.e., excluding single premium) policies sold in 2021 after
having accounted for 3.0 percent of stand-alone LTCI sales in
2020 and only 1.6 percent of combination life/LTCI sales in 2020.
Including estimated sales, we think more than 70 percent of the
stand-alone policies sold in 2021 were sold in WA. (Note: WA had
received 470,000 applications for exemption as of March 2022.)
[I]nsurers reported 44 times as many
stand-alone policies sold in WA in 2021 as in 2020 but only 12
times as much new annualized premium. …
[I]nsurers reported 92 times as many
combination on-going premium policies sold in WA in 2021 as in 2020
but only 9.8 times as much new annualized premium. Outside WA,
insurers reported 0.6 percent more policies and 18 percent more
premium in 2021 than in 2020. As a result, our national data for
such combination policies shows 2.5 times as many new policies and 1.4
times as much annualized new premium. …
WA sales distorted the characteristics of sales significantly, as will
be explained throughout this report. Given the observed sales in WA, it
appears likely consumers generally sought the least expensive way to
opt out of WCF.
The national placement rate increased from 57.8 percent in 2020 to
61.7 percent in 2021 … driven by WA sales. WA had a 72.7 percent
placement rate, which appears to be influenced by healthy and young
applicants. Outside WA, the placement rate was 54.1 percent. Only
13.3 percent of WA business was declined (27.4 percent elsewhere)
and declines were lower in WA for all age bands. Only 14.1 percent of WA
business was incomplete, suspended, not taken out or returned during the
free look period (18.5 percent elsewhere). Our surveys have never found
placement rates parallel to 2021 WA experience. …
Current premiums are much more stable than past premiums, partly
because today’s premiums reflect much more conservative assumptions
based on far more credible data and lower assumed investment yields.
LTC Comment: Wow!
That’s amazing. All of a sudden, national sales tripled, though premiums
only increased one-third. Worksite sales jumped over nine fold, but
worksite premiums only tripled. More men than women bought policies for
the first time ever. National placement rates jumped from
57.8 percent in 2020 to 61.7 percent in 2021.
Most amazing of all, one state—Washington—accounted for 60 percent
of national sales after generating only three percent the year before. But
it’s not all good news. Outside of Washington, new insureds dropped 9.4
percent and premiums declined 6.0 percent.
What’s going on? It’s
pretty obvious. Faced with a real and immediate risk and cost of long-term
care—that is, Washington’s payroll tax threat—people grabbed the only way
available to avoid it—to buy LTCI by a date certain. Nearly half a million
workers sought the exemption. Overrun by demand the LTCI market froze and
most seeking the coverage were unable to close the deal by actually
purchasing a policy. No problem. That and other issues of poor design
caused the state to send
WA Cares back to the drawing board, delaying implementation until July
2023. But the key point was made.
Lesson learned: while
consumers won’t buy private long-term care insurance to offset a risk and
cost that may or may not occur decades in the future, they will snap up
the product to escape an immediate cost imposed by the government in the
form of a compulsory payroll tax.
Hmmm. What should we
make of that new insight? Should every state, or even the federal
government itself, impose a WA Cares-like payroll tax to fund meager LTC
benefits and give everyone a chance to opt out in the hope they’ll insure
privately to escape the trap? Even if others did a better job than WA
Cares of planning and designing such a program, it would be a very
unfortunate development indeed. It would follow the social insurance
programs we already have, such as Medicare and Social Security, currently
unfunded to the tune of
$56 trillion, down the fiscal sinkhole.
There is a better way.
Instead of imposing a politically unpopular and economically ill-advised
new tax to fund an inadequate LTC “trust fund” with a private LTC
insurance escape hatch, why not simply establish and publicize a new
personal long-term care responsibility. Let a private organization or
agency actuarially determine each individual’s personal contribution and
responsibility to the LTC risk pool. Then allow people to meet their
responsibility as they see fit as long as they satisfy agreed upon
measures of accountability. How?
The possibilities are
endless. One could purchase private LTC insurance in a sufficient amount.
Or earmark a portion of home equity--now
$11.12 trillion just among older homeowners--to long-term care. Or tap
life insurance--$19.6
trillion. Or draw from IRAs
($13.2 trillion)/401Ks ($7.3
trillion). Or contribute to a new kind of IRA for LTC. Or formally
encumber part of one’s estate. Given a reason to do so, consumers and
entrepreneurs would find creative, economically beneficial ways to meet
each person’s LTC responsibility.
Research shows that the
LTC responsibility is not as onerous as previously thought. On average “an
American turning 65 today will incur $138,000 in future LTSS costs, which
could be financed by setting aside $70,000 today” (Favreault
and Dey, 2016, p. 1). That does not sound so daunting. If we could get
most Americans to satisfy that level of risk now, we would be left with a
far tinier share of the overall cost of LTC for public financing to pick
up later.
But what about those who
do not or cannot cover their personal LTC responsibility up front? If they
can but will not, then let government enforce the responsibility, but not
with a universal, compulsory, payroll tax punishing everyone and damaging
the economy. Rather more conventional methods should suffice such as
withholding other public benefits or imposing a new, narrowly focused tax
clearly defined to cover the individual’s LTC responsibility.
For those who don’t
satisfy their individual LTC responsibility because they can’t, well, at
least there will be many fewer of them when the time eventually comes that
they need long-term care and less depleted public coffers will be better
able to provide access to and quality of care for them.
It turns out financing
long-term care for an aging population isn’t the overwhelming problem all
the studies make it out to be. Reconceptualized as an immediate cost,
long-term care planning is manageable. There’s more than enough wealth in
the American economy to ensure every person receives quality care in the
most appropriate setting when they need it.
We tried getting people
to plan responsibly for long-term care by threatening them with the loss
of their life’s savings if they have catastrophic LTC costs. But in the
end, when the time came, Medicaid stepped in and paid for most high-cost
long-term care. So generation after generation never came to grips with
the real risk and cost of LTC. That was the real problem all along. Now
that we understand it, we know what to do about it. All that remains is to
summon the political will and act.
#############################
Updated, Monday, July 25, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-023 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Accessing Long Term Care Through Medicaid
-
CMS releases first-ever quality measures
for home- and community-based services
-
The Perfect Storm: Nursing Home Industry
Outlook is ‘Not Pretty’ Amid Rising Inflation, Labor Costs
-
Adults poorly planning for long-term care
needs, surveys find
-
Record Social Security bump could push
seniors into higher tax bracket, experts say
-
Congress’ Epic Fail In Caring For Frail
Older Adults
-
Almost half of all long-term care insurance
applications declined for those over 70
-
AHCA calls for action as 60 percent of SNFs
limit new admissions
-
COVID-19 public health emergency extended
again
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, July 18, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-022 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
LTSS
reform needed to ensure access to quality care, doctors’ group says
-
Medicaid Financial Eligibility in Pathways Based on Old Age or
Disability in 2022: Findings from a 50-State Survey
-
Could a
hybrid model be the solution to serving millions more older adults?
-
Long
Term Care State Payroll Tax Update
-
Many
Baby Boomers Will Soon Need Adult Supervision
-
Democrats Propose Raising Taxes on Some High Earners to Bolster Medicare
-
Bonuses, 5.49% salary jump part of soaring costs for CCRC nurse leaders:
report
-
Jobs
Aplenty, but a Shortage of Care Keeps Many Women From Benefiting
-
As
interest rates climb, life-LTC combined insurance premiums decline,
expert says
-
Making
Difficult Decisions: Long-term care or keep farming assets?
-
9
Emerging Senior Living Technologies That Will Power the Future of
Assisted Living
-
Home
health patients experience higher rehospitalization rates in study
-
The
Supreme Court just put regulatory oversight on notice
· ###############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Friday, July 15, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC Comment: If you want
consumers to take the risk and cost of long-term care seriously enough to
prepare for them, make the responsibility real and move it forward to now.
We explain after the ***news.***
*** TODAY'S LTC BULLET is sponsored by Claude
Thau with BackNine Insurance. In addition to many
unique services to advisors relative to individual, worksite and
affinity LTCi (including his revolutionary “Range of Exposure” tool
that protects FPs from risks most don’t recognize). New service: your
own free insurance website allowing clients to buy insurance with as
little or as much of your involvement as you or they want. Claude is
the lead author of Milliman’s annual Broker World LTCi Survey & a past
Chair of the Center for Long-Term Care Financing. Contact him at
913-707-8863 or
claude@back9ins.com to kick his tires &
discuss how he might help you. *** |
*** LTC CLIPPINGS
are news items we send to Center Premium Members daily with news, data,
studies, and information they need to know to stay at the professional
forefront. Steve Moses scans the popular and scholarly media, condenses
vital information, and forwards to you a message with the title, author, a
link, a representative quote and his “LTC Comment” analyzing the
significance. Don’t miss any more LTC Clippings. To subscribe
contact Damon at 206-283-7036 or
damon@centerltc.com. Here are three examples of need-to-know LTC
clippings we sent recently:
7/11/2022, “Medicaid
Financial Eligibility in Pathways Based on Old Age or Disability in 2022:
Findings from a 50-State Survey,” by MaryBeth Musumeci, Molly O'Malley
Watts, and Meghana Ammula, KFF
Quote: “This issue brief presents state-level data on Medicaid
financial eligibility criteria and adoption of the major non-MAGI pathways
as of January 2022. It includes mandatory and optional pathways to full
Medicaid eligibility as well as state options to expand Medicaid financial
eligibility for people who need long-term services and supports (LTSS) in
nursing homes or other institutions or in the community.”
LTC Comment: I’m often asked about state-level Medicaid financial
eligibility rules. Today I have good news and bad news. The good news is
that this publication by the Kaiser Family Foundation has tons of that
information. The bad news is that Medicaid eligibility is so complicated—a
Serbonian bog according to one jurist—that you may not be able to make
much sense out of it. Still, this is a very valuable resource for those of
us who can’t just shake our heads in dismay and ignore the subject. For
the rest of you, here’s a useful, and much simpler, rule of thumb. Anyone
with income less than the cost of a nursing home can qualify for Medicaid
LTC benefits. Assets don’t matter because the big ones are exempt and the
rest can easily be converted to exempt status. Is it any wonder people
don’t worry about paying for LTC until they need it?
6/2022, “Long
Term Care State Payroll Tax Update,”
BuddyIns
Quote: “This update is intended for our community of LTC planning
advocates and insurance practitioners to stay up-to-date on the latest
legislative news that we are following at BuddyIns. This is not a
comprehensive assessment, so please email us with any news from your neck
of the woods.”
LTC Comment: Thanks to BuddyIns for this update on a question I’m
probably asked more than any other: which states are doing what about LTC
financing? What all the state initiatives have in common is to rely on the
threat of government force to impose compulsory participation in social
insurance plans on the model of existing, failed federal entitlement
programs. Watch for this coming Friday’s [now today’s] “LTC Bullet:
Frontload LTC” for a better solution grounded in personal responsibility
and individual freedom.
7/4/2022, “The
Supreme Court just put regulatory oversight on notice,” by John
O’Connor, McKnight’s LTC News
Quote: “By any measure, the Supreme Court just wrapped up one
of its more memorable sessions. … But the decision that may most directly
affect long-term care providers was actually directed at the Environmental
Protection Agency. And its potential impact on skilled care might be hard
to overestimate. … The majority
opinion, written by Chief Justice John Roberts, claimed the agency’s
heightened emissions rules were a ‘fundamental revision’ of existing law.
He added that it’s up to Congress, not the EPA, to make ‘a decision of
such magnitude.’”
LTC Comment: What’s that got to do with long-term care? O’Connor
explains: “Talk about the importance of timing: Just one day earlier, the
Centers for Medicare & Medicaid Services proposed regulations that would
allow surveyors to use payroll data to investigate staffing rules
violations, force facilities to hire infection preventionists, and revamp
arbitration requirements, among other provisions. … And it’s not just
these latest rules for nursing homes that could come under fire. Any
regulation that arguably steps over the line would appear to be fair game.
So how big is the Supreme Court’s EPA ruling? Let’s put it this way:
Regulatory oversight might never be the same.” Let’s hope the ongoing,
long growing tyranny by bureaucrats is finally curtailed. ***
LTC BULLET: FRONTLOAD
LTC
LTC Comment: The
fundamental problem with long-term care is that people don’t worry about
it until they’re too old, frail, demented, infirm or broke to plan
responsibly for it. That’s why most people who need expensive care for a
long time end up relying on public financing, usually from Medicaid. But
Medicaid is welfare and “programs for the poor are poor programs.” So too
many people needing long-term care are stuck in underfunded nursing homes
or waiting in long lines (665,000
deep) for scarce, waivered home care slots. What’s to be done?
Governments, federal and
state, think they have a solution. If people won’t take responsibility to
plan for long-term care before it’s too late, then force them to do it.
Require companies to charge employees payroll deductions to create trust
funds that can pay benefits when covered individuals qualify. Whether
federal (WISH
Act) or state (WA
Cares) the principle is the same in such proposals: use the
government’s monopoly on the legal use of force to compel people to
prefund their long-term care. But we’ve seen that principle at work
already in Social Security and Medicare, two entitlements on the brink of
insolvency with unfunded liabilities totaling
$56 trillion. Do we really want to go there again?
What else might work? We
know what didn’t work. The federal government tried telling people that if
they don’t prepare for long-term care but need it later they could lose
their life’s savings. That might have worked if it had been true. But
giant Medicaid asset exemptions and financial eligibility loopholes along
with non-enforcement of mandatory estate recoveries defeated that plan.
People who ignored the warnings and ended up needing expensive long-term
care got Medicaid, often while protecting most of their wealth. So,
unsurprisingly, the next generation followed suit, ignoring long-term care
until they needed it, then relying on Medicaid. The long-term care system
spiraled downward into its current dismal state.
What have we learned? A
couple things. Threatening people with impoverishment doesn’t work if you
don’t enforce it. Forcing people to pay extra taxes, premiums, or payroll
deductions (whatever you want to call them), under threat of fines or
imprisonment, for a promise of minimal benefits from another government
program likely to become insolvent is repugnant. Voters
twice
rejected WA Cares and every attempt to impose a federal LTC social
insurance program has proved a non-starter.
Still, we have learned
something important from the government’s clumsy attempts to force people
to comply with a long-term care imperative. I refer to what happened when
the WA Cares program offered citizens an option to escape its mandatory
payroll deductions by purchasing private long-term care insurance. Nearly
half a million Washingtonians clutched that parachute and jumped. New
LTC insured lives nearly tripled from
57,200 in 2020 to 153,687 in 2021 … nationwide! Who knew? People won’t
buy insurance for an unknowable risk off in the distant future, but they
will leap at the chance to avoid a mandatory government program right now!
Well, now we know. So is
there a way to have the good result (widespread early LTC planning)
without the bad outcome (compulsory government interference)? Of course.
Treat the public like grownups. Explain LTC risk including each person’s
responsibility to prepare for it. To wit: long-term care can and probably
will happen to them some day. They have a personal responsibility to plan
for it and prepare. If they do, the government will leave them alone. If
they don’t, they may lose government benefits that would otherwise accrue
to them or have to answer to a public or private agency entrusted with the
task to establish and enforce each individual’s LTC responsibility.
How can you meet your
LTC responsibility and avoid loss of your government benefits or
garnishment of other income? Many ways. Buy private LTC insurance in an
amount satisfactory to meet your actuarially determined risk. Carve out a
portion of your home equity and earmark it to meet that responsibility.
Tap your life insurance value. Set aside sufficient funds in a new
IRA-like fund to be created. Obligate part of your estate, secured and
recorded (unlike Medicaid estate recoveries) to fund your long-term care
if needed. The possibilities are endless. All that is needed is a private
entity to calculate each individual’s LTC responsibility, track it, and
ensure it is met. Government could follow up with those who don’t
participate voluntarily, hopefully very few, but otherwise stay out of the
LTC market.
Why would people
cooperate with this plan when they ignore LTC risk and cost now? Two
reasons. First, they confront this risk and cost immediately, not as a
maybe in the distant future. Second, they are only responsible for the
risk they bring into the risk pool. Researchers found that the average
individual’s LTC cost risk is
$138,000 and that it could be met by setting aside and investing $70,000
now. Obviously some people will incur more costs and some less, but
removing the average risk from the risk pool will leave any remaining
public responsibility, such as a vastly reduced Medicaid program, greatly
relieved.
The only solution to
what ails long-term care in the USA is to engage citizens to plan and
prefund their risk and cost as early as possible. To do that without using
government force to compel compliance, establish a legal obligation to a
minimum level of individual LTC preparation and offer creative ways to
meet the responsibility voluntarily. Only enforce the obligation to plan
on those who do not act. Frontload long-term care!
#############################
Updated, Tuesday, July 5, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-021 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
US
long-term care insurers see large spike in new customers in 2021
-
Staffing Shortages Have U.S. Nursing Homes in Crisis
-
LeadingAge chastises HHS for ‘devastating’ home health rule
-
AARP
Poll Reveals Strong Support for Family Caregiver Tax Credit
-
Cocktail lounge attendant? Eclectic mix of people filling heretofore
unheard-of senior living positions
-
Long-term inflation threatens life plan community margins
-
Flu vax
cuts seniors’ dementia odds by 40 percent over 4 years, large study
finds
-
Post-acute and Long-term Care Providers and Services Users in the United
States, 2017–2018, Analytical and Epidemiological Studies
-
Many
Retirees Wish They'd Planned, Saved Earlier: EBRI Survey
-
Average
Annual Assisted Living Rates Surpass $51K, New Jersey Most Expensive
State
-
Senate
Retirement Bill Could Include LTCI Premium Provision
-
WA
Cares 'relatively higher risk' investment policy approved
-
Nursing
home COVID-19 infections quadruple as booster rate slows
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, June 24, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: MEDICAID’S PLAN TO FAIL
LTC
Comment: AARP says too few people plan for old age even though most
believe they’ll need long-term care, but it offers no clue as to why or
what to do about it. Insights and analysis after the ***news.***
***
LTC CLIPPINGS are news items we send to Center Premium Members
daily with news, data, studies, and information they need to know to stay
at the professional forefront. Steve Moses scans the popular and scholarly
media, condenses vital information, and forwards to you a message with the
title, author, a link, a representative quote and his “LTC Comment”
analyzing the significance. To subscribe to LTC Clippings, contact
Damon at 206-283-7036 or
damon@centerltc.com.
Here are two examples of LTC clippings sent this week:
5/2022,
“Post-acute
and Long-term Care Providers and Services Users in the United States,
2017–2018, Analytical and Epidemiological Studies,”
by Sengupta, Manisha, et. al., National Center for Health Statistics
Quote:
Key Findings [excerpts]
In 2018, about 69,000 paid, regulated post-acute and long-term care
services providers in seven major sectors served more than 9.5 million
people in the United States.
•
Post-acute and long-term care services were provided by 4,200 adult day
services centers, 11,500 home health agencies, 4,700 hospices, 15,600
nursing homes, 31,400 assisted living and similar residential care
communities, 1,200 inpatient rehabilitation facilities, and 400 long-term
care hospitals (Appendix III, Table IX).
•
In
2018, an estimated 251,100 current participants were enrolled in adult day
services centers; 1,321,200 people were current residents in nursing
homes; and 918,700 current residents were living in residential care
communities. In 2017, about 4,940,300 patients were discharged from home
health agencies; 1,562,500 patients received services from hospices;
380,400 patients received services from inpatient rehabilitation
facilities; and 115,800 patients received services from long-term care
hospitals (Appendix III, Table XII).
LTC
Comment:
Consult the report for much more data on the LTC continuum. Center friend
Bill Comfort observed that “the CDC data notes that Home HEALTH Care is
for Medicare-paid skilled care at home. From my first look at the report,
it appears that this doesn’t address at all private-duty, private-pay,
custodial home care. The 11,500 home HEALTH agencies do not include the
likes of Home Instead, Right At Home, Comfort Keepers, and all the mom and
pop home care agencies at all! We continue to get a distorted view of
post-acute and just basic custodial care from this oversight.”
6/23/2022,
“Many
Retirees Wish They'd Planned, Saved Earlier: EBRI Survey,”
by Dinah Wisenberg Brin, ThinkAdvisor
Quote:
“Half of surveyed retirees said they would have changed their financial
habits during their working years. But those who paid a professional to
develop a financial plan were satisfied and felt the service was worth the
expense. Unexpected medical expenses, preventive health spending,
inadequate retirement savings and inflation led the list of retirees'
pre-retirement financial concerns.”
LTC
Comment:
Yet few people plan for old age. To learn why and what to do about it,
read tomorrow’s [now today’s] “LTC
Bullet: Medicaid’s Failure to Plan.”
LTC
BULLET: MEDICAID’S PLAN TO FAIL
LTC
Comment: There are few people in the LTC profession I’ve known longer and
respect more than
John
O’Connor.
He is editorial director, vice president and associate publisher at
McKnight’s Long-Term Care News and
sister publication,
McKnight’s Senior Living.
I’ve been reading John’s thoughtful commentaries since 1989 when I left
government LTC research to join the private sector.
O’Connor’s “Editor’s Column” yesterday made several points that form a
fine foundation for a crucial conclusion. Read “Worse
than a bad plan for senior living”
and then rejoin me for some observations.
He
begins:
“Even though Ben Franklin uttered the words more than two centuries ago,
they still ring true today: ‘If you fail to plan, you are planning to
fail.’ I was reminded of his gentle warning while reading about the AARP’s
latest ‘Long-Term
Care Readiness’ survey.”
Who
in the insurance side of the LTC business hasn’t heard that Franklin quote
and probably used it in sales?
The
AARP study John refers to, titled “Long-Term Care Readiness: An AARP
Survey of Adults 50+,” is available
here.
Read its “Key Findings” below and then we’ll see what John does with them.
“Key
findings
“Uncertainty about Medicare coverage of long-term care services is common
among adults 50-plus.
Roughly half (46%) incorrectly believe Medicare covers care in a nursing
home or care in the home from a home health aide.
“Recognizing that they may need assistance as they get older does not mean
that adults 50-plus have really thought about *how* they will live
independently.
Nearly seven in 10 (68%) believe that they will need assistance with their
daily activities as they get older, yet fewer than three in 10 (28%) have
given a lot of thought to how they will continue to live
independently if they need such assistance.
“The
COVID-19 pandemic has had little effect on one’s thinking about
independent living,
with more than six in 10 (62%) thinking about the topic about the same
now as two years ago.
“Roughly six in 10 adults 50-plus are concerned about multiple issues
regarding aging,
with concerns about not being able to live independently and becoming a
strain or burden on family topping the list. Slightly fewer say they are
concerned about not having enough money saved, needing to live in a
nursing home or assisted living facility, or not being able to remain in
their own home.
“When it comes to planning for their futures, half have discussed their
end-of-life plans with family and have written a will.
More
than four in 10 have also planned for their funeral expenses and have
designated a legal Power of Attorney, but far fewer say they have
researched or made plans for in-home, community-based, or nursing home
care.”
Back
to John O’Connor’s column:
“Consider, less than a third of the respondents (28%) have given much
thought to how they will live independently should a need for assistance
arise. That’s right, 28%. It’s a safe bet the percent of people in this
crowd planning their next vacation is considerably higher. And it’s not
like those who are 50 or older are unaware bad things might happen later
in life. In fact, more than two-in-three (68%) believe they will need help
with their daily activities at some point. For those who have reached age
65, the number spikes to 75%.”
He
concludes:
“If I’m running a senior living organization, these findings scare the
heck out of me. Because what they strongly suggest is that more and more
senior living services will need be paid for by states and the federal
government going forward. Many potential prospects in the suddenly popular
middle market may not have the means to pay their own way.”
What
does he advise senior living providers to do?
If you don’t want to be a “publicly subsidized enterprise” subject to the
“regulatory hoops” and less than “generous” payments skilled nursing
facilities endure, then consider waging “a campaign to get people to
actually prepare for the decline old age will surely bring.”
He
continues:
“But be warned, your work is cut out for you. … it’s probably safe to say
the fail-to-plan crowd is pretty dug in. Which is very unfortunate. Their
eat, drink and be merry mentality may be OK for a night of celebration.
But it’s no way to prep for the challenges of old age. As many will
discover, once the party ends.”
LTC
Comment:
What I don’t find in John O’Connor’s column, nor in the AARP study, is the
question “Why don’t people plan?” much less an answer. So let me try to
provide both.
What
could possibly explain why so few people worry or plan for old age? Why
will their failure to plan leave future senior living providers as
dependent as nursing home operators on meager government reimbursements?
What could possibly be done to reverse this unfortunate outcome?
To
me the answers are as glaringly obvious as the questions themselves.
People don’t plan for old age because they’ve been assured the don’t need
to by (1) Social Security, (2) Medicare, and (3) Medicaid. Read
Medicaid and Long-Term Care
for a full explanation.
Senior living providers are doomed to follow nursing homes down the
primrose path of Medicaid dependency, including excessive regulation and
inadequate payments, because of the moral hazard (“lack of incentive to
guard against risk where one is protected from its consequences”) the
entitlement program caused.
What
could/should be done to fix this mess?
Stop doing what government has always done. Stop giving easy access to
Medicaid-funded care after the insurable event has already occurred. In
other words, end “The
Entitlement Put.”
Instead, move the LTC responsibility forward to a time when it’s not too
late for people to plan. Enforce it then, but not by channeling everyone
into compulsory payroll-funded government programs that are no better than
the ones that caused LTC’s problems in the first place. Let people choose
how to meet their LTC obligation—through insurance, or a home equity carve
out, or an investment set aside, or a formal, recorded lien on their
estate, or some other legitimate, trackable means—as a way to avoid
government interference altogether instead of as an escape from a public
program that traps everyone like WA Cares.
Closing LTC Comment:
Hey John, how would you answer those three questions? What do you think of
my answers? I’ll keep an eye out for that “Editor’s Column.” Thanks
for the important contribution you and sidekick Jim Berklan make toward
our common objective of improving long-term care.
#############################
Updated, Monday, June 20, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-020 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Healthy lifestyle shown to decrease
dementia risk up to 36 percent: study
-
The Future Of WA Cares: A Response To
Warshawsky
-
Update on number of people opting out of
state's long-term-care program
-
Can I Use a Medicaid Beneficiary’s
Inheritance to Pay Her Assisted Living Facility Three Months in Advance?
-
New form of dementia prevalent in 40% of
older adults
-
‘Startling’ lack of physical activity found
in assisted living pilot study
-
Older adults more likely to have multiple
ailments compared with prior generations
-
A Permanent Pandemic Means a Huge Medicaid
Expansion
-
Shingles is not associated with increased
risk of dementia, finds study
-
Assisted living’s place in the long-term
care continuum
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated, Monday, June 13, 2022, 10:40
AM (Pacific)
Seattle—
#############################
LTC
E-ALERT #22-019 LTC NEWS AND COMMENT
LTC
Comment: Do you spend hours searching the internet for useful articles,
key data, and relevant reports to keep you on the forefront of
professional knowledge? Do you lose business because you’re blindsided by
clients or competitors who learn critical information before you do?
Here’s an antidote:
LTC
Clippings: The Center for Long-Term Care Reform notifies subscribers to
our LTC Clippings service daily of information you need to know. Each
message contains only the critical facts about new publications: a title,
representative quote, a link to the original, and our analysis in a
sentence or two. To inquire or subscribe, contact Steve at 425-891-3640 or
smoses@centerltc.com.
Read testimonials by satisfied subscribers
here.
To subscribe online, please click
here.
LTC
E-Alerts: Once a week, we compile our daily LTC Clippings into a summary,
email it to Center for Long-Term Care Reform members, and archive it in
The Zone, our password-protected members-only website. Center members also
receive our weekly LTC Bullet op-ed. To join the Center and receive all
these benefits and more, contact Steve at 425-891-3640 or
smoses@centerltc.com.
We no
longer post our LTC E-Alerts on the Center’s public access website, but
here’s what today’s LTC E-Alert contained: links, quotes and
comments on the following articles, reports, or data:
-
Medicaid Weighs Attaching Strings to Nursing Home
Payments to Improve Patient Care
-
Nursing Home Closures Hit Smaller Markets as
Financial, Staffing Crisis Deepens Across Industry
-
OPM Expects to ‘Revise’ FLTCIP Premiums, Could
Temporarily Bar New Enrollments
-
A Two-Year Reprieve For Medicare Insolvency Sounds
Like Good News. But It Isn’t
-
Under the radar: cash-only caregivers
-
House members launch new caucus focused on
long-term care
-
A Small World Is a Big Solution for Workforce Woes
-
US Nursing Homes Face Closure Risks From Staffing
Shortages
-
With 41% leap in nursing home costs, ‘doing
nothing’ not an option: AHCA
-
Long-term care’s mortal risk
#############################
"LTC E-Alerts" are
a feature
offered by the Center for Long-Term Care Reform, Inc. to members at the
$150 per year level or higher. We'll track and report to you news and
analysis regarding long-term care financing, service delivery, and
research. We hope The LTC E-Alerts will help you attain and maintain a
high level of knowledge and competency in this complex field. The
Center for Long-Term Care Reform, Inc. is a private institute dedicated to
ensuring quality LTC for all Americans (www.centerltc.com).
#############################
Updated,
Friday, June 10, 2022, 10:40 AM (Pacific)
Seattle—
#############################
LTC
BULLET: THE ENTITLEMENT PUT
LTC
Comment: Eliminating personal risk is morally hazardous especially when
government does it. Considerations after the ***news.***
***
STEVE MOSES’S latest published articles:
“Long-Term
Care Epiphany,”
by Stephen A. Moses, Broker World, June 2022
“Long-term
care’s mortal risk,”
by Stephen A. Moses, McKnight’s LTC News, June 6, 2022 ***
***
WILL NY FOLLOW WA CARES down the primrose path of compulsory public LTC
financing? Rumor has it New York State may copycat Washington State’s WA
Cares Fund program. We asked longtime Center friend
Bob
Vandy,
President of
Advisors Insurance Brokers
(an Integrity Marketing Group Company). Bob assures us based on advice
from a knowledgeable Empire State lobbyist that there is a Senate Bill in
NY, but no companion bill in the Assembly. “The legislation’s sponsor is
interested in LTC and someone we will engage with in preparation for next
session/budget. My NAIFA lobbying contact says ‘all indications are that
the bill is unlikely to go any further in this legislative session.’” So
rest easy for the time being. In the meantime, if you want to know what
New York really should do about long-term care, read
Long-Term Care Financing in New York: How to Save Money While Serving the
Needy.
***
LTC
BULLET: THE ENTITLEMENT PUT
LTC
Comment: Human beings evolved to fear danger and to respond with “fight or
flight.” Then around the turn of the twentieth century governments took it
upon themselves to make private risk go away. They set out to provide
collective security instead. We’re living now with the consequences of
100-plus years of that policy. We don’t worry about or plan ahead for the
“thousand
natural shocks that flesh is heir to”
as much as we otherwise would.
Lose
your job? Get unemployment insurance. Face a pandemic? Checks will roll
in. Get sick? Apply for ObamaCare or Medicaid. Old and sick? Medicare.
Broke? Welfare. Old and broke? Supplemental Security Income. Frail or
demented? Medicaid LTC. Want college? Get a guaranteed student loan. Can’t
pay it back? Ask forgiveness. Do we have a safety net or a
hammock in which we’ve |