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Join the Center for Long-Term Care Reform. Help us fight for rational LTC policy reform. Receive our daily email publications. Get a user name and password to our Members-Only Zone. Only $150 per year. Mail your check to Center for Long-Term Care Reform, Inc., 2212 Queen Anne Avenue North, #110, Seattle, Washington, 98109. Contact Damon at 206-283-7036 or damon@centerltc.com if you have questions. Join the team!

READ STEVE'S BIO

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Updated, Friday, July 20, 2018, 9:57 AM (Pacific)

Seattle—

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LTC BULLET: THE STILL BROKEN RHYTHM OF LONG-TERM CARE REFORM

LTC Comment: Why did Medicaid long-term care eligibility reforms quickly follow economic recessions until the year 2000, but no longer? The answer follows after the ***news.***

*** LTC CLIPPINGS are our way of keeping premium Center members abreast of all the news, data, reports and articles they need to read to be at the forefront of professional knowledge. If you’re not receiving our daily (2 on average) LTC Clippings contact Damon at 206-283-7036 or damon@centerltc.com to subscribe. Here are a couple examples from last week to help you keep your finger on the pulse of change in long-term care:

7/15/2018, “Baby boomers bode well for CCRCs,” by Lois A. Bowers, McKnight's Senior Living

Quote: “Continuing care retirement communities are expected to hold much appeal to baby boomers, and the good news is, the first wave of boomers will be entering the target age range for such communities within the next five years, notes a new “Market Insight” report from CBRE. … The oldest baby boomers are turning 72 this year, and CCRC residents typically are in their late 70s to mid-80s at move-in, according to CBRE.”

LTC Comment: And so it begins . . . finally. But what happens 13 years from now when the oldest boomers start turning 85 and moving into the highest acuity CCRC settings?

7/16/2018, “CCRCs Move Away From Skilled Nursing As Demand Drops,” by Maggie Flynn, Skilled Nursing News

Quote: “By the industry’s own definition, continuing care retirement communities (CCRCs) include skilled nursing care — but there is a growing trend of developing similar communities that lack such care, according to a report from the commercial real estate services firm CBRE.”

LTC Comment: We reported yesterday that boomers are moving into their peak years for joining CCRCs, age 72. We observed it’ll be a much bigger problem when they start turning 85 in 2031 and need more skilled nursing care. Now we learn CCRCs are cutting back the SNF option. First a shortage of kindergartens in 1950; now a shortage of nursing homes coming to a CCRC near you soon.

LTC BULLET: THE BROKEN RHYTHM OF LONG-TERM CARE REFORM

LTC Comment: Why have we seen no progress for eight years (now nine) to protect Medicaid as a long-term care safety net for the poor? Why are Medicaid LTC benefits more readily available than ever to middle class and affluent people who failed to plan for long-term care? Why has the previously steady rhythm of long-term care reform been broken? I wrote this article to address those questions.

“The Broken Rhythm of Long-Term Care Reform”
by
Stephen A. Moses

(This article was originally published as an LTC Bullet in May of 2017. But the situation persists, so we’ll revisit the matter once a year until it changes.)

Historically, progress toward making Medicaid a better long-term care safety net for the poor tended to occur shortly after major economic downturns when state and federal governments faced serious budgetary constraints. After most recessions since 1965, Congresses and Presidents of widely divergent ideological persuasions backed legislation that closed Medicaid long-term care eligibility loopholes and encouraged early and responsible long-term care planning. But as each recession was followed by a rapid economic recovery and fiscal pressure abated, Medicaid long-term care benefits always reverted to virtually universal availability for all economic classes. That pattern prevailed for the first 35 years of the program, but it ended at the turn of the millennium. It has been eight years since the end of the “Great Recession” in June 2009; the country is mired in a slow, [now long-in-the-tooth] recovery; but we’ve still seen no movement, much less legislation, to target Medicaid’s scarce resources to the needy. Why?

The Rhythm of Long-Term Care Reform

On July 30, 1965, President Lyndon Johnson signed Medicaid into law providing “medical assistance on behalf of . . . aged, blind, or permanently and totally disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services.” The new program’s costs immediately exploded far beyond expectations. The U.S. suffered a recession from December 1969 to November 1970, which sensitized the country to the spiraling guns-and-butter expenditures of the Viet Nam War and Great Society programs. By 1970, a Wisconsin Law Journal article concluded

To evaluate Medicaid at the halfway mark to 1975, i.e., in terms of its ability to provide comprehensive medical care to substantially all needy and medically needy, would show not merely a failure but, perhaps, a disaster.^{^[i]}

The country fell into economic recessions again from November 1973 to March 1975 and from January to July 1980. Finally, Congress acted to curtail spiraling Medicaid LTC expenditures. On December 5, 1980, President Jimmy Carter signed the Omnibus Reconciliation Act, imposing the first ever restriction on asset transfers done in order to qualify for Medicaid. Until then, Medicaid “applicants were expressly permitted to transfer resources that otherwise would have disqualified them from receiving any benefits.”^{^[ii]}

July 1981 to November 1982 brought another recession during which, on September 3, 1982, President Reagan signed the Tax Equity and Financial Responsibility Act authorizing, but not requiring, state Medicaid programs to penalize asset transfers, place liens on real property, and recover benefits from the estates of deceased recipients. Reagan doubled down on April 7, 1986, signing the Consolidated Omnibus Budget Reconciliation Act that restricted the use of Medicaid Qualifying Trusts. He followed through again on July 1, 1988 by signing the Medicare Catastrophic Coverage Act, which made asset transfer penalties mandatory and expanded the transfer of assets look-back period to 30 months.

Unfortunately, these Reagan-era measures were not strongly enforced or publicized. With the economy booming, it was easier for the state and federal governments to pay the still-burgeoning Medicaid bills and avoid the political sensitivity of enforcing restrictions on Medicaid long-term care eligibility. But that changed when the country experienced another recession from July 1990 to March 1991. All of a sudden, state and federal officials were again having trouble making budget ends meet. Congress responded and President Bill Clinton signed the Omnibus Budget Reconciliation Act on August 10, 1993, making estate recovery mandatory, expanding the look back period to three full years, eliminating the cap on asset transfer penalties, and prohibiting “pyramid divestment.” When costs continued to skyrocket, Clinton also doubled down. On August 21, 1996, he signed the Health Insurance Portability and Accountability Act (the “Throw Granny in Jail Law”) making it a crime to transfer assets for less than fair market value for the purpose of qualifying for Medicaid.

But the latter Clinton years brought renewed prosperity as the technology boom intensified. With revenues up and welfare rolls down, why worry about enforcing rules to target Medicaid to the needy? On August 5, 1997, President Clinton signed the Balanced Budget Act repealing the criminalization of asset transfers to qualify for Medicaid, but making it a crime to recommend asset transfers for the purpose of qualifying for Medicaid in exchange for a fee. Shortly thereafter, this “Throw Granny’s Lawyer in Jail Law” was deemed unconstitutional and thus unenforceable. Back to square one.

The Rhythm of Reform Breaks

This historical pattern of rapid statutory action to control Medicaid planning abuse following each economic recession ended with the start of the new millennium. After the March to November 2001 recession resulting from the internet bubble’s implosion, economic recovery came more slowly than before. Likewise, it took much longer for legislation discouraging the excessive use of Medicaid long-term care benefits to be passed. The Deficit Reduction Act of 2005, placing the first cap ever on Medicaid’s home equity exemption, extending the asset transfer look back period to a full five years, limiting the half-a-loaf loophole, amending the annuity rules, and unencumbering the Long-Term Care Partnership Program, was not signed into law by President George W. Bush until February of 2006, nearly five years after the start of the previous recession. Ultimately, economic recovery did come and true to form, enforcement of the DRA ’05 declined.

The next economic boom ended when the housing bubble burst causing the Great Recession of December 2007 to June 2009. Again, economic recovery has come very slowly and meagerly.^{^[iii]} To date, eight years after the end of the last recession, we have seen neither a full economic recovery nor action to spend Medicaid’s scarce resources more wisely by aiming them toward people most in need. In fact, public policy analysts and advocates are moving in the opposite direction, toward proposing yet another government program funded by taxpayers to expand public financing of long-term care for all.

What Broke this Rhythm of Reform?

What might explain both phenomena, i.e., slower economic recoveries in recent years and less attention to the cost of Medicaid long-term care benefits?

The Federal Reserve forced interest rates to artificially low levels after the internet bubble burst and to almost zero during and since the Great Recession. The consequences of this policy have ramified through the economy in many ways. One way is that government has been able to finance deficit spending and the rapidly increasing national debt at considerably lower carrying costs than before, when interest rates were much higher. By enabling politicians to spend more without facing the previously inevitable fiscal consequences, this new economic policy has attracted greater financial resources, including borrowed funds, into public financing of all kinds and simultaneously diverted private wealth into low-interest-rate-induced malinvestment. Consequently, political concern about mushrooming budgets and debt has abated and no significant effort to preserve Medicaid funds by targeting them to the poor has occurred.

The danger is that just as excessive public spending and private malinvestment in the early 2000s led to the housing bubble and its consequent mid-decade recession, so the current much larger credit bubble driven by excessive government borrowing and spending could lead to an even greater economic collapse. With the current national debt nearing $20 trillion [now $21.3 trillion] and total unfunded entitlement liabilities around $106 trillion, a return to economically realistic market-based interest rates would render the federal government immediately insolvent.^{^[iv]}

Rendezvous with the Age Wave Looms

Further exacerbating the problem of long-term care financing is the fact that the long anticipated age wave is finally cresting and will soon crash on the U.S. economy.

Baby boomers began retiring and taking Social Security benefits at age 62 in 2008. At age 65 in 2011, they turned the Social Security and Medicare programs cash-flow negative. Boomers began taking Required Minimum Distributions (RMDs) from their tax-deferred retirement accounts in 2016, depleting the supply of private investment capital. They will reach the critical age (85 years plus) of rising long-term care needs in 2031, around the time Social Security and Medicare are expected to deplete their trust funds forcing them to reduce benefits.

Of course, Medicaid is the main funder of long-term care, but according to the Center for Medicare and Medicaid Services Chief Actuary, in a statement of consummate denial, “. . . Medicaid outlays and revenues are automatically in financial balance, there is no need to maintain a contingency reserve, and, unlike Medicare, the ‘financial status’ of the program is not in question from an actuarial perspective.”^{^[v]} In summary, conditions are coalescing for a potential economic cataclysm in or before the second third of this century and public officials are almost totally ignoring the risk.

Conclusion

Old-fashioned monetary and fiscal discipline kept Medicaid long-term care spending somewhat in check during the program’s early decades. Spending skyrocketed all along, but when the country fell into recessions, state and federal legislators responded with measures to reduce the overuse of Medicaid. Those measures helped to discourage prosperous people from ignoring long-term care risk and hence ending up on Medicaid by default.

But any semblance of monetary and fiscal discipline ended after the year 2000. Artificially low interest rates invited deficit spending and enabled politicians to keep Medicaid eligibility very generous without breaking their budgets. Easy access to Medicaid long-term care benefits after care was needed anesthetized the public to LTC risk and cost, impaired the private home care market, and crowded out sources of private funding such as home equity conversion and long-term care insurance.

Consequently, the country is on the cusp of aging demographic and economic crises of historic proportions without the resources to continue funding the current system nor the incentives in public policy to inspire more responsible long-term care planning by the public. The solution, and the only hope for a benign outcome, is to end Federal Reserve manipulation of interest rates and stop federal deficit spending, so we can once again target Medicaid’s scarce resources to people genuinely in need.

While we are unlikely to see such policy changes soon, we definitely should redouble our efforts toward those objectives.

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[i] Sydney E. Bernard and Eugene Feingold, “The Impact of Medicaid,” Wisconsin Law Review, Wis. L. Rev. 726 1970.

[ii] Timothy N. Carlucci, “The Asset Transfer Dilemma: Disposal of Resources and Qualification for Medicaid Assistance,” Drake Law Review, 36 Drake L. Rev. 369 1986-1987

[iii] According to the Wall Street Journal, we are experiencing “the weakest pace of any expansion since at least 1949.” Eric Morath and Jeffrey Sparshott, “U.S. GDP Grew a Disappointing 1.2% in Second Quarter,” Wall Street Journal, July 29, 2016; http://www.wsj.com/articles/u-s-economy-grew-at-a-disappointing-1-2-in-2nd-quarter-1469795649.

“Even seven years after the recession ended, the current stretch of economic gains has yielded less growth than much shorter business cycles.” Eric Morath, “Seven Years Later, Recovery Remains the Weakest of the Post-World War II Era,” Wall Street Journal, July 29, 2016; http://blogs.wsj.com/economics/2016/07/29/seven-years-later-recovery-remains-the-weakest-of-the-post-world-war-ii-era/

[iv] The “National Debt Clock” (http://www.usdebtclock.org/) places U.S. national debt at $19.9 trillion and unfunded liabilities at $106.0 trillion (cited May 2, 2017).

[v] Christopher J. Truffer, Christian J. Wolfe, and Kathryn E. Rennie, “Report to Congress: 2016 Actuarial Report on the Financial Outlook for Medicaid,” Office of the Actuary, Centers for Medicare & Medicaid Services, United States Department of Health & Human Services, Sylvia Mathews Burwell, Secretary of Health and Human Services, 2016, p. 3; https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/medicaidReport2013.pdf. This identical quote was in the 2013 version of the “Actuarial Report” and was critiqued in S. Moses, “LTC Bullet: Does Medicaid Solvency Matter?,” Friday, October 31, 2014; http://www.centerltc.com/bullets/archives2014/1062.htm

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Updated, Monday, July 16, 9:57 AM (Pacific)

Seattle—

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LTC E-ALERT #18-027: 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 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:

New Study Links MA Plans to Lower Levels of Hospital Visits
The 'Big Bang' of Alzheimer's: Scientists ID genesis of disease
With little saved, employers and aging employees share same fear: Can retirement happen?
The 2018 Medicare Trustees Report: Fiscal and Policy Challenges
Skilled Nursing Facilities Rank Low on Operators’ Investment Wish Lists
Advocacy group calls for 'immediate' Congressional hearings into nursing home staffing
Gen X's Deep Dive Into Financial Stress
Medicaid Backlog to Shutter Central Illinois Nursing Home
It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years
The truth behind long-term care insurance
New ways to estimate and fund long-term care costs
Aging Population to Be Major Driver of Healthcare M&A
Life-LTC Hybrid Sales Soar: LIMRA
U.S. Interest Payments to Equal Social Security Spending by 2048: CBO
An aspirin a day may keep dementia away, study finds
Study rebuts idea that Medicare is wasted on the dying
Where Do Older Americans Die?

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"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).

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Updated, Friday, July 13, 2018, 11:17 AM (Pacific)

Seattle—

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LTC Bullet: Long-Term Care News and Analysis

LTC Comment: Center for Long-Term Care Reform Premium members have the option to receive our LTC Clipping Service and weekly LTC E-Alerts newsletters. Today, we’d like to share a sample of these members-only services with a wider audience. Our topic is the news this week, so we’ll skip our usual ***news*** section and dive straight in.

LTC Bullet: Long-Term Care News and Analysis

Many Center for Long-Term Care Reform Premium members are familiar with our LTC Clipping Service, and from what we hear, get great value from this benefit of Premium membership.

For those who don’t already know, our LTC Clipping Service is an excellent way to stay on top of current and critical long-term care news without having to spend hours a day researching on the internet. We send our Clipping Service subscribers an average of 2-3 emails per workday with a must-read-article link, a pull quote and some brief analysis. We’re sensitive to the fact that we all receive too many emails, so we’re very careful to send along only the most important LTC news items.

As an added benefit and for convenient reference, we keep a running archive of the clippings we send in our new LTC Clippings Archive, dating back to January 2016. This archive is organized by LTC-related subject and sub-category. While CLTCR Premium members will continue to receive their LTC Clippings in real time, they and Individual members, have access to the Clippings Archive through our Members-Only Zone website. Here’s a breakdown of the Archive’s subject categories:

INSURANCE (Long-Term Care Insurance, Critical Illness Insurance, Hybrid and Miscellaneous (including alternative financing solutions))

LONG-TERM CARE (General, Cost, Assisted Living, Nursing Homes, Home Care, Caregiving, Veterans Affairs and Government Solutions)

MEDICAID (General, Medicaid Planning and Crowd-Out Effect)

MEDICARE (including Medi-Gap and Medicare Advantage)

SOCIAL SECURITY

ALZHEIMER'S DISEASE

POLITICS, LEGISLATION AND PUBLIC POLICY

ECONOMICS, DEMOGRAPHICS AND DATA

RETIREMENT PLANNING

HEALTH AND HEALTHCARE

OTHER

If you’re reading this, chances are you play a valuable role in protecting people from the risk and cost of long-term care and to that end we think the Clipping Service allows our subscribers to be more effective doing so. Based on their feedback, we think our subscribers feel the same. For example:

Your clipping service is the best. I seldom give out insurance company brochures to prospects, much preferring the third party endorsement of published articles that are far more believable than an insurance company brochure. The news does a great job of creating urgency to act as well. You bundle them and send to my inbox for me to use, wonderful! I’m speaking to a group at lunch today and will be handing out an article that was published two days ago that you alerted me to. Keep up the good work, saves me time, and makes me money. -- Romeo Raabe, www.TheLongTermCareGuy.com

In my entire 24- year career in the long term care insurance industry I have never seen such a spate of articles in popular media – including print, digital, radio, TV - highlighting long term care as one of the top worries of aging Americans facing retirement. As a supporter of the Center for Long Term Care Reform and a subscriber to “LTC Clippings” I have been kept completely “in the loop” and fully up to date on the vastly increasing information flow about the need for LTC planning. I can not only see what my prospects and clients are reading and hearing about the industry but also have good quality information to share with the “centers of influence” that depend on me for information. The “clipping service” is just one of many benefits provided by the Center and I am grateful to Stephen and Damon Moses for providing a tool that has been so important over the years to the success of Franklin & Associates and Franklin Funding Reverse Mortgages. -- Barbara Franklin, CEO

Please find below a sample collection of clippings we’ve sent to our Clipping Service subscribers over the past few months. Read through them and if you think that receiving news items like these in real time would be valuable to you, please consider subscribing at the Premium membership level. By doing so, you can stay on the forefront of professional knowledge and help us fight for rational long-term care policy reform.

Contact Damon at 206-283-7036 / damon@centerltc.com to start your Premium Membership immediately or go directly to our secure online subscription page and sign up for as little as $21 per month.

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7/9/2018, “Gen X's Deep Dive Into Financial Stress,” by Christy DeFrain, Advisor Magazine

Quote: “Gen X (born between 1965 and 1979) is now the second largest generation in the workforce today, and this group of ‘latchkey children’ and ‘slacker’ young adults can be viewed as America’s neglected middle child. Bookended by two much written-about generations — the Baby Boomers ahead and the Millennials behind — this driving force behind today’s companies is easily overlooked despite the fact that they are the most committed and engaged at work. Truly, Gen Xers are the source of power that keeps a business together”

LTC Comment: A new generation of LTCI prospects comes online.

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6/28/2018, “The Infamous Medicaid Look Back Rule… Why Does it Matter and What Does it Mean?,” by Casey Sauerwine, Marshall, Parker & Weber LLC

Quote: “Engaging in trust planning or gifting more than five years before applying for Medicaid can be an effective strategy to protect assets from nursing home costs. Gifting ahead of time can reduce the amount of available assets an individual will have at the time a Medicaid application is completed. It is important to talk about trust planning and gifting with your elder law attorney if you are considering going down one of these paths.”

LTC Comment: Academics who favor turning LTC over to the government pretend Medicaid planning is so minor as to justify they’re ignoring it. This is a sample of the kind of information elder law firms all across the country routinely purvey to their affluent clients.

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6/21/2018, “Senior living might want to take a new look at an old friend,” by John O’Connor, McKnight's Senior Living

Quote: “Odd as it now seems, there was a time when private insurance was allowed to sit with the grownups. … Turns out the sellers grossly underestimated how expensive and likely senior living services would turn out to be. Most of the dozens of firms that once sold private long-term care coverage culled it from their portfolio as quickly and quietly as possible. … But a rebound of sorts appears to be underway. A growing number of firms are starting to sell hybrid products that combine LTC insurance with a potential life insurance benefit. More than a quarter million of these combo policies were sold last year, primarily as estate-planning tools. By comparison, the number of traditional LTC policies sold was only 66,000.”

LTC Comment: If LTC provider pooh-bahs and their political allies paid attention to the real problem—dependency on Medicaid and crowd out of private financing—all forms of LTC insurance would resurge.

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6/20/2018, “New screening tool could help diagnose early cognitive decline in dementia from home,” Science Daily

Quote: “An international team of scientists have developed a new way to screen for age-related cognitive decline at home using a test which asks people to detect sounds and flashes on their laptop or phone.”

LTC Comment: Early diagnosis is more critical than ever as behavioral modifications to reduce or reverse cognitive decline become more seriously considered.

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6/13/2018, “Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients,” by Jordan Rao, Kaiser Health News

Quote: “With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions. Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large. Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.”

LTC Comment: Rewarded? Really? Medicaid pays nursing homes less than the cost of providing their care for 60% of their residents which is why medical staffing is skeletal. Nursing homes have to maximize relatively generous Medicare reimbursements for a small minority of their residents to make up part of the difference. Poor public policy is the problem and can’t be solved by punishing LTC providers with more regulation and penalties.

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6/2/2018, “'Invisible workforce' of caregivers is wearing out as boomers age,” by Jackie Crosby, Star Tribune

Quote: “Growing numbers of Americans face the immense and often overwhelming challenge of caring for an aging parent or other loved one, a burden that will skyrocket as 76 million baby boomers move into their 80s and need help coping with dementia, cancer, heart disease or just plain frailty and old age. … Soon, Minnesota and the nation will reach a demographic crossroad. In 2030, the first wave of the baby boom generation will turn 85, an age when people are twice as likely as those even a decade younger to need help getting through the day.”

LTC Comment: Good article on the topic especially because it recognizes the sea change coming in 2030. Add to the wave of boomers turning 85 the exhaustion of Social Security and Medicare “trust funds” and you have a clear view of the coming mayhem.

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5/17/2018, “The Hidden Costs Of Caregiving,” Securian Financial

Quote: “Securian Financial recently conducted a survey of more than 800 people currently providing, or who have provided, unpaid care to a parent, in-law or spouse who is aging, or has a disability or chronic disease. The survey found the majority of caregivers (60 percent) spend more than 10 hours per week caring for a family member, and about one in four (29 percent) spend more than 20 hours per week. Women (32 percent) are more likely than men (26 percent) to spend more than 20 hours each week on caregiver duties.”

LTC Comment: Information to share with prospects and clients to trigger and sustain their concern about planning ahead for long-term care.

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5/9/2018, “Why Families Need a Plan for Caregiving,” by Kimberly Lankford, Kiplinger’s Personal Finance

Quote: “Kamilah Williams-Kemp, 43, is the head of Northwestern Mutual's long-term-care insurance business. She was the primary caregiver for her mother last year.”

LTC Comment: The personal story of one of our own in the LTCI business.

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5/2/2018, “The Myth of Outliving Your Retirement Savings,” by Gail MarksJarvis, Reuters

Quote: “Most retirement research points to an impending retirement crisis for about half of Americans who save too little. But a new study suggests that behavior like Anderson’s makes the outlook far less dire. Because people worry about outlasting their savings, most adjust by living humbly – often overly so. Consequently, they make even modest savings last for years longer than expected by researchers.

“What can devastate financially are divorce, caring for a mentally or physically ill adult child who cannot work, and long-term care expenses, according to the Society's research. Still, debilitating healthcare costs are far more rare than people fear, according to the EBRI research. Half of retirees face no nursing home expenses since Medicare covers short recoveries after hospital stays and Medicaid can help when resources run out.”

LTC Comment: Unfortunately, the author here fails to mention that the supposed rareness of debilitating healthcare costs doesn’t make those costs less impactful to those who experience them.

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5/2/2018, “Medicare Advantage Plans Can Pay for Many LTC Services in 2019: Feds,” by Allison Bell, ThinkAdvisor

Quote: “The Centers for Medicare and Medicaid Services is getting ready to let Medicare Advantage plan issuers add major new long-term care benefits to their supplemental benefits menus.”

LTC Comment: Medicaid made nursing home care free in 1965 without enforcing spend-down rules thus desensitizing the public to LTC risk, locking in institutional bias, and impeding private financing of LTC through savings, home equity conversion and private insurance. This new government venture into “free LTC” will also end badly.

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4/27/2018, “Largest LTCi Claim Exceeds $2 Million,” by Jesse Slome, Advisor Magazine

Quote: “A single long-term care insurance policyholder claim has exceeded two million dollars (actually $2.6M for a female). The largest claim still being paid to a male policyholder reached nearly $1.6 million. Why is this important? First, it’s the first time we’ve seen a single claim in excess of $2 million. Second, because consumers mistakenly perceive this protection in ‘investment’ terms … will I get my money back? Advisors need info like this to tell the story properly! When it comes to LTC insurance (or most insurance for that matter) some will get NO benefit … some will get SOME benefit … and a few will get HUGE benefit.”

LTC Comment: Fascinating findings. I wonder how many million-dollar claims Medicaid has paid.

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4/20/2018, “No Spend Down,” by Stephen D. Forman, LTCA Weekly Reader

Quote: “The Employee Benefit Research Institute (EBRI) always publishes high-quality research. In their latest study they find that retirees do a poor job of asset decumulation. Those with few assets (who enter retirement with median assets of $31,740) still have $24,000 eighteen years later, a parsimony which is ‘not irrational,’ according to the authors. But even when assets are plentiful upon retirement (a median of $857,450), eighteen years later this group still maintains a healthy bank account worth $763,900. In short, EBRI finds that retirees spend their income (what comes in, goes out), but rarely touch assets. That's what the chart above illustrates. (This is not what ‘life cycle theory’ or traditional financial planning has presumed.)”

LTC Comment: So much for the idea that wide swaths of the American public are spending down into impoverishment for long-term care. As we’ve explained frequently and most recently here, Medicaid pays for most expensive LTC in the USA and for most Americans it’s easy to get after care is needed without spending down significantly.

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4/20/2018, “Couples in retirement face average health care costs of $280,000, Fidelity estimates,” by Adam Shell, USA Today

Quote: “Fidelity estimates it will cost a couple $280,000 to cover their health care costs in retirement, up 2% from last year and 75% since its 2002 estimate of $160,000. The math assumes a couple retires at 65 and is eligible for Medicare. The cost for care for males in retirement is an estimated $133,000, while the tab for women, who tend to live longer than men, is $147,000.”

LTC Comment: Annual update excludes long-term care costs.

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4/19/2018, “'60 Minutes' To Air Unprecedented Video Study On The Progression Of Alzheimer's,” by Robin Seaton Jefferson, Forbes

Quote: “The chief medical correspondent to CBS News and professor of medicine at NYU Langone Medical Center has spent the last 10 years recording the effects of Alzheimer’s disease on a patient and her husband, who over the course of his study have become not only his subjects but his friends. … LaPook will share his journey and their stories-said to be the longest video study of its kind-Sunday on "60 Minutes," chronicling the long-term devastation of Alzheimer’s disease on both patient and caregiver.”

LTC Comment: Watch this 60 Minutes episode if you have access. If not, click the article for the story. See also: “LTC Bullet: The End of Alzheimer’s.”

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4/15/2018, “65% of Baby Boomers Are Making a Huge Financial Mistake That Could Leave Them Broke,” by Christy Bieber, Motley Fool

Quote: “Many pre-retirees think they don't need to worry about healthcare because they anticipate care costs will be covered by Medicare. But the reality is that Medicare makes seniors responsible for picking up a significant percentage of their cost of care. Seniors may face high deductibles, coinsurance costs, premiums, and coverage limitations. … There are also many services Medicare doesn't cover, including hearing aids, long-term care, and dental care. … Qualifying for Medicaid could also help you afford care costs by subsidizing Medicare premiums and paying for some services not covered by Medicare, such as routine nursing home care. While there are strict asset limits to obtain Medicaid, an attorney can help you to develop a plan that protects your wealth and still allows you to obtain coverage.”

LTC Comment: There’s the essence of the problem in a nutshell. People are in denial about the long-term care risk, but not irrationally so because “an attorney can help you” protect your wealth and get the government to pay if you ever need LTC. The truly irresponsible parties in this public policy fiasco are the academics, politicians and policy-makers who refuse to take this simple, obvious reality into account. For details see How to Fix Long-Term Care Financing.

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4/4/2018, “Caring for elderly parents can put a dent in your budget,” by Sarah O’Brien, CNBC

Quote: “The biggest monthly expenses for caregivers are medicine and medical supplies ($273), food ($159) and personal-care items ($151).

About half of current and past caregivers did not know in advance that they would be stepping into that role.

In advance of finding yourself in that situation, whether expected or not, it's worth having a conversation with your parents about how they envision their care if they reach a point where they no longer can care for themselves.”

LTC Comment: Sound advice.

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3/26/2018, “As Trump Targets Immigrants, Elderly Brace To Lose Caregivers,” by Melissa Bailey, Kaiser Health News

Quote: “Nationwide, 1 million immigrants work in direct care — as CNAs, personal care attendants or home health aides — according to the Paraprofessional Healthcare Institute, a New York-based organization that studies the workforce. Immigrants make up 1 in 4 workers, said Robert Espinoza, PHI’s vice president of policy. Turnover is high, he said, because the work is difficult and wages are low. The median wage for personal care attendants and home health aides is $10.66 per hour, and $12.78 per hour for CNAs. Workers often receive little training and leave when they find higher-paying jobs at retail counters or fast-food restaurants, he said.

“The country faces a severe shortage in home health aides. With 10,000 baby boomers turning 65 each day, an even more serious shortfall lies ahead, according to Paul Osterman, a professor at Massachusetts Institute of Technology’s Sloan School of Management. He predicts a national shortfall of 151,000 direct care workers by 2030, a gap that will grow to 355,000 by 2040. That shortage will escalate if immigrant workers lose work permits, or if other industries raise wages and lure away direct care workers, he said.

“‘What people don’t seem to understand is that people from other countries really are the backbone of long-term care,’ said Sister Jacquelyn McCarthy, CEO of Bethany Health Care Center in Framingham, Mass., which runs a nursing home with 170 patients. She has eight Haitian and Salvadoran workers with TPS, mostly certified nursing assistants. They show up reliably for 4:30 a.m. shifts and never call out sick, she said. Many of them have worked there for over five years. She said she already has six CNA vacancies and can’t afford to lose more.

“Osterman, the MIT professor, said the sum of all of these immigration policy changes may have a serious impact. If demand for workers exceeds supply, he said, insurers may have to restrict the number of hours of care that people receive, and wages may rise, driving up costs. ‘People aren’t going to be able to have quality care,’ he said. ‘They’re not going to be able to stay at home.’”

LTC Comment: Politics + demographics = LTC - TLC.

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Updated, Monday, July 2, 2018, 10:41 AM (Pacific)

Seattle—

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LTC E-ALERT #18-026: LTC NEWS AND COMMENT

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:

Millennials May Care Deeply About Long-Term Care Benefits
Voices Pushing through client fears about LTC needs
Some Advisors Call for Early Long-Term Care Planning
Hannover Re Backs OneAmerica Life-Based LTC Product
Medicaid: Actions Needed to Mitigate Billions in Improper Payments and Program Integrity Risks
Help clients face up to long-term care
More time in SNF does not 'yield better health,' new study asserts
Pain, bed sores more common at most VA nursing homes than private facilities, data show
Survey: Older adults prefer assisted living over home health or nursing home care
Medicare Allows More Benefits for Chronically Ill, Aiming to Improve Care for Millions
Spending on Medicare Advantage Plans Nearly Doubled Over Last Decade
AHCA/NCAL President Parkinson Shares Lessons Learned from China Visit
Despite slower Medicare growth, higher taxes may be needed to cover aging population, researchers say

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Updated, Friday, June 22, 2018, 11:00 AM (Pacific)

Seattle—

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LTC BULLET: THE NEW FALLACY OF IMPOVERISHMENT

LTC Comment: Government should declare success in the War on Poverty and eliminate policies that discourage personal responsibility and work, after the ***news.***

*** TODAY'S LTC BULLET is sponsored by Claude Thau, a GA whose proprietary tools help advisors find and educate clients, reducing the “Ping-Pong” in the LTCi sales process. Help clients project their exposure to LTC risk, compare Combo vs. Stand-Alone LTCi easily, and make informed final decisions about buying LTCi in 15-20 minutes! Change work-site LTCi sales from a series of proposal deliveries to a single interactive consultation! Claude is the lead author of the Milliman Broker World LTCi Survey, one of Senior Market Advisor's 10 "Power People" in LTCi in 2007, & a past Chair of the Center for Long-Term Care Financing. Contact Claude at 800-999-3026, x2241 or claudet@targetins.com to ask questions or get references. ***

*** GC AND AIM JOIN INTEGRITY MARKETING: American Independent Marketing and GoldenCare are now part of Integrity Marketing. The announcements came on February 6 in AIM’s case and on May 8 for GC. Lenny Anderson (GC) and John Wane (AIM) and their companies have been pioneers and leaders in long-term care insurance for over four decades. Both men cited succession planning, the ability to stay involved, and the ongoing success of the companies they founded as reasons for the move. Check out this video press release for a more personal insight on the decision. We congratulate these two great men of the private LTC insurance business and wish them, their companies and Integrity Marketing every success going forward. By the way, GC and AIM were the organizing sponsors of the Center for LTC Reform’s 2008 “Long-Term Care Consciousness Tour” and they continue to support our LTC financing policy research and advocacy generously. ***

LTC BULLET: THE NEW FALLACY OF IMPOVERISHMENT

LTC Comment: In 1990, the Gerontologist published my article “The Fallacy of Impoverishment” explaining how middle class and affluent people take advantage of Medicaid long-term care benefits intended for the needy. In 2005, I updated that research in a “Policy Analysis” for the Cato Institute titled “Aging America’s Achilles’ Heel: Medicaid Long-Term Care.” My work shows how people do not have to be poor to get public welfare. Now Cato has published a new “Policy Analysis” that proves most of the poor … well … aren’t.

Whoa, say what? We’ve whipped poverty? How can that be? For answers, check out “Reassessing the Facts about Inequality, Poverty, and Redistribution” by John F. Early, published in April by the Cato Institute. Or read this summary by Phil Gramm and Robert B. Ekelund, Jr. in the June 24 Wall Street Journal: “How Income Equality Helped Trump: Working Americans sense that taxes and transfers now leave them little better off than those who work less.” What follows are snippets from the Cato piece to give you the gist followed by our comments. Footnotes are omitted.

Cato: “Improved estimates of poverty show that only about 2 percent of today’s population lives in poverty, well below the 11 percent to 15 percent that has been reported during the past five decades.” (p. 1)

LTC Comment: How can that be?

Cato: “By design, the official estimates of income inequality and poverty omit significant government transfer payments to low-income households; they also ignore taxes paid by households.” (p. 2)

LTC Comment: Interesting, how about some examples?

Cato: “The inequality debate is most frequently framed in terms of the differences in money income as measured by the Current Population Survey (CPS) from the U.S. Census Bureau.” (p. 2) [but] “Census money income estimates explicitly exclude the following:

The Earned Income Tax Credit (EITC)
The monetary value of benefits from the Supplemental Nutrition Assistance Program (SNAP), more commonly known as food stamps
Free or subsidized medical care such as Medicaid and the Children's Health Insurance Program (CHIP)
Free, subsidized, or controlled rent or other ‘affordable housing’ schemes
Heating subsidies
Free or reduced-fee social services such as daycare, tax preparation, or meal services” (p. 4)

LTC Comment: So, when analysts report the percentage of people living in poverty and levels of inequality they’re leaving out cash and in-kind benefits provided by all those government programs? Wouldn’t that make people look a lot poorer than they really are?

Cato: “The net result is that although the lowest income group has only 2.2 percent of earned income, it receives 8.3 percent of spendable income available for consumption and savings. … Beneficiaries in the lowest income quintile during their working years receive 10 times more benefits per dollar contributed than those in the top two quintiles.” (pps. 5-6)

LTC Comment: Wait a minute. Wouldn’t this effect be counterbalanced by the taxes poor people have to pay, especially sales and payroll taxes?

Cato: “Official income statistics make no adjustments for taxes paid.” (p. 4)

LTC Comment: If that’s true, doesn’t it make higher income people look richer than they are? Leaving out government benefit transfers and taxes would make the poor look poorer and the affluent look wealthier. Right?

Cato: “The net effect is that pretax data overstate the true income of upper-income households by as much as 50 percent, and missing transfers understate the true income of lower-income households by a factor of two or more.” (p. 4)

LTC Comment: It sounds like all the anguishing we hear about poverty and inequality in the USA is vastly overstated.

Cato: “If the government were to raise taxes on the wealthy tomorrow and transfer all the additional money to the lowest income groups through a larger EITC [earned income tax credit], the official metrics of inequality would not budge by a single cipher because neither the new taxes taken from the top nor the additional income transfers given to the bottom would be used in the calculations.” (p. 4)

LTC Comment: What’s the bottom line?

Cato: “The net result was that the average spendable income for the highest income group was only three times higher than that for the lowest group.

Government redistribution eliminated 88.5 percent of the ratio between the highest and lowest market income quintiles.
The 3.0:1 ratio in spendable income between the highest and lowest quintiles is more than five times smaller than the 16.2:1 ratio highlighted by the annual Census Bureau money income estimate.” (p. 10)

LTC Comment: What does this really mean for the middle class?

Cato: “On average, households with $63,136 in earned market income get to keep it all. They pay taxes averaging approximately $17,000 per year, but on average they also get an equal amount of government transfers.” (p. 10)

LTC Comment: So, you’re saying we’ve practically eliminated poverty, as only 2% remain genuinely impoverished, and the middle class is getting back in benefits as good as it gives in taxes. Who’s picking up the tab?

Cato: “The top 47.5 percent of households were taxed to do the following:

Transfer enough money to the bottom 52.5 percent of households, to give them average spendable incomes close to the median income
Pay for the many activities of government that require 40 percent of all government spending
Pay the interest on the national debt, which constitutes 12 percent of government expenditures” (p. 10)

LTC Comment: But surely widespread hunger and homelessness belie your rosy statistics.

Cato: “Other independent data confirm that only small numbers of Americans live in conditions that would normally be considered poverty. These data show that families classified as poor have lifestyles that would usually be considered middle class. For example:

Only about 2.5 percent of the U.S. population has even a single day of hunger or malnutrition in a year.
Only about 1 percent of the population lives in housing that is severely inadequate or crowded-one-fourth as many as in 1975. Less than one-half of 1 percent of the population is homeless for even a short time during a year.
Most families that are defined as ‘poor’ have many goods and services that would be classified as luxury items. Air conditioning is seven times more prevalent among poor families today than among the general population when the War on Poverty began. Most poor families have microwave ovens, at least one vehicle, video games, flat-screen TVs, and personal computers.

“These metrics are consistent with the improved measures that show about 2 percent poverty prevalence. (p. 20)

LTC Comment: I spent 1968-70 in the Peace Corps in Venezuela and I correspond with friends suffering there now. I know what poverty is. That isn’t it.

Cato: “More than 50 years after the United States declared the War on Poverty, poverty is almost entirely gone. … Public policy debate should begin with the realization that only about 2 percent of the population—not 13.5 percent—live in poverty.” (p. 21)

Closing LTC Comment: Well, there you have it. Poverty is gone for all intents and purposes. We spend one trillion dollars a year to erase it. But that’s not the only cost.

We “[t]ransfer enough money to the bottom 52.5 percent of households, to give them average spendable incomes close to the median income.” (p. 10)

Re-read that last sentence and then ask yourself:

Does taxing half the people enough to pull the other half up to the median income make sense?
What effect does getting so much unearned income have on the motivation and effort expended by the recipients?
What effect does paying their own bills and those of the other half of the population have on the motivation and effort expended by the payers?
Have we eliminated poverty at the cost of inhibiting economic incentives and rewards?

One last quote from the Cato report:

During the 15 years before President Johnson's announcement of the War on Poverty, the measured poverty rate had fallen from 34.8 percent to 19.0 percent. Two years after Johnson's speech and before most of the new programs were fully implemented, the rate had dropped to 14.7 percent, well within the range that would prevail for the next 48 years. (p. 15)

One last question: By eliminating the economic consequences of laziness, irresponsibility and poor behavior, did we punish producers, reward indolence, create dissension, polarize our politics, handicap the economy and make everyone’s life less rewarding?

The Cato “Policy Analysis” does not draw those conclusions, but it definitely provides ample evidence to support them.

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Updated, Monday, June 25, 10:02 AM (Pacific)

Seattle—

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LTC E-ALERT #18-025: LTC NEWS AND COMMENT

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:

White House releases sweeping proposal to reorganize government
Senior living might want to take a new look at an old friend
New Stand-Alone LTCI Player Continues to Move Forward
The Nation's Fiscal Health: Action Is Needed to Address the Federal Government's Fiscal Future
How to Talk About Long-Term Care Planning Now
New screening tool could help diagnose early cognitive decline in dementia from home
Dr. Atul Gawande, new healthcare company CEO, no stranger to senior living
Help clients come to grips with long-term care
The Low-Down on the Medicaid Spend-Down
House GOP 2019 Budget Takes a Swing at Social Security, Medicare
Health Care Choices Proposal: A Plan to Lower Costs, Provide Better Choices in Health Care and Return Power to Consumers
LTSS financing proposal 'a promising start,' providers say
Walgreens and Humana are partnering to create senior health hubs
Despite not using long-term care, millennials have strong opinions on how it should be paid for
Second hospice employee pleads guilty in alleged $60 million kickback scheme involving assisted living communities
MedPAC calls for lower SNF pay rates; provider advocates fire back
Secret VA nursing-home ratings hid poor quality care from public
Research shows that the prevalence of dementia has fallen in the United States

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Updated, Friday, June 22, 2018, 11:00 AM (Pacific)

Seattle—

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LTC BULLET: TRIBUTE TO PHYLLIS SHELTON

LTC Comment: LTCI trainer, consultant and author Phyllis Shelton says goodbye and hello after the ***news.***

*** LTC CLIPPINGS, our special service for premium Center members, keeps you abreast of the latest LTC news, data, reports and articles. We drop brief messages into your email inbox a couple times per day with a title, author, source, representative quote, and our comment. Contact Damon at 206-283-7036 or damon@centerltc.com for details and to subscribe. Examples from this week include:

6/20/2018, “New screening tool could help diagnose early cognitive decline in dementia from home,” Science Daily

LTC Comment: Early diagnosis is more critical than ever as behavioral modifications to reduce or reverse cognitive decline become more seriously considered.

6/20/2018, “Despite not using long-term care, millennials have strong opinions on how it should be paid for,” by Marty Stempniak, McKnight's LTC News

Quote: “That's one of the key takeaways from a AP/NORC survey of young individuals about LTC, highlighted by Forbes this week. As noted by AARP, about 1 in every 4 caregivers is between the ages of 18 and 34. They spend about 20 hours per week delivering care, which is only going to balloon as the population ages. … Some 62% are in favor of instituting tax breaks for purchasing long-term care insurance. And 60% said they would like to see a government-administered LTC insurance program in the same vein as Medicare. Another 81% said they would favor employers offering long-term care insurance plans as a benefit, the report notes.”

LTC Comment: I’m not sure how you square 62% favoring LTCI tax breaks and 81% wanting employer LTCI plans with 60% preferring a Medicare LTC takeover. But, hey, at least the generation that will have to pay for our Social Security and Medicare is starting to think about long-term care. ***

LTC BULLET: TRIBUTE TO PHYLLIS SHELTON

LTC Comment: Anyone involved in the long-term care insurance business knows the name Phyllis Shelton. Her training company, LTC Consultants, prepared thousands of eager new producers to ascend the steep learning curve of LTCI sales. Her book, Long-Term Care: Your Financial Planning Guide, introduced consumers to the perils of long-term care and the protection private insurance provides. Phyllis’s omnipresence at key industry events; her penetrating questions; her informative comments are well known to her fellow professional travelers. That’s why it was with some surprise and disappointment this week that we received Phyllis Shelton’s “goodbye letter.” She’s closing LTC Consultants and moving on to other pursuits, including Christian speaking opportunities and helping families personally with retirement planning.

We asked Ms. Shelton if we could re-publish excerpts from her goodbye letter in this week’s LTC Bullet including a link to the whole story. She replied “When Steve and Damon asked if they could publish my goodbye letter for LTC Consultants, my agent training company, I said of course! The Center for LTC Reform has been an integral part of my success by making sure I was always up on the latest news and research in the LTCi industry.” Thanks, Phyllis, the feeling is mutual.

Now, here’s enough of Phyllis Shelton’s goodbye letter for LTC Consultants to give you the flavor and the gist. We’ve focused on the professional stories including the names of people and companies that helped her along the way. Read the full unedited version with photos and all of its personal content here: http://ltcconsultants.com/good-bye/good-bye.html.

June 16, 2018

Dear Long-Term Care Insurance World,

It has been my honor and pleasure to serve you from a training standpoint since August 7, 1991, the birth of this wonderful company known as LTC Consultants … .

The mission of LTC Consultants was to provide a way for me to teach as many who wanted to learn my simple sales presentation and how I was selling 40-year-olds back in 1988-1991. … I hate cold calls and after three failed phone calls with the last one telling me he already had someone to mow his lawn, I resolved to NEVER make another one! I resolved to work as hard as it took doing seminars, networking with other professionals and PR, like writing articles and giving radio/television interviews to never, ever face another cold call. …

When the $500 marketing system [she designed] didn’t fly off the shelves after paying $1200 for a booth at the 1991 NALU (now NAIFA) annual convention … and after calling all the major insurance companies with no result, God gave me a vision to do a national training tour which would be a grassroots marketing effort … [with financial help] from Long-Term Preferred Care, spearheaded by Gerald Witcher and Robert Forman. Robert is now president of LTC-Associates. …

Two big bonuses: I met Suze Orman at my San Francisco meeting in November, 1994, and secured my first big training contract (40 cities) with Banker’s Life at that same meeting. I told them I could train their 3000 agents for the cost of two 6 packs of Diet Coke per agent! Plus, they bought the rights to print my marketing materials, so each agent would have a flip chart and sales script, and each office would have a seminar system. I still have the letter – their LTCI production went up 34.6% in 1995. Home Run.

Nine additional companies followed in the ensuing years, including a large bank and a large LTC provider, and two online training programs. … The second one was for the mandated training with Phil Sullivan of Selling LTC.

Prior to the mandated training, we had to bring on additional trainers so we could do five cities on the same day for big accounts like State Farm, Allstate and Prudential. [Husband] Bill orchestrated that entire effort with John Ferroni, Dave Miller, Catherine Dove and Randy Smith. … The best thing that came out of the grueling training they went through was “The Medicaid Blues,” compliments of John and Dave playing hooky one night and escaping to the Bourbon Street Blues and Boogie Bar in downtown Nashville. We incorporated it into the Medicaid section of every training class we ever did after that! If you’ve never heard it, it’s a crack-up. You can listen to it here.

Then we implemented the first live training in 2001 for Harley Gordon with the CLTC designation and brought in Bill Comfort, Betty Doll and Shelly Kapfhammer, along with Catherine Dove. That was a true Hall of Fame effort as we taught the course in 33 cities using a 2 ¾ day format. Each city had a guest elder law attorney, and we used two videos that Harley did on the estate planning and Medicaid planning segments. I found the elder law attorney for each city to make sure he or she believed in long-term care insurance. I remember telling a well-known elder law attorney in Long Island that he didn’t qualify, and he was flabbergasted that I “fired” him for not being what we were looking for, as he was an avid Medicaid planner. If you want to see how a great elder law attorney behaves, click here.

Then in 2002 came the Federal LTC Insurance Program (FLTCIP). I was referring MetLife to a firm in Nashville that specialized in employee meetings, but they came back and asked if I would consider doing 1,000 meetings for them. I’m sure that request came from my wonderful friend Joyce Ruddock, who was head of MetLife’s LTCi effort at that time. …

2003 saw LTC Consultants helping with the launch of the State of Tennessee group LTCi program with MedAmerica. …

In 2005-2006, we helped MetLife build a field sales force for the AARP program. …

2007-2010 was crazy with the mandatory LTCi training, which Phil [Sullivan] and I put together based on the chapters in my big book with added audio/video effects. I’m a huge believer in the LTC Partnership, so somehow I got involved with helping several states implement it…Washington, Louisiana, Tennessee and Alabama…as well as forming relationships with insurance departments and Medicaid managers throughout the country to gather credible information for the course, LTCi Training.com.

I continued to do live training tours every year and a big meeting in Nashville with a BAND (my favorite part!), and now all of my materials were in digital form and editable…One-on-One, Seminar Selling, Worksite Selling with new books for a turnkey training and presentation system. Unfortunately, the compliance police killed that business, even though everything I put out was the most well-researched material in the industry.

2011 saw the publication of Suze Orman’s The Money Class. I had been serving as a resource for Suze for a number of years prior, but she decided to bring me out of the closet by putting my name in her book as a resource for those who don’t have a knowledgeable LTCi professional. …

So today I’m back where I started in 1988, on the front lines, serving families. Yet now I can do it in all 50 states from the comfort of my beautiful office in Tennessee. …

So what do I tell people today who ask what I do for a living?

I say “I help people retire with dignity.” How, they ask?

Simple – I help people avoid the two biggest mistakes people make in retirement. They fail to plan for a long chronic condition and they fail to keep a paycheck. I can solve both of those with some form of LTC insurance, whether it be traditional or hybrid, and I can provide a lifetime paycheck that they can’t outlive with a fixed index annuity for only 1% a year. I can also provide a way for their money to grow with zero market risk for no fee. …

All this leads me to why I’m closing LTC Consultants. …The percentage of agents who became my students over the years and wanted the annual updates became fewer and fewer as the compliance police made my materials black market.

My last tour was in 2010 on worksite and combo LTCi and I used that to go to Washington, D.C., and try to convince regulators that I had a plan to fix Medicaid. How? By educating financial professionals and state governments on how to sell worksite LTCi with limited underwriting and take the burden off Medicaid. I even provided a budget on how to do it with funding from the additional premium tax that would go to the state as a result of more LTCi being sold. Part of the materials at the live meetings and on my website gave agents a press kit so they could do the same thing in their states. That failed miserably as you can imagine, but I know I gave it my best shot, so no regrets.

So I’m signing off on the training and coaching business, and directing my effort into helping families first-hand. Believe me, there’s NO SHORTAGE of people who want my help in this arena…and your help too. We need knowledgeable professionals in LTC planning more now than ever!! …

[Special thanks] to Martin Bayne and Kevin Johnson of New York LTC Brokers (now Advisors Insurance Brokers), who hired me for my first training gig on September 29, 1994 in Albany NY.

How do you say good-bye after 28 years?

Good-bye.

Phyllis Shelton

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Updated, Monday, June 18, 2018, 9:16 AM (Pacific)

Seattle—

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LTC E-ALERT #18-024: LTC NEWS AND COMMENT

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:

Gout Linked to Higher Risk of Dementia
Five myths about Alzheimer’s disease
‘Dying at your desk is not a retirement plan’
A New Congressional Proposal For A Medicare Long-Term Care Insurance Benefit
America’s Entitlement Crisis Just Keeps Growing
Announcement: Moody's: Legacy long-term care blocks concerns heightened as focus on actuarial assumptions could lead to margin declines
AMA adopts policy to make long-term care more affordable
Association between systolic blood pressure and dementia in the Whitehall II cohort study: role of age, duration, and threshold used to define hypertension
Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients
APNewsBreak: Nursing homes sue to halt Montana Medicaid cuts
Big state budget changes alter nursing homes' outlook
Visual Association Test, MMSE Highly Predictive of Dementia in Older Adults
Genworth Clears Major Obstacle to Completing China Oceanwide Deal
China Oceanwide’s $2.7 Billion Takeover of Genworth Financial Passes U.S. Security Review

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Updated, Friday, June 15, 2018, 11:04 AM (Pacific)

Seattle—

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LTC BULLET: STANDING GUARD

LTC Comment: The Center for Long-Term Care Reform celebrated our 20^th year last April. In those two decades, we’ve analyzed, criticized and rebutted just about every study, report, article or commission that attacked private financing or promoted government financing of long-term care. We’ve identified ideological bias by scholars, think tanks, advocacy organizations and the media. We’ve denounced their confirmation bias when they ignore evidence contradicting their preconceptions. We’ve refuted fallacies in their logic. Today’s LTC Bullet includes links to six dozen LTC Bullets we’ve published taking these groups and individuals to task:

Media: Consumer Reports, National Public Radio (NPR), Public Broadcasting System (PBS), New York Times, Wall Street Journal, Washington Post, Dow Jones MarketWatch

Organizations: National Academy of Elder Law Attorneys (NAELA, Medicaid planners’ trade association), AARP, Alzheimer’s Association, Leading Age (formerly American Association of Homes and Services for the Aging, LTC provider trade association)

Thinktanks or companies: Kaiser Family Foundation (KFF), Georgetown Long-Term Care Financing Project, Urban Institute, Avalere, SCAN, Employee Benefit Research Institute (EBRI), Bipartisan Policy Center (BPC), Center for Retirement Research at Boston College, LTC Collaborative

Government Agencies and Commissions: Government Accountability Office (GAO), the Medicaid Commission, the Long-Term Care Commission, Congressional Research Service (CRS), Congressional Budget Office (CBO), Medicare Trustees, Centers for Medicare and Medicaid Services (CMS)

Scholars: Ellen O'Brien, Peter Kemper, Harriet L. Komisar, Lisa Alecxih, Timothy Waidmann, Korbin Liu, Judith Feder, Richard W. Johnson, Joshua Wiener, Mark Merlis, Lee Shirey Thompson, Anne Tumlinson, Christine Aguiar, Molly O'Malley Watts, Diane Rowland, David G. Stevenson, Marc A. Cohen, Janemarie Mulvey, Sudipto Banerjee, Richard G. Frank, Neale Mahoney, Howard Gleckman, Leora Friedberg, Wenliang Hou, Wei Sun, Anthony Webb, Gretchen Jacobson, Shannon Griffin, Tricia Neuman, Karen Smith, Norma B. Coe, and Melissa M. Favreault

Speaking truth to power is a mostly thankless job. Please review the efforts we’ve made to correct attacks on you for supporting responsible long-term care planning. Browse the following LTC Bullets’ titles and teasers. Pick a few to download and read in full. Then, if you find value in our work, please support the Center for Long-Term Care Reform by becoming a member or making a contribution. Contact Damon at 206-283-7036 or damon@centerltc.com to join our fight for rational long-term care financing policy.

LTC Bullets Standing Guard

LTC Bullet: More Bad Advice from Consumer Reports, November 15, 1999
LTC Comment: Individuals and organizations most critical of private long-term care insurance are usually the ones lining their pockets with Medicaid estate planning profits.

LTC Bullet: They're Baaaack . . . Medicaid Planners Rise Again, April 25, 2001
LTC Comment: Ever since Congress and then-President Bill Clinton nailed them with mandatory estate recovery (OBRA '93), "Throw Granny in Jail" (HIPAA '96) and "Throw Granny's Lawyer in Jail" (BBA '97), the Medicaid estate planning attorneys have laid low. No longer.

LTC Bullet: "Nursing Home Care Virtually Free For Life," Tuesday, May 7, 2002
LTC Comment: What follows is a transcription of excerpts from a professionally produced and mass-distributed videotape from a man and his company who promise lifelong free long-term care.

LTC Bullet: Medicaid Planners Confess, October 2, 2003
LTC Comment: A survey intended to exonerate Medicaid planners is actually the strongest indictment of artificial impoverishment yet.

LTC Bullet: Where There's Smoke, There's Fire, May 18, 2005
LTC Comment: Our critique follows of "Medicaid's coverage of nursing home costs: Asset shelter for the wealthy or essential safety net?" by Ellen O'Brien of the Georgetown Long-Term Care Financing Project.

LTC Bullet: LTC Bombshell, June 29, 2005
LTC Comment: Results from a poll of state Medicaid programs by a Congressional office with subpoena power may blow the lid off a carefully orchestrated cover-up of Medicaid planning abuses. Lists, summarizes and analyzes studies that pooh-pooh Medicaid planning.

LTC Bullet: Alzheimer's Association Shortsighted on LTC Financing, July 6, 2005
LTC Comment: The Alzheimer's Association's public position on Medicaid reform and long-term care financing is a classic example of how good intentions invite unintended consequences.

LTC Bullet: GAO on TOA Underwhelms, October 5, 2005
LTC Comment: The Government Accountability Office's new report on Medicaid asset transfers asks the wrong questions, uses the wrong data, and so provides few helpful answers.

LTC Bullet: NPR Defends Medicaid Planning, Attacks Messenger, January 4, 2006
LTC Comment: National Public Radio's "All Things Considered" show took a slanted swipe at responsible Medicaid reform yesterday while defending Medicaid planning abuse. Hear the broadcast version, followed by our side of the story.

LTC Bullet: Georgetown, GAO and Kaiser: The Bermuda Triangle of Good LTC Policy, January 25, 2006
LTC Comment: LTC doubletalk is not the exclusive province of Medicaid planners and AARP lobbyists. Otherwise often reliable analysts get long-term care policy wrong too.

LTC Bullet: LTC Victory, February 2, 2006
LTC Comment: The Deficit Reduction Act of 2005 passed yesterday curbing Medicaid abuse and unleashing LTC Partnerships. Celebrate? Sure. But don't take a victory lap until you consider what can go wrong.

LTC Bullet: Microsimulate This!, March 28, 2006
LTC Comment: The fundamental things apply as time goes by--like "garbage in, garbage out." Take for example a recent Inquiry article that estimates future public and private LTC costs. Our critique follows.

LTC Bullet: Kaiser Cover-Up Continues," April 27, 2006
LTC Comment: Urban Institute "scholars," aided and abetted by the Kaiser Family Foundation, employed an underhanded straw man argument in the foundation's latest unsuccessful attempt to debunk the impact of Medicaid planning abuse.

LTC Bullet: Medicaid Commission Errs by Omission, August 9, 2006
LTC Comment: The national Medicaid Commission, appointed last year to fix Medicaid (including its dysfunctional LTC component) before the welfare program implodes financially, is way off track.

LTC Bullet: The DRA Bullets, January 9, 2007
LTC Comment: Two Medicaid planners lament the DRA we praised and defended in 21 LTC Bullets last year. Their whining, our replies plus links to all the DRA Bullets follow.

LTC Bullet: Take Georgetown's Facts With a Big Grain of Salt, February 15, 2007
LTC Comment: Three new "fact sheets" from the Georgetown LTC Financing Project are spoiled by ideological bias. This Bullet critiques Medicaid's Spousal Impoverishment Protections (February 2007) , Medicare and Long-Term Care (February 2007) and National Spending for Long-Term Care (February 2007)

LTC Bullet: GAO AWOL on LTC TOA, May 2, 2007
LTC Comment: The Government Accountability Office has again displayed stunning miscomprehension of the Medicaid eligibility, Medicaid planning and transfer of assets issues.

LTC Bullet: GAO on LTCI Partnerships, June 20, 2007
LTC Comment: GAO drops the ball again on the issues of Medicaid, long-term care financing and private insurance.

LTC Bullet: Medicaid Estate Recover. . .up, July 5, 2007
LTC Comment: Medicaid estate recovery could be a major source of non-tax revenue for the ailing LTC safety net for the poor, but AARP would tie the program in bureaucratic knots.

LTC Bullet: The NY Compact: Analysis, Conclusions, and Recommendations, July 31, 2007
LTC Comment: Is the New York Compact the future of long-term care financing or the last gasp of an old, failed system?

LTC Bullet: Hillary Clinton on LTC, January 3, 2008
LTC Comment: Presidential candidate Senator Hillary Clinton has promised a cornucopia of LTC benefits if elected. Would our service delivery and financing system be better or worse if she delivered? We comment.

LTC Bullet: WSJ Attacks LTCI, We Respond, February 26, 2008
LTC Comment: Today's front-page Wall Street Journal article criticizing long-term care insurance was as one-sided and misguided as a similar piece published by the New York Times also during a major industry conference. We reply, same day, as follows.

LTC Bullet: NYT Asks Medicaid Planner to Advise on LTCI, July 18, 2008
LTC Comment: The New York Times added insult to injury by inviting a notorious Medicaid planner to advise readers on private long-term care insurance. We respond.

LTC Bullet: We Critique WSJ on Medicaid Planning, January 16, 2009
LTC Comment: Within 24 hours, we replied to a Wall Street Journal column that promoted Medicaid planning for long-term care.

LTC Bullet: New LTC Financing Study Uninterpreted or Misinterpreted, March 24, 2009
LTC Comment: A new report on LTC financing by Avalere Health was reported uncritically by many and mistakenly by one source.

LTC Bullet: LTC Clueless, May 26, 2009
LTC Comment: Consumers' denial of LTC risk and cost is nothing compared to the naiveté of professionals who should know better.

LTC Bullet: KFF Misfires on LTCI, June 9, 2009
LTC Comment: A new study of private long-term care insurance published by the Kaiser Family Foundation fails in the usual, predictable ways. Details follow.

LTC Bullet: How Much More Wrong Can They Get It?!, July 21, 2009
LTC Comment: Another "report" from the usual suspects gets long-term care advice dead wrong.

LTC Bullet: We Reply to Washington Post Blast at Federal LTCI, August 14, 2009
LTC Comment: Read our reply to the Washington Post's "Federal Diary" criticism of Federal LTCI's premium increase.

LTC Bullet: CLASS Consciousness, October 21, 2009
LTC Comment: To hear Kaiser Family Foundation speakers, the CLASS Act is a no-brainer for passage and implementation. We offer a wake-up call.

LTC Bullet: The Enemy of LTC Truth, February 8, 2010
LTC Comment: Albert Einstein said "Unthinking respect for authority is the greatest enemy of truth." See how this principle applies to long-term care.

LTC Bullet: New LTCI Report: Research or Propaganda?, June 8, 2010
LTC Comment: Is a newly updated report on LTC insurance by the Congressional Research Service really research, or CLASS Act propaganda? You decide.

LTC Bullet: CLASSless Journalism, September 21, 2010
LTC Comment: Reporting only the CLASS program's dubious benefits and none of its inevitable detriments is negligent journalism. An example follows.

LTC Bullet: Friendly Fire in the Class War (LTC Embed Report #6), September 22, 2011
LTC Comment: Steve Moses's Congressional testimony on Wednesday was well-received except for an ad hominem attack, "friendly fire" in the class war. An explanation, witness testimonies, and a video of the hearing follow.

LTC Bullet: Moses Replies to Congressman's Questions (LTC Embed Report #11), October 13, 2011
LTC Comment: House Oversight and Government Reform Healthcare Subcommittee ranking member Danny Davis (D, IL) asked me some questions in writing after the 9/21 hearing on "Examining Abuses of Medicaid Eligibility Rules." His questions and my answers follow.

LTC Bullet: Nursing Home Spend Down Misunderstood and Late-Breaking LTCI Industry News, July 20, 2012
LTC Comment: A recent EBRI study that claims nursing home stays are wiping out Americans’ savings is based on a fallacy and mistaken. What’s really happening?

LTC Bullet: SCAN the LTC Possibilities, April 5, 2013
LTC Comment: SCAN is a fountainhead of ideas about long-term care financing, but are those ideas potable? We analyze.

LTC Bullet: What Should the LTC Commission Do?, June 21, 2013
LTC Comment: How should the LTC Commission prioritize its work and recommendations? Some thoughts follow.

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. We answer who, what, when, where and why.

LTC Bullet: The LTC Blind, October 25, 2013
LTC Comment: “There are none so blind as those who will not see.” That proverb applies perfectly to a recent column about long-term care by the Urban Institute’s Howard Gleckman.

LTC Bullet: PBS’s 6 LTC Tips Miss the Mark, November 8, 2013
LTC Comment: What’s wrong with the conventional wisdom about how to resolve America’s long-term care crisis?

LTC Bullet: WSJ Misfires on LTC Insurance, February 14, 2014
LTC Comment: We dissect and correct a misbegotten column in the Wall Street Journal.

LTC Bullet: Who Gets Medicaid LTC?, March 28, 2014
LTC Comment: Is Medicaid a long-term care safety net for the poor, the middle class, even the affluent, all of the above? Questions remain, but answers abound.

LTC Bullet: Will Bipartisan LTC Policy Be Better?, April 11, 2014
LTC Comment: Heads up! Consensus is coalescing around a bipartisan long-term care financing solution. Let’s be hopeful, but wary.

LTC Bullet: GAO Punts on Medicaid Planning, July 3, 2014
LTC Comment: Another GAO report underplays dramatic findings about the role, methods and extent of Medicaid planning and loose LTC eligibility rules.

LTC Bullet: Entitlement Double Talk, August 1, 2014
LTC Comment: To read the major media coverage of the 2014 Medicare Trustees report, you’d think things are looking up for the 49-year-old mega-program. Think again.

LTC Bullet: CMS Health Expenditure Data Mask LTC Cost Growth, September 5, 2014
LTC Comment: CMS actuaries’ estimates of health expenditures for 2013-2023 downplay the big story, snowballing LTC costs. We explain.

LTC Bullet: Does Medicaid Solvency Matter?," October 31, 2014
LTC Comment: CMS says Medicaid solvency “is not an issue.” We beg to differ.

LTC Bullet: IG Report Reveals Costly Medicaid Enforcement Failures, November 21, 2014 LTC Comment--The USDHHS Inspector General reports that many states failed to implement mandatory provisions in OBRA ’93 and/or DRA ’05 designed to discourage abuse of Medicaid LTC benefits. Details follow.

LTC Bullet: IG Report Reveals Medicaid Estate Recovery Weakness, December 5, 2014
LTC Comment—A newly released USDHHS Inspector General report shows few states do Medicaid estate recoveries well resulting in a potential annual loss, we infer, of $2.5 billion. Details, numbers, and why it matters follow.

LTC Bullet: How Careless Economists Boosted LTC Risk, December 12, 2014
LTC Comment: We explain how Boston College economists generated poor long-term care planning advice that national media unfortunately amplified.

LTC Bullet: When Bad Models Happen to Good People, January 16, 2015, guest Bullet by Stephen D. Forman
LTC Comment: We offer the last word on that Boston College fiasco of poor scholarship and bad economics.

LTC Bullet: Holding CMS’s Feet to the Fire, February 6, 2015
LTC Comment: When a federal agency fails to enforce the law hurting the poor it’s supposed to help and costing tax payers billions of dollars, bureaucratic heads should roll. Background and details follow.

LTC Bullet: New Data on LTC Incidence, Duration, Cost and Financing Sources, July 24, 2015 LTC Comment: New numbers, better than the old numbers, but they require further clarification and explanation.

LTC Bullet: Pandora Meets Rosy Scenario in CMS Projections, July 31, 2015
LTC Comment: The aging demographic evils in Pandora’s “box” don’t find their way into CMS actuaries’ health expenditure estimates for the coming decade. Quotes and our comments follow.

LTC Bullet: Another LTCI Hit Job?, October 9, 2015
LTC Comment: What shall we make of this new attack on private long-term care insurance? Answers follow.

LTC Bullet: A New Revolution in Long-Term Care Financing . . . by Government, November 6, 2015
LTC Comment: Radical, disruptive changes in how government pays for long-term care are advancing rapidly. We provide background.

LTC Bullet: The Future of Long-Term Care Seen Through the Prism of History, November 13, 2015
LTC Comment: Big changes are afoot in government financing of post-acute and long-term care--changes that will rattle private LTC financing options as well. We cover the big picture.

LTC Bullet: The Arrogance of LTC Analysts' Elitism," December 4, 2015
LTC Comment: Arrogance, ideological bias and elitism spoil the recent research of abundantly endowed LTC analysts. We explain .

LTC Bullet: Three Cheers (But Two From the Bronx) for New BPC-LTC Recommendations, February 5, 2016
LTC Comment: The Bipartisan Policy Center’s new report on long-term care leads with LTCI (hear, hear!), but makes Medicaid even more tempting (boo!) and adds a new, expensive, mandatory government program (boo!) based on faulty premises. Our analysis and critique follow.

LTC Bullet: Losing Principles, April 29, 2016
LTC Comment: What’s happening to the basic principles of personal responsibility and self-reliance that validate private insurance? We reflect.

LTC Bullet: LTC at a Crossroads, June 3, 2016
LTC Comment: Long-term care financing policy is at a critical crossroads and may take a wrong turn. We explain.

LTC Bullet: How the Government Ruined LTC (and We’ll Fix It), June 10, 2016
LTC Comment: Government interference in the LTC marketplace since 1965 caused harmful unintended consequences that only clear analysis and bold action can fix.

LTC Bullet: Half a Century of Bad Medicaid LTC Policy, August 5, 2016
LTC Comment: Medicaid long-term care policy is a classic story of good intentions leading to unfortunate consequences.

LTC Bullet: Behind AHEAD, September 2, 2016
LTC Comment: The people and organizations advocating a new, compulsory, payroll-financed government program to fund catastrophic LTC expenses base their arguments on dubious sources and reasoning. Details follow.

LTC Bullet: How Fiscal and Monetary Malfeasance Will Ruin Long-Term Care, October 7, 2016
LTC Comment: Fiscal malfeasance ($20 trillion federal debt) enabled by monetary malfeasance (artificially low interest rates) bode ill for the economy and for Medicaid LTC financing. Here’s why and how.

LTC Bullet: Medicaid LTC Data Insights, October 14, 2016
LTC Comment: What’s happening with Medicaid LTC financing and why it matters.

LTC Bullet: What’s Wrong with Bundled and Value-Based LTC Payments? January 20, 2017 LTC Comment: Big changes are afoot in government financing of post-acute and long-term care--changes that will rattle private LTC financing options as well. We present the big picture.

LTC Bullet: Hoist with its Own Petard , April 28, 2017
LTC Comment: This Kaiser Family Foundation “Issue Brief” blows up its own argument. We explain.

LTC Bullet: The Broken Rhythm of Long-Term Care Reform, May 19, 2017
LTC Comment: Why did Medicaid long-term care eligibility reforms quickly follow economic recessions until the year 2000, but no longer? The answer follows.

LTC Bullet: Is it Really Hopeless to Reduce Medicaid LTC Costs?, June 23, 2017
LTC Comment: Kaiser Family Foundation researchers despair of reducing Medicaid LTC expenditures, but their “literature review” is incomplete, misleading and risky.

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 and give examples.

LTC Bullet: Have Your Cake Until It Eats You, March 23, 2018
LTC Comment: Americans want to have their cake (entitlements) and eat it too, but trends show this cake will eat our economy first. Scary evidence follows.

LTC Bullet: Retirement Confidence and Asset Spend Down, April 27, 2018
LTC Comment: Two new EBRI studies shed light on how workers/retirees’ expectations and behavior differ.

Feder Fantasy Fatally Flawed (Cohen Contribution Notwithstanding), May 4, 2018
LTC Comment: A new Feder/Cohen proposal would take long-term care out of the frying pan into the fire.

LTC Evasion, May 11, 2018
LTC Comment: We explain what LTC scholars evade and why.

Feder/Cohen Proposal Ignores LTC Problems’ Cause, May 18, 2018
LTC Comment: We explain how government intervention caused the dysfunctions in long-term care that Feder/Cohen seek to correct with more government intervention, including institutional bias, poor access and quality, excessive dependency on family caregiving, inadequate financing, and lack of insurance.

LTC Policy Blinders, May 25, 2018
LTC Comment: We explain why and how LTC policy analysts evade facts that contradict their predisposed positions in favor of compulsory government LTC insurance.

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Updated, Monday, June 11, 2018, 9:17 AM (Pacific)

Seattle—

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LTC E-ALERT #18-023: LTC NEWS AND COMMENT

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:

This is how to truly save Social Security and Medicare
Millennials and retirement: How bad is it?
Integrating Medical and Nonmedical Services — The Promise and Pitfalls of the CHRONIC Care Act
Planning for Retirement as a Single Person
Long-Term-Care Insurance Isn’t Dead. It’s Now an Estate-Planning Tool
No, Medicare Won't Go Broke In 2026. Yes, It Will Cost A Lot More Money
Medicaid: CMS Should Take Steps to Mitigate Program Risks in Managed Care
Social Security trust fund reserves on track to be depleted by 2034
Medicare fund to fall short in 2026, sooner than last forecast
Political grandstanding hurting long-term care again
Social Security COLA Could Top 3% in 2019

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Updated, Friday, June 8, 2018, 11:00 AM (Pacific)

Seattle—

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LTC BULLET: WHO’S RESPONSIBLE? WHO ISN’T?

LTC Comment: Social Security and Medicare are underfunded by trillions of dollars, while private LTC insurance is fully funded. Who’s responsible and why, after the ***news.***

*** NBC BLASTS LTCI: In a June 2 video report titled “Consumers reconsidering long-term care insurance as premiums skyrocket,” NBC News said “The nation’s largest long-term care insurer says its lost billions of dollars, forcing them to raise rates. Now families are choosing between paying for insurance they may not need, or risk going without it.” Such criticism stings, especially because it’s unwarranted as today’s LTC Bullet explains below, but it annoyed LTCI producer Romeo Raabe for a different reason. He writes:

NBC recently had a segment on supposedly horrible increases on LTCi premiums and how the companies jack up the price on seniors. Interesting that they never mentioned what benefit was purchased on the sample LTCi policy whose premium increased to $3,500 a year for two people in their 70’s.

When we sell LTCi, do you think the client really grasps the concept of how the benefits will increase over 20 – 25 – or 30 years? That benefit with the inflation factor it should have, might be $500,000 or more. Quite a good deal for $3,500 a year, wouldn’t you agree?

At 5% compound, the benefit will double every 15 years, so $100/day can become $400/day. Even this does not adequately convey the growth in benefits.

You propose a premium of $4,000/year with 5% compound inflation and a daily benefit of $100/day. The client sees a cost of $4,000 and a benefit of $100 and thinks it’s too expensive.

I propose a premium of $4,000/year with 5% compound inflation and a daily benefit of $100/day. I tell the client that if they pay this premium for 30 years and then one person claims for 10 years of care that one person will receive $1,984,140 in total benefits. Now this looks like a good deal and they buy. That is nearly $4,000,000 total benefits for both insureds.

The point is, why let them expect to receive only $100 as a benefit when the total years later will be huge? Prospects who would and could buy will not if they perceive it to be too expensive.

I keep this little chart laminated and in my pocket, with 3% inflation on one side and 5% inflation on the other. Just multiply the initial daily benefit by the factor for the full benefit potential. Yes, not all will claim for the full benefit, but show them the potential!

3%
20 years – 3 yr benefit 2036.7
20 years – 5 yr benefit 3500.35
20 years – 10 yr benefit 7555.5
25 years – 3 yr benefit 2361.55
25 years – 5 yr benefit 4058.8
25 years – 10 yr benefit 8760
30 years – 3 yr benefit 2737.5
30 years – 5 yr benefit 4704.85
30 years – 10 yr benefit 10157.95

5%
20 years – 3 yr benefit 3051.4
20 years – 5 yr benefit 5350.9
20 years – 10 yr benefit 12180.05
25 years – 3 yr benefit 3898.2
25 years – 5 yr benefit 6829.15
25 years – 10 yr benefit 15545.35
30 years – 3 yr benefit 4971.3
30 years – 5 yr benefit 8716.2
30 years – 10 yr benefit 19841.4

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

LTC BULLET: WHO’S RESPONSIBLE? WHO ISN’T

LTC Comment: Their trustees have just delivered the annual financial prognosis for Medicare and Social Security. As usual, the prospects for both programs are dismal. The outlook for Medicare is especially bad with its expected insolvency coming three years sooner, 2026, than predicted just last year. I’ll list a few places where you can learn about just how bad the situation is, but pointing those details out is not my objective today.

“The 2018 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds,” June 5, 2018

“2018 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” June 5, 2018

“The 2018 Medicare Trustees Report: Fiscal challenges and future reforms,” American Enterprise Institute video panel discussion featuring Paul Spitalnic, the chief actuary for the Centers for Medicare and Medicaid Services (CMS), June 6, 2018

“Medicare’s Trust Fund Is Set to Run Out in 8 Years. Social Security, 16,” by Robert Pear, New York Times, June 5, 2018

“Social Security Expected to Dip Into Its Reserves This Year,” by David Harrison, Wall Street Journal, June 5, 2018

“Medicare Financial Outlook Worsens,” by Phil Galewitz, Kaiser Health News, June 5, 2018

Rather, my purpose today is to compare and contrast the way government has handled its responsibilities to citizens with the way the private insurance industry has handled its obligations to policy holders.

First, who’s responsible? If you promise somebody something, whether as a political commitment or in a private contract, you are responsible. So in the case of Social Security and Medicare, politicians are responsible. They made the promises. But most of the politicians who made the promises are long gone and the ones in office now would not be for long if they did what needs to be done to keep the promises. In other words, the responsible parties are irresponsible and those of us impacted, American citizens, have no recourse.

Compare that situation with the condition of a private citizen who has a commercial insurance policy, say for example a long-term care insurance contract. Such a policy holder owns a commitment enforceable in a court of law to receive certain specified benefits in exchange for a specific premium. Make the payments and you’re guaranteed the benefits. What if your carrier goes bankrupt? Then a guaranty association pays with funds supplied by the rest of the industry. But what if the whole industry fails? Then you’d be stuck, just like Social Security and Medicare beneficiaries. But that isn’t what happened to long-term care insurance.

Unlike irresponsible politicians who’ve failed to ensure entitlement programs’ solvency, the private long-term care insurance industry bit the bullet. They took the difficult, costly, embarrassing, financially responsible steps to be sure their LTC insurance policies can pay in full when claims come due. They raised premiums, tightened underwriting, and/or exited the market, passing on new business while taking responsibility for their previous commitments. Ironically, yellow journalists criticized private insurance carriers mercilessly for doing the right thing while largely exempting their irresponsible political counterparts from criticism.

When the current generation has to pay for the unfunded social insurance liabilities run up by earlier generations, the questions “Who’s Responsible?” and “Who Isn’t?” will be answered starkly. By then, however, it will be too late for private insurance to save the day, because you can’t buy private coverage after the insurable event has already occurred. But if it’s too late to dodge the social consequences of politicians’ irresponsibility, it’s not too late for individuals and families to mitigate the aftermath for themselves. Save, invest or insure for long-term care before it’s too late.

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Updated, Monday, June 4, 2018, 10:16 AM (Pacific)

Seattle—

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LTC E-ALERT #18-022: LTC NEWS AND COMMENT

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:

'Invisible workforce' of caregivers is wearing out as boomers age
The Many Shades of Boomer Health
Genworth Updates Website
Long-Distance Caregiving, Up Close: LTCI Insider
Younger People Find Long-Term-Care Insurance Is Harder To Get
Live Free and Die
‘They Deserve It’: In Foster Homes, Veterans Are Cared For Like Family
'Short-Term Care Insurance' Faces a Name Fight
Clues to Parkinson’s and Alzheimer’s From How You Use Your Computer
What Explains The Widening Gap In Retirement Ages By Education?
Alzheimer's: Rethinking the 'One-Size-Fits-All' Approach
Researchers I.D. barriers to care as Alzheimer's diagnoses in Latinos explode

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Updated, Friday, June 1, 2018, 11:16 AM (Pacific)

Seattle—

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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.***

*** TODAY'S LTC BULLET is sponsored by Claude Thau, whose revolutionary “Range of Exposure” tool projects clients’ likelihood (joint for a couple) of spending $100,000; $250K; $500K or over $1,000,000 on LTC, based on their personal characteristics. Claude offers ways to educate clients and reduce “Ping-Pong” in the LTCi sales process. Help clients compare Combo vs. Stand-Alone LTCi easily and make informed final LTCi decisions in 15-20 minutes! Change work-site LTCi from a series of proposal deliveries to a single interactive consultation! Claude is the lead author of Milliman’s annual Broker World LTCi Survey & a past Chair of the Center for Long-Term Care Financing. For questions or references, reach Claude at 913-403-5824 or claudet@targetins.com. ***

*** HEADS UP! “My Million Dollar Mom” is available to download and watch. From the movie’s website:

Based on a true story, a loving mother is diagnosed with Alzheimer's. Her devoted son steps forward to care for her. Her needs are so great that he must decide whether to pursue his final chance for his lifelong dream of high political office, something she wanted so much for him, or give it all up to fulfill a promise he made to her long ago that he would care for her and be by her side at the end of her life.

“My Million Dollar Mom” is densely emotional and satisfying to watch. Those who know the joy, difficulty and complexity of caregiving should relate to the son. Those who don’t know, yet, will learn. All will gain important insight into the growing epidemic of Alzheimer’s disease and what it means to be a caregiver for a loved one with Alzheimer’s. The writer, Ross Schriftman, states: “You'll laugh. You'll cry. You'll cheer. Bring tissues.” Indeed.

We own “My Million Dollar Mom” and you can, too. It’s only $4.95 through Vimeo. Visit http://www.mymilliondollarmom.com/ to learn more and buy your copy. ***

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, June 15, 2018. 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. ***

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.

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.

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Chapter 1: Aging Demographics

United States

General Stats

2017OlderAmericansProfile 0418 URL

4/30/2018, “2017 Profile of Older Americans,” The Administration for Community Living, which includes the Administration on Aging

Quote: “Highlights

Over the past 10 years, the population age 65 and over increased from 37.2 million in 2006 to 49.2 million in 2016 (a 33% increase) and is projected to almost double to 98 million in 2060.
Between 2006 and 2016 the population age 60 and over increased 36% from 50.7 million to 68.7 million.
The 85 and over population is projected to more than double from 6.4 million in 2016 to 14.6 million in 2040 (a 129% increase).
Racial and ethnic minority populations have increased from 6.9 million in 2006 (19% of the older adult population) to 11.1 million in 2016 (23% of older adults) and are projected to increase to 21.1 million in 2030 (28% of older adults).
The number of Americans aged 45-64 – who will reach age 65 over the next two decades – increased by 12% between 2006 and 2016.
About one in every seven, or 15.2%, of the population is an older American.
Persons reaching age 65 have an average life expectancy of an additional 19.4 years (20.6 years for females and 18 years for males).
There were 81,896 persons age 100 and over in 2016 (0.2% of the total age 65 and over population).
Older women outnumber older men at 27.5 million older women to 21.8 million older men.
In 2016, 23% of persons age 65 and over were members of racial or ethnic minority populations--9% were African-Americans (not Hispanic), 4% were Asian or Pacific Islander (not Hispanic), 0.5% were Native American (not Hispanic), 0.1% were Native Hawaiian/Pacific Islander, (not Hispanic), and 0.7% of persons 65+ identified themselves as being of two or more races. Persons of Hispanic origin (who may be of any race) represented 8% of the older population.
A larger percentage of older men are married as compared with older women---70% of men, 46% of women. In 2017, 33% older women were widows.
About 28% (13.8 million) of noninstitutionalized older persons lived alone (9.3 million women, 4.5 million men).
Almost half of older women (45%) age 75 and over lived alone.
The median income of older persons in 2016 was $31,618 for males and $18,380 for females. The real median income (after adjusting for inflation) of all households headed by older people increased by 2.1% (which was not statistically significant) between 2015 and 2016. Households containing families headed by persons age 65 and over reported a median income in 2016 of $58,559.
The major sources of income as reported by older persons in 2015 were Social Security (reported by 84% of older persons), income from assets (reported by 63%), earnings (reported by 29%), private pensions (reported by 37%), and government employee pensions (reported by 16%).
Social Security constituted 90% or more of the income received by 34% of beneficiaries in 2015 (23% of married couples and 43% of non-married beneficiaries).
Over 4.6 million older adults (9.3%) were below the poverty level in 2016. This poverty rate is not statistically different from the poverty rate in 2015 (8.8%). In 2011, the U.S. Census Bureau released a new Supplemental Poverty Measure (SPM) which takes into account regional variations in living costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure. In 2016, the SPM showed a poverty level for persons age 65 and over of 14.5% (more than 5 percentage points higher than the official rate of 9.3%). This increase is mainly due to including medical out-of-pocket expenses in the poverty calculations.
The need for caregiving increases with age. In January-June 2017, the percentage of older adults age 85 and over needing help with personal care (22%) was more than twice the percentage for adults ages
75–84 (9%) and more than six times the percentage for adults ages 65–74 (3%).”

LTC Comment: Annual update of a premier source of data on older Americans.

Expenditures of the Aged

EBRI on Assets 0418 URL: https://www.ebri.org/pdf/briefspdf/EBRI_IB_447.pdf

4/20/2018, “No Spend Down,” by Stephen D. Forman, LTCA Weekly Reader

Elderly Below Poverty

KFF on Senior Poverty 0318 URL: http://files.kff.org/attachment/Data-Note-How-Many-Seniors-Are-Living-in-Poverty-National-and-State-Estimates-Under-the-Official-and-Supplemental-Poverty-Measures-in-2016

3/2018, “How Many Seniors Are Living in Poverty? National and

State Estimates Under the Official and Supplemental Poverty Measures in 2016,” by Juliette Cubanski, Kendal Orgera, Anthony Damico, and Tricia Neuman, Kaiser Family Foundation

Quote: “Payments from Social Security and Supplemental Security Income have played a critical role in enhancing economic security and reducing poverty rates among people ages 65 and older. Yet many older adults live on limited incomes and have modest savings. In 2016, half of all people on Medicare had incomes less than $26,200. This analysis provides current data on poverty rates among the 49.3 million seniors in the U.S. in 2016, as context for understanding the implications of potential changes to federal and state programs that help to bolster financial security among older adults.”

LTC Comment: We don’t know that SS and SSI have enhanced economic security and reduced poverty rates compared to what would have happened if those programs had not undercut the public’s sense of personal responsibility to save, invest and insure privately against the risk and costs of aging and retirement. Further, what matters is not that half of all Medicare recipients have incomes below $26,500. We have them covered with a wide range of government programs. What matters is how many people are getting those same programs, including Medicaid long-term care benefits, who have incomes far in excess of the median. KFF’s ideological bias is to over-estimate poverty in order to promote ever more government spending on the very programs that have created the problems it is claiming to fix.

Retirement Planning

EBRI on Retirement Confidence 0418 URL

4/24/2018, “Only 16% of retirees 'very confident' they can afford long-term care,” by Lois A. Bowers, McKnight's Senior Living

Quote: “Only 16% of current retirees are ‘very confident’ that they will have enough money to pay for long-term care should they need it during their retirement, according to the results of a survey released Tuesday. That percentage, said the nonpartisan Employee Benefit Research Institute and research firm Greenwald & Associates, is a decrease from last year's 20%, which they defined as ‘down significantly.’ The firms polled 1,040 retirees between Jan. 3 and 16 for the annual Retirement Confidence Survey.”

LTC Comment: Sounds like denial is declining, but how do you reconcile these findings with the reality that few people worry enough about LTC expenses to plan for them? Answer: By paying for most expensive LTC, Medicaid enabled people to claim they worry about LTC, do nothing to prepare, and still preserve most of their wealth for heirs. That’s been the reality for 53 years and it explains America’s dysfunctional LTC services and financing.

RBC on Wealth 0318 URL

3/2/2018, Good data source referenced by Stephen D. Forman in the “LTCA Weekly Reader”

Quote: “RBC Wealth Management did a bang-up job on their new report, "Taking Control of Healthcare in Retirement." It's a readable mix of text, graphs and well-sourced information that points frequently toward long-term care. Pre-retirees reading its 20-pages will not only get a better handle on the magnitude of the challenges they face, but also an encouraging tour of the manageable steps they can take.”

LTC Comment: We thank Center friend and Corporate member Steve Forman of Long-Term Care Associates for this resource tip.

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

National Health Expenditures

Health Affairs on National Health Expenditures for 2016 URL: https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.1299

See also LTC Bullet: So What If the Government Pays for Most LTC?, 2016 Data Update, Friday, December 8, 2017

Unfunded Liability Estimates

Heritage on Welfare 040518 URL: https://www.heritage.org/sites/default/files/2018-04/BG3294_4.pdf

4/5/2018, “Understanding the Hidden $1.1 Trillion Welfare System and How to Reform It,” by Robert Rector and Vijay Menon, Heritage Foundation Backgrounder

Quote: “The true cost of welfare or aid to the poor is largely unknown because the spending is fragmented into myriad programs. Current welfare is focused largely on increasing benefits and enrollments and redistributing income. Self-defeating behaviors that increase the need for assistance are rarely even mentioned. Policymakers should replace welfare’s current focus with a new set of interlinked goals: reducing self-defeating and self-limiting behaviors, increasing self-support, and improving true human well-being. Welfare reform should (1) require all able-bodied adult recipients to work or prepare for work as a condition of receiving aid, (2) remove the substantial penalties against marriage within the welfare system, and (3) fund programs aimed at improving behavior on a payment-for-outcome basis rather than today’s fee-for-service basis.”

LTC Comment: This fascinating report is a case study in the unintended consequence of well-intentioned, but perversely counterproductive public policy.

Chapter 6: Long-Term Care Financing

General

BPC-Health-Policy-Roadmap-For-Individuals-With-Complex-Care-Needs 0118 URL: https://bipartisanpolicy.org/wp-content/uploads/2018/01/BPC-Health-Policy-Roadmap-For-Individuals-With-Complex-Care-Needs.pdf

https://www.forbes.com/sites/howardgleckman/2018/01/31/a-new-publicprivate-long-term-care-financing-plan/#23370cc23b9b

1/31/2018, “A New Public/Private Long-Term Care Financing Plan,” by Howard Gleckman, Forbes

Quote: “Two years ago, the Long-Term Care Financing Collaborative proposed a public catastrophic long-term care insurance program. In effect, people would use private insurance, savings, or home equity to pay for the first few years of their care needs, then the government would pick up costs for people with true catastrophic needs. Today, two highly-respected long-term care experts offered an important refinement to that basic structure: A plan that ties the time period before insurance benefits are available to a person’s income. As a result, lower-income people could access new benefits sooner than higher-income people.”

LTC Comment: This new plan is more of the same old, same old. It calls for compulsory, payroll-funded, means-tested social insurance for long-term care supplemented by wrap-around private coverage that converts LTCI from real insurance, with all its benefits, to a kind of Medi-Gap policy, with all its drawbacks. What’s worse, it won’t work because it fails to address the real problem, easy access to Medicaid after the insurable event occurs. We’ll have more to say in a future LTC Bullet.

Cost of Care Surveys

PWC on Cost of Care 0318 URL: https://www.pwc.com/us/en/insurance/assets/pwc-insurance-cost-of-long-term-care.pdf

https://www.pwc.com/us/en/insurance/assets/pwc-insurance-cost-of-long-term-care.pdf

3/16/2018, “Formal Cost of Care,” by Stephen D. Forman, LTCA Weekly Reader

Quote: “Formal Cost of Care: Price Waterhouse Cooper analyzed 223,963 claims worth $14.8B of payments from carriers representing 72% of the inforce population to produce the report: "Formal Cost of Long-Term Care Services." It concludes the average lifetime cost of formal care (i.e., excluding informal services) is $172,000. As you can see from Figure 4, a quarter of the time, the cost is less than $26,000, while another quarter of the time it's over $240,000, and there's a 5% chance of exceeding $578,000. In Figure 5, we see that the largest cohort of policyholders incur claims under $50,000 (this is supported by Figure 7, not shown, which reports that 49% of claims are 1-yr or less). Should you download the 29-pg report, you'll find that males average 2.5 yrs on claim, while females average 3.4 yrs-- but 16% of women and 9% of men outlive their benefits. Meanwhile, non-cognitive claims average $140,000, while cognitive claims cost much more: $216,000 (and last 1 yr longer). There's more stuffed into this brief report than I can share here, but you should consider the PwC stats the most current on the subject.”

LTC Comment: Thanks to Steve Forman of Center-corporate-member LTCA for this excellent summary of the PWC findings.

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

NHE Estimates 2017-2026 URL: https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.1655

2/14/2018, “National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth,” by Gigi A. Cuckler, Andrea M. Sisko, John A. Poisal, Sean P. Keehan, Sheila D. Smith, Andrew J. Madison, Christian J. Wolfe, and James C. Hardesty, Health Affairs

Quote: “National health spending growth is expected to average 5.5 percent per year for 2017–26 and to reach $5.7 trillion by 2026 (exhibit 1). Over the same period, growth in the nation’s gross domestic product(GDP) is expected to be 4.5 percent per year. This 1.0-percentage-point differential is expected to result in an increase in the health share of the economy from 17.9 percent in 20161 to 19.7 percent in 2026.”

LTC Comment: We don’t need Ben Franklin to remind us spending beyond our means is problematical. But what’s really interesting about this iteration of CMS’s annual projection of the coming decade’s national health expenditures is that it doesn’t mention long-term care! Oh, you can find “home health care” and “nursing care facilities” in the detailed tables, but LTC isn’t highlighted for consideration in the analysis as in past years. Nevertheless, nursing facility care is expected to grow from 3% annually in 2013 to 5.3% by 2026, topping around $261 billion in expenditures by 2026. Likewise, home health care, rising 5.1% in 2013 will be going up 6.7% annually by 2026 to $172.6 billion. Dramatic numbers, but evidently not worth highlighting in CMS’s analysis.

Chapter 9: LTC Providers

HCBS: Cost-Effective or Not? (See also similar section under LTC Financing)

GAO on Medicaid ALFs 0218 URL: https://www.gao.gov/assets/690/689302.pdf

https://www.nytimes.com/

2/3/2018, “U.S. Pays Billions for ‘Assisted Living,’ but What Does It Get?,” by Robert Pear, New York Times

Quote: “Federal investigators say they have found huge gaps in the regulation of assisted living facilities, a shortfall that they say has potentially jeopardized the care of hundreds of thousands of people served by the booming industry. The federal government lacks even basic information about the quality of assisted living services provided to low-income people on Medicaid, the Government Accountability Office, a nonpartisan investigative arm of Congress, says in a report to be issued on Sunday. … Assisted living was not part of the original Medicaid program, but many states now cover it under waivers intended to encourage ‘home and community-based services’ as an alternative to nursing homes and other institutions.”

LTC Comment: In "The Sirens' Call, The Primrose Path, and Assisted Living," Assisted Living, April 2004, I warned “In a nutshell, as an industry leader told me once, ‘Medicaid demands Ritz Carlton care for Motel 6 rates while imposing a regulatory Jihad.’ The assisted living industry should keep that in mind before accepting more Medicaid money.” Evidently, those chickens are coming home to roost.

Chapter 10: Medicaid

Medicaid Spousal Impoverishment Tables

2018 SSI and Spousal Impoverishment Numbers URL: https://www.medicaid.gov/medicaid/eligibility/downloads/spousal-impoverishment/ssi-and-spousal-impoverishment-standards.pdf

See also LTC Bullet: Why Couples Worry So Little about Long-Term Care, Friday, December 15, 2017

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LTC E-ALERT #18-021: LTC NEWS AND COMMENT

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:

Private Pay Skilled Nursing Shouldn’t Be Ignored, Especially in Rural Areas
What the Hell Happened at GE?
How HSA savings can be used for long-term care in retirement
With death rate up, US life expectancy is likely down again
Now More Of Us Can Count On More Time Dodging The Dementia Bullet
The cost of long-term-care insurance keeps rising
Congress enacts bill to protect senior citizens from scam artists
Aging Baby Boomers are Continuing to Impact the Composition of the American Labor Force
Analysis: New Mexico Nursing Homes Worst in Nation
How to Age Well and Stay in Your Home
Why the pharmaceutical industry is giving up the search for an Alzheimer’s cure

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Updated, Friday, May 25, 2018, 11:06 AM (Pacific)

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LTC BULLET: LTC POLICY BLINDERS

LTC Comment: We explain why and how LTC policy analysts evade facts that contradict their predisposed positions in favor of compulsory government LTC insurance, after the ***news.***

*** LTC CLIPPINGS: Premium members of the Center for Long-Term Care Reform receive our daily LTC Clippings. These are brief emails, averaging two per work day, alerting them to critical LTC-related news, articles, reports or data they need to see ASAP. The idea behind our LTC Clippings is that people in the LTC financing foxholes need to spend more time doing what they do and less time sorting through the barrage of largely useless information on the internet. We have to review everything; you don’t. Let us screen the chaff and send you what you most need to see. Following is one example of an LTC Clipping this week. (We usually keep our “LTC Comment” briefer, but this one was irresistible.) To subscribe to LTC Clippings, contact Damon at 206-283-7036 or damon@centerltc.com.

5/23/2018, “The cost of long-term-care insurance keeps rising,” by Walecia Konrad, CBS News

Quote: “Long-term-care insurance seemed like such a great idea. Buy a policy when you're in your 50s or 60s, while you're still relatively healthy, pay your monthly premiums and in return you'll have help managing the astronomical costs of a nursing home, assisted-living facility or personal aide when the time comes. … But long-term-care insurance hasn't exactly worked out that way.”

LTC Comment: This article, relatively more accurate than most of its ilk, has gotten wide play in the media. Ironically, the same problems it recounts besetting LTC insurance, a relatively small payer, also apply to Medicaid, the major LTC payer. For example: higher premiums for LTCI? Compare decades of exploding costs for Medicaid. Insurance actuaries underestimated LTC costs? Where were the Medicaid actuaries? Assisted living popularity caught LTCI carriers by surprise? Medicaid continues to expand ALF and HCBS coverage which people prefer with no end in sight. Low lapse rates hurt LTCI? Medicaid is the LTC default with no lapses possible to mitigate future costs. Low interest rates hurt LTCI? Imagine what will happen to Medicaid and all the entitlement programs when interest rates return to the norm and the federal government can’t afford the carrying costs for $21 trillion in debt, not to mention another $100 trillion or more of unfunded liabilities. If you think private LTC insurance disappointed, just wait until you see the inevitable outcome for its public sector alternatives. ***

LTC BULLET: LTC POLICY BLINDERS

LTC Comment: How to finance long-term care has bedeviled analysts, public officials, study commissions and families for decades. To little avail. Everyone knows the Rube Goldberg system we have now fails miserably. But no one agrees on how to change it for the better. So it persists.

Lately, however, a consensus is developing around the suggestion that the federal government should compel citizens to participate in a back-end, catastrophic LTC insurance system funded by mandatory payroll taxes. The latest iteration of this idea is “A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance.”

Over the past three weeks, we have (1) refuted the arguments in that paper (LTC Bullet: Feder Fantasy Fatally Flawed (Cohen Contribution Notwithstanding), May 4, 2018), (2) explained the consequences of the paper’s discounting Medicaid’s role in long-term care financing (LTC Bullet: LTC Evasion, May 11, 2018) and (3) critiqued the paper’s plan to solve problems created by government intervention by adding more of the same (LTC Bullet: Feder/Cohen Proposal Ignores LTC Problems’ Cause, May 18, 2018). In a nutshell, we’ve made the case that ignoring the evidence of Medicaid’s role in long-term care financing led these authors to propose a solution worse than the problem itself.

This week, we explain why and how these authors and others have dodged evidence they should have considered leading them to (1) discount Medicaid’s role and (2) conclude more government intervention is the answer. The following is from “How to Fix Long-Term Care Financing,” published by the Foundation for Government Accountability and the Center for Long-Term Care Reform in July 2017.

Why Do Analysts Wrongly Claim Medicaid Long-Term Care Eligibility Requires Impoverishment?

If people with substantial assets and income can, and do, receive Medicaid-financed long-term care benefits, why do so many analysts say that Medicaid requires impoverishment? The answers lie in a confusion of key concepts and the use of ambiguous language to explain them.

First, analysts wrongly claim Medicaid requires impoverishment because they equivocate on the meaning of “impoverishment.”

Medicaid long-term care eligibility requires inadequate cash flow, i.e. insufficient income, to cover all an individual’s medical and long-term care costs. But it does not require low income, low assets, or financial destitution. Even so, statements like these abound:

Medicaid (the federal-state health care program for the poor) covers long-term care costs for individuals below certain income levels, but the deductible for Medicaid is nearly all of an individual’s income and assets. As a result, Medicaid is the long-term care coverage of last resort for those with no assets.⁴⁸

Medicaid is a means-tested welfare program, and eligibility is limited to people who are poor or become poor after incurring high medical and long-term services and supports expenses, and who have very low levels of assets.⁴⁹

The right conclusion to reach about Medicaid’s role in long-term care financing is that it substantially ameliorates the risk and cost of long-term care, not that it impoverishes people. In the absence of Medicaid, if people truly had to bear the entire cost of long-term care, impoverishment would prevail, reverse mortgages would consume home equity to fund care, Medicaid long-term care expenditures would decline substantially, and many more people would plan, save, invest, and insure for long-term care risk and cost.

Those are not reasons to eliminate or replace Medicaid but rather reasons to target the program to its originally intended recipients — the truly needy — and to increase both positive and negative incentives for the middle and upper classes to prepare for long-term care and avoid Medicaid dependency.

Second, analysts wrongly claim Medicaid requires impoverishment because they equivocate on the meaning of “spend down.”

Real asset spend down comes from expending income and savings for care before applying for Medicaid benefits. Artificial spend down comes from divesting or sheltering wealth by legal or other means to qualify for Medicaid. An expansive legal literature on methods to qualify for Medicaid while preserving wealth began in 1981, immediately after the first restriction on asset transfers was imposed in the Omnibus Reconciliation Act of 1980. It continues today.⁵⁰ A 2012 article on preserving wealth through Medicaid planning describes the strategy this way:

Medicaid planning may be defined as the process of effectively accessing government resources to pay for long-term health care of a disabled person in the manner that is least financially disruptive to the wellbeing of the person’s spouse and family. These government resources derive primarily from Medicaid.⁵¹

The ability to access “government resources to pay for long term health care” in order to preserve the “wellbeing of the person’s spouse and family” sounds highly desirable. Who wouldn’t take advantage of such resources when faced with catastrophic long-term care expenses? In fact, why would anyone plan for long-term care expenses when such an option is available after expensive care is needed and the cost is no longer insurable privately? The reality is that public policy incentives like these discourage early and responsible planning for long-term care and result in excessive Medicaid dependency and cost.

Despite this reality, economists and health policy analysts who write about Medicaid and long-term care financing rarely mention that Medicaid eligibility can be achieved by means other than paying cash for long-term care services. A common error is to claim falsely that Medicaid asset spend down must be done by purchasing medical or long-term care services.

Medicaid requires applicants to spend down their income on medical and long-term care costs to reach allowable income limits. But Medicaid does not require applicants to spend down their assets on medical or long-term care services to reach allowable asset limits. Assets may be divested or spent down in exchange for any exempt product or service without reducing eligibility so long as fair market value is received in the exchange. Spending down one’s income may hurt financially, but spending down one’s assets can be financially painless.

Nevertheless, analysts often refer to asset spend down as though it refers to spending savings on long-term care. For example, an otherwise excellent article by a well-regarded economist on the influence of Medicaid estate recovery on wealth accumulation and decumulation states that “spend-down of assets occurs as individuals are required to contribute liquid resources toward the cost of their care until the typical state threshold of $2,000 is reached.”⁵²

Third, analysts wrongly claim Medicaid requires impoverishment because they equivocate on the meaning of “Medicaid planning.”

Analysts seldom cite the extensive legal literature on Medicaid planning nor acknowledge the omnipresent information on Medicaid planning in the popular media and on the internet.⁵³ Instead, when writing about decumulating wealth to qualify for Medicaid, they usually assume and imply that the money is used to purchase long-term care rather than being divested, diverted, or sheltered to achieve eligibility. This ignores Medicaid’s lenient income and asset eligibility criteria that allow people with substantial resources to qualify for long-term care benefits; it ignores the fact that Medicaid rules do not require that assets be spent down for long-term care services; and it evades the reality that information on ways to qualify for Medicaid without paying for care is universally available.

In the rare instance where analysts consider the possibility that people might qualify for Medicaid without spending down wealth, they tend to write only about “asset transfers” without considering other Medicaid planning methods and they often misrepresent the arguments of those seeking to preserve resources for the truly needy.^54-56

Asset transfers are very expensive for taxpayers, crowding out resources for the most vulnerable. Transferring assets may have increased Medicaid spending by as much as $1.5 billion in 2014 alone.^57-58 But focusing only on asset transfers ignores the more widely practiced techniques of Medicaid planning. Indeed, asset transfers are only the tip of the Medicaid planning iceberg.

Routine practices of eliminating countable assets by converting them into exempt assets, setting up caregiver agreements, employing Medicaid-friendly annuities, or making use of trusts, spousal refusal, or even divorce are far more common than asset transfers. Elder law specialists not only describe these techniques in the estate planning literature but frequently encourage their use.

Unfortunately, analysts rarely consult and almost never cite this legal scholarship, despite its direct relation to the topic at hand. By focusing only on asset transfers, they overlook the far more extensive and costly forms of Medicaid planning.

(See the supplemental bibliography in Appendix I of “How to Fix Long-Term Care Financing” for numerous examples of Medicaid planning techniques that are not based on transferring assets.)

Fourth, some analysts wrongly claim that Medicaid requires impoverishment because they equivocate on the meaning of “out-of-pocket” expenditures for long-term care by claiming they are higher than they really are.

Some analysts say the out-of-pocket share of long-term care expenditures has skyrocketed to more than 50 percent.⁵⁹ But they arrive at that figure by including room and board expenses in residential care settings — costs that people would incur whether they need long-term care or not — and by excluding Medicare post-acute care expenditures from the total even though Medicare’s relatively generous nursing home and home care reimbursements are the only thing enabling Medicaid to pay long-term care providers less than the cost of providing the care to a majority of long-term care patients.⁶⁰

In reality, the proportion of long-term care expenses paid by taxpayers has been rising and the proportion paid by families has been declining for half a century. When Medicaid first started paying for long-term care in the late 1960s, out-of-pocket expenditures were very high – upwards of half of all nursing home expenditures. Since then, Medicaid and Medicare spending have increased rapidly and dramatically. Out-of-pocket expenditures declined to around one-fourth of total long-term care expenditures. But even that low figure is misleadingly high because roughly half of it is not savings being spent down as often implied but Social Security and other income being “spent-through” by people already on Medicaid to offset Medicaid’s cost of care as federal law requires.⁶¹ To this day, upwards of 85 to 90 percent of nursing home expenditures are accounted for without dipping into personal savings and only 8.9 percent of formal home health care costs were paid out of pocket.⁶²

Nevertheless, analysts continue to argue that out-of-pocket long-term care expenditures are higher than they really are in order to justify new, government-funded long-term care financing programs.

Fifth, analysts wrongly claim Medicaid requires impoverishment because they rely on data, much of it faulty, from HRS and AHEAD surveys.

When economists and health policy analysts claim that older people approaching the need for long-term care retain few assets and spend down rapidly, they generally draw their evidence from survey data provided by the Health and Retirement Study (HRS) and its auxiliary, the Asset and Health Dynamics among the Oldest Old (AHEAD) study. These surveys have information on home values, automobile ownership, liquid assets, farms and other businesses, retirement accounts, and other assets.⁶³

Noteworthy is the fact that each of these financial holdings is either expressly exempt under federal law or easily converted into an exempt asset for purposes of Medicaid long-term care eligibility. For example, between $572,000 and $858,000 of home equity is exempt from eligibility limits, depending on the state.

Additional real estate such as vacation homes may easily be made exempt. As one Medicaid planning attorney explains in his newsletter, a spouse could take out a loan in the amount of the second home’s equity to “reduce its effective value to $0” and then spend the borrowed money on home improvements or invest it in other exempt resources.⁶⁴ Another estate planner explained that a couple with a second vacation home could simply rent its own home and claim the rental income as necessary for the spouse’s maintenance needs, converting it into a non-countable resource.⁶⁵

One automobile is exempt regardless of value so long as it is used at least occasionally for the benefit of the Medicaid recipient. Liquid wealth such as bank accounts or securities may be converted from countable to non-countable status by purchasing exempt assets. These strategies typically involve converting countable assets into home equity, a new car, household items, travel, funeral expenses, or burial plots.⁶⁶

Farms and other businesses, including their capital and cash flow of unlimited value, are exempt without any dollar limit.⁶⁷

Tax-deferred retirement accounts, including IRAs, Keoghs, and 401(k)s are exempt if the holder is receiving a regular payout.⁶⁸ Such payouts are required by the time an individual reaches 70.5 years old, though may begin as early as 59.5 years old.

HRS/AHEAD Data are highly questionable.

While the HRS and AHEAD surveys provide the most reliable longitudinal data currently available, they are far from foolproof. One expert found significant data quality issues in the surveys due to “measurement errors in the data, particularly those arising from item nonresponse and from inaccurate respondent reports of the ownership and level of assets.”⁶⁹ He concluded that the survey data make it “difficult to reach consensus among research studies” because “each author must arbitrarily decide whether to exclude, censor, or impute particular observations.”⁷⁰ Other researchers have noted similar limitations, explaining that “information on people who are cognitively impaired and who die is derived from proxy respondents, often relatives, who may not know about specific long-term services and supports use or Medicaid eligibility.”⁷¹ Given these facts, these surveys provide a dubious foundation on which to generalize about long-term care financing policy.

Furthermore, there are many reasons why survey respondents and their representatives might fail to report income and assets to surveyors or even purposefully misrepresent the facts. People who have reconfigured their wealth to qualify for public welfare benefits may be ashamed of having done so or simply unaware that their heirs did this on their behalf. Seniors reporting on themselves may be cognitively impaired or intimidated by self-interested family members. Heirs who benefit from preserving parents’ estates may prefer to conceal the facts. Lawyers who do Medicaid planning are protected from disclosure by attorney/client privilege, while long-term care providers and Medicaid eligibility staff, who often know which wealthy locals are taking advantage of Medicaid, cannot disclose the information because of legally enforced confidentiality. Getting to the truth in such matters is extremely difficult.

Finally, the HRS/AHEAD surveys pose the wrong questions regarding wealth transfer and do not address the larger issue of Medicaid planning at all. They typically ask if the respondents gave financial help worth more than $500 to any children, not counting shared housing or food costs, within the preceding two years.⁷² But there are several problems with this question. Transfers of assets relevant to qualifying for Medicaid long-term care benefits are not necessarily done to provide “financial help” to children. Looking back only two years is insufficient, as Medicaid has a look-back period of five years. Finally, focusing as narrowly as the question does on asset transfers ignores the much larger issue of other sophisticated Medicaid planning tactics.⁷³

Sixth, analysts wrongly claim Medicaid requires impoverishment because they do not ask the people who know the truth.

Besides passing over the formal legal literature on Medicaid planning, long-term care scholars have paid little attention to the voluminous testimony of Medicaid staff, financial advisors, Medicaid planners, consumers and long-term care providers about the ease and impunity with which middle and upper-class individuals take advantage of Medicaid long-term care benefits. In the 1990s, The Gerontologist published several articles quoting these sources on that topic, but very little such information has found its way into the peer-reviewed literature since.⁷⁴ Despite this absence, popular media abound with such examples.

Since 1998, for example, the Center for Long-Term Care Reform has published 144 articles about Medicaid planning.⁷⁵ Unfortunately, most academic scholars either do not read such material or they think they can ignore anything in it, however conclusive, that contradicts the conventional scholarly wisdom about long-term care financing. Unfortunately, such arrogance has significant consequences not only for taxpayers but ultimately for the truly needy. After all, every dollar spent on Medicaid benefits for middle-class and affluent seniors is a dollar that cannot be spent on the truly vulnerable.

Closing LTC Comment: Why don’t analysts consider the overwhelming evidence about Medicaid’s true LTC financing role? Because taking it into account would overturn their arguments in favor of government control of long-term care financing. How do they evade germane facts? By equivocating on key concepts, relying on highly questionable survey data, and ignoring evidence that contradicts their ideologically biased preferences. Most galling is their casual sophistry, such as brushing off solid proof of Medicaid planning abuse because “no one wants to go on Medicaid,” as Judith Feder claims. Hello. When all your options have run out; when it’s too late to plan, save or insure for long-term care; when you’re facing high expenditures for LTC; when your heirs step in to take early inheritances leaving you dependent on public welfare; you better believe Medicaid becomes very attractive and most people do want it at that stage. In fact, that’s why we’re in the mess we’re in. Evading this reality only sinks us deeper in. We’ll make no real progress to improve LTC services and financing until analysts take their policy blinders off and cope honestly with the truth.

(In the following footnotes, you will find examples of the evasion and misrepresentation of facts that I’ve alleged above with links to articles in which I’ve critiqued those sources. See especially footnotes # 48, 49, 54, 55, 56, 57, 59, and 75.)

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⁴⁸ Sudipto Banerjee, "Effects of Nursing Home Stays on Household Portfolios," EBRI Issue Brief, no. 372, June 2012, p. 4; http:// www.ebri.org/pdf/briefspdf/EBRI_IB_06-2012_No372_NrsHmStys.pdf. Critiqued in S. Moses, "LTC Bullet: Nursing Home Spend Down Misunderstood and Late-Breaking LTCI Industry News," July 20, 2012; http://www.centerltc.com/bullets/ archives2012/966.htm
⁴⁹ Joshua M. Wiener, et al., "Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform: Final Report," prepared for the SCAN Foundation by RTI International, Research Triangle Park, North Carolina, March 2013, p. 1; http://www.thescanfoundation.org. Critiqued in S. Moses, "LTC Bullet: Medicaid Spend Down that Isn't and Why it Matters," July 19, 2013; http://www.centerltc.com/bullets/archives2013/1007.htm
⁵⁰ Generally recognized as the first published law journal article on Medicaid planning is William G. Talis, "Medicaid as an Estate Planning Tool," Massachusetts Law Review, Spring 1981, p. 94. See the online bibliography for quotations from this article.
⁵¹ Sean R. Bleck, Barbara Isenhour, and John A. Miller, "Preserving Wealth and Inheritance Through Medicaid Planning for Long-Term Care," MSU Journal of Medicine and Law, 17 Mich. St. U. J. Med. & L. 153 2012, p. 155
⁵²Nadia Greenhalgh-Stanley, "Medicaid and the housing and asset decisions of the elderly: Evidence from estate recovery programs," Journal of Urban Economics 72 (2012), p. 211; http://econpapers.repec.org/article/eeejuecon/ v_3a72_3ay_3a2012_3ai_3a2_3ap_3a210-224.htm
⁵³ Do an internet search for "Medicaid planning in [your state]" to find dozens of law firms advertising their Medicaid planning services.
⁵⁴ Ellen O'Brien, "Medicaid's coverage of nursing home costs: Asset shelter for the wealthy or essential safety net?," Georgetown University Long-Term Care Financing Project Issue Brief, May 2005, p. 2; http://www.canhr.org/reports/2005/ nursinghomecosts.pdf. Critiqued in S. Moses, "LTC Bullet: Where There's Smoke, There's Fire," May 18, 2005; http://www. centerltc.com/bullets/archives2005/558.htm
⁵⁵ Joshua M. Wiener, et al., "Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform: Final Report," prepared for the SCAN Foundation by RTI International, Research Triangle Park, North Carolina, March 2013, p. 9; http://www.thescanfoundation.org. Critiqued in S. Moses, "LTC Bullet: Medicaid Spend Down that Isn't and Why it Matters," July 19, 2013.
⁵⁶ S. Moses, "LTC Bullet: Where There's Smoke, There's Fire," Wednesday, May 18, 2005; http://www.centerltc.com/bullets/ archives2005/558.htm "Other researchers have offered estimates of the prevalence of Medicaid estate planning that vary greatly, ranging from 5% to 54% of Medicaid beneficiaries. Burwell and Crown (1995) estimated that 5% to 10% of unmarried applicants and 20% to 25% of married applicants transfer wealth to qualify for Medicaid. The estimates of the Minnesota Department of Human Services (1996) and GAO (1993) are 22% and 54%, respectively. Walker and colleagues (1999) also estimated the rate of Medicaid estate planning at 25% to 50%." Jinkook Lee, Hyungsoo Kim, and Sandra Tanenbaum, "Medicaid and Family Wealth Transfer," Gerontologist, Vol. 46, No. 1, 2006, p. 8.
⁵⁷ Timothy Waidmann and Korbin Liu, "Asset Transfer and Nursing Home Use: Empirical Evidence and Policy Significance," The Urban Institute, Washington, DC, April 2006; http://kff.org/medicaid/issue-brief/asset-transfer-and-nursing-home-use-empirical/. Critiqued in S. Moses, "LTC Bullet: Kaiser Cover-Up Continues," April 27, 2006; http://www.centerltc.com/bullets/ archives2006/630.htm
⁵⁸ Total FY 2014 long-term care expenditures come from Steve Eiken, et al., "Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2014," Contract No. HHSM-500-2010-00026I, between Mathematica Policy Research, Inc. and the Centers for Medicare & Medicaid Services (CMS), under which project Truven Health Analytics was a subcontractor, p.3, April 15, 2016; https://www.medicaid.gov/medicaid/ltss/downloads/ltss-expenditures-2014.pdf
⁵⁹ Melissa Favreault and Judith Dey, "Long-Term Services and Supports for Older Americans: Risks and Financing," USDHHS Assistant Secretary for Planning and Evaluation (ASPE) Issue Brief, July 1, 2015, revised February 2016, p.5; https://aspe.hhs. gov/basic-report/long-term-services-and-supports-older-americans-risks-and-financing-research-brief. Critiqued in S. Moses, LTC Bullet: New Data on LTC Incidence, Duration, Cost and Financing Sources, July 24, 2015; http://www.centerltc.com/ bullets/archives2015/1094.htm
⁶⁰ "Nursing centers rely heavily on two public programs, Medicare and Medicaid, to pay for the services they provide to most of their patients. The rates paid by states for Medicaid do not adequately reimburse the actual costs incurred by providers, resulting in a major disconnect between payment levels and the needs of the patients. Unreimbursed allowable Medicaid costs for 2015 are projected to exceed $7.0 billion. Expressed as a shortfall in reimbursement per Medicaid patient day, the estimated average Medicaid shortfall for 2015 is projected to be $22.46, which is a 6.0 percent increase over the preceding year's projected shortfall of $21.20." ELJAY, LLC & Hansen Hunter & Company, PC, "A Report on Shortfalls in Medicaid Funding for Nursing Center Care," American Health Care Association, Washington, D.C., April 2016, p. 1; https://www.ahcancal.org/
⁶¹ People in nursing homes on Medicaid are required to contribute all of their income, except for a small personal needs allowance, to offset Medicaid's cost for their care.
⁶² See S. Moses, "LTC Bullet: So What If the Government Pays for Most LTC?, 2015 Data Update," December 6, 2016; http://www. centerltc.com/bullets/latest/1159.htm
⁶³ De Nardi M, French E, Jones JB. Medicaid insurance in old age. Am Econ Rev. 2016;106(11):3480-520
⁶⁴ Michael Gilfix, "Practice Tip: Protect Non-Residential Real Property and Medi-Cal," Gilfix ElderLaw News Alert, Vol. VII, No. 1, February 1997, p. 3
⁶⁵ John J. Regan, Tax, Estate & Financial Planning for the Elderly, Matthew Bender, New York, 1991, 1993 update, p. 10-68
⁶⁶ Lawyers Weekly, September 27, 1993
⁶⁷ Rebecca L. Shandrick, "The Family Business: An Exempt Resource for Medicaid Eligibility," The ElderLaw Report, Vol. 4, No. 3, October 1992, pps. 1-4, emphasis in the original.
⁶⁸ ElderLawAnswers, "Can an IRA Affect Medicaid Eligibility?," article last modified 03/17/2015, cited May 10, 2017; http:// www.elderlawanswers.com/can-an-ira-affect-medicaid-eligibility-14544. The relevant Social Security Administration, Program Operations Manual System (POMS) reference is "SI 01120.210 Retirement Funds," https://secure.ssa.gov/apps10/poms.nsf/lnx/0501120210. Nevertheless, Warshawsky and Marchand found that roughly two-thirds of retirement assets, such as IRAs, are counted in determining Medicaid eligibility. Mark J. Warshawsky and Ross A. Marchand, "Improving the System of Financing Long-Term Services and Supports for Older Americans," Mercatus working paper, Mercatus Center, George Mason University, Washington, DC, January 2017, p. 27; https://www.mercatus.org/system/files/mercatus-warshawsky-marchand-ltss-v2.pdf.
⁶⁹ Steven F. Venti, "Economic Measurement in the Health and Retirement Study," Dartmouth College and NBER, January 21, 2011, p. 3; https://www.degruyter.com/view/j/fhep.2011.14.issue-3/1558-9544.1273/1558-9544.1273.xml
⁷⁰ Ibid., p. 4.
⁷¹ Joshua M. Wiener, et al., "Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform: Final Report," prepared for the SCAN Foundation by RTI International, Research Triangle Park, North Carolina, March 2013, p. 50; http://www.thescanfoundation.org/
⁷² Jinkook Lee, Hyungsoo Kim, and Sandra Tanenbaum, "Medicaid and Family Wealth Transfer," Gerontologist, Vol. 46, No. 1, 2006, p. 9; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1450010/
⁷³ Ibid., p. 12
⁷⁴ Examples include Stephen A. Moses, "The Fallacy of Impoverishment," Gerontologist, Vol. 30, No. 1, 1990; http:// gerontologist.oxfordjournals.org/content/30/1/21.abstract Leslie Walker, Cynthia Gruman, and Julie Robison, "Medicaid Estate Planning: Practices and Perceptions of Medicaid Workers, Elder Law Attorneys, and Certified Financial Planners," Gerontologist, Vol. 38, No. 4, 1998, pps. 405-411; http:// gerontologist.oxfordjournals.org/content/38/4/405.full.pdf Leslie Walker, Cynthia Gruman, and Julie Robison, "Medicaid Eligibility Workers Discuss Medicaid Estate Planning for Nursing Home Care," Gerontologist, Vol. 39, No. 2, 1999, pps. 201-208; http://gerontologist.oxfordjournals.org/content/39/2/201.full. pdf
⁷⁵ Find 144 articles on Medicaid planning here: http://www.centerltc.com/bullets/subject.htm#medicaid_plan

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Updated, Monday, May 21, 2018, 10:02 AM (Pacific)

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LTC E-ALERT #18-020: LTC NEWS AND COMMENT

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 the growing wealth gap could mean for senior living
Survival for the Sandwich Generation: Navigating the hidden costs for working caregivers
Improving Long-Term Care Insurance Rate Increase Communications
The Hidden Costs Of Caregiving
Leaders Declare Senior Care Staffing Crisis in Texas Amid 97% Turnover
National summit leads to 700 dementia recommendations
How to Protect Yourself and Your Family From Long-Term Care Insurance Scams
AP-NORC Poll: Young adults feel stress of long-term care
‘Simple test’ improves dementia prediction rates
Fewer Americans Are Delaying Major Life Events Because of Money Worries
Why Yelp Could be Superior to Five-Star Ratings for Nursing Homes
Nancy Pelosi wrong on Medicaid's role for children, elderly

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Updated, Friday, May 18, 2018, 10:58 AM (Pacific)

Seattle—

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LTC BULLET: FEDER/COHEN PROPOSAL IGNORES LTC PROBLEMS’ CAUSE

LTC Comment: We explain how government intervention caused the dysfunctions in long-term care that Feder/Cohen seek to correct with more government intervention, including institutional bias, poor access and quality, excessive dependency on family caregiving, inadequate financing, and lack of insurance, after the ***news.***

*** WATCH “MY MILLION DOLLAR MOM” MOVIE: Ross Schriftman reports “I am so pleased to tell you that the time has finally come. The ‘My Million Dollar Mom’ short film is now available for you to enjoy right from our website at www.mymilliondollarmom.com. To see our film, you can watch the 2-minute trailer and then click the button to buy the film through Vimeo. You will be asked to ‘join’ Vimeo (if you haven't already) which simply means you enter your email and create a password. Then you can purchase the film [for $4.95] and keep it in your personal Vimeo library so you can watch whenever you want. You can also sign up for email updates on our progress.” ***

LTC BULLET: FEDER/COHEN PROPOSAL IGNORES LTC PROBLEMS’ CAUSE

LTC Comment: “If you are unable to understand the cause of a problem, it is impossible to solve it.” – Naoto Kan

“We cannot solve our problems with the same thinking we used when we created them.” – Albert Einstein

That’s good advice that Judith Feder, Marc Cohen and Melissa Favreault ignored in their recent proposal for LTC financing reform: “A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance.”

They tell us “Current U.S. policy toward the financing of long-term services and supports (LTSS) underserves people who need care, overburdens families who care for them, and strains state budgets supporting Medicaid services when personal resources fall short. The fundamental LTSS financing problem is the absence of an effective insurance mechanism to protect people against the costs of extensive LTSS they may require over the course of their lives.” (p. i)

All right, but why? Blank out. They say nothing about how these problems came to exist or why they persist so intractably. Instead, these advocates proceed immediately to prescribe a complex, top-down, payroll-financed, heavily bureaucratic and compulsory new government LTC program. This is folly.

We’ve already explained that Feder/Cohen’s fundamental error was discounting Medicaid’s role in LTC financing (“LTC Bullet: Feder Fantasy Fatally Flawed (Cohen Contribution Notwithstanding))” and we addressed the consequences of their evading that reality (“LTC Bullet: LTC Evasion”).

Let’s consider today the diametrically different conclusions and recommendations one reaches by analyzing and understanding the problems of LTC service delivery and financing first before proposing solutions.

The following is adapted and updated from a series of seven “briefing papers” we published in 2012 titled “How to Fix Long-Term Care.”

Briefing Paper #1: The History of Long-Term Care Financing, or How We Got Into This Mess

The Status Quo

Long-term care (LTC) service delivery and financing in the United States are fraught with problems. Families provide most LTC for free, but suffer enormous financial and emotional strain. We have too many nursing homes and not enough home care. Medicaid and Medicare pay for most expensive LTC, but they are short of funds. LTC is a high probability and very expensive, yet too few people save or insure against the risk. Many end up as dual eligibles, the most costly of Medicaid's and Medicare's beneficiaries. Access to LTC and quality of care are always in doubt. Capital is in short supply to build, operate and maintain LTC facilities or to support home care services. Bankruptcies and closures loom. Yet America's demographic age wave is only beginning to crest.

What Should We Do?

This is the first question most people [including Feder/Cohen] ask, but it is the wrong question. To address the dysfunctional status quo without first examining why it exists can lead to more of the same expensive interventions that have already failed. For example, here’s the typical academic’s approach to address these problems:

Free care stresses families? Subsidize them. Too little home care? Make Medicaid buy more. Medicaid and Medicare lack funds? Tax and spend more. LTC insurance is unpopular? Subsidize it. Too many dual eligibles? Manage them better. Access and quality problems? Hire more surveyors and increase penalties. Too little capital and investment? Offer tax incentives (more tax expenditures). Bankruptcies threatening? Increase reimbursements. Can't afford boomers' entitlements? Borrow more. Bottom line: Find yourself in a hole? Dig faster. Keep doing what you’ve always done and hope for a different result.

The Right Question

Lincoln said: "If we could first know where we are and whither we are tending, we could better judge what to do and how to do it." (House Divided Speech, 1858) Faced with any problem, the right question to ask first is: How did we get into this mess? Otherwise, we run the risk of doing more of what caused the problem in the first place. Before we propose LTC solutions, we should ask "How did long-term care come to be the way it is today?"

History of LTC Financing or How We Got Into This Mess

By 1965, most of the 20th century's life span extension had already occurred. People lived longer and died slower often from the chronic illnesses of old age. Increasing numbers lived long enough to need LTC. Medicaid began to pay for nursing home care. Initially, the new program had no penalty for transferring assets to qualify and no requirement for recovery of benefits paid from recipients' estates. Virtually anyone could qualify easily for Medicaid-financed LTC.

Several things happened as a result. The public placed aging parents in nursing homes paid for by the government instead of paying for home care themselves. The nursing home industry expanded to take advantage of the new government funding source. Thus began the heavy use of nursing homes or "institutional bias," the lack of a privately financed home and community-based services market, and the absence of private LTC financing alternatives, such as home equity conversion or LTC insurance.

The 1970s

Political satirist P.J. O'Rourke says "If you think health care is expensive now, just wait until it's free." With nursing home care virtually free, Medicaid LTC expenditures exploded, rising from $900 million in 1970 to $7.1 billion in 1980. In response, government capped the bed supply by requiring "certificates of need" before new nursing homes could be built. Medicaid could not be charged for beds that didn't exist went the reasoning.

But limiting their ability to expand gave existing nursing homes a government-enforced monopoly. To compensate for limits on growth, they began charging Medicaid higher rates. Government responded by capping the rates nursing homes could charge. This was the origin of "cost shifting," which resulted from the differential between low Medicaid reimbursement rates (about 2/3 of private-pay rates) and much higher private-pay rates (about 1.5 times the Medicaid rate on average).

The 1980s

With nursing home supply and prices capped, and few controls on Medicaid LTC eligibility, demand soared. Costs continued to explode, rising from $7.1 billion in 1980 to $16.4 billion in 1990. Unable to build more beds or charge Medicaid more, nursing homes cut corners on quality to make ends meet.

By the mid-1980s, reports of dismal conditions in America's nursing homes led to Congressional action. The Omnibus Budget Reconciliation Act of 1987 required nursing homes to improve care or face legal and financial penalties. But OBRA '87 provided no extra Medicaid funds to finance the mandated improvements.

Caught now between the rock of inadequate reimbursement and the hard place of mandatory quality, nursing homes started suing state Medicaid programs for higher reimbursements. They won most of these lawsuits based on the 1981 "Boren Amendment" which required Medicaid to pay at least minimally adequate rates. But Congress repealed Boren in 1997 leaving no floor underneath Medicaid nursing home reimbursements.

The 1990s

Several cross currents developed in the 1990s, as Medicaid nursing home expenditures continued to rise from $16.4 billion in 1990 to $31.9 billion in 2000. Private payers declined as people, enticed by free or subsidized Medicaid benefits, found more and more creative ways to qualify for the program. Out-of-pocket expenditures fell from 49.5% of nursing home revenues in 1970 to 32.5% in 2000, while Medicaid's share of costs increased from 23.3% to 37.4% in the same period.

Starting with the Tax Equity and Fiscal Responsibility Act of 1982 and continuing through the Deficit Reduction Act of 2005, the federal government tried to restrain the growth of Medicaid LTC expenditures by closing income and asset eligibility loopholes and by mandating recovery from recipients' estates. Briefing Paper #3 in this series, on "Medicaid Planning for Long-Term Care," covers those developments in detail and explains their failure to restrain costs significantly.

Simultaneously, throughout the 1990s and up to the current day, state and federal policy makers, encouraged by academic researchers, have argued that Medicaid can reduce costs by "rebalancing" from nursing home care to home and community-based services (HCBS). Briefing Paper #4 in this series, on "Rebalancing Long-Term Care," explains that Medicaid's combined nursing home and HCBS expenditures have continued to increase in every state despite efforts to rebalance. This trend will continue absent restraints on Medicaid's generous eligibility criteria, which are described in Briefing Paper #2, titled "Medicaid Long-Term Care Eligibility."

The 2000s

A strong economy during the late 1990s, with lower welfare rolls and higher tax revenues, deflected political attention from Medicaid's growing role as the dominant LTC payer for most Americans. After 9/11, the internet bubble's collapse and the ensuing recession, state and federal officials began to worry about Medicaid LTC again and more than ever.

In the first decade of the new century, Medicaid nursing home expenditures moderated somewhat growing only 41.1% from $31.9 billion in 2000 to $45.0 billion in 2009. Total LTC costs did not decline, however, because Medicaid's home health care expenditures soared 113% from $11.5 billion in 2003 to $24.3 billion in 2009.

Meanwhile in the Deficit Reduction Act of 2005, the federal government tried to restrain Medicaid LTC growth by tightening eligibility criteria and encouraging the purchase of private long-term care insurance. In the same legislation, however, it made qualifying for Medicaid more attractive than ever by encouraging the program to offer more of the home care benefits people prefer and less of nursing home care they'd rather avoid.

Today

The preceding thumbnail history of long-term care services and financing answers the key question we posed at the beginning: How did we get into this mess? It suggests that our search for solutions should look in a different direction than increasing government intervention and financing, which clearly has not worked. For example:

Do families provide most LTC for free, but suffer enormous financial and emotional strain? Medicaid crowded out a market for affordable home and community-based services and discouraged private financial products to pay for them by subsidizing nursing home care.

Do we have too many nursing homes and not enough home care? Medicaid made nursing home care free in 1965, leaving lighter care the responsibility of families and making nursing homes the dominant venue for custodial care.

Are Medicaid and Medicare short of funds for LTC? By paying for most expensive LTC since 1965, these public programs exploded in cost while discouraging other venues for care and hampering potential private sources of payment.

Do few people save or insure against the high risk and cost of LTC? Easy access to Medicaid benefits after the insurable event occurred desensitized the American public to LTC liability resulting in their failure to plan early to save, invest or insure for LTC.

Do too many people end up as dual eligibles, the most costly of Medicaid and Medicare beneficiaries? Medicaid's home equity exemption, which was unlimited until 2006 and is still at least $572,000 [as of 2018], prevented the use of home equity to fund LTC privately which could have delayed or prevented Medicaid dependency altogether for many duals.

Are access to LTC and quality of care always in doubt? By dominating long-term care financing and paying too little to ensure quality care, Medicaid created a serious drag on access and quality.

Do we lack adequate capital to build, operate and maintain LTC facilities or to support home care services? Capital migrates to its highest and best use. Because of Medicaid's low reimbursement rates, profitability in the LTC sector is too low to attract enough investment capital.

Do LTC bankruptcies and closures loom? Medicaid's easy availability and low reimbursement rates caused cost shifting from public to private patients who gradually converted to Medicaid in large numbers leaving LTC providers without adequate revenue.

The Future

Medicaid's heavy spending on LTC services created a perverse incentive that discourages responsible LTC planning and private financing. Government spending and interference in the LTC financing market caused the problems the system faces. More government spending and interference will exacerbate rather than ameliorate these problems.

Most measures currently under consideration to improve LTC services and financing, such as subsidizing family caregivers, rebalancing to more desirable home care services, and offering tax incentives for private insurance or investment, would increase public expenditures just when they need to be reduced. [Let us add the new Feder/Cohen proposals for higher payroll taxes to fund compulsory public LTC insurance to the list of potential counterproductive government interventions.]

America's demographic age wave is only beginning to crest. Soon it will crash as 76 million baby boomers retire, stop paying payroll taxes, and start drawing benefits from entitlement programs that are already facing unfunded liabilities in the trillions of dollars. The question we should be asking now is "How can we preserve Medicaid as a quality safety net for people in need while reducing instead of increasing the program's LTC expenditures? The remainder of these Briefing Papers will explain how that can be done.

LTC Comment: To summarize, ignoring how long-term care services and financing became so dysfunctional led Feder and Cohen to propose more of the same kind of government interference that created those problems in the first place. This outcome is potentially even more tragic than it is ironic. Implementing their recommendations would make long-term care services worse, financing less, and the human tragedy graver. Ironically, doing the opposite, reducing government interference in long-term care, by targeting Medicaid to the truly needy and using some of the savings to incentivize responsible LTC planning, would improve and expand long-term care services, enhance private sources of funding, and finally relieve the caregiving burden on families and loved ones.

See the aforementioned “Briefing Papers” and “How to Fix Long-Term Care Financing” for a fuller exposition of these arguments, conclusions and recommendations.

Next week: why analysts like Feder, Cohen and Favreault wrongly claim Medicaid LTC requires impoverishment, which mistaken claim results in their making such potentially disastrous policy recommendations. Are they blinded by ideology? Do they rely on faulty data from the HRS and AHEAD surveys? Is it confusion, contempt or fear that prevents them from considering evidence that contradicts their assumptions? All of the above? Don’t miss the exciting conclusion of our LTC Bullet series critiquing the Feder/Cohen/Favreault proposals.

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Updated, Monday, May 14, 10:42 AM (Pacific)

Seattle—

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LTC E-ALERT #18-019: LTC NEWS AND COMMENT

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:

Report Says Medicare Health Plan Tool Needs Major Overhaul
Death rate from falls increases 31% over 9 years
Why Families Need a Plan for Caregiving
A proposal to enhance competition and reform bidding in the Medicare Advantage Program
Official Gives Hints About Medicare Advantage LTC Benefits
Britain 'should learn from Japan' when it comes to care of the elderly
Maybe Traditional Medicare Should Cover Chronic Care: Hearing Witnesses
Financial abuse against the elderly most often committed by those closest to them
Nearly 25% of Americans Over 85 Need Personal Care
Even Mild Concussion Tied to Greater Dementia Risk Later
Obesity soars among long-stay nursing home residents
'Mass chaos': 37,000 nursing home eviction notices prepared in
Retirees: Here's Why You Might Be Investing All Wrong

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Updated, Friday, May 11, 2018, 10:01 AM (Pacific)

Seattle—

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LTC BULLET: LTC EVASION

LTC Comment: We explain what LTC financing scholars evade and why after the ***news.***

*** LTC CLIPPINGS are our daily “heads up” emails to premium members/subscribers to advise them of news, data and reports they should see to stay at the forefront of professional expertise. We send an average of two clippings per day. Perhaps the biggest benefit of receiving LTC Clippings is the ones we don’t send! Those are all the stories, articles, and reports that we reviewed and decided they are not worth your time and focus to read. Our screening saves you research time and ensures you read the best of the best. To subscribe, contact Damon at 206-283-7036 or damon@centerltc.com. Here are three sample LTC Clippings from the past week.

5/9/2018, “Why Families Need a Plan for Caregiving,” by Kimberly Lankford, Kiplinger’s Personal Finance

Quote: “Kamilah Williams-Kemp, 43, is the head of Northwestern Mutual's long-term-care insurance business. She was the primary caregiver for her mother last year.”

LTC Comment: The personal story of one of our own in the LTCI business.

5/10/2018, “Report Says Medicare Health Plan Tool Needs Major Overhaul,” by Patrick Connole, Provider

Quote: “A tool used by older Americans and others to explore which Medicare health plans to purchase needs improvement, notably in the areas of gauging plan costs and providers' in-network status, according to a recent report and corresponding scorecard by the Clear Choices Campaign, a health care cost transparency initiative of the Council for Affordable Health Coverage and National Council on Aging (NCOA). ... ‘The scorecard gives the MPF 'A' grades only for its anonymous browsing capabilities and non-English translation services. MPF earned 'D' or 'F' grades in seven other criteria,’ said the report, titled, ‘Modernizing Medicare Plan Finder: Evaluating and Improving Medicare's Online Comparison Shopping Experience.’”

LTC Comment: One more reason not to turn LTC over to Medicare.

5/7/2018, “Nearly 25% of Americans Over 85 Need Personal Care,” by Tim Regan, Senior Housing News

Quote: “It’s no secret that the need for caregiving services tends to grow with age, but a newly released report from the federal Administration for Community Living sheds light on just how many older adults in the U.S. need personal care. The percentage of older adults age 85 and older needing help with personal care was 22% between January and June of last year. That’s more than twice the amount of people between the ages of 75 and 84 (9%) and more than six times the percentage of adults 65 to 74 (3%) who reported needing help with personal care during the same period, according to the ‘2017 Profile of Older Americans’ report, which was published in April.”

LTC Comment: The perfect storm hits in 2031, just 13 years from now, when boomers start turning 85 in the same decade that Social Security and Medicare trust funds are depleted. ***

LTC BULLET: LTC EVASION

LTC Comment: Last week we disentangled and refuted the convoluted reasoning in Feder and Cohen’s “A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance.” We attributed the authors’ fundamental error to their discounting Medicaid’s role in long-term care financing. See “LTC Bullet: Feder Fantasy Fatally Flawed (Cohen Contribution Notwithstanding).” Today we summarize the consequences of evading LTC reality. In future weeks, we’ll explore each of those consequences more deeply. If you just can’t wait to get the full picture, go directly to “How to Fix Long-Term Care Financing.” For now, here’s the overview.

Medicaid Matters Most

“Give me a lever long enough and a fulcrum strong enough and single-handed I can move the world.” --Archimedes

“The simplest answer is most often correct.” --Occam’s Razor

Medicaid is in the news daily, particularly its expansion under the Affordable Care Act, or ObamaCare. But ObamaCare primarily affected acute care for young people. And while the young are three-fourths (75 percent) of Medicaid’s recipients, they account for only slightly more than one-third (36 percent) of the program’s expenditures. The aged, blind, and disabled, on the other hand, are just one-fourth of the recipients (24 percent) but account for nearly two-thirds (63 percent) of expenditures, mostly for the long-term services and supports that they require.^1-2 Given its disproportionately high impact on Medicaid costs, long-term care deserves much more attention than it currently receives from policymakers.

With that said, long-term care financing is complicated. Consider all the research studies, journal articles, and special commissions that have unsuccessfully grappled with it for decades. Recall the myriad variables, perplexing questions, noble goals, and stubborn obstacles standing in the way of progress. To name a few:

Who should pay? Are families responsible for payment or is the government? Should planning be voluntary or compulsory? Why do people ignore long-term care risk and cost until it is too late to prepare? How can nursing home bias prevail when people prefer cheaper home care? Why is long-term care fraught with access and quality problems? How can taxpayers spend so much for long-term care but the sector remains starved for funding? Who will provide care when compensation is so low? What is going to happen when the age wave finally crests and crashes in the 2030s?

Most policy analysts [including Feder and Cohen] respond to these perplexities by wringing their hands. They conclude that the government must compel people to prepare for long-term care by paying higher taxes. But what if public financing caused the long-term care dysfunctions in the first place? What if the questions and problems we face have a simpler answer? Do Occam’s razor and Archimedes’ leverage principle apply to long-term care?

Medicaid is not just a factor in long-term care financing. It is the critical factor.

Medicaid is not just a factor in long-term care financing; it is the critical factor. Since its founding in 1965, Medicaid has evolved from a minor funding source to the primary funder of formal paid care. This near monopsony status has serious ramifications. Because it requires state programs to pay for nursing home care, Medicaid has an institutional bias. Because it pays notoriously low reimbursement rates, Medicaid causes caregiver shortages, access, and quality problems. Because it pays for care after it is needed, Medicaid enables the public’s denial of long-term care risk and cost. Because it pays after the insurable event occurs, Medicaid crowds out private long-term care insurance. And because it increasingly pays for home care, Medicaid inhibits the private home care market. Name a deficiency of long-term care service delivery or financing and you will find Medicaid at the root of the problem.

Many policy analysts will agree with that assessment or at least some parts of it. They too blame Medicaid for numerous long-term care problems but for different reasons. Most analysts claim Medicaid requires impoverishment, that people must spend down their life’s savings to qualify for long-term care benefits, and that wide swaths of the American public are devastated by catastrophic expenditures before they receive help from Medicaid.

What such analysts do not and cannot explain is, if Medicaid requires impoverishment, why do most people ignore such a calamitous risk? Why do they fail to plan, save, invest, or insure for long-term care and end up dependent on a means-tested welfare program to receive nursing home care they would rather avoid? Since they cannot explain this logical contradiction, most analysts [including Feder and Cohen] evade it.

Therein is the fulcrum strong enough and the lever long enough to render a simple answer to the long-term care financing quandaries: Medicaid long-term care benefits do not require impoverishment. Virtually unlimited income does not obstruct eligibility if medical and long-term care expenses are high enough, as they usually are for people in need of formal, paid long-term care. Virtually unlimited assets are exempt in the form of home equity [between $572,000 and $858,000], one business, one auto, IRAs paying periodically, term life insurance, Medicaid-compliant annuities, life care contracts, prepaid burials, personal belongings, and home furnishings. In addition to these routine exemptions, the use of trusts, “spousal refusal,” disinheritance, divorce, and numerous sophisticated “Medicaid planning” techniques make access to Medicaid long-term care benefits available to nearly anyone who chooses to take advantage of the program.

This report explains and substantiates the argument that easy access to Medicaid after care is needed has caused most of long-term care’s problems.

Once it is clear that Medicaid does not require impoverishment, the puzzles associated with long-term care financing disappear. If people can ignore the risk of long-term care, avoid the premiums for private insurance, wait to see if they ever need expensive paid long-term care, and, if they do, transfer most of the cost to Medicaid, then everything else follows logically. Most people do not plan for long-term care; instead, they end up on Medicaid by default when they need care, leaving Medicaid to pick up the cost and overburdening its scarce resources. Consequently, Medicaid has too little revenue to pay care providers adequately, causing caregiver shortages as well as access and quality problems. Consumers lack choice of services and providers that a freer market could ensure. The system struggles financially in the absence of private revenue from genuine asset spend down, home equity conversion, or long-term care insurance.

That analysis requires fuller exposition and proof. This report [“How to Fix Long-Term Care Financing”] explains and substantiates the argument that easy access to Medicaid after care is needed has caused most of long-term care’s problems. This report demonstrates that access to Medicaid long-term care benefits does not require impoverishment and explains why most analysts wrongly claim that it does. It describes Medicaid’s true role as the dominant factor in long-term care financing and traces the history of how it became that way. It recounts how legislative and regulatory efforts to target Medicaid’s limited resources to its originally intended needy recipients have failed repeatedly. It explains why such efforts ended in 2005, show no signs of recurring, and must begin anew to salvage long-term care financing. Finally, this report proposes simple solutions to improve Medicaid as a long-term care safety net for people in need while improving the access to and quality of long-term care for people of all economic levels.

1. Kaiser Family Foundation, StateHealthFacts.org, “Distribution of Medicaid Enrollees by Enrollment Group,” cited May 8, 2017; http://kff.org/medicaid/state-indicator/distribution-of-medicaid-enrollees-by-enrollment-group/.

2. Kaiser Family Foundation, StateHealthFacts.org, “Medicaid Spending by Enrollment Group,” cited May 8, 2017; http://kff.org/medicaid/state-indicator/medicaid-spending-by-enrollment-group/.

LTC Comment: Even more basic than their evasion of Medicaid’s detrimental LTC financing role is the failure of LTC scholars, including Feder and Cohen, to explain why America’s long-term care services and funding system is so dysfunctional. They merely accept the defective status quo and propose solutions without understanding, much less explaining, why the problems exist in the first place. Consequently, their solutions always entail more of the same government control and revenue, which ironically, caused the dysfunctions in the first place. We’ll develop that theme in future LTC Bullets by explaining how long-term care came to be the way it is so that we can propose solutions that fix, instead of exacerbate, the problems.

Next week: How Medicaid caused most of the dysfunctions in long-term care including institutional bias, poor access and quality, inadequate financing, and excessive dependency on family care-giving.

Following week: How and why LTC academics refuse to acknowledge these realities, evade the consequences, and contribute to the problems instead of solving them.

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Updated, Monday, May 7, 2018, 10:01 AM (Pacific)

Seattle—

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LTC E-ALERT #18-018: LTC NEWS AND COMMENT

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:

Eating a Mediterranean Diet Could Delay Alzheimer’s Disease by Years
The Myth of Outliving Your Retirement Savings
Federal Panel Puts Off Dementia Financial Burden Battle
Proposed Medicare Change Would Create Long-Term Care Benefit
Medicare Advantage Plans Can Pay for Many LTC Services in 2019: Feds
Increases in Medicaid Spending Come at the Expense of Higher Education: Study
New Report Blasts ‘Confusing’ Medicare Search Tool
Crisis in care | Lack of quality caregivers, constant turnover tough on the disabled, families
Wisconsin's Long-Term Care Workforce At 'Crisis Level,' Report Finds
Visit from home care nurses linked to more emergency department use by seniors
How to Talk About Moving to a Retirement Home: ‘It’s a Journey’
2017 Profile of Older Americans
How Nursing Homes Can Destroy Families

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Updated, Friday, May 4, 2018, 9:00 AM (Pacific)

Seattle—

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LTC BULLET: FEDER FANTASY FATALLY FLAWED (COHEN CONTRIBUTION NOTWITHSTANDING)

LTC Comment: A new Feder/Cohen proposal would take long-term care out of the frying pan into the fire. We explain after the ***news.***

*** “MY MILLION-DOLLAR MOM” TRAILER RELEASED: Longtime Center friend and supporter, LTCI producer and expert Ross Schriftman announces the trailer for the movie based on his book of the same title. Watch it here for a moving reminder of why we care so much about getting long-term care right. Ross reports “we plan to release the film for purchase on line off our website on May 15th. So stay tuned. Finally, Kevin Jameson of the Dementia Society of America and [Ross] were interviewed by John Ralston on WNPV's Bucks Mont Live program last week.” Listen to that interview here beginning at 5.5 minutes in. ***

LTC BULLET: FEDER FANTASY FATALLY FLAWED (COHEN CONTRIBUTION NOTWITHSTANDING)

LTC Comment: Professor Judy Feder dreams of expanding government financing (and control) of long-term care. Marc Cohen, Ph.D. is a respected analyst and advocate of private long-term care insurance. Oil and water?

Maybe not. They’ve put their heads together and come up with an ingenious concoction to fix public LTC financing and supercharge private LTC insurance with a single legislative remedy. But like any mixture of insoluble ingredients, it quickly comes apart.

Their paper, co-authored with Melissa Favreault, Ph.D. of the Urban Institute, is titled “A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance.” Read it first so you have the big picture and then come back here for our challenge and analysis.

Challenge: Frankly, I’ve had it with wishful-thinking plans like this that ignore the facts of long-term care financing reality. Below is a detailed analysis and refutation of this proposal, but first, here’s the crux of the matter and an invitation to its authors.

The fatal flaw in their proposal is that it purports to achieve major savings including a 15% cut in out-of-pocket LTC costs and a 23% reduction in Medicaid expenditures by increasing Medicare premiums for individuals and businesses, jaw-boning the purchase of LTC “gap insurance” (an oxymoron) and leaving Medicaid eligibility rules unchanged. None of this will work, as I explain below and elsewhere. In fact, it would make the long-term care financing problem much worse.

Yet these authors ignore their critics’ arguments. They claim against the facts that Medicaid LTC asset spend down is unavoidable and causes impoverishment, that middle class and affluent people taking advantage of Medicaid LTC benefits is rare, and that Medicaid estate planning amounts to little more than rumors. Instead of acknowledging and addressing our evidence and objections, they dodge them with misdirection, straw-man arguments, and equivocation on key terms like “impoverishment,” “spend down,” and “out-of-pocket.” We need to pierce the shield wall of “peer review” that enables scholars of conventional wisdom to ignore evidence and logic they don’t want to consider.

Therefore, I invite Judith Feder and/or Marc Cohen to a public debate of these issues in the venue of their choice. Let’s see whose arguments and conclusions the facts support!

Here’s what I propose: A formal debate with ten-minute opening statements by each side (total 20 minutes). Then three rounds (six questions total) with the discussants probing each other’s positions including a one-minute question, a three-minute-reply, and a one-minute rebuttal for each of the six questions (30 minutes). Q&A from the audience for any time remaining. Jury of objective reviewers chosen by voir dire to score, judge and report the result. Wouldn’t such an intellectual duel be entertaining, informative and a great draw for any germane conference? RSVP to smoses@centerltc.com.

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Analysis: Following are quotes from the Feder, Cohen, Favreault (FCF) paper with our comments.

FCF: “The intent with this design is twofold: first, to target publicly-financed benefits to expenses that exceed amounts that middle-income (along with higher-income) people can reasonably be expected to manage – either with private insurance or personal resources; and second, to enhance the attractiveness and purchase of the limited-coverage private insurance products that insurers prefer by positioning them as gap fillers that, in combination with public insurance, facilitate relatively comprehensive protection against LTSS costs.” (pps. 5-6)

LTC Comment: OK, sounds interesting. They want to use public funds only to cover what middle class people can’t afford. But wait, wasn’t that supposed to be the idea behind Medicaid “spend down?” They want to turn private insurance into a first-dollar “gap filler.” But wait, isn’t the purpose of insurance to replace the small risk of a catastrophic loss with the certainty of an affordable premium? Wouldn’t their plan be like using car insurance for oil changes? What are we really talking about here?

FCF: “A public catastrophic insurance program for LTSS costs that takes effect after an income-related waiting period has been met. … Eligibility … phased in over ten years, with people eligible for benefits once they work 40 quarters after the law’s enactment …. Benefits would become available once people incur impairments in 2+ ADLs and/or severe cognitive impairment … . Up to $110/day cash benefit (2014 dollars) … Paid out either daily or weekly … Unlimited benefit once an income-related waiting period is met … Waiting period of 1 year for people with lifetime incomes in the lowest two quintiles of the distribution and 2, 3, and 4 years for people with incomes in the third, fourth and highest quintiles, respectively. … Annual benefits increase at the rate that hourly costs increase for home health aide workers” (p. 7)

LTC Comment: My, that does sound complicated. Is the government up to handling such administrative complexity? What if I don’t think so and I want to say “no thanks?” They considered giving people the freedom to opt out, but “Though potentially feasible and a lighter political lift, previous analysis suggests that the scope of coverage would likely be much more limited with this approach.” (pps. 24-25) Ya think? You won’t find the words involuntary, mandatory or compulsory in the plan, but they do apply. Just like Social Security and Medicare; you’re in this program whether you want to be or not. So, hmmm, who’s going to pay for this new entitlement?

FCF: “The program would be financed in large part by increasing the Medicare tax split

between employees and employers that would begin at age 40. … For ease of estimating, we … estimated that an additional tax of about 1.0 percent of earned Medicare-covered income would be sufficient to finance the proposed program over the required period assuming that the surplus revenue from early years were invested in a secure Trust Fund.” (pps. 13, 22)

LTC Comment: Medicare already faces unfunded liabilities of $48 trillion. Its “trust fund” has nothing in it except IOUs for money the federal government has already spent on other things. Any new money we put into a long-term care trust fund will inevitably be misappropriated in the same way. This idea is like adding deck chairs to the Titanic after the incident with the iceberg. But we’re going to save a ton of money by reducing Medicaid expenditures and selling private LTC gap insurance, right?

FCF: “In fact, we project a public catastrophic program for older Americans would enhance LTSS spending by 14 percent, reduce out-of-pocket spending by 15 percent, and reduce Medicaid spending by 23 percent, compared to projected spending under current law. … The implication is that Medicaid will remain a vital part of the nation’s overall LTSS system – whether for people currently impaired or for people for whom our proposal is insufficient to provide meaningful insurance protection against substantial LTSS risk.” (pps. i, 25)

LTC Comment: This plan’s architects leave Medicaid, the dominant long-term care payor currently, in place. They propose no changes to Medicaid LTC eligibility and yet they expect to save almost a quarter of its cost. How? Blank out. There is nothing in this proposal to explain why consumer behavior with regard to Medicaid would change. Instead of paying privately or buying insurance to cover the plan’s one-to-four year waiting period before the new government program kicks in, people will go directly onto Medicaid as they do now. No savings will accrue to Medicaid. Nor will significantly more people buy LTC gap insurance than buy regular LTC insurance now for the same reasons. For the evidence to support this conclusion, see “The Fallacy of Impoverishment” (1990), “How to Fix Long-Term Care Financing” (2017), and our many state and national studies in between those publications here.

FCF: “While some have argued that the Medicaid program, which represents the largest public payer of LTSS, ‘crowds out’ or suppresses demand for private insurance, evidence suggests that the impact is likely modest in light of other issues affecting demand and that such effects are operant at the lower end of the income scale;⁵ even proponents of the theoretical argument for ‘crowd-out’ point to problems with the private products as an empirical explanation of the market’s failure to thrive.^{6,7,8,9,10,11,12}” (p. 2)

LTC Comment: “Some have argued” Medicaid crowds out private LTC insurance? Who? Blank out. We get not a single reference to the dozens of published reports (many, if not most, written by yours truly) that present the evidence that Medicaid exempts most assets, is easy to qualify for after care is already needed, and therefore desensitizes consumers to long-term care risk and cost, discourages early and responsible long-term care planning, undercuts the use of private resources to pay for long-term care by means of asset spend down, home equity conversion or private LTC insurance, and thus contributes to institutional bias by channeling people into nursing homes who could have paid for home care or assisted living. Instead, we get footnotes to eight sources that allegedly prove otherwise, but are easily refuted and were disproved contemporaneously. For example:

We refuted Footnote #9 (Waidmann, T., & Liu, K. (2006). Asset transfer and nursing home use: Empirical evidence and policy significance) with LTC Bullet: Kaiser Cover-Up Continues, Thursday, April 27, 2006: “Urban Institute ‘scholars,’ aided and abetted by the Kaiser Family Foundation, employed an underhanded straw man argument in the foundation's latest unsuccessful attempt to debunk the impact of Medicaid planning abuse.”

We addressed a fundamental flaw in Footnote #10 (Lee, J., Kim, H., & Tanenbaum, S. (2006). Medicaid and family wealth transfers. Gerontologist, 46, 6–13) with “LTC Bullet: Behind AHEAD,” Friday, September 2, 2016: “The people and organizations advocating a new, compulsory, payroll-financed government program to fund catastrophic LTC expenses base their arguments on dubious sources and reasoning.”

We refuted Footnote #12 (Wiener, J, Anderson, W., Khatutsky, G., Kaganova, Y and O’Keefe, J. (2013). Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform: Final Report) with “LTC Bullet: Medicaid Spend Down that Isn’t and Why it Matters,” Friday 19, 2013: “Claiming ‘transitions’ to Medicaid are evidence of catastrophic LTC asset ‘spend down’ misrepresents the truth and should be publicly recanted. [We explain:] Who, what, when, where and why.”

For a complete exposition of the evidence and logic refuting the argument that the proposed compulsory, payroll-financed, public catastrophic LTC insurance plan will reduce Medicaid expenditures and encourage the purchase of private LTC insurance, see “How to Fix Long-Term Care Financing.” That paper includes a “Supplemental Bibliography of Books, Elder Law Treatises and Law Journal Articles on Medicaid Planning Listed Chronologically with Dates of U.S. Economic Recessions and Passage of Major Legislation to Control Medicaid Planning” (pps. 34-63) and dozens of “Examples of Medicaid Planning Techniques; Home Equity Potential; Estate Recovery and Medicaid-Compliant Annuities” (pps. 64-65)

FCF: “At the same time, public ‘insurance’ – through Medicaid – supports services only after people pay what might be called an ‘infinite deductible’ – that is, only after they expend most, if not all, of their personal liquid financial resources.” (p. 2)

LTC Comment: Contributing income and cash resources toward one’s cost of long-term care is a tiny price to pay, while retaining for heirs all the wealth Medicaid routinely allows recipients to keep. In most states, Medicaid lets LTC recipients retain only $2,000 in cash or assets easily convertible to cash. But that doesn’t mean people have to spend down into impoverishment in order to qualify. Rather, they can retain virtually unlimited wealth in the form of home equity (at least $572,000 and up to $858,000 in some states) as well as unlimited amounts of personal belongings, home furnishings, one automobile, one business including the capital and cash flow, term life insurance, IRAs paying periodically (as they must do after age 70 ½), Medicaid-compliant annuities, life care contracts, and prepaid burials for the recipient and immediate family members. In addition to these routine exemptions, the use of trusts, “spousal refusal,” disinheritance, divorce, and numerous sophisticated “Medicaid planning” techniques make access to Medicaid long-term care benefits available to nearly anyone who chooses to take advantage of the program. Nor is income an obstacle to Medicaid LTC eligibility in most cases. Virtually unlimited income does not obstruct eligibility if medical and long-term care expenses are high enough, as they usually are for people in need of formal, paid long-term care.

FCF: “Changes in the political landscape have replaced efforts to reform federal LTSS financing, and instead are increasingly focused on limiting public LTSS spending. But financing challenges will continue to grow with the aging of the population. Research undertaken now on the design and challenges of specific proposals for LTSS financing reform will provide the necessary intellectual infrastructure and foundation for effective action when policymakers are inevitably forced to address the issue in the years ahead. (pps. 4-5)

LTC Comment: True, but what if future policymakers are facing the far more likely outcome that public programs are imploding because of their gargantuan unfunded liabilities? This new LTC plan only adds an extra bale of hay to the “camel’s back.” A far better and much simpler solution is to redirect public financing to those most in need and use some of the savings to incentivize early, responsible long-term care planning and private financing. For details on how to do this, see “How to Fix Long-Term Care Financing.”

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Updated, Monday, April 30, 2018, 10:25 AM (Pacific)

Seattle—

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LTC E-ALERT #18-017: LTC NEWS AND COMMENT

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:

A Data Dump That Could Make a Difference in Health Care
Largest LTCi Claim Exceeds $2 Million
Provider-sponsored Medicare Advantage plans seeing big growth in membership
Only 16% of retirees 'very confident' they can afford long-term care
The myth and reality of the Medi-Cal 'spend-down'
Retirees Come Face To Face With Longevity
Following a couple from diagnosis to the final stages of Alzheimer's
U.S. Pension Fund Collapse Isn't a Distant Prospect. It Could Come in 5 Years
Thousands of nursing home patients nationwide affected by NJ company's financial trouble
No Spend Down
Couples in retirement face average health care costs of $280,000, Fidelity estimates

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Updated, Friday, April 27, 2018, 10:08 AM (Pacific)

Seattle—

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LTC BULLET: RETIREMENT CONFIDENCE AND ASSET SPEND DOWN

LTC Comment: Two new EBRI studies shed light on how workers/retirees’ expectations and behavior differ, after the ***news.***

*** LTC CLIPPINGS: Three LTC Clippings sent this week to Center premium members follow. To inquire about premium membership including a subscription to LTC Clippings, contact Damon at 206-283-7036 or damon@centerltc.com.

4/18/2018, “U.S. Pension Fund Collapse Isn't a Distant Prospect. It Could Come in 5 Years,” by Aaron Brown, Bloomberg

Quote: “Warnings about looming public pension disasters have regularly cropped up since the 1950s, pointing to problems 25 years or more down the line. To politicians and union leaders, the troubles were someone else's predicament. Then crisis fatigue set in as the big problem remained down the road. Today, the hard stop is five to 10 years away, within the career plans of current officials. In the next decade, and probably within five years, some large states are going to face insolvency due to pensions, absent major changes. … The next phase of public pension reform will likely be touched off by a stock market decline that creates the real possibility of at least one state fund running out of cash within a couple of years. … I cannot see any plausible scenario in which full promised benefits are paid.”

LTC Comment: The perfect storm for all pensions and entitlements arrives no later than the 2030s when baby boomers start turning 85 and Social Security and Medicare have to cut benefits.

4/22/2018, “Following a couple from diagnosis to the final stages of Alzheimer's,” by Jonathan LaPook, CBS News

Quote: “For 10 years, Dr. Jon LaPook has been checking in on Carol Daly, a woman diagnosed with Alzheimer's, and her caregiver husband, Mike. After a decade, the disease has had a devastating impact on each of them.”

LTC Comment: We tipped you to this 60 Minutes episode in advance, but did you see it? If not, click through and watch it now. This may be the most powerful 12 minutes you, your prospects and clients will ever see about Alzheimer’s disease. Here’s how longtime Center friend and premium member Bill Rives, Ohio State University Finance Professor Emeritus, described it to me.

“You may have caught it, but if not, you really need to see the final segment of 60 MINUTES yesterday (APR 22). Producers have been following a husband and wife for the last decade. She was diagnosed with Alzheimer’s in 2006 (or thereabouts) and he (a retired police officer) is her sole caregiver. They conducted a 20-30 minute interview once a year each year. The couple agreed to the interviews because they wanted people to see what Alzheimer’s does over time as the patient deteriorates (not to mention the caregiver). I watched the episode last night. Sad, depressing, insightful. They play segments from all the early interviews to show how her condition has gradually melted away. She goes from being able to answer any question to not knowing anything – not even her or her husband’s name. Her husband also goes from being upbeat about prospects to someone who admitted that he’s contemplated suicide more than once in the last few years. People in denial about the ravages of Alzheimer’s should watch these episodes. Much more powerful than all the articles and data on the disease. It’s hard to sit there and not think, ‘This could be me.’”

4/24/2018, "The myth and reality of the Medi-Cal 'spend-down'," by Philip P. Lindsley, San Diego Union-Tribune

Quote: “What’s the reality? The need to ‘spend down’ is almost never true. There are many assets that are considered exempt or unavailable and are not counted in the qualification process. Just two of several examples would be the home and all IRAs and other pension plan funds. There are also other substantial additional allowances and planning opportunities available for those who are aware and use them. Few do.”

LTC Comment: Few do? Hardly. Most do. Not because most consult Medicaid planners. They don’t, though many do. Rather, Medicaid eligibility workers routinely explain all the asset exemptions and even some of the “loopholes.” After all, they’re social workers; they want to help people, and it’s only government money, right? Ironically, whether or not you qualify for Medicaid benefits depends as much on how “caring” your worker is as on the rules and how much wealth you possess. ***

LTC BULLET: RETIREMENT CONFIDENCE AND ASSET SPEND DOWN

LTC Comment: Two recent reports by the Employee Benefit Research Institute enlighten us about retirement planning versus performance. EBRI’s “2018 Retirement Confidence Survey” is their latest in the longest running (28 years) survey series covering worker and retiree confidence about retirement. Also published by EBRI this month is “Asset Decumulation or Asset Preservation? What Guides Retirement Spending?,” by Sudipto Banerjee, which bursts a long-standing myth about asset “spend down.”

Let’s consider retirement confidence first. We’ll quote EBRI’s Retirement Confidence Survey (RCS), then comment.

RCS: “The share of workers who feel very confident in their ability to live comfortably in retirement remains low at just 17%, but another 47% are somewhat confident. … Retirees remain more confident than workers, with a third (32%) very confident and another 44% somewhat confident that they will have enough money to live comfortably throughout retirement.”

LTC Comment: Almost 2/3 (64%) of workers and over ¾ (76%) of retirees feel confident about their economic security in retirement. What are they smoking? Are they inEBRIated? Evidently workers and retirees haven’t read the omnipresent reports that they’re saving too little and depending on public programs and pensions too much.

RCS: “Why are workers confident? Workers [76%] appear to be very positive about their workplace defined contribution (DC) retirement plans and that may be impacting overall retirement confidence. Those with a DC plan are far more likely to be confident in their ability to live comfortably in retirement.”

LTC Comment: Now, that’s interesting. Remember how progressives lament the transition from “guaranteed” public and company pensions to defined contribution plans that employees own personally? Looks like those DC plans are propping up workers’ confidence in the face of widespread reports of impending entitlement shortfalls and pension collapses.

RCS: “Why are retirees less confident? Retirees’ overall confidence shows signs of decline, but their confidence in being able to afford medical and long-term care expenses in retirement is down significantly. Relatedly, their confidence that Social Security and Medicare will continue to provide benefits equal to what retirees receive today has decreased.”

LTC Comment: Ah-ha! Retirees are finally starting to awaken to the real financial risks they face: growing health and LTC costs exacerbated by impending safety net cuts.

RCS: “Only 19% of workers and 39% of retirees have tried to calculate how much money they would need to cover healthcare costs in retirement.”

LTC Comment: In other words, the vast majority of workers and retirees have no clue what they’ll need in retirement and no idea what it’ll cost. Evidently, their “feelings” of confidence recorded by EBRI have no basis in reality. Why might that be? Social entitlements like Medicare, Medicaid and Social Security have provided a false sense of security for many decades which unfounded confidence is eroding now as those programs’ unfunded liabilities approach the terminal stage.

RCS: “Two in three retirees report Social Security is a major source of income, while only about a third of workers believe Social Security will be a major source. … Workers expect to rely on their workplace DC retirement plans as a source of income in retirement far more than retirees report they have. Eight in ten believe this will be a major or minor source of income in retirement, compared to just 50% of retirees.”

LTC Comment: QED. The inevitable sea change from government dependency to personal responsibility is underway as workers lose confidence in entitlement programs and gain confidence from their ownership of real assets.

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Let’s turn now to the other April EBRI report: “Asset Decumulation or Asset Preservation? What Guides Retirement Spending?,” by Sudipto Banerjee. Our comments follow quotes from “ADAP.”

ADAP: “One of the assumptions underlying many models used to measure retirement income adequacy is that retirees will spend down their accumulated assets to fund their retirement needs. While this may make sense in theory, do people actually behave like this?”

LTC Comment: Wow! Someone is finally asking the right question. The universal assumption among academics is that wide swaths of the American public spend themselves into impoverishment on long-term care expenses before qualifying for Medicaid. Of course, as I’ve shown in many studies, Medicaid does not require that and there is no evidence it’s true. So, what is the reality?

ADAP: “Over the 18-year period, there was a very small drop in the median assets of this group [those who started retirement with less than $200,000 in non-housing assets], from $31,740 (after 1- 2 years of retirement) to $24,000 (after 17 - 18 years of retirement). This was only a 24.4 percent drop. Such a rate of asset decumulation was definitely much lower than what has been traditionally assumed by most retirement models.”

LTC Comment: Interesting. How about the other groups studied, i.e. those with $200K to $500K at retirement and those with more than $500K?

ADAP: “In the first two years of retirement, the non-housing asset median for Group B [$200K to $500K] was $333,940. After 13-14 years of retirement the median was still above $300,000 (at $301,620). By the 17th-18th year of retirement, the non-housing asset median was $243,070, a 27.2 percent drop compared to the asset median in the first two years. So, in this group as well, retirees did not spend down their assets as quickly as retirement models would generally predict.”

“The asset decumulation rate was even slower for this group [those with over $500K]. The non-housing asset median for retirees in this group was $857,450 in the first two years of retirement. After 19-20 years of retirement, the median dropped to $756,300 – an 11.8 percent drop. So, the group with the highest level of assets had the lowest rate of asset spend down.”

LTC Comment: OK, the more you have, the more you’re able to retain. No great insight there. What can we glean from these findings?

ADAP: “Discussion Why are retirees not spending down their assets? There are probably a number of reasons. First, there are the uncertainties. People don't know how long they are going to live or how long they have to fund their retirement from these assets. Then there are uncertain medical expenses that could be catastrophic if someone has to stay in a long-term care facility for a prolonged period. Of course, if people have to self-insure against these uncertainties, they need to hold onto their assets. Second, some of these assets are likely to be passed on to their heirs as bequests. But, what percentage of actual bequests are planned vs. accidental is an open question. Third, another possible reason for this slow asset decumulation rate could be lack of financial sophistication, or in other words, people don't know what is a safe rate for spending down their assets. So, they are erring on the side of caution. Finally, some of it could be just a behavioral impediment. After building a saving habit throughout their working lives, people find it challenging to shift into spending mode. They continue to build up their assets or hold on to their assets as long as possible.”

LTC Comment: Gee, that’s very complicated. Let me offer a simpler explanation. Decades of academic studies and media reports have convinced the public they will lose everything if they succumb to the high risk of needing long-term care. So, as best they can, people preserve their assets and spend only income. But catastrophic 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.

ADAP: “This EBRI study shows that the majority of retirees do not spend down their assets in the first two decades of their retirement. This behavior is not limited to those with lower levels assets. In fact, those with the highest level of assets show the lowest rates of spending down. … When household income of retirees is compared to household spending, the study finds that majority of households indeed limit their spending to their income.”

LTC Comment: This drives home a point I’ve made repeatedly over the years. As much as possible, people retain their assets (for security and/or bequest) and spend only their income. Then, when long-term care becomes necessary, it’s the assets their heirs want to preserve. Heirs have not had the use of their parents’ income so turning it over to Medicaid is no loss. But the assets, including home equity, personal belongings, IRAs, the car, etc. are tempting and easy to preserve. Most Medicaid eligibility workers will explain how to save most assets. Medicaid planning attorneys will show how to preserve the rest.

Closing LTC Comment: Academics pull their hair out trying to explain consumer behavior. For example: why are people more confident about their retirement security than they should be objectively? Why do they spend down less in retirement than logic and asset decumulation models suggest they should? Researchers will never find the answers as long as they cling to their belief in social insurance and the myth of Medicaid spend down.

As people adjust positively to owning their savings (defined contribution plans) and negatively to the impending curtailment of public safety net programs (welfare, Social Security, Medicare and Medicaid), they’re becoming more realistic. They’ll save and insure more and place less and less confidence in government entitlements. The big question is whether the 70-plus-year assault on personal responsibility by public promises of retirement security has gone too far for a healthy private economy to recover. I fear it has.

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Updated, Monday, April 23, 2018, 9:18 AM (Pacific)

Seattle—

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LTC E-ALERT #18-016: LTC NEWS AND COMMENT

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:

Most who collect long-term care insurance benefits not in nursing homes
Opinion: What the rise of dementia may mean for your financial future
New Census Bureau data show steady increase in prospective residents
This state won’t extend Medicaid benefits to elderly nuns
Home Sharing: Growing Trend or Desperate Need?
IG: OPM Needs Contingency Plan for Long-Term Care Insurance
Many Retirees Are Not Spending Down Their Accumulated Assets To Fund Their Retirement Needs
High-quality, short-term nursing stays lower risk of seniors entering long-term care
Investors Should Still Be Skeptical About GE's Long-Term Care Obligations
Thought Leaders Want Alzheimer's At The Top Of G20 Agenda
Are Medicare Advantage Plans Steering Enrollees to Lower-Quality Nursing Homes?
Clichés about only being as old as you feel are starting to have scientific backing
65% of Baby Boomers Are Making a Huge Financial Mistake That Could Leave Them Broke

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Updated, Friday, April 20, 2018, 9:18 AM (Pacific)

Seattle—

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LTC BULLET: THE END OF ALZHEIMER’S

LTC Comment: Is there hope for delaying, mitigating, even ending Alzheimer’s? We report, you decide, after the ***news.***

4/19/2018, “New Census Bureau data show steady increase in prospective residents,” by Lois A. Bowers, McKnight's Senior Living

Quote: “Most U.S. older adults who make the move to a senior living community do so between ages 75 and 84, according to the American Seniors Housing Association's Where You Live Matters consumer education campaign. Data released by the Census Bureau on Thursday show a steady increase in the number of 75-year-olds from the years 2010 to 2017.”

LTC Comment: OK, but you ain’t seen nothin’ yet. Baby boomers don’t start turning 75 until 2021. After that, look out!

4/17/2018, “This state won’t extend Medicaid benefits to elderly nuns,” Associated Press

Quote: “A vow of poverty by more than 20 elderly nuns isn’t enough to qualify for Medicaid in Nebraska. The state cut Medicaid benefits earlier this year for the Sisters of Mercy, one of the oldest Roman Catholic religious orders in Nebraska, the Omaha World-Herald reported. … The state fears that expanding Medicaid to cover the Sisters of Mercy could prove costly if other people also qualify. Ignoring the sisters’ patrimony requires accounting for tithing in income qualification reviews of Medicaid recipients of all faiths, state officials said. Doing so could cost Nebraska $3 million annually by adding more than 300 Medicaid recipients by 2020.”

LTC Comment: How ironic. When I did the following study back in 2003, Nebraska routinely granted Medicaid LTC benefits to middle class and even savvy affluent people: The Heartland Model for Long-Term Care Reform. Not much has changed because many of the same mandatory eligibility loopholes still exist in federal law and regulation.

4/15/2018, “65% of Baby Boomers Are Making a Huge Financial Mistake That Could Leave Them Broke,” by Christy Bieber, Motley Fool

Quote: “Many pre-retirees think they don't need to worry about healthcare because they anticipate care costs will be covered by Medicare. But the reality is that Medicare makes seniors responsible for picking up a significant percentage of their cost of care. Seniors may face high deductibles, coinsurance costs, premiums, and coverage limitations. … There are also many services Medicare doesn't cover, including hearing aids, long-term care, and dental care. … Qualifying for Medicaid could also help you afford care costs by subsidizing Medicare premiums and paying for some services not covered by Medicare, such as routine nursing home care. While there are strict asset limits to obtain Medicaid, an attorney can help you to develop a plan that protects your wealth and still allows you to obtain coverage.” (Emphasis added.)

LTC BULLET: THE END OF ALZHEIMER’S

LTC Comment: Everything about Alzheimer’s disease jades me with pessimism, hopelessness and worry. Research goes nowhere. Incidence increases. Costs rise. Funding languishes. Patients and families suffer. Analysts and policymakers dither. You want to throw up your hands and cry “What’s the use?”

So, when a serious, well-credentialed, highly experienced research neurologist says cognitive decline is not inevitable, is actually reversible, and claims he has the evidence to prove it, we should at least listen. Today’s LTC Bullet introduces you to Dr. Dale Bredesen’s book The End of Alzheimer’s: The First Programme to Prevent and Reverse the Cognitive Decline of Dementia.

I’ve compiled a few pages of quotes from the volume to give you a sense of its content and argument. But first, here’s my takeaway in a nutshell. Alzheimer’s disease is not a single malady like cancer. So targeting a single cure, such as removing amyloid plaques, doesn’t work. Rather, cognitive decline leading to Alzheimer’s comes from a variety of sources, especially poor diet, lack of exercise, deficient sleep, and excessive stress. Eliminate those causes and, Bredesen’s research and clinical results show, cognitive decline can be avoided, stopped, reversed and Alzheimer’s evaded even in people who carry genes that predispose them toward the disease.

The following quotes from the book give you only a conceptual framework to consider. I haven’t attempted to summarize the extensive research, findings, case studies, or specific recommendations you’d need to consider to judge conclusively. I recommend that you get the book and see for yourselves.

Hopelessness:

“It is impossible to escape the drumbeat of grim news about Alzheimer’s disease: that it is incurable and largely untreatable, that there is no reliable way to prevent it, and that the disease has for decades beaten the world’s best neuroscientists.” (p. 3)

False start:

“[S]eemingly rock-sold evidence from lab rodents suggested that Alzheimer’s disease is caused by the accumulation in the brain of sticky synapse-destroying plaques made of a piece of a protein called amyloid-beta. (p. 6)

“But here’s the thing: when drug companies tested compounds that are based on any piece of the amyloid hypothesis, the results have ranged from frustrating to bewildering. … the experimental compounds did precisely what their inventors intended, following the amyloid rule book, but patients either got no better or, incredibly, got worse. … Targeting amyloid was supposed to be the golden ticket to curing Alzheimer’s. It wasn’t.” (p. 7)

False assumption:

“Just as tragic as the blinkered adherence to the amyloid hypothesis is mainstream medicine’s assumption that Alzheimers is a single disease.” (p. 7)

“Alzheimer’s is not a single disease. … [T]here are three main subtypes of Alzheimer’s. … Each one requires a different treatment. … Type 1 is inflammatory (hot). … Type 2 is atrophic (cold). … Type 3 is toxic (vile).” (pps. 9, 98, 102, 104)

“Alzheimer’s ‘disease’ is not the result of the brain doing something it isn’t supposed to do, the way cancer is the result of cells proliferating out of control or heart disease is the result of blood vessels getting clogged with atherosclerotic plaque. Alzheimer’s arises from an intrinsic and healthy downsizing program for your brain’s extensive synaptic network. … In Alzheimer’s, an otherwise normal brain-housekeeping process has gone haywire.” (pps. 12-13)

The right track:

“Contrary to the current dogma, therefore, what is referred to as Alzheimer’s disease is actually a protective response to, specifically, three different processes: inflammation, suboptimal levels of nutrients and other synapse-supporting molecules, and toxic exposures.” (p. 16)

Hopefulness:

“Let me say this as clearly as I can: Alzheimer’s disease can be prevented, and in many cases its associated cognitive decline can be reversed.” (p. 10)

“These are bold claims deserving of healthy skepticism. I expect you to exercise that skepticism as you read about the three decades of research in my lab, which culminated in the first reversals of cognitive decline in early Alzheimer’s disease and its precursors, MCI (mild cognitive impairment) and SCI (subjective cognitive impairment).” (p. 10)

“By following the protocol I describe, those with cognitive impairment that is not yet Alzheimer’s disease, as well as those who are already in the grip of Alzheimer’s, can not only halt but often actually reverse the cognitive decline they have already suffered.” (pps. 10-11)

“Called ReCODE, for reversal of cognitive decline, the protocol not only achieved the reversal of cognitive decline in Alzheimer’s disease and pre-Alzheimer’s that no one thought possible; it also allowed patients to sustain that improvement.” (p. 13)

The stakes:

“Because Alzheimer’s disease strikes an estimated one in nine Americans 65 and older, or 5.2 million people as I write this, the aging of the baby boom generation threatens to bring a tsunami of Alzheimer’s immense enough to bankrupt medicare and Medicaid and overwhelm the nation’s long-term care facilities—to say nothing of the toll it will take on tens of millions of families whose love ones are swallowed by this merciless disease.” (p. 15)

“[I]f enough people adopt ReCODE, the consequences would ripple across the nation and the world, cutting medical costs by many billions of dollars a year, preventing Medicare’s bankruptcy, reducing the global burden of dementia, and enhancing longevity. All of these are feasible.” (p. 15)

ReCODE:

“The solution is a very effective combination of DESS (diet, exercise, sleep, and stress reduction)—which is so important for your cognitive health that you might call them your ‘desstiny’—along with some simple supplements and, as a last resort, medication.” (p. 177)

Diet: “This is a largely plant-based diet with an emphasis on vegetables, especially nonstarchy ones. It is best to include both uncooked vegetables, such as those in salads, and cooked ones, and to include as many colors as possible, from deep green to bright yellow and orange. Some fish, poultry, and meat are fine, but remember that meat is a condiment, not a main course.” (p. 180)

Exercise: “Sitting is the new smoking! … We are sitting ourselves to death! Research has shown not only that exercise is beneficial, but that sitting is detrimental to cognitive and physical (especially cardiovascular) health. … What is the optimal exercise for cognition? You want to combine aerobic exercise, such as jogging or walking or spinning or dancing, with weight training, preferably at least four or five days per week, for 45 to 60 minutes in total each day.” (p. 191)

Sleep: “When I asked whether [an expert in Alzheimer’s disease evaluation and clinical research] saw any differences between those who continued to decline [from mild cognitive impairment] and those who improved [avoiding Alzheimer’s] she thought about it for a few moments. ‘Yes,’ she said, ‘the ones who get good sleep are the ones who tend to improve.” (p.192) Then follows “how to optimize your sleep, thus improving brain function.”

Stress: “Stress is a factor in most cases of cognitive decline, but an especially strong one in type 3 (toxic) Alzheimer’s disease, MCI, or SCI. For those individuals, stress worsens cognition especially rapidly. The onset of cognitive decline in such patients often coincides with a period of great stress.” (p. 197)

Go figure:

“If someone had told me a few decades ago that, as a research neurologist, I would be recommending protocols that involve medication, yoga, laughter, music, joy, fasting, exercise, herbs, nutrition, and sleep, I would have laughed. But I cannot argue with results, or with the conclusions of years of research.” (p. 247)

Summary:

“Cognitive decline, including dementia, is a hugely complicated process, affected by dozens of factors. Targeting all of the factors that are relevant to your case in order to change the course of illness has yielded the greatest success to date. The fact that no one of these alone is curative does not mean that a combination may not be helpful.” (p. 265)

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Updated, Monday, April 16, 9:18 AM (Pacific)

Seattle—

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LTC E-ALERT #18-015: LTC NEWS AND COMMENT

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:

Report identifies seven ways to prevent dementia
Improper payments, bad data threaten access to long-term care, GAO health leader testifies
How Growing Inequality Is Altering The Long-Term Care Policy Battlefield, While Tightening The Financing Knot
Breakthrough: Researchers fix Alzheimer's gene
Is There Such A Thing As Normal Aging?
Kaiser Study: Nursing homes have fewer residents, but those residents need more help
Group Defends Stand-Alone Long-Term Care Insurance With Infographic
Older Pre-Retirees Worry a Lot About Social Security: Gallup
New way of defining Alzheimer’s aims to find disease sooner
Beyond mystery meat
Do You Have What It Takes? A Workbook in Preparation for Caregiving
Why Americans' Life Expectancy Is Getting Longer
Arthritis: Long Term Pain May Require Long Term Care
The deeper cause behind the school strikes: Teachers are competing with the elderly

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Updated, Monday, April 13, 10:26 AM (Pacific)

Seattle—

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LTC Bullet: LTCI’s Responsibilities

LTC Comment: Today’s guest author, LTCI specialist Gene Cutler, asks what responsibilities LTC insurance producers, distributors and carriers have to current and future clients, after the ***news.***

***LTC CLIPPINGS: Following are a couple of our recent “LTC Clippings.” To subscribe and receive the clippings by email once or twice per day, contact Damon at 206-283-7036 or damon@centerltc.com. ***

4/11/2018, “Is There Such A Thing As Normal Aging?,” by Bruce Horowitz, Kaiser Health News

Quote: “Drawing on their decades of practice along with the latest medical data, Gill and three geriatric experts agreed to help identify examples of what are often — but not always – considered to be signposts of normal aging for folks who practice good health habits and get recommended preventive care.”

LTC Comment: If you’re older, read this article to see how you’re doing in comparison to others. If you’re younger, find out what you have to look forward to!

4/10/2018, “How Growing Inequality Is Altering The Long-Term Care Policy Battlefield, While Tightening The Financing Knot,” by Karl Polzer, Health Affairs Blog

Quote: “For many years, long-term care (LTC) policy makers have tended to fall into two warring camps: those favoring expanded social insurance, and those wanting tighter Medicaid eligibility criteria to incentivize people to plan for and buy LTC insurance. Both sides have warned of looming financial catastrophe as the Baby Boomers move into retirement and more than double the population needing care. Disagreement has resulted in a policy stalemate. The vanguard of the Boomer generation is less than 10 years away from beginning to drive up demand for LTC, and the country is unprepared to pay for it. It’s time that the policymakers stepped out of the old trenches. The war they’ve been fighting is largely obsolete.”

LTC Comment: Congratulations to longtime friend and fellow LTC policy plodder Karl Polzer for publication of this piece on the Health Affairs Blog. Read it for sure, but keep in mind that as pessimistic as its message is, the reality is much bleaker. None of the interventions he mentions would mitigate the impending LTC financing crisis significantly. Such proposals address only symptoms, not the cause, i.e. easy access to Medicaid LTC benefits after the insurable event has already occurred. I address that cause and propose a realistic solution in How to Fix Long-Term Care Financing, published last July by the Foundation for Government Accountability and the Center for Long-Term Care Reform. Read it for balance.

LTC BULLET: LTCI’S RESPONSIBILITIES

LTC Comment: I’ve known Gene Cutler and followed his career for over 20 years. He is one of the top LTCI producers in the country. When someone like Gene becomes concerned about how his industry is treating customers, he bears hearing. So here’s what Mr. Cutler wants to say to you and ask. Contact him directly to reply at gene.cutler@acsiapartners.net and copy ltcbullets@centerltc.com to keep us in the loop as we’re interested too.

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“What are LTCI’s Responsibilities to Customers?”
By
Gene Cutler

I have been a long term care specialist exclusively since 1994. I’ve placed well over $7,000,000 of business with the major carriers, some of which are still writing LTCI and some no longer accepting new business.

I frequently hear from clients I’ve written well over 20 years ago to update me. They say they’ve “become that person you were there to introduce me to … the one I didn’t want to meet.” They reassure me that the reasons for taking out this coverage have become clearer and more meaningful, validating not only their worries at the time but also my efforts to awaken them to long-term care risk.

We gave good advice back then. We should be there again as industry evolution and adjustments require our clients once more to make difficult decisions. They need our guidance and recommendations, which have proven so right.

I’m looking for suggestions from those of us who have made it our mission to help clients confront the unavoidable and disconcerting challenges that long-term care planning resolves. Specifically, I seek reassurance that when care needs arise, long-term care providers will be there as promised.

As our industry has evolved and companies have stopped accepting new applicants, our existing clients need to feel confident they will receive the benefits their policies promise. This is true now more than ever, as necessary rate adjustments have been approved and implemented.

The challenges for policyholders arise when they receive notifications pronouncing 50, 65, 80 percent + increases--unexpected and unwelcome--typically stating an increase on page 1 followed by multiple pages rationalizing why and offering options--scripted by attorneys and actuaries--that are too often more confusing than clarifying. In this situation, customer support is critically needed to clarify and advise, but carriers have downsized or outsourced channels, ultimately causing additional frustrations.

As writing/servicing agents, we are all motivated, willing and able to console, explain and advise clients if and when we are notified in advance and provided with the options. Some carriers do notify us ... some don’t. If a policyholder can’t get through to the carrier and/or frustration leads to a potential lapse, the agent should be there to help the client maintain the original objectives of the plan with appropriate modifications. But that can happen only as long as the carrier notifies the agent of an impending lapse.

Long-term care insurance carriers have declined in number from over 100 at one time down to perhaps 15 now. Some were up to the task of guiding their insureds through these difficulties initially upon departing the business, while many have clearly reduced policyholder services. Some never intended to notify the agent of impending lapses, prompting if not encouraging higher lapse rates.

Is that part of their business model? Where are the State Departments of Insurance and the regulators? NAIC? Tax incentives and LTC Partnerships were intended to emphasize financial concerns and transfer this risk into the private sector, yet a blind eye to this unfortunate behavior will bring it right back to states and the federal government.

I’d like to believe that the initial intentions of both producers and carriers when we encouraged these transactions were and remain honorable and supported as policyholders approach potential claims. I’d like to feel that companies still in the game maintain the commitment they advertise in marketing promotions, and that they will enable us, as the points of contact for the industry with their insureds, to support policyholders’ rights with confidence and sincerity. Our clients deserve no less.

Major carriers still want us to promote other products on their behalf, such as Life/Health/Annuities, etc., as we once did their LTCI products. They emphasize their customer support, as they once did for LTCI, should problems arise or claims occur. Are we as comfortable and confident as we once were that we will be able to give that support?

What can we do?

Think about calls you’ve handled recently, or wished you could have handled better. Express your concerns through your wholesalers. Make recommendations to your clients based on your confidence and experience with the carrier.

I’ve heard it said many times that LTCI specialists have a passion about their work that other specialists don’t exhibit. Our passion arises from the satisfaction of listening to and then addressing a client’s worst fears. It is justified and reinforced as years go by. In the end, those clients and their families understand and express appreciation for the value of our advice. That instills the confidence in each one of us to continue.

It would be nice to believe our carriers feel the same.

Gene Cutler, Master Agent, ACSIA Partners, gene.cutler@acsiapartners.net

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LTC Comment: Gene Cutler isn’t the only source of LTCI industry self-analysis and self-criticism. We’ve noticed a lot of healthy introspection among thought leaders in the business lately. Another example is Ron Hagelman’s excellent recent columns in Broker World. We highlighted one of them in LTC Bullet: The Medicaid Prevention Business. Here’s an excerpt from another, titled “Monday Morning Quarterback” in the magazine’s March 2018 issue.

All our futures in long term care insurance must now be guided not by our past success of a mere 8 million policy owners after 20 years, but by the 54 million we failed to encourage to “do the right thing.” The truth is we have been looking at this from the wrong end of the telescope. It was not how big and simple that was needed—it was how small and customized to the actual circumstance and dimensions of the most likely claim experience! The corollary truth is that for too long our goal has been to replace as much risk as possible with insurance. The affluent have always done just that and I see no reason for them to stop. Our goal should have been how many can we save from the intrinsic inadequacies of government dependence. How little is needed to maintain the freedom of choice that comes from remaining a private pay patient?

I wish I could say we’re seeing the same kind of modesty and self-review among the advocates of government financing. After all, they created the mess we’re in with inadequate retirement, health care and long-term care funding. But they only advocate more entitlement spending, which further anesthetizes the public to financial risk and loads the country with unprecedented debt. Doing the same thing and expecting a different result is, in a word, nuts.

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Updated, Monday, April 9, 10:26 AM (Pacific)

Seattle—

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LTC E-ALERT #18-014: LTC NEWS AND COMMENT

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:

2 Big Financial Shocks That Most Retirees Face
Understanding the Hidden $1.1 Trillion Welfare System and How to Reform It
The National Debt Grew by $1 Trillion in Just Six Months
Insurers likely to add and trim senior living benefits, thanks to relaxed Medicare rule
All-cause mortality is increased for older adults with sudden loss of wealth in the US
Caring for elderly parents can put a dent in your budget
The Long-Term-Care Insurance Dilemma
Insurer that cheated seniors raising rates again
Why you shouldn’t bother with memory or brain health supplements
What You Need To Know About Social Security and Medicare Changes for 2018
DNA and Long-Term-Care Insurance
U.S. government sets 3.40 percent hike in 2019 payments to Medicare insurers

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Updated, Friday, April 6, 11:45 AM (Pacific)

Seattle—

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LTC Bullet: The State of LTCI: Myths, Facts and the Wall Street Journal Article

LTC Comment: Tired of reading misguided and bad information in media coverage of long-term care insurance? MAGA’s Brian Gordon offers a much-needed reality check by rebutting the infamous “Wall Street Journal article” with facts, after the ***news***.

*** Those who attended the closing session (The Coming Revolution in Long Term Caregiving: The Future is Now!) at last month’s ILTCI conference know that technology and robotics will play an increasingly substantial role in caregiving going forward. However, in the meantime, caregiving continues to affect real people in real ways. Here are two recent articles we sent to our Clipping Service subscribers that deal with the current and forthcoming caregiving challenges we face. To inquire about our Clipping Service, contact Damon at 206-283-7036 or damon@centerltc.com. Please enjoy these sample clippings:

4/4/2018, “Caring for elderly parents can put a dent in your budget,” by Sarah O’Brien, CNBC

· Quote: “The biggest monthly expenses for caregivers are medicine and medical supplies ($273), food ($159) and personal-care items ($151).

· About half of current and past caregivers did not know in advance that they would be stepping into that role.

· In advance of finding yourself in that situation, whether expected or not, it's worth having a conversation with your parents about how they envision their care if they reach a point where they no longer can care for themselves.”

LTC Comment: Sound advice.

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3/26/2018, “As Trump Targets Immigrants, Elderly Brace To Lose Caregivers,” by Melissa Bailey, Kaiser Health News

LTC Comment: Politics + demographics = LTC - TLC. ***

ltc Bullet: The State of LTCI: Myths, Facts and the Wall Street Journal Article

LTC Comment: Recently we, at the Center for Long-Term Care Reform, celebrated 20 years in operation. In those 20 years, we’ve published over 1,200 LTC Bullets and have all of them archived on our website by date and by subject. One of those vital subjects we call “Reality Check: The Facts on LTCI.” This is where we store over 120 LTC Bullets, dating back to 1998, that address inaccuracies and faulty data that abound in media coverage of long-term care insurance. Lately, with the abundance of LTCi-related inaccuracies, faulty data and bad advice in the popular press, we’ve added a lot of “Reality Check” LTC Bullets to our archive. Today, we add one more. This latest addition is a guest LTC Bullet by Brian Gordon, president of MAGA Ltd., a CLTCR corporate member. We wish to thank Brian Gordon and MAGA for their role in protecting people from the risk and cost of long-term care. Reprinted with permission is Brian Gordon’s piece: “The State of LTCI: Myths, Facts and the Wall Street Journal Article.”

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“The State of LTCI: Myths, Facts and the Wall Street Journal Article.”

by Brian Gordon

By now, you've probably read Leslie Scism's Wall Street Journal article, "Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice." The "awful choice" in question is Ms. Scism's assertion that today, LTCI policyholders must either 1) accept large premium increases or 2) drop their coverage.

We found this gloom-and-doom argument-that there is no other reality and no other options-to be misleading and incomplete. Most disturbingly, it invites consumers to throw up their hands in despair, rather than encourage thoughtful long term care planning.

On the plus side, this opinion piece sparked an important conversation, eliciting a range of responses. Here is our rebuttal to some of the key points in the WSJ editorial.

WSJ: Today, LTCI insureds have two bitter choices: pay stiff premium increases or forfeit coverage.
Fact: Those facing increases (not everyone is) have multiple solutions available to them. Most LTCI insureds can keep their policies inforce and premiums down simply by modifying their benefits-solutions known as "landing spots." For example, we've recommended to clients that they reduce their inflation rider benefit-say, from 5% to 3%-or shorten their benefit period, resulting in little or no premium change. Most clients are receptive and it's worked very well.

WSJ: LTCI carriers made a huge pricing mistake and now their insureds will pay for it forever in the form of steep rate increases.
Fact: It's true that when actuaries first priced LTCI 40+ years ago, they made some mistaken assumptions-not uncommon with brand new insurance products. They assumed more insureds would drop their policies than actually did so, and they did not foresee a decade of historically low interest rates. Combined with larger-than-anticipated claims that lasted longer than expected, it resulted in "a perfect storm." As a result, older LTCI policies have seen larger rate increases as more claims are paid on older policies.

However, in recent years, carriers have corrected their pricing. Consider this: rate assumptions made in 2014 were based on 16 times as much actuarial experience as those made in 2000. Companies are more informed. We do prime clients purchasing traditional LTCI today to expect some modest rate increases, just like their car and health insurance.

WSJ: When an insured's LTCI premiums increase, they're getting a raw deal.
Fact: Actually, a reason some insureds' LTCI premiums have increased is because they got way too good a deal in the first place. In some cases, they received incredibly valuable protection at what we now know was unsustainable premiums. Many older LTCI policies offered such generous benefits-for example, lifetime coverage-that they cannot be purchased today.

WSJ: Since hybrid/combo LTCI products are costly, they aren't worth consideration.
Fact: To dismiss the entire spectrum of hybrid/combo LTCI policies wholesale is disingenuous. (In WSJ's 50+ paragraph article, only a single paragraph addressed hybrid policies, which now are nearly as popular as traditional LTCI policies.) Yes, premiums are higher-because hybrid products by their nature include additional benefits, such as life insurance or an annuity. However, they can also offer guaranteed premiums and peace of mind-for some clients they make excellent sense.

WSJ: With such limited choices, why bother with long term care planning at all?
Fact: Americans face a proven likelihood of needing long term care at some point, and Medicaid is a solution intended for only the poorest individuals. To forsake long term care planning altogether may be shortsighted, particularly for families with enough assets to engage a professional financial planner. Between traditional LTCI policies, hybrids and the option of self-funding or partially self-funding one's long term care risk, there are numerous long term care funding solutions available.

If you'd like to explore this topic further, we suggest reading the recent Forbes article, "Why the WSJ Is Wrong about Long- Term Care Planning," by Jamie Hopkins, the Co-Director of the American College's New York Life Center for Retirement Income and an Associate Professor of Taxation at the American College. And if you'd like to discuss this further with us, please don't hesitate to get in touch.

MAGA Ltd is a LTCI pioneer established in 1975. The award winning MAGA team provides education to consumers, financial advisors and insurance professionals. Licensed nationally, they represent highly rated carriers for both Asset-Based and Traditional LTCI products. The Founder Murray Gordon, along with Brian Gordon CLTC and Peter Florek CLTC, have over 90 Years combined experience in the LTC Industry. MAGA clients have received millions of dollars in LTC insurance benefits thanks to their dedication to service.

For more info, call 800-533-6242 or email Maga@ltc.com. Visit our website at www.Magaltc.com.
We are located at 2610 Lake Cook Road, STE 250, Riverwoods, IL 60015.

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Updated, Monday, April 2, 10:31 AM (Pacific)

Seattle—

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LTC E-ALERT #18-013: LTC NEWS AND COMMENT

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:

'Aggressive' advance directive would allow patients to decline food, water at end of dementia battle
Automatic Adjustments Within Entitlement Programs: A Look at the Swedish Pension Reform Model
How much do retirees really depend on Social Security? Far less than you’d think
Why Are the New Hybrid LTC Policies So Popular?
Medicare’s condition-specific readmission measures are poor reflectors of hospital quality
How to figure out elder care for your aging parent
As Trump Targets Immigrants, Elderly Brace To Lose Caregivers
The power of biases
Key Points for Long-Term Care Insurance Purchases
Shift in Long-Term Care Planning Shapes ILTCI Meeting

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Updated, Friday, March 30, 2018, 10:11 AM (Pacific)

Seattle—

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LTC Bullet: Virtual Visit to the 18th Annual ILTCI Conference in Las Vegas, Nevada

If you couldn’t attend last week’s 18^th Annual Intercompany Long-Term Care Insurance Conference in Las Vegas, you missed out. But don’t fret. Your Center for Long-Term Care Reform has you covered. We attended and will provide our “Virtual Visit” of this must-attend LTCi industry conference after the ***news***.

*** HAPPY BIRTHDAY: The Center for Long-Term Care Reform will turn 20 years old on Easter Sunday. No April fooling. Steve Moses and attorney David Rosenfeld founded the Center on April 1, 1998. Today, our mission continues: “to ensure quality long-term care for all Americans.” We wish to thank our many generous supporters for their financial and moral support through the years. We could not have reached this milestone without you. ***

*** CLTCR Premium Membership -- Center for Long-Term Care Reform premium members receive our full suite of individual membership benefits including:

All LTC Bullets and E-Alerts
Access to our Members-Only Zone website and Almanac of Long-Term Care
Subscription to our Clipping Service
Email/phone access to Steve Moses for 24-hour turnaround queries

Our Premium Membership is designed to give you a competitive advantage in your long-term care profession. Your increased knowledge of the critical issues and challenges we face in the field of long-term care service delivery and financing equals improved professional success for you and better LTC services for your clients and for those who have no choice but to rely on scarce public resources.

Stay on the forefront of professional knowledge and help us fight for rational long-term care policy reform by contacting Damon at 206-283-7036 / damon@centerltc.com to start your Premium Membership immediately or go directly to our secure online subscription page and sign up for as little as $21 per month. ***

LTC Bullet: Virtual Visit to the 18th Annual ILTCI Conference in Las Vegas, Nevada

The 18^th Annual Intercompany Long-Term Care Insurance Conference, held March 18-21, at the Paris Hotel & Casino in Las Vegas, NV was another excellent industry event. Attendance was high at over 1,000 attendees, 60+ exhibitors and nearly 40 sponsors. An ample 45+ breakout sessions covered a diverse array of topics:

Actuarial
Legal, Regulatory & Compliance
Claims & Underwriting
Marketing, Distribution & Sales
Traditional, linked and combination products
Technology

These educational sessions combined with the high caliber of attendees, exhibitors and sponsors offered plentiful occasions for valuable learning and professional development, while receptions and meals provided many indispensable opportunities for networking with a diverse range of industry professionals. With Steve unable to attend the conference and Damon busy volunteering at conference registration, our coverage will be limited; however, we attended some sessions, mingled with attendees and received a sense for the state of the long-term care insurance industry.

Every year the Intercompany Long-Term Care Insurance Conference takes the pulse of the LTCi industry and offers direction forward. To that end, “A Matrix of Opportunities” was the tagline for this year’s conference and that optimism filled the agenda. According to the conference website’s homepage:

A quiet revolution is taking place in the long-term care insurance industry. More interest than ever is being focused on private sector solutions to the growing societal issues pertaining to long-term care. Planning choices for consumers are growing at a rapid pace. Insurance companies are developing new innovative approaches to providing long-term care liquidity at various life stages and insurance agents and financial advisors are showing renewed interest in talking to consumers about their long-term care planning needs.

With entitlements and social programs strained, longevity and healthcare costs increasing, caregiver supply decreasing and the age wave cresting, how we finance long-term care now and in the future is a demographic, political and fiscal Rubik's Cube. This year’s ILTCI conference contributed to solving that multi-dimensional puzzle by hosting the innovators who are offering new directions and products designed to save people from the risk and cost of long-term care.

The conference opened with keynote speaker, Vinh Giang, a business person and magician. From his profile:

Vinh’s mission in business and life is to share the psychology of illusion. He has devoted himself to understanding the ways in which people are fooled by illusions and by the tricks we play on ourselves. During his presentations, he demonstrates how this occurs.

By all accounts Mr. Giang’s presentation was engaging and the strong work ethic he espoused was something with which people in the long-term care insurance industry could identify.

Mr. Giang got the conference off to a good start. Next, we’ll provide a summary of some of the sessions we attended. We stuck primarily to the “Public Policy & Alternative Financing Solutions” and “Producers & Sales” tracks, but there were plenty of other worthwhile tracks to follow and sessions to attend. Access the complete conference schedule here for session information and presentation documents not provided below.

We’ll begin with three sessions focused on long-term care financing innovation:

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Session: The Case for Variable LTC Insurance
Track: Public Policy & Alternative Financing Solutions
Speakers: Joan Melanson, CLTC, LTCP - Long Term Care Partners, LLC - Director of Program Promotions / Marc Cohen, PhD - University of Massachusetts - Clinical Professor of Gerontology / Paul Forte - Long Term Care Partners, LLC - Chief Executive Officer / Roger Loomis, FSA, MAAA - Actuarial Resources Corporation (ARC) – Principal
Documents: Presentation, The Case for Variable Insurance - Final Contingencies

Highlights:

This session was a perfect example of top LTCi industry professionals offering creative innovation in the field of long-term care financing. From the session’s description:

The LTC industry has been dealing with the ongoing challenges of rate increases. But what if, instead of attempting to fine-tune the LTCI premium after the fact, we were to allow the benefit to fluctuate from the outset, such that it would track and reflect emerging experience over time?

Presenter, Roger Loomis, used an apt oil drilling analogy to describe this. When people seek to extract oil from underneath an ocean they don’t simply set up an oil rig, point a drill towards oil and hope for the best. They find out exactly where the oil is, point the drill and make countless corrections to the drill’s course until the exact destination is reached. The session continued by exploring the viability of using a similar approach to LTCi using a variable benefits design.

See the session’s documents for further details.

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Also in the vein of offering creative alternative financing solutions, we attended:

Session: Consumer View of New Long Term Care Combination Products
Track: Public Policy & Alternative Financing Solutions
Speakers: Eileen Tell, MPH - ET Consulting, LLC - Independent Consultant / John O'Leary - O'Leary Marketing Associates – President / Vincent Bodnar, ASA, MAAA - Genworth - SVP, Product Management / Cindy Malone - Maddock Douglas - Senior Vice President Research
Documents: Presentation

Session’s online description:

While consumers today better understand the risks and costs of needing long term care, there is a significant gap between awareness and action. The lack of viable solutions, from the consumer perspective, is a key factor. The social marketing literature defines two key elements needed for behavior change: (1) awareness of the problem and (2) offering solutions which consumers deem as viable and appropriate. Based on very limited product acceptance, current mainstream private LTC insurance products do not satisfy the latter component. Hence an interest in creating new and affordable coverage options for consumers. Two new product concepts – LifeStage and Retirement Plus – have emerged from the Society of Actuaries’ Think Tank as creative ways to combine LTC coverage with existing financial vehicles to create new kinds of combination products. This session reports on findings from consumer research to understand how well these new options might meet consumers’ needs. The research also includes a demand model to estimate market potential.

See the session’s documents for further details.

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Session: Home as a Strategic Asset for Retirement and Long Term Care Needs
Track: Public Policy & Alternative Financing Solutions
Speakers: Eileen Tell, MPH - ET Consulting, LLC - Independent Consultant / Amy Ford - National Council on Aging (NCOA) - Senior Director, Home Equity Initiatives and Social Accountability / Barbara Stucki, Ph D. - NestCare FPC - Cofounder and CEO / Sandra Timmermann - American College of Financial Services - Visiting Professor of Gerontology and Retirement Living
Documents: Presentation

Session’s online description:

Home equity represents a significant portion of the financial net worth of older adults, most of whom want to age in place in their current homes. Despite the importance of home equity as part of the financial portfolio, recent research shows that older homeowners do not understand the home equity release products available to them. They also do not know how to decide when and how to leverage home equity in addressing retirement concerns. Greater education and understanding could enhance affordability to buy long term care insurance or pay for in-home care through the appropriate use of home equity release options. This session summarizes new consumer survey findings on the topic and identifies new and improved home equity product options.

Here we have another session focusing on solutions for financing retirement and long-term care needs. Basically, the home is a “pot of money” that people can use to help finance the many costs associated with aging. However, homeowners are at odds with tapping their homes’ equity because they are stuck between an emotional connection to their home on one side and their financial needs on the other. Furthermore, it doesn’t help that home equity release products are poorly understood. This session helped to reconcile all the facets of the home equity dilemma and presented home equity as a viable retirement and long-term care planning asset.

See this session’s presentation for further details.

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THE HUMAN INTERFACE

Innovative products are nothing without innovative people to connect them with the right consumers. The next session we attended covered successful sales strategies to do just that.

Session: Return of the Jedi: Best Practices of the Masters
Track: Producers & Sales
Speakers: Terry Truesdell - National LTC Network - President/CEO / Matt McCann - McCann Insurance Services – Owner / Jim Dawson, CLTC - PNW Insurance Services - Agency Mentoring Leader / Melissa Barnickel, CPA, CLTC - Baygroup Insurance LLC - Accountant & Insurance Broker / Sally Leimbach, CLU®, ChFC®, CEBS, LTCP, CLTC - TriBridge Partners LLC - Senior Consultant for Long Term Care Insurance
Documents: Presentation

Session’s online description:

This panel discussion of leading producers and Jedi Masters will share the business practices that have allowed them to build large books of business and to maintain a steady flow of new business. When not fielding questions from the audience they will be sharing tried and true closing techniques, as well as the elements of a successful placement rate ranging from effective field underwriting and solidifying the sale to client communications and referral generation.

Highlights:

Sally Leimbach eschews stupidity in her sales strategy by flipping the KISS (Keep It Simple, Stupid) approach. She espouses KISUI: “Keep It Simple, Understandable and Intelligent.” Perfect. Everyone involved in the LTCi sales transaction is intelligent and should be treated that way.

Useful sales tips were provided in abundance from these experienced sales pros, but some session attendees shared their sales techniques as well. One attendee shared a crowd-pleaser something to the effect of: “2 out of 3 people will need long-term care. I already decided I won’t, so it looks like you will.”

See this session’s presentation for each speaker’s “Pearls” of wisdom.

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Branding and marketing are other key human elements in the sales process. The next session we attended employed the expertise of four more sales savants to explore the empirically successful methods they use to effectively brand and market their services.

Session: Building YOUR Brand
Track: Producers & Sales
Speakers: Denise Gott, MBA, CLTC - ACSIA Partners – CEO / Marilee Driscoll – Speaker / Honey Leveen, LUTCF, CLTC - Your LTCI Specialist – Owner / Betty Doll, MBA, CLTC - Doll & Assoc. Long Term Care Insurance Services - Owner/Broker
Documents: Presentation

Session’s online description:

In today’s world, everyone is connected to others electronically and your life is very visible. So, YOU have a brand that your client will see. Is it what you want? Learn from marketing experts how to create a positive brand that will attract clients. Also, covered are the latest methods of: creating/utilizing a website, generating new leads and referrals, utilizing social media, and general effective marketing techniques.

Highlights:

This session covered key elements such as logo format, design and size (keep it simple); how to choose a website domain; how to yield beneficial web search results; and how to keep in contact with your clients and prospects (newsletters). Ultimately, building a brand is a “get rich slow” process.

See this session’s presentation for further details.

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Closing session: The Coming Revolution in Long Term Caregiving: The Future is Now!

The conference closed with a shift from long-term care planning innovation to caregiving innovation. Caregiving is a dangerous job and with long-term care needs increasing and available caregivers declining, technology is the future of caregiving. Specifically, robots. Speakers, Jeremy Pincus, PhD and Marjorie Skubic, PhD, were not fantasizing about science fiction; they were describing the current technological advances in robotics and how they will fill the “caregiver void.” Will caregiving robots prove to be “Disruptive Innovation” for the long-term care industry?

------------------------------

Final thoughts: What I take home from each ILTCI conference is a renewed sense of appreciation for the LTCi industry and all the talented people in it who devote themselves to protecting others from the risk and cost of long-term care. It’s a diverse group of attendees, but I’ve noticed that what draws many to the industry (and to these conferences) are personal long-term care experiences and the resulting desire to help others plan for their long-term care needs. Many thanks are due to Jim Glickman, everyone on the conference organizing committee, Meeting Masters, A/V crew, Paris hotel staff and, of course, all the sponsors, exhibitors, speakers and attendees for making this event exceptional. See you next time.

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Updated, Monday, March 26, 2018, 10:16 AM (Pacific)

Seattle—

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LTC E-ALERT #18-012: LTC NEWS AND COMMENT

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 LTC insurance conundrum: Slumping sales, but no shortage of demand
NAIFA Launches Center For Excellence In Long Term Care
Spotting Alzheimer’s Early Could Save America $7.9 Trillion
6.6% of those 65+ need help with ADLs, says CDC
Formal Cost of Care
Everything You Need To Know About The New Medicare Cards (But Beware Of Scams)
MedPAC: Congress Should Cut Medicare Rates for Skilled Nursing Facilities
Long-term care costs could reach $5.6 trillion by 2047: report
Why advisers should be offering critical illness policies
Dementia study links your risk with your fitness level
Skilled Nursing Occupancy to Keep Falling in 2018
How In-House Insurance Plans Can Boost Skilled Nursing’s Fortunes
New Technologies Help Seniors Age In Place — And Not Feel Alone
Americans Are Spending More But Planning Less For Caregiving
One State’s Quest to Introduce Long-Term Care Benefits
What the Rise of Medicare Advantage Means for Skilled Nursing
Looking At Tax Deductibility Of LTC Combo Policies
What influences older adults' preferences for care?

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Updated, Friday, March 23, 2018, 9:15 AM (Pacific)

Seattle—

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LTC BULLET: HAVE YOUR CAKE UNTIL IT EATS YOU

LTC Comment: Americans want to have their cake (entitlements) and eat it too, but trends show this cake will eat our economy first. Scary evidence after the ***news.***

HEADS UP! Ross Schriftman tells us: “We now have our 12 minute documentary of the making of the My Million Dollar Mom short up on our website at www.mymilliondollarmom.com.” Soon to follow will be the premiere of the movie on May 14. Check the film’s website to stay tuned for details and further information.

LTC BULLET: HAVE YOUR CAKE UNTIL IT EATS YOU

LTC Comment: We invite your attention to two excellent columns published recently in the Wall Street Journal.

The first, titled “Americans Want Big Government,” by William A. Galston, explains how Americans want more “free” stuff, but neither they nor their political representatives say how to pay for it.

The second, “Why America Is Going Broke,” by John F. Cogan, explains how our prodigious appetite for the unearned will come back to bite us.

Here are some telling facts from the Galston piece:

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

What more should we be doing and for whom?

“A Pew study last month found majorities endorsing the view that government does too little to help young people, the elderly, the middle class and the poor.”

“According to the Kaiser survey, 40% of Americans favor more defense spending while only 19% want less. Seventy percent want more spent on education, while only 7% want less. The Spring 2017 Pew survey found broad support for increased spending on veterans’ benefits, infrastructure, scientific research, environmental protection and assistance to the needy.”

Sounds great, right? But don’t we have to pay for all this largesse? Why worry?

“Not surprisingly, surveys also register a steep decline in public concern about the federal budget deficit. In 2013, according to the January 2018 Pew study, 72% of Americans regarded deficit reduction as a top priority. By the beginning of this year the figure had fallen to 48%.”

Well, at least our public officials are addressing this issue head on. Not.

“Last December, President Trump signed a Republican tax bill that will raise the deficit by an estimated $1 trillion over the next decade, and the new budget will add to this figure. Based on data from the Congressional Budget Office, the Committee for a Responsible Federal Budget calculates that the budget deficit will rise from $800 billion in 2018 to $1.19 trillion in 2019, and will increase even more in 2020. If the spending increases for these two years are made permanent, the annual deficit will reach an estimated $1.7 trillion by 2027. And political pressure will make it nearly impossible to roll back these increases.”

Oh well, “eat, drink and be merry for tomorrow we die,” right?

“We do not know for sure. But we do know that when the next recession comes, the government will have few fiscal and monetary tools left to fight it. If annual budget deficits already exceed $1 trillion, and if the burden of the national debt is already at an all-time high, little room will be left for the antirecessionary measures that governments of both political parties have employed since the early 1930s.”

“The American people have told Congress how much government they want. Responsible leaders would now inform the people what it will take to pay for this much government. In the absence of such responsibility, our fiscal policy will remain on a collision course with reality. The only question is when the crash will come.”

The second article, by John Cogan, focuses on entitlements as the elephant of anti-austerity. First, the problem:

“President Trump’s budget estimates a deficit of nearly $900 billion for 2018 and nearly $1 trillion (with total spending of $4.4 trillion) for 2019. Its balance sheet reveals that the public debt will reach $15.7 trillion by October. This works out to $48,081.61 for every man, woman and child in the U.S. That doesn’t count unfunded liabilities, reported by the Social Security and Medicare Trustees, that are four times the current public debt.

“How did the federal government’s finances degenerate this far? It didn’t happen overnight. For seven decades, high tax rates and a growing economy have produced record revenue, but not enough to keep pace with Congress’s voracious appetite for spending. Since the end of World War II, federal tax revenue has grown 15% faster than national income—while federal spending has grown 50% faster.”

Next, the cause:

“[A]ll—yes, all—of the increase in federal spending relative to GDP over the past seven decades is attributable to entitlement spending. Since the late 1940s, entitlement claims on the nation’s output of goods and services have risen from less than 4% to 14%. Surprising as it may seem, the share of GDP that is spent on national defense and nondefense discretionary programs combined is no higher today than it was seven decades ago.”

“If you’re seeking the reason for the federal government’s chronic budget deficits and crushing national debt, look no further than entitlement programs. … Since the early 1970s, entitlements have been the federal budget’s largest spending category, the sole source of the federal budget’s growth relative to GDP, and the primary cause of chronic budget deficits.

“Today, entitlement spending accounts for nearly two-thirds of federal spending. Defense spending still only accounts for about a sixth of the federal budget, even with recent increases. Defense spending could be doubled and it would still be only half what the federal government spends on entitlements. Significant reductions in the budget deficit can only be achieved by restraining the growth of entitlement spending.”

But, unfortunately:

“The president has ruled out any significant reform of Social Security and Medicare, the two largest entitlement programs. His budget shows that this year Social Security and Medicare expenditures will exceed the payroll taxes and premium payments dedicated to supporting them by $420 billion. Social Security and Medicare deficits will account for half this year’s total budget deficit.”

Maybe Congress will step into the breach. Well, no:

“The situation is no better at the other end of Pennsylvania Avenue. Democrats are getting domestic spending increases and Republicans are getting increases to the defense budget. Instead of offsetting higher spending with reductions elsewhere, Congress simply increased both defense and domestic spending in the recently enacted continuing resolution to fund the government. At the same time, by eliminating the need to vote on a debt ceiling this year and ruling out the reconciliation process for any budget bill, Congress signaled that it has no stomach for entitlement restraint.”

The future bodes ill:

“Social Security and Medicare expenditures are accelerating now that baby boomers have begun to collect their government-financed retirement and health-care benefits. If left unchecked, these programs will push government spending to levels never seen during peacetime.

“Financing this spending will require either record levels of taxation or debt. Economics teaches us that high tax rates reduce economic growth and living standards. History teaches us that high public debt aggravates economic volatility and makes a country’s financial system more prone to crisis.”

LTC Comment: OK, so where does this leave us? We’re on a collision course with economic disaster. Neither the public nor its political representatives have the stomach to confront excessive entitlement spending. But, in the end, we can’t have that cake and eat it too. The suffering when the inevitable end comes will be tragically greater than the need these entitlement programs sought to meet in the first place.

It fascinates and frightens me that America, founded in the spirit of freedom, independence and individual enterprise, could have deteriorated to its current state of collective self-deceit, authoritarianism, and dependency. I find a clue to how this happened in the Galston article’s opening sentence:

“In a well-functioning democracy, the people articulate their desires and grievances, and their elected officials shape these sentiments into sustainable policies. With this division of labor between citizens and representatives, democracy can be both responsive and responsible.”

That statement is fundamentally mistaken. It is not democratic politics that bring us sensible policies and prosperity. Political majorities will always vote themselves more free stuff until they run out of other people’s money.

That’s the fix we’re in now. And that’s why our founders and the Constitution they wrote tempered democracy with principled protection of individual rights and property. The Supreme Court’s failure to keep those principles inviolable has allowed government encroachment into economic spheres it was never intended to enter.

To wit: majorities of people demand more and more free stuff and their political representatives give it to them in order to remain in power. It’s a vicious downward spiral the awful bottom of which we’re nearing today.

What’s a better way? Get government out of the business of being the people’s nanny. Have confidence that most human beings, left to their own devices (as the founders intended) will not only survive, but prosper. The resulting economic bonanza would enable private charity to provide for the few who need help better than the bloated, ineffectual social programs the needy rely on now.

Why will this happen? In free markets, unencumbered by excessive government interference, taxation and regulation, people vote with their hard-earned dollars for what they want. Entrepreneurs anticipate what people may want. If they get it right, they profit. If they get it wrong, they lose and disappear. Investors choose which entrepreneurs to support with their hard-earned capital. Smart ones win; others lose. The only guaranteed winners in capitalism are consumers. They are the net beneficiaries of the many risks entrepreneurs and investors take.

There is no room for self-deceit, authoritarianism or government dependency in such a system. No unearned free stuff stolen from producers undercuts individual initiative. The resulting prosperity unleashes the natural human generosity to help those less fortunate. Everyone is better off. But, alas, don’t hold your breath.

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Updated, Monday, March 12, 2018, 9:15 AM (Pacific)

Seattle—

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LTC E-ALERT #18-011: LTC NEWS AND COMMENT

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:

Using a Health Savings Account to Pay for Long-Term-Care Insurance
Per-bed SNF price plummets in 2017; NIC's cross-sector collaboration to support industry
Assisted living sets record for price per unit
Amazon extends discounted Prime memberships to Medicaid recipients
Why Long-Term Care Insurance Is a Bad Investment
Letting an LTC insurance policy lapse
CMS allots $30M for new quality measures
The 37 States That Don't Tax Social Security Benefits
As Trump Pushes Medicaid Testing, the Grading Falls Short
The Long-Term Care Insurance Market Evolves
How Many Seniors Are Living in Poverty? National and State Estimates Under the Official and Supplemental Poverty Measures in 2016
These 5 defensive moves can protect your money and wealth
Why the daunting economics of elder care are about to get much worse

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Updated, Friday, March 9, 2018, 8:43 AM (Pacific)

Seattle—

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LTC Bullet: Long-Term Care News and Analysis

LTC Comment: Center for Long-Term Care Reform Premium members have the option to receive our LTC Clipping Service and weekly LTC E-Alerts newsletters. Today, we’d like to share a sample of these members-only services with a wider audience. Our topic is the news this week, so we’ll keep our ***news*** section brief then dive straight in.

*** Some CLTCR staff will be attending the upcoming 18th Annual Intercompany Long-Term Care Insurance Conference in Las Vegas. In preparation for this vital and not-to-be-missed annual affair, we’ll skip next week’s LTC Bullet, but don’t fret: There’s over 1,200 LTC Bullets dating back to 1998 and archived by date and subject here. In lieu of anticipating and reading your Friday Bullet, why not have a look at our archive? If you need some direction, start by reading our LTC Bullets rebutting some of the unbalanced and negative treatment of LTCi in the popular press recently. To that end, we offer: Don’t Buy LTCI?!, LTCI Under Fire, LTCI Expert Fights Back and last week’s piece from Phyllis Shelton, It’s Time to Stop Bashing Long-Term Care. If that’s not enough, try our Reality Check: The Facts on LTCI section which compiles LTC Bullets dating back to 1998 that combat inaccurate media coverage of LTCi with facts and sound analysis. Enjoy. ***

LTC Bullet: Long-Term Care News and Analysis

Many Center for Long-Term Care Reform Premium members are familiar with our LTC Clipping Service, and from what we hear, get great value from this benefit of Premium membership.

INSURANCE (Long-Term Care Insurance, Critical Illness Insurance, Hybrid and Miscellaneous (including alternative financing solutions))
LONG-TERM CARE (General, Cost, Assisted Living, Nursing Homes, Home Care, Caregiving, Veterans Affairs and Government Solutions)
MEDICAID (General, Medicaid Planning and Crowd-Out Effect)
MEDICARE (including Medi-Gap and Medicare Advantage)
SOCIAL SECURITY
ALZHEIMER'S DISEASE
POLITICS, LEGISLATION AND PUBLIC POLICY
ECONOMICS, DEMOGRAPHICS AND DATA
RETIREMENT PLANNING
HEALTH AND HEALTHCARE
OTHER

I depend on the clipping service to keep me abreast of all LTC breaking news. It is a huge time-saver and contributes to my overall sense of confidence and knowledge as a LTCi specialist. I really think the service gives me an “edge,” and helps keep me one step ahead of my competitors. Conveying the insights I gain from the clipping service often enables me to more easily and relevantly educate my clients on the importance of LTCi ownership. -- Honey Leveen

I LOVE receiving your clippings, because . . . I'm able to get the info quickly and can pass it on to my colleagues. Honestly, without your service, I probably wouldn't be aware of half of the things that you serve up to me, on a “silver platter" as the saying goes. Thanks for making my life so much easier! -- Susanne E. Howarth, Director of Long-Term Care, TBG West

Please find below a sample collection of clippings we’ve sent to our Clipping Service subscribers over the past two weeks. Read through them and if you think that receiving news items like these in real time would be valuable to you, please consider subscribing at the Premium membership level. By doing so, you can stay on the forefront of professional knowledge and help us fight for rational long-term care policy reform.

Contact Damon at 206-283-7036 / damon@centerltc.com to start your Premium Membership immediately or go directly to our secure online subscription page and sign up for as little as $21 per month.

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3/7/2018, “What influences older adults' preferences for care?,” MedicalPress

Quote: “The researchers found that support from family was the most important influence on care preferences for older adults. But people also usually formed their preferences based on a variety of factors. They also discovered that it was unusual for older adults to know their care preferences or to have a clear understanding of how they formed their preferences.

“The key findings of this study were:

· The level of support from families was the most important influence on care preferences. Often, older adults changed their preferences based on the concerns of family members or a wish to avoid ‘being a burden’ to others. This was especially true for preferences regarding the places where people wished to receive care (for example, at home versus in a healthcare facility).

· Older adults' experiences of previous illness and of caring for others also influenced preferences about their own future care.

· Being more seriously ill strongly influenced care preferences, especially for older adults who were aware that they were unwell.”

LTC Comment: Interesting that not being a burden on others and prior care-giving experience influence type-of-care preferences. Having LTCI would ameliorate both concerns and keep all options open.

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3/7/2018, “Using a Health Savings Account to Pay for Long-Term-Care Insurance,” by Kimberly Lankford, Kiplinger

Quote: “Q: Can I withdraw money tax-free from my health savings account to pay my long-term-care insurance premiums? If I can, is there a limit to the amount I can use? Does it have to be for a stand-alone long-term-care policy, or can it be for a life insurance policy with long-term-care benefits, too?”

LTC Comment: Click through to the article for the answers.

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3/7/2018, “Why Long-Term Care Insurance Is a Bad Investment,” by Jason Notte, TheStreet

Quote: “‘Mathematics work against [long-term care insurance] because most people will need long-term care eventually,’ Kibler says. ‘For insurance to make economic sense, the risk must be spread across a pool of participants.’”

“With other types of insurance, only a portion of the population collects, while the others continue to pay their premiums. That covers expenses paid out and keeps premiums manageable. However, since most buyers of long-term care insurance will eventually collect, Kibler notes that insurers will have to raise premiums. That will cause the healthier portion of the population to opt out, leaving a pool of less-healthy participants who all believe they will need to collect their insurance in the immediate future.”

LTC Comment: The argument here is specious and the nuance the author misses is that through LTCi some people will be spared catastrophic loss, others will be glad they never needed it and many people will fall somewhere in-between and have protection.

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3/7/2018, “Letting an LTC insurance policy lapse,” by Karin Price Mueller, nj.com

Quote: “Q, My husband and I are 84 and 85 and we have had long-term care insurance for 17 years. The premiums are going up too much and we are on a fixed income, earning a little over $30,000 a year. We have a good amount of other assets, and we're trying to decide if we should keep the insurance or cancel it.
-- Tough decision

A. As you know, long-term care insurance can be a very important part of your financial plan.

You shouldn't let the policy lapse without serious consideration.”

LTC Comment: Some welcome good advice.

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3/5/2018, “The Long-Term Care Insurance Market Evolves,” by Mark Miller, Morningstar

Quote: “It's a paradox: More Americans are worried about the risk that long-term care expenses can pose for their retirement plans, but few take action to protect themselves. The commercial long-term care insurance industry has never achieved mass market penetration levels, and sales have been falling steadily over the past five years. Chalk it up, in part, to consumer resistance. People are reluctant to spend thousands of dollars annually on insurance premiums for a long-term care need that might come far down the road, or not at all.”

LTC Comment: Some paradox! Medicaid has paid for the vast majority of all expensive long-term care since 1965. There’s no mystery why most Americans don’t worry about LTC costs until they need care after which it’s too late to do anything responsible like buy private insurance.

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3/2018, “How Many Seniors Are Living in Poverty? National and State Estimates Under the Official and Supplemental Poverty Measures in 2016,” by Juliette Cubanski, Kendal Orgera, Anthony Damico, and Tricia Neuman, Kaiser Family Foundation

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3/5/2018, “These 5 defensive moves can protect your money and wealth,” by Liz Miller, MarketWatch

Quote: “Every well-considered wealth-management plan includes an assessment of personal, property, and financial risk. Investments have risks that can’t readily be insured, so other risks must be managed in order to minimize threats to overall wealth goals. Fortunately, many of the personal risks that can threaten one’s wealth can be managed with proper insurance. Consider these five ways to reduce your exposure to risk:

“2. Consider long-term care insurance:

Studies indicate that at least one member of every couple living today is likely to need some kind of long-term medical assistance. Many people have the means to pay these expenses out of their wealth savings, but for many others, a long-term stay in a luxury care facility — due to dementia or some other debilitating condition — can derail their lifestyle or legacy goals. If you have any medical conditions or family history that make you particularly vulnerable to health risks, or you do not have the means to cover these costs, consider long-term care insurance options. This is relatively inexpensive insurance to add prior to age 50, but it can get pricey later in life.”

LTC Comment: A pretty good concept offering LTCi as a type of lifestyle insurance or even “portfolio insurance.”

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3/2/2018, “Why the daunting economics of elder care are about to get much worse,” by Patricia Smith, The Conversation

Quote: “When no relative steps up to serve as an unpaid caregiver when the need arises, families hire paid caregivers or move their loved one into a nursing home, where a private room may cost $100,000 or more per year. Medicare rarely covers nursing home stays, and eligibility for Medicaid coverage is limited, so institutional care like that is generally out of reach for all but the wealthiest Americans or those with long-term care insurance – which also costs a lot. … In the meantime, Medicaid and Medicare can make caregiving more financially rewarding by increasing the rates they pay for elder care, spurring the kind of salary growth for home health aides required to make the profession more attractive. And to ease the financial burden of caregiving all around, Medicaid and Medicare could ramp up benefits for care delivered in the home and in institutions and extend coverage to more people.”

LTC Comment: Typical balderdash: fix the LTC problem by spending more on what caused it in the first place.

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3/2/2018, Good data source referenced by Stephen D. Forman in the “LTCA Weekly Reader”

LTC Comment: We thank Center friend and Corporate member Steve Forman of Long-Term Care Associates for this resource tip.

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2/27/2018, “Aerobic exercise slows cognitive decline in Alzheimer’s disease,” by Mary Gillis, Reuters

Quote: “Researchers assessed data from 19 studies conducted between 2002 and 2015 that examined the effects of exercise on cognitive ability in 1,145 people at risk of or diagnosed with Alzheimer’s disease. Nearly 90 percent were randomized controlled trials, which are the most reliable type of study.

“Results indicated that exercise - specifically, cardiovascular exercise - had a strong favorable impact, researchers reported in the Journal of the American Geriatrics Society.

“This study is the first to suggest that aerobic exercise may be more effective than other types of exercise when the goal is to preserve the cognitive health of older adults at risk of or with Alzheimer’s disease, Panza said.”

LTC Comment: It’s pretty gloomy here in Seattle, but I think I’ll go for a run later.

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2/27/2018, “Here’s a surprise source you can tap for long-term care services,” by Darla Mercado, CNBC

Quote: “It isn't every day that an older client might consult experts to help him become impoverished as he prepares for long-term care. Enter Medicaid planning, a corner of personal finance that brings together elder law attorneys, accountants and financial advisors to help seniors pay for nursing home care while protecting their family members.

“Those who participate in Medicaid planning work with attorneys, accountants and advisors to shift their wealth to trusts or annuities in order to qualify.”

LTC Comment: We hesitate to forward articles such as this that are basically advertisements for Medicaid planning and contribute to the overall desensitization to the need for responsible long-term care planning. However, people read articles like this when researching options for financing long-term care and it’s better to know when there’s a new one out there. For some balance, see also our recent LTC Bullet: The Medicaid Prevention Business, which features Ron Hagelman’s column from the latest Broker World.

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2/23/2018, “HSA use increasing among those under 65,” by Allison Bell, ThinkAdvisor

Quote: “U.S. residents’ use of public and private health coverage stayed about the same between 2016 and the first three quarters of 2017, but use of health savings accounts (HSAs) may have climbed 15 percent. The number of U.S. residents under the age of 65 who had HSAs increased to 17.9 million in 2017, from 15.5 million in 2016, according to new National Health Interview Survey (NHIS) data.”

LTC Comment: Many will use the HSAs to fund the next generation of LTCI after Medicaid stops subsidizing the middle class and affluent.

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2/26/2018, “Are You Prepared To Live To Be 100?,” by Alexander Koury, Forbes

Quote: “Today, we are living healthier lives, which has increased our life expectancy and changed the way in which we should prepare to live well beyond our expectations. We are living in an age when medicine and technology are being designed to keep us living longer, and future developments will continue to push life expectancies higher. This is the new reality, and unless you choose to solve the problem now, you could outlive your money. Ask yourself, ‘How long will my money last?’ If you do not know, now is the time to figure out how you will get on track.

“Last, consider buying long-term care, and shop for a plan that fits your budget and your goals. If we go back to the example I presented earlier, long-term care may end up costing you as much as a $700,000 home. Imagine having to buy one for you and your spouse. These are things you should consider reviewing now before too much time passes. The older you are, the less time there is to make sure your financial plan is intact.”

LTC Comment: A pretty good article and reminder of the various costs associated with increasing longevity and how to prepare for them.

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2/21/2018, “Immigration Curbs Will Weaken Social Security,” by Howard Gleckman, Forbes

Quote: “President Trump has proposed deporting hundreds of thousands of immigrants and backed curbs on legal immigration into the US. The president’s aggressive views on immigration have generated intense debate over the past year, but much of that discussion has ignored a key issue: What immigration restrictions would mean for the long-term health of Social Security.

“A new study by my Urban Institute colleagues Damir Cosic and Rich Johnson finds that just one proposal—a Senate bill to reduce the number of permanent residency visas (green cards)-- would increase unfunded Social Security obligations by $1.5 trillion, or 13 percent, over the next 75 years. In the nearer term, it would accelerate by one year the date by which the Social Security trust fund is projected to be depleted—from 2034 to 2033.”

LTC Comment: This affects the long-term care industry because those would-be immigrant workers could fill positions as much-needed long-term caregivers and pay into Social Security and Medicare which are both connected to Medicaid via spend-through and reimbursement, respectively.

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2/18/2018, “1.5 Million Retirees Await Congressional Fix for a Pension Time Bomb,” by Jim Tankersley and Alan Rappeport, New York Times

Quote: “The sprawling agreement to boost government spending reached by Republicans and Democrats this month quietly included a step toward defusing what could be a financial time bomb for 1.5 million retirees and hundreds of companies in the industrial Midwest and the South. The deal creates a select congressional committee to craft what could effectively be a federal rescue of as many as 200 so-called “multiemployer” pension plans — in which employers and labor unions band together to provide retirement benefits to employees.
Many of these plans are hurtling toward insolvency in the coming decade, with benefits owed to retirees projected to swamp what the plans can afford to pay. The 16-member, bipartisan committee will have to come up with a solution and legislation by the end of November, which the full Senate would need to vote on by the end of the year.”

LTC Comment: Who’s going to bail out Social Security and Medicare?

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Updated, Monday, March 5, 11:06 AM (Pacific)

Seattle—

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LTC E-ALERT #18-010: LTC NEWS AND COMMENT

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:

Good data source referenced by Stephen D. Forman in the “LTCA Weekly Reader”
Why the daunting economics of elder care are about to get much worse
When is the Skilled Nursing Wave Coming? Depends Who You Ask
Minnesota LTC pros apologize to public after abuse claims
Widows Got Bad Social Security Claiming Advice From SSA: IG Report
Aerobic exercise slows cognitive decline in Alzheimer’s disease
Here’s a surprise source you can tap for long-term care services
HSA use increasing among those under 65
Are You Prepared To Live To Be 100?
Alzheimer's Death Rate Continues to Rise: CDC

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Updated, Friday, March 2, 2018, 9:14 AM (Pacific)

Seattle—

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LTC Bullet: It’s Time to Stop Bashing Long-Term Care Insurance

LTC Comment: The title of this week's LTC Bullet says it all. Phyllis Shelton speaks her mind after the ***news.***

*** CLTCR Premium Membership -- Center for Long-Term Care Reform premium members receive our full suite of individual membership benefits including:

All LTC Bullets and E-Alerts
Access to our Members-Only Zone website and Almanac of Long-Term Care
Subscription to our Clipping Service
Email/phone access to Steve Moses for 24-hour turnaround queries

LTC Bullet: It’s Time to Stop Bashing Long-Term Care Insurance

LTC Comment: Many of you surely know Phyllis Shelton, but for those who don't, she's a highly regarded author, teacher and consumer advocate for LTC planning. She's a friend and member of the Center for Long-Term Care Reform and is passionate and prolific in her work helping to protect people from the risk and cost of long-term care. We enjoy following her work. We have all noticed a recent spate of negative and unbalanced media treatments of LTCi, so when we read her latest blog post, "It’s Time to Stop Bashing Long-Term Care Insurance," it resonated with us. The title says it all. If you're tired of reading articles that bash LTCi without context or an opposing view, read what follows.

Reprinted below with permission is "It’s Time to Stop Bashing Long-Term Care Insurance" by Phyllis Shelton. Get in touch and read more of her blog posts via her website: www.gotltci.com.

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It’s Time to Stop Bashing Long-Term Care Insurance

by Phyllis Shelton

Enough. Stop. The plethora of LTC insurance bashing articles has gotten to me.

These people aren’t bashing LTC insurance!

Mr. C. Vernon Duckett – he was able to take care of Helen, his most precious asset, with the best care possible AND continue to play golf four times a week for his own well-being.
Mary and Don – Don died the day before his 75th birthday after 10 years of Parkinson’s disease and Alzheimer’s. He paid just over $18,000 in premium before receiving about $530,000 in tax-free cash benefits. Mary has received two rate increases and is the first to tell you she will never let her policy go. (names changed to preserve anonymity)
Ella Keith spent her 65th birthday in the hospital, having suffered a major stroke. Her family was able to keep her at home for the next 15 years because her LTC insurance policy paid over $300,000, almost half.
Russell Polston – he is not only happy with how his wife’s claim was paid, but also the three year claim paid for another family member.

Rate Increases and Why the Sky Isn’t Falling

Yes, there have been rate increases. Long-term care insurance is “guaranteed renewable” which means it can never be canceled as long as you pay your premium in a timely manner. It also means there can be a “class” rate increase, which means on an entire class of people, not just on individual policyholders at the whim of the insurance company. Frankly, I struggle with why this is a big deal when I look at my health insurance going from $330 a month for my husband and me in 1993 to $1690 a month in 2016. I’m not a math whiz, but isn’t that FIVE times as much?

I’ve had people come to me with a 90% rate increase on long-term care insurance. After I compare what they can spend by age 80 vs. the benefits at that time, they peel themselves off the ceiling…I don’t have to do it for them. It’s all relative. Older policies were so underpriced that while a rate increase of 130% sounds terrible, it doesn’t even get the premium up to what is being charged today. Why were they so underpriced?

No one knew how to price for long-term care back in the 80s and 90s.
Companies thought many more people would let their policies lapse but most people don’t, even when they receive rate increases. They appreciate them for the gold they are.
People are living much longer today than anyone expected, which means they are more likely to have a claim.
Claims are lasting longer than expected, largely influenced by the really nice assisted living facilities that exist today but didn’t exist 30 years ago when I got in the LTCi business. The latest claims study (also from the Society of Actuaries) shows that women who need care longer than a year average 4.67 years and men 3.8 years, as opposed to 3.7 and 3.1 respectively. The average for all claims regardless of length has gone from 1.9 years to 2.5.
The cost of care is steadily growing. I project the cost of a “country club” assisted living facility at 5% compound as only 10% of the 80 million baby boomers are in their care receiving years. So if the current cost is $5000 a month today, that’s $21,000 a month in 30 years. Yes believe it.
The bottom fell out of interest rates as we all know back in 2008ish. When an insurance company prices for a 7% interest rate on reserves and gets 2-3%, you can imagine the impact!
Yes, there were a few bad apples that intentionally priced policies too low, accepted people in poor health and paid out higher commissions than other companies. They did this to steal market share, but it backfired on them. I warned agents away from them in my 20 training years.

So when you hear the annual premium for a 55 year old female as follows…

$5,700 (single)
$4,848 (part of a couple)
$3,992 (both issued)

…you fall over with shock. But when I tell you these premiums are buying a plan that will be worth $1.5 MILLION in 30 years, payable at $21,000 a month for six years, now what do you think? Even the highest one of $5,700 x 30 years equals only $171,000, vs. $1,500,000 in benefits. Will there be rate increases? Maybe, but there’s a huge difference between $171K and $1.5M. That particular company can pay dividends in the older years, thus offsetting the need for a rate increase.

The Society of Actuaries just came out with research that shows policies issued 2014 and later have been priced correctly for all the bad stuff that has hit long-term care insurance. (FYI, those of you who have had much larger rate increases most likely bought before 2000.)

Some people maintain 5% compound inflation is too aggressive. This article just came out today.

New estimates released today from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) and published online in Health Affairs project an average annual rate of national health spending growth of 5.5 percent for 2017–26, outpacing average projected growth in gross domestic product (GDP) by 1.0 percentage point.

LTC facility costs usually outpace overall health costs. Home care has been growing much slower but I’m seeing it start to pick up as more and more people need extended health care.

But What if I Never Need Care?

Listen to me. Walk around your neighborhood and ask every single household if their house has ever burned to the ground. Not many yes answers, right? Now ask if they know someone who has needed help longer than three months with bathing and dressing or with a cognitive impairment. That’s long-term care. How many people can you think of in that situation?

Do you honestly think people sit around and worry that they haven’t gotten their money’s worth out of their homeowners or auto policies? Just how do you want to “get your money’s worth” out of your long-term care insurance? Do you want to have a brain tumor, get hit by a drunk driver, have a major stroke…or maybe suffer with Parkinson’s or Alzheimer’s for 10 years?

If you never need care, count your blessings! It means you paid the annual premium for peace of mind.

!	You will die before you will know you never needed it, so you will always be glad you had it!

I see so many families who are SAVED by long-term care insurance and it cuts me to the quick to read the bashing articles. Let’s reward the hand full of companies that have weathered the pricing storm and stayed in the market. Some offer both traditional and products combined with life insurance and/or annuities. If you don’t have a professional who is well-versed in the latest LTC planning options today, I would be honored to help you. Click here for my questionnaire that will get you a no-obligation consultation.

Share this:

Phyllis Shelton is celebrating her 30th year in long-term care insurance as an author, teacher and consumer advocate for LTC planning.

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Updated, Monday, February 26, 2018, 8:21 AM (Pacific)

Seattle—

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LTC E-ALERT #18-009: LTC NEWS AND COMMENT

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 Did Life Begin? Key Alzheimer's Protein Has Surprising Tie to the Primordial Soup
1.5 Million Retirees Await Congressional Fix for a Pension Time Bomb
Heavy Drinking Is the Biggest Risk Factor for Dementia, Study Says
Senior living could lead cultural shift related to aging, report author says
Nebraska Senators Eye Incentive for Long-Term Care Insurance
Immigration Curbs Will Weaken Social Security
Michigan inching toward privatization of long-term care
Managed Care Payments Continue to Squeeze Skilled Nursing Providers
Future Retirees Will Be More Vulnerable to Market Shocks: CRR
Planning Smart for Your Clients’ Senior Caregiving Duties
Will This 1 Expense Prevent You From Living Your Dream Retirement?

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Updated, Friday, February 23, 2018, 9:04 AM (Pacific)

Seattle—

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LTC BULLET: THE MEDICAID PREVENTION BUSINESS

LTC Comment: What went wrong with LTC insurance and what should happen next? Ron Hagelman opines after the ***news.***

*** CLTCR Premium Membership -- Center for Long-Term Care Reform premium members receive our full suite of individual membership benefits including:

· All LTC Bullets and E-Alerts

· Access to our Members-Only Zone website and Almanac of Long-Term Care

· Subscription to our Clipping Service

· Email/phone access to Steve Moses for 24-hour turnaround queries

LTC BULLET: THE MEDICAID PREVENTION BUSINESS

LTC Comment: Ron Hagelman’s column in the current issue of Broker World caught our eye. He argues the time has come to acknowledge how LTC insurance failed and to refocus its mission. Or put another way, he suggests we look beyond the product’s remarkable success, insuring eight million Americans, to contemplate how it might protect another 50 million! The secret to achieving that goal, he argues, is to pursue a more modest objective. Focus on helping people avoid the Medicaid trap, i.e. the risk of ending up by default on the underfunded welfare program that dominates long-term care financing in the USA.

Reprinted below with permission is Ron’s column. If you aren’t already a Broker World subscriber, become one now and read Hagelman’s “Last Word on LTCI” every month. I do.

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“The Last Word On LTCI...Process of Elimination”
By
Ronald R. Hagelman, Jr.
February 2018

The entire long term care/chronic illness industry must face the reality of our unsuccessful attempt to soften the economic and emotional blow of an extended need for care and to finally accept that many of our overly optimistic rationalizations about future outcomes may have been structurally flawed at inception. We must publicly and politically recognize the inevitable and potentially expensive nature of the risk for most Americans. The truth is we can now measure our failure. We currently have about 8 million brilliant consumers who bought policies, will keep their policies, and will maintain the freedom of choice and dignity of control of their own claims. Unfortunately the most recent numbers I’ve seen suggest that over the last 20 years we have left over 50 million behind. Those who could have and should have done something. Blame for the failure is irrelevant. Mistakes in pricing assumptions are hopefully, for the most part, just history. We now live in a world of closed blocks of premium continuing to fester from the weight of our own false assumptions. We have certainly learned that more of the same is hubris on steroids.

Frankly what is required is a little humility. Most claims are financially manageable and some extra “supplemental” insurance assistance can make a world of difference to a much wider audience. The goal for the affluent needs to remain that the best way to replace the risk with insurance. But the underlying need to maintain private pay status must become the industry’s new “Battle Cry!” Current claims analysis is definitive: 90+ percent are over in three years, 83 percent of all past claims reviewed would have been covered by $100,000. Stop asking, “How much insurance is enough?” The question is, “How little is needed to keep you free of government dependence?” Medicaid care is not necessarily bad, it’s just inferior. It is discounted care by definition. I apologize for repeating myself but the fact is that last year alone it was $7 billion short of the actual cost. Please do not misunderstand: God Bless Lyndon Johnson my fellow Texan. This country desperately needed a social safety net for those most in need of care. However, after a 20 year friendship with Stephen Moses, I am morally required to humbly suggest that: If those who could and should afford their own care did not artificially impoverish themselves and steal from those truly in need, the quality of governmental warehoused care would improve. I am happy to proclaim from the highest mountain top that “I am in the Medicaid prevention business and that I am ready, willing and able to make sure that never happens to those I care about.”

Our futures in long term care planning need to move to opposite corners of the decision making processes. We must openly recognize our failures. We can increase our sales success by refocusing our goals. More middle class Americans must understand that a little goes a long way to maintaining basic human freedom of choice. We must acknowledge all the dollars that can come into play at the point of claim and make absolutely sure we have added sufficient supplemental protection to keep those we care about in complete control of their own claim destiny. And we must acknowledge that the 90 percent we left behind still need our help at “The Point of Care” when it hits the fan, and then be prepared to do all in our power to leverage every available source of funding. Medicaid is wrong for those we love and it does take so little additional protection to guarantee personal control and freedom of choice. Eliminate absolutes, take no prisoners when placing some level of supplemental help, and do not forget all those we missed the first pass through the orchard.

Other than that I have no opinion on the subject.

Ronald R. Hagelman Jr., CLTC, CSA, LTCP, CLTC, CSA, LTCP, has been a teacher, cattle rancher, agent, brokerage general agent, corporate consultant and home office executive. As a consultant he has created numerous individual and group insurance products. A nationally recognized motivational speaker, Hagelman has served on the LIMRA, Society of Actuaries, and ILTCI committees. He is past president of the American Association for Long Term Care Insurance and continues to work with LTCI company advisory boards. He remains a contributing "friend" of the SOA LTCI Section Council and the SOA Future of LTCI committee. Hagelman is president of Broadtower Insurance Solutions, a national IMO helping BGAs enhance LTCI production. Hagelman can be reached at Broadtower Insurance Solutions, Inc., 156 N. Solms Rd., New Braunfels, TX 78132. Telephone: 830-620-4066. Email: rhagelman@broadtowerinsurancesolutions.com. Website: www.BroadtowerInsurance.com.

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Updated, Tuesday, February 20, 2018, 8:34 AM (Pacific)

Seattle—

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LTC E-ALERT #18-008: LTC NEWS AND COMMENT

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:

FDA Sets the Stage for Earlier-Stage Alzheimer's Treatments
Six emerging housing trends in 55+ living communities
National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth
New AALTCI Guide Explores Section 1035 Exchanges for Long-Term Care Insurance Planning
How To Sell LTCi To Millennials For Their Parents
Trump officials face decision on lifetime limits for Medicaid
Operators Bearish on Future of Standalone Skilled Nursing Facilities
Here's the Latest on What Healthcare Will Cost in Retirement -- and It Isn’t Pretty
Trump administration drafting 'scorecard' for Medicaid changes
President's budget proposes Medicaid changes, affordable housing funding cuts
Skilled Nursing Operators Face Down ‘Unsustainable’ $2 Billion Cut

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Updated, Friday, February 16, 2018, 9:05 AM (Pacific)

Seattle—

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LTC BULLET: LTC CALCULATION

LTC Comment: We explore why socialism always fails, especially when applied to long-term care, after the ***news.***

*** SUBSCRIBE TO LTC CLIPPINGS: We scan the news searching for data, articles and reports you need to know about. Then we send you a brief email (like the one below) with title, author, source link, a representative quote, and our brief analysis. LTC Clippings help you stay at the forefront of professional knowledge. To subscribe, contact Damon at 206-283-7036 or damon@centerltc.com. ***

*** SAMPLE LTC CLIPPING: 2/14/2018, “National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth,” by Gigi A. Cuckler, Andrea M. Sisko, John A. Poisal, Sean P. Keehan, Sheila D. Smith, Andrew J. Madison, Christian J. Wolfe, and James C. Hardesty, Health Affairs

Quote: “National health spending growth is expected to average 5.5 percent per year for 2017–26 and to reach $5.7 trillion by 2026 (exhibit 1). Over the same period, growth in the nation’s gross domestic product (GDP) is expected to be 4.5 percent per year. This 1.0-percentage-point differential is expected to result in an increase in the health share of the economy from 17.9 percent in 20161 to 19.7 percent in 2026.”

LTC Comment: Ben Franklin would remind us that spending beyond our means is problematical. But what’s really interesting about this latest iteration of CMS’s annual projection of the next decade’s national health expenditures is that it doesn’t mention long-term care! Oh, you can find “home health care” and “nursing care facilities” in the detailed tables, but LTC isn’t highlighted for consideration in the analysis as in past years. Nevertheless, nursing facility care is expected to grow from 3% annually in 2013 to 5.3% by 2026, topping around $261 billion in expenditures by 2026. Likewise, home health care, rising 5.1% in 2013 will be going up 6.7% annually by 2026 to $172.6 billion. Dramatic numbers, but evidently not worth highlighting in CMS’s analysis which focuses mostly on acute care. ***

LTC BULLET: LTC CALCULATION

LTC Comment: Why doesn’t socialism work? Why does “from each according to his ability to each according to his needs” lead inevitably to dysfunctional states like the Soviet Union and Venezuela. Why do socialists’ good intentions always end in disaster?

Socialism’s Fatal Flaw

The Austrian economist Ludvig von Mises answered these questions. He said the problem with socialism is that it has no means of economic calculation. It lacks data reflecting consumers’ preferences because it has no market prices. With no way to know who wants what based on their willingness to spend their hard-earned money, socialist economic systems must rely on decisions by some authority about what and how much to make. Sooner or later, such an authority unconstrained by market prices, destroys the economy by trying evermore desperate measures to fix it.

Here’s why. In a free market, people buy what they want and pass over products or services they prefer less. Entrepreneurs anticipate what people want and/or what they might want if a new product or service were created. Every purchase by a consumer is a bit of information for entrepreneurs. It says at this price for this item, the consumer would rather have the item than the money and the entrepreneur would rather have the money than the item.

Billions of transactions like that across a national economy provide invaluable information to investors, entrepreneurs and consumers alike. Investors gauge the economy’s direction and choose what kinds of businesses to support with their capital and from which to withdraw their support. Entrepreneurs who calculate correctly, prosper. Those who miscalculate disappear. The system is self-regulating with consumers the biggest beneficiaries. Consumers gravitate to the products and services that please them most, thereby voting, as it were, for more of this, less of that, and so on.

From this complex interaction comes, some say miraculously, order out of seeming chaos. Left to themselves, markets adjust to reward smart investment, punish careless or wishful thinking, and deliver the closest approximation to what consumers want and the greatest quantity of what they prefer.

A fully socialist economy lacks the data private markets deliver. When the government owns the means of production and people can only buy or bypass what the central planners decide to produce, there is no market to produce the data needed to choose rationally what should be produced and in what amounts. It takes a while for collapse to occur because socialist systems can rely temporarily on vestigial domestic markets or market data from freer systems elsewhere, but sooner or later economic miscalculation leads to rationing, price controls, suppression, repression and failure.

Interventionism

What about a third way? Can’t government intervene in markets to make them work better without destroying them entirely? Suffice it to say, poison in any dosage is still poison. It’s beyond my scope here to explain why interventionism leads directly, albeit more slowly, to the same disastrous outcome. Read Mises or other Austrian economists for that.

LTC Calculation

My purpose here is to draw the analogy to what’s wrong with long-term care financing. The government began interfering in long-term care services and financing many decades ago. But let’s begin this analysis in 1965 with the start of Medicaid and Medicare. Before then most long-term care was provided by families as now, only more so. When needs exceeded what families could provide, Mom and Pop care homes were the rule. Often churches and other philanthropic organizations provided help. Big commercial nursing home companies were far fewer than today. Assisted living didn’t exist at all. Most paid care came out of private pockets, not from government or insurance, whether public or private.

But by 1965, life spans were starting to expand into lengths that lead inevitably to more chronic illnesses of old age. The age wave was only just beginning, but it was clear something had to change. We’ll never know how long-term care services and financing might have evolved if the government had not stepped in to “fix” this increasingly inadequate pre-1965 system. But we can surely speculate. What if consumers had been left to their own devices in the sixties as more and more people began to need long-term care? What if we’d allowed a free market in long-term care services to find its way, generate market data measuring consumers’ preferences, and point investors and entrepreneurs toward inventing and financing better LTC mousetraps?

A Free Long-Term Care Market

As more and more people lived long enough to require long-term care, individuals and families would have realized they had to expect and meet such needs. Entrepreneurs would have offered home and community based services as it became obvious that people preferred receiving care at home and were much more willing to spend their own money for such care than to enter expensive institutional settings. When necessary to provide semi-acute or recuperative care, skilled nursing facilities would have persisted, but not as providers of custodial care, which is much more efficiently and humanely provided in smaller settings such as Dr. Bill Thomas’s Green Houses.

As time went on and more and more people needed longer and more intense, and hence more expensive long-term care, economic solutions would have evolved to pay the costs. Home equity conversion could have provided trillions of dollars to ensure millions of families had the money to afford top quality long-term care at whatever acuity level and venue they needed and preferred.

Gradually, as it became obvious that the risk of expensive long-term care was sufficiently great to warrant private insurance protection, as for other similar risks such as major medical, fire, or life, long-term care insurance products would have been offered. Those probably would have made some actuarial errors. But over time actuaries--in the absence of government-induced distortions like easy access to Medicaid and artificially low interest rates--would have discovered and corrected those errors leading to stable products as in other lines of insurance.

We would have ended up with a mostly privately financed long-term care system providing a continuum of care with most people getting care at home by families or professionals funded from personal savings and/or insurance. Assisted living as we know it now would likely have evolved much earlier than it did. Skilled nursing facilities would be far fewer in number having never provided custodial care for a majority of people in need of long-term care. Skilled nursing facilities would be much more closely integrated with hospital care and much more focused on easing the transition from acute care to health and recuperation.

What about the poor? Who would take care of them? We’d have many fewer poor to help without perverse incentives in Medicaid preventing people from planning, saving, investing or insuring for long-term care. For example, in the absence of Medicaid’s huge home equity exemption, many of the income-poor, house rich elderly would have better access to higher quality care by using the wealth hidden in their homes to stay in their homes. The genuinely needy who truly must have help would be served, as they were before the Great Society programs intervened, by fraternal organizations, churches, and other philanthropic organizations.

The Unfree Long-Term Care Market

What happened instead? Government intervened in 1965 and we can see the dysfunctional results all around us. Medicaid made nursing home care virtually free. The public stopped worrying about long-term care risk and cost. With a government created monopoly on long-term care, the nursing home industry exploded in size and lobbying power. As Medicaid expenditures, skyrocketed, reimbursements were reduced to compensate. With reimbursements less than the cost of care, access and quality plummeted. Private payers shrank in numbers when they had to make up the shortfall in Medicaid reimbursements. More and more people sought the advice of lawyers who could artificially impoverish them to qualify for Medicaid. Families tore themselves apart fighting over the spoils, i.e. Mom and Dad’s estate, as preserved by shifting the long-term care cost to tax payers.

Responding to these and other problems, well-intentioned analysts, public officials and politicians wracked their brains to find solutions. But invariably they made the problems their earlier interventions had caused, even worse. They capped bed supply when Medicaid costs exploded causing nursing homes to sue successfully for higher rates. Then they capped rates creating the fateful differential between higher private pay and impecunious Medicaid rates. When quality suffered, they demanded higher quality without providing adequate funding. Then, when quality didn’t improve, they imposed regulations and inspections that made quality care even more difficult to provide. The inevitable results were huge tort liability suits punishing hapless Medicaid nursing homes for providing the low quality of care the government was willing to finance.

Now, some 53 years after Medicaid arrived to fix long-term care, the “experts” want to add more government money and regulation. You can’t extinguish a fire by dowsing it with gasoline. More of the same intervention that caused long-term care’s problems in the first place will not solve them.

LTC Calculation

What should we do instead? Give the private long-term care services and financing markets some room to breathe. Back off government intervention enough to allow those markets to generate the kinds of data that investors, entrepreneurs and consumers need to chart a better course. What exactly might we try?

In “How to Fix Long-Term Care Financing,” I explained the problems created by government intervention much more thoroughly and I outlined the needed corrections in greater detail than I can do here. Check it out, but here are the key corrective measures we could take to reduce the negative influence of public policies on long-term care services and financing.

1. Return Medicaid to its true purpose as a long-term care safety net for the poor, not the primary long-term care funding source for all Americans.

2. Toward that end, eliminate Medicaid’s gigantic home equity exemption so that people have reason to access trillions of dollars of wealth to purchase quality long-term care.

3. Eliminate other eligibility loopholes, especially “spousal refusal” and “Medicaid-friendly annuities” that allow the wealthy to co-opt Medicaid funds that should go to the poor instead.

4. Re-direct gerontological research from focusing on alleged impoverishment to analyzing (1) how many Medicaid long-term care recipients own homes and with what values, (2) what their economic status was ten or twenty years before needing long-term care, when they still might have — with the right incentives and absent the existing disincentives — taken measures to prepare for long-term care and avoid Medicaid dependency, and (3) what happened to the wealth they formerly possessed and to what extent it was expended for long-term care or used or transferred in some other way.

5. Give state Medicaid programs more authority and flexibility to experiment with measures like these either by block-granting the program (less money, more flexibility) or by creative use of “1115 waivers,” a well-established means to try out new approaches.

In other words, little by little remove the counterproductive government interventions in long-term care which have prevented the free market from developing the data and sending the signals that consumers, investors and entrepreneurs need to make wise decisions.

Do this and we’ll see entrepreneurial creativity unleashed. We’ll see new products and services evolve that better meet consumers’ needs. We’ll see a flood of private funding flow through to long-term care providers raising access and quality for all. We’ll see fewer people dependent on public programs and therefore more public resources available for those who need them most. As more people have to spend more of their own money, including their home equity, on long-term care, we’ll see more of them planning earlier to prepare for long-term care risks and costs. We’ll see products like reverse mortgages and private long-term care insurance prosper as never before, bringing more jobs and tax revenue to the economy.

It boils down to a simple truth: don’t expect a different result until you stop doing what you’ve always done. Get out of the way and let “LTC Calculation” in a free market point the way to a better long-term care system.

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Updated, Monday, February 12, 2018, 9:04 AM (Pacific)

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LTC E-ALERT #18-007: LTC NEWS AND COMMENT

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:

Americans Will Struggle to Grow Old at Home
Today's Massive Budget Deal Makes Big Medicare Changes
A Medicare Benefits Update Could Cut Medigap Sales: GAO
Long-term care insurance: Buyer beware
Genworth Faces Deal Resistance in Delaware
CDC data show how small, large assisted living communities differ
Too Few People Bought What You Sell: Treasury Economist
Trump administration considering lifetime limits on Medicaid benefits
American Independent Marketing Joins Integrity Marketing Group
Drinking alcohol can clear brain waste, study finds
The Rough Lives of Older Americans in ‘Nomadland’
U.S. Pays Billions for ‘Assisted Living,’ but What Does It Get?

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Updated, Friday, February 9, 2018, 9:50 AM (Pacific)

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LTC BULLET: LTC CAUSE AND EFFECT

LTC Comment: New Bipartisan Policy Center LTC report puts the services cart before the financing horse as usual. We explain after the ***news.***

*** IS THIS THE BIG ONE? As I write this (yesterday), the Dow Jones Industrial Average just dropped over 1,000 points after a similar fall last week. Could the reckoning we’ve predicted in these LTC Bullets be about to happen? (Probably not. Probably just a long overdue correction in the equity markets. But what if?)

The U.S. economy has been living on borrowed money … and time. The National Debt Clock shows us $20.6 trillion in the hole not counting $111.9 trillion in unfunded entitlement liabilities and $18.8 trillion in personal debt. The 2-year budget deal President Trump signed this morning spikes the federal budget deficit another $265 billion.

When it becomes obvious that the USA cannot pay back the debt it has already incurred, our lenders—money printers at the Fed, domestic bond buyers, China, etc.—will stop purchasing new debt and demand repayment of existing debt. When that happens, the Federal Reserve will have to make up the difference by printing more money and buying more bonds. That’s the same “Quantitative Easing” they did the last two times the U.S. economic bubble popped: 2000 and 2008.

Only this time, QE4 will have to be levels of magnitude greater than ever before. That means huge new increases in the money supply which is already at historically stratospheric levels. More money chasing the same amount or fewer goods is the definition of inflation. Inflation means the dollar is worth less. The biggest risk right now is that people will lose confidence in the dollar as it loses value. Who wants to loan a destitute Uncle Sam money at historically low interest rates when it looks less and less likely Sam will pay it back? What’s different this time is that we’re so much deeper in debt and interest rates are still so low that the Fed has very little room to lower them to goose the economy. A perfect economic storm is brewing.

If this is the big one, look for the things we’ve been predicting to play out sooner rather than later. Interest rates will continue to increase to the point where the U.S. government cannot meet its obligations even by pumping the debt limit higher and higher. Budgetary austerity will no longer be only a gleam in a few fiscal conservatives’ eyes. Revenue shortfalls will be a stark reality compelling major cutbacks in all federal and state spending programs, including the big three entitlements: Medicare, Social Security and Medicaid.

Medicaid specifically will no longer have the luxury to allow affluent people to shift the cost of long-term care onto taxpayers to the detriment of genuinely needy people. The central planners’ pipe dreams for new entitlements to fund long-term care (see the LTC Bullet below) will go up in smoke. Private markets will survive and prosper with the reduction of government interference. Smart investors know "the time to buy is when there's blood in the streets." (Baron Rothschild) Private money will flow into smarter investments. Entrepreneurs will seek and offer better LTC mousetraps. Consumers spending their own money, including their no-longer-Medicaid-protected home equity, will demand quality LTC in the most appropriate venues. Private long-term care insurance will revive.

Does it sound like I’m wishing for this to happen? Not exactly. It’s more like how you’d feel if a friend with a drug addiction were putting off treatment. The worst is going to happen sooner or later regardless. The longer we delay it with phony economic policies that hide the reality while making the underlying problems worse, the harder the consequences will be when they do occur. So, bring it on. Let’s work on fixing this mess instead of kicking the can even further down the road.

(These are Steve Moses’s opinions and do not necessarily reflect the views of any Center for Long-Term Care Reform members, sponsors or supporters.) ***

LTC BULLET: LTC CAUSE AND EFFECT

LTC Comment: Cause and effect are simple, straightforward concepts. When a cue ball hits the rack of fifteen, something happens. You don’t need Newton’s Third Law of Physics to understand that. In reality, causes have effects; not the other way around. So why do analysts studying long-term care always start with effects and never with causes?

The Bipartisan Policy Center’s latest in a string of reports on long-term care is a perfect case in point. “A Policy Roadmap for Caring for Individuals with Complex Care Needs” is paved with good intentions, but fraught with unintended consequences, because it seeks to fix America’s long-term care system without first explaining why it is so dysfunctional.

Following is the crux of the Bipartisan Policy Center’s report extracted from its “Executive Summary.” Let’s deconstruct and examine their “pathway” to improving long-term care. Here are each of the “Roadmap’s” key components followed by our comments explaining how BPC has everything backwards.

BPC’s Roadmap: “The pathway to improving the quality of care and controlling the cost of serving individuals with complex care needs must address the following issues:

“A focus on person- and family-centered care, that places a priority on understanding the care goals of families and delivering the services that support them;”

LTC Comment: Sounds good, but why aren’t person- and family-centered care already central to the long-term care system? Answer: Medicaid and Medicare made care providers, instead of patients, the customers of long-term care spending. Patients and families lack control and choice because public LTC financing removed them from the market. They don’t find and pay for their own care, so they have to take whatever the government offers. The many tweaks to our Rube Goldberg LTC system recommended by BPC in the pages that follow will only make it more complicated and expensive unless and until they address the cause, government interference in the market, ahead of its effects.

BPC’s Roadmap: “An emphasis on coordinating care to ensure that services work across programmatic silos and avoid unnecessary or duplicative care and costs;”

LTC Comment: OK, but why is care uncoordinated in the first place? Where did those programmatic silos that cause unnecessary or duplicative care costs come from? Answer again: Medicaid and Medicare. In a freer long-term care market, with less public financing, consumers would select services they want in venues they prefer. Entrepreneurs would vie to invent and provide services consumers favor. Investors would direct their capital investments toward what the public wants instead of what government spending incentivizes. Starting with the ruinous effects of public LTC financing and trying to fix them with more of the same is folly. Instead, recognize the cause and mitigate the damage it does.

BPC’s Roadmap: “Creating a path from medical-driven models that provide care based on what is reimbursed to person-centered models that provide what people need and want;”

LTC Comment: Again, the first question to ask is why we have medical-driven care models. The answer is the same: government interference in the long-term care financing system. That’s why people can’t get what they need and want. The way to fix the problem is to address the cause, not to tinker with the effects.

BPC’s Roadmap: “Support for family caregivers; and,”

LTC Comment: Why do family caregivers need support in the first place? By paying for most long-term care, Medicare and Medicaid convinced consumers they don’t need to worry about LTC risk and thus crowded out private LTC insurance. Medicaid diverted seniors’ biggest asset, home equity, from long-term care liability thus starving the service delivery system for private financial oxygen from home equity conversion. Decades of Medicaid’s institutional bias impaired development of a private home-care market to meet the public’s care preferences. Should we trust finding more “support for family caregivers” to advocates and defenders of the public financing programs that caused the shortage in the first place?

BPC’s Roadmap: “Efforts to identify financing strategies, both public and private, to support the delivery of LTSS.” (p. 5)

LTC Comment: Before they decreed that America needs a new compulsory, backend, payroll-financed, Medicare-cloned entitlement program to finance long-term care, the Bipartisan Policy Center should have given some thought to why long-term care in the United States is short of financing in the first place. Read “How to Fix Long-Term Care Financing” for the answer to that conundrum. Until you understand that answer clearly, tinkering with current financing models will only exacerbate their dysfunctionalities.

Closing LTC Comment: I encourage LTC Bullets readers to review the Bipartisan Policy Center’s “A Policy Roadmap for Caring for Individuals with Complex Care Needs.” What you’ll find is dozens of complicated recommendations for nips and tucks in America’s defective long-term care service delivery and financing system. What you will not find is any effort whatsoever to understand why the problems they’ve set out to fix exist in the first place. Consequently, the BPC has once again put the services cart in front of the financing horse and placed both on a pathway to further bipartisan political depredation.

Stay tuned for next week’s LTC Bullet. We’re going to explain why turning over any sector of an economy to central planners (like the folks at BPC) inevitably fails. Fundamental, incontrovertible economic principles are at work here. Once you understand them, the problems and the solutions for long-term care light up. Read “LTC Bullet: LTC Calculation” next Friday.

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Updated, Monday, February 5, 2018, 10:09 AM (Pacific)

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LTC E-ALERT #18-006: LTC NEWS AND COMMENT

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:

If Immigrants Are Pushed Out, Who Will Care for the Elderly?
CMS Tries to Flush ‘Sick Creep’ Out of Medicare Advantage Rates
CMS to Allow Non-Skilled Home Care Benefit in Medicare Advantage
What to Say Now About LTCI Rate Increases
A New Public/Private Long-Term Care Financing Plan
LTC Insurance Payouts Increased 6 Percent In 2017
70% of Senior Living Communities Don’t Offer Discounted Rents
Amazon, Buffett's Berkshire And JPMorgan To Launch Healthcare Company
CCRCs Gain Luster as Standalone SNFs Fade
What Will Senior Housing Look Like in 2028?
What’s Bad for GE Will Be Worse for America
More Than One-Third of People with Traditional Medicare Spent at Least 20 Percent

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Updated, Friday, February 2, 2018, 8:50 AM (Pacific)

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LTC BULLET: LTCI EXPERT FIGHTS BACK

LTC Comment: Bill Comfort, a seasoned veteran of many LTCI policy skirmishes, offers evidence and logic in response to the often uninformed media criticism of the product and its purveyors, after the ***news.***

*** BIG SONIA is not to be missed! It’s an inspirational film spotlighting the resiliency of Sonia Warshawski, a 4’8” holocaust survivor. I saw this movie last week in Santa Fe. It’s the right antidote if you’re feeling beaten down by life’s adversities (including the attacks on LTCI). This indomitable woman survived more than we can imagine and yet thrived, giving hope and inspiration to others. Click here for a trailer; here for a review; and here for a list of screenings. Special thanks to long-time Center friend and supporter Claude Thau and his wife Tina, for their non-profit financial support of this moving film. Claude says “You might like to inform schools, religious groups, and prisons, as well as friends. Schools or non-profits (for $300) and theaters can request screenings by submitting contact information at https://bigsonia.com/request-a-screening/.” ***

*** MORE MOVIE NEWS: Center member and LTCI producer/author Ross Schriftman reports his movie is cast: “Based on the book of the same name by Ross Schriftman, My Million Dollar Mom is a film about a mother diagnosed with Alzheimer's just as her son is offered his last chance to be elected to Congress. He must decide between his life-long dream and his mom's wishes to remain in her home under his care. The script for the feature film was selected as a semi-finalist in Story Pros' screenwriting contest in the drama category.” Read more and learn the cast here. ***

*** LTC E-ALERTS PRAISED: “I look forward to every E-Alert. A definite, mandatory read for anyone in the LTC market. Personally, I appreciate the time and effort that Damon and Steve put in everyday to keep us not only motivated, but ahead of the naysayers. It’s tough down here in the trenches especially when you get those negative WSJ articles. I ask a favor. Would you please send that latest article by Leslie Scism, from the WSJ, Jan 17^th 2018, on “Millions Bought Insurance….They Face an Awful Choice” I don’t subscribe to the WSJ but would like to see the article in its entirety…thank you.” Thank you, Randy Gallas, CLTC, LTCP, President, Long-Term Care Insurance Agency, LLC, for your support. We’re happy to help. ***

LTC BULLET: LTCI EXPERT FIGHTS BACK

LTC Comment: It seems like private long-term care insurance is always under fire. But the last few weeks have been worse than ever. Like shooting fish in a barrel, the media have been taking easy shots at the product and the people who manufacture, distribute and sell it.

We’ve covered the latest onslaught in (1) LTC Bullet: Don’t Buy LTCI?!, January 12, 2018, correcting errors in “Long-Term Care Insurance Is a Poor Buy, CFP Says;” (2) LTC Bullet: Three to Get Ready, January 19, 2018, responding to “Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice,” by Leslie Scism, in the Wall Street Journal; and (3) LTC Bullet: LTCI Under Fire, January 26, 2018, bringing you LTCI veteran Claude Thau’s comments on and partial rebuttal of the WSJ fusillade.

The latest article about LTCI that deserves mention and response is “What’s Bad for GE Will Be Worse for America,” by Timothy L. O’Brien of Bloomberg. This piece is much better than the earlier ones, but it does invite comment. We covered it this way in an LTC Clipping:

1/29/2018, “What’s Bad for GE Will Be Worse for America,” by Timothy L. O’Brien, Bloomberg

Quote: “General Electric’s multi-billion-dollar loss in a unit that sold long-term-care insurance is a blow from which the iconic company is still reeling. But it’s also a harbinger of a much greater challenge for society at large: paying to care for the growing number of Americans who can’t look after themselves. … [T]he debacle illustrates a troubling truth: Private insurance can’t handle this problem by itself. … Medicare covers only a short period of care after a person has been hospitalized. That leaves Medicaid, the state-administered program for the poor. But it kicks in only after people have burned through their assets -- precisely the outcome that insurance is meant to avoid. … The challenge is to design a safety net that will deliver long-term care when it’s needed -- without making people destitute first, yet without burdening taxpayers unduly.”

LTC Comment: Finally an article that recognizes the magnitude of the long-term care financing problem without casting blame. Good. On the other hand, it adopts the conventional wisdom that Medicaid LTC benefits are only available to the poor. If that were true, people would be eager to buy private LTC insurance at almost any price. The fallacy that only the poor get Medicaid stands in the way of a “safety net that will deliver long-term care when it’s needed -- without making people destitute first, yet without burdening taxpayers unduly.” We delivered the evidence, the logic and the solution in “How to Fix Long-Term Care Financing.”

What else in the Bloomberg editorial needs comment and correction? For that we turn to Bill Comfort of Comfort LTC, a highly regarded LTCI expert and trainer. Following are Bill’s comments on “What’s Bad for GE Will Be Worse for America,” by Timothy L. O’Brien, Bloomberg. We recommend that you click through to the article first, read it and then consider what Mr. Comfort has to say.

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Comments on “What’s Bad for GE Will Be Worse for America”
By
Bill Comfort

The overall point of the Bloomberg editorial (1/29/2018) is important: we need to look more deeply at how we fund long-term custodial care in America. However, the editorial perpetuates several significant misunderstandings:

The LTC business that is at issue with GE is NOT the direct pricing, issuing, and managing of LTC policies (that business was spun-off into Genworth in 2004), but rather the REINSURANCE of other companies' LTC business. In fact Moody's recently issued a report stating that because of the limited scope of policies backed by GE's reinsurance and GE's indirect ability to manage those blocks, that this is NOT a good example for the health of the rest of the overall LTCI industry.

LTC insurers did NOT miscalculate on how long people would live or how many would go on claim - the "claims rate" or percentage of policyholders who would claim - they have hit that pretty much on the mark. What they missed - dramatically - was the "lapse rate,” that is how many policyholders would keep the coverage in-force over the long term. If you expect about 33% (yes, that's the real number) of policyholders to claim but you have 2x to 3x more policies in-force than you predicted then you have made a huge pricing mistake, like 100%+. The unpredictable lapse "mistake" has contributed to about 50% of the pricing changes needed.

2.a. Most LTC companies in the 1990s priced a disability/individual health insurance lapse rate of about 7%. Interestingly AMEX LTC - the early leader that was acquired by GE Financial now Genworth - priced its lapse rate at 4.5% in 1994, which was thought to be extremely conservative at the time. Actual lapse rate for the LTCI industry: 2%; actual lapse rate for Genworth/GE/AMEX: less than 1%. No financial insurance product EVER had such low lapses; the closest is whole life insurance at 3.5%. This was unknowable and devastating.

After the lapse picture started to become clear, the claims issue was not more people (a greater percentage) going on claim, but rather that claims were lasting longer than expected. On average the durations were just an additional year or two (something like 33% to 50% longer for women, 25% to 33% longer for men), but when compounded against more than twice the number of people expected to claim this was disastrous. The claim duration mistake has contributed to about 30% of the pricing mistake, but again all of the elements compounded the individual “mistakes.” We now have 70-times more claims data than in just 2004 - it's approaching true "credibility" and not just an estimated assumption.

Finally, our historically-low for historically-long low interest rate environment put the final catastrophic spin into the perfect storm of LTCI rating problems. If long-term reserve earnings were priced at 6-7% (as they'd been for 60+ years in the industry), and all of a sudden new premiums and maturing reserves had to go into 3% bonds it's a problem.

The Good News: New business premiums today already have all of these more conservative realities priced-in. Looking forward, LTCI will be, must be, more rate stable.

A final note on the ability – or inability – to price long-term care as an “insurable risk.” I see this stated in many places – including an insinuation by Bloomberg – but it’s often said without evidence, and too often paired with the “fact” that “70% of people will need care.” Rhetorically then how could we possibly price and insure a risk that is very likely to happen?! This is where the constant harping on “70%” is so dangerous, because it’s not true – the 70% data assumes help with only one ADL and/or 4 IADLs (shopping, cooking, cleaning, transportation, bill paying, etc.), these don’t qualify for LTC insurance benefits. Using this standard, sure, 70% will need “some type of care,” but not Tax Qualified LTC Insurance-triggered care. One actuarial study from a few years ago showed that using TQ LTCI triggers (2 of 6 ADLs on at least a stand-by basis expected to last 90 days, OR continual supervision for a cognitive impairment) coupled with a 90-day EP would mean that about 33% (1/3) of policyholders could be expected to receive at least $1 in benefits; only about 20% (1/5) would receive benefits for more than a year. It IS an insurable risk, and it IS now being priced correctly.

Bill Comfort, CLTC® is the owner of Comfort LTC, a member of the National LTC Network, with offices in St. Louis, MO, and Raleigh/Durham, NC. Contact him at Bill@ComfortLTC.com or 314-821-5001

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Updated, Monday, January 29, 2018, 8:50 AM (Pacific)

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LTC E-ALERT #18-005: LTC NEWS AND COMMENT

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:

Assisted living communities top nursing homes for caregiver pay
What's Wrong With The New RAISE Act To Help Family Caregivers
Out-of-pocket health-care costs likely to take half of Social Security income by 2030, analysis shows
This is the reality of being in a nursing home
How the Age Wave Will Transform Health, Longevity and Medicine: Ken Dychtwald's Keynote at the Exponential Medicine Conference
Latest Alzheimer's Flop Raises Doubts About 'Amyloid Hypothesis’
GE is under SEC investigation
Why The WSJ Is Wrong About Long-Term Care Planning
GE's LTCI Block Might Be Different: Rating Agency
The true cost of obesity to SNFs

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Updated, Friday, January 26, 2018, 9:41 AM (Pacific)

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LTC Bullet: LTCI Under Fire

LTC Comment: Analysis and commentary on the Wall Street Journal’s recent critique of private long-term care insurance by a leading LTCI expert follow the ***news.***

*** TURNABOUT is fair play: In the midst of LTCI criticism, it’s good to consider testimonials like this one addressed to Honey Leveen, the self-styled “Queen of LTC Insurance": “Hi Honey, one of the best days in my life was when you walked through my door and sold me my LTCi. That was almost 20 years ago. I never thought I'd have to use it. I will move to an assisted living facility shortly. Without my LTCi I could never afford it. I am grateful to you." Nancy S, Houston, TX, January 2018 Click here for additional client comments. ***

*** SAMPLE LTC CLIPPING: 1/22/2018, “Why The WSJ Is Wrong About Long-Term Care Planning,” by Jamie Hopkins, Forbes

Quote: “A recent Wall Street Journal article, “Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice,” has been circulating on the internet but for all the wrong reasons. The WSJ piece essentially falls into the ‘bad news sells’ category of reporting. While the article itself provides plenty of great statistics and touches on a very important topic, the article really misses the mark on two main points about long-term care insurance. Its ‘Woe is me!’ theme actually pushes people away from doing quality long-term care planning. Instead of lamenting past missteps, the article could have emphasized some of the new techniques for building effective and sustainable solutions to the budding long-term care crisis.”

LTC Comment: A good rebuttal of the WSJ attack on LTCI by Jamie Hopkins, whose credentials for the task are excellent. To wit: “I am the Co-Director of the American College’s New York Life Center for Retirement Income and an Associate Professor of Taxation at the American College where I helped develop the Retirement Income Certified Professional® (RICP®) designation. I also hold the Larry R. Pike Chair in Insurance & Investments. I’ve written about, and published, a variety of articles on retirement. I frequently write and publish law review articles dealing with retirement issues, such as long-term care, taxation of insurance benefits, and estate planning. I am extremely passionate about the retirement security of Americans and believe that a better prepared public can enjoy a more secure and fulfilling retirement.”

LTC BULLET: LTCI UNDER FIRE

LTC Comment: Private long-term care insurance has been on the receiving end of media criticism from the very beginning. But lately, the onslaught has seemed heavier than ever. One piece in particular, “Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice,” by Leslie Scism, published January 17 in the Wall Street Journal, struck a chord. Response from LTCI defenders was quick and frequent including our reply in last week’s “LTC Bullet: Three to Get Ready” and “Why The WSJ Is Wrong About Long-Term Care Planning,” by Jamie Hopkins in Forbes, which we cited in the LTC Clipping above.

But few participants in or observers of the long-term care insurance business are better equipped to review what’s right and what’s wrong in the current criticism than today’s Guest Bullet author Claude Thau. He’s directed a major LTCI insurance operation, been a leading distributor of the product for decades, and is a highly respected analyst and author on the topic. We asked Claude if we could share his recent review and critique of the WSJ article with you as today’s LTC Bullet. With his permission, that follows.

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For the most part, Leslie Scism’s Wall Street Journal article is accurate, however it leads readers to reach false conclusions. From my perspective, it is clear that:

Insurers are losing a lot of money on their old LTCi policies. Although it was clear from the start that LTCi was a risky business, the “perfect storm” problems that the insurers are experiencing was unforeseeable.
Both claimants and healthy policyholders cherish their policies (for good reason), hence will either stretch to pay the increased premiums or will reduce coverage to keep their policy in effect.
Price increases are a big problem for people who bought LTCi policies long ago and don’t have the cash flow to pay the premium increases.
People who can afford the price increases are getting a good deal, although they expected a much better deal. I think it is appropriate that the burden of the adverse experience is being split between the insurers and the policyholders, but choosing the right balance is subjective. I empathize with both sides, but more so with the policyholders.
The industry is not meeting its potential in helping to solve the country’s LTC financing problems. There are many reasons why the industry is not developing adequate market share. Some people blame the industry; some people blame various levels of government. However, human nature and other factors also contribute.
Despite the problems, a good number of insurers have stayed in the market or entered the market, offering good ways that many people can insure their LTC risk.
The price increases are taking a heavy toll on the industry, partly because media attention is focused on these older blocks, which causes people to be unduly wary of good opportunities to protect against LTC risk.
The problems of existing policyholders, while severe, are significantly less common than Ms. Scism suggests.
A key issue: How do we encourage insurers to develop coverage for new risks, particularly distant future risks (long-term care is much more risky for insurers than annual property and casualty risks such as cyber risks).

The industry is losing money because the insurers ARE paying claims¹. Insurers sometimes erroneously fail to pay a claim, but failure to pay a claim appropriately is not necessarily bad faith. I have generally succeeded in getting errors fixed or in explaining to the policyholder or family why the claim decision was right. The Independent Review process, which protects against some wrongly-denied claims, is rarely used, which suggests that claims are resolved fairly. To the degree that the July 2017 Milliman LTCi Survey was able to identify such appeals, independent reviewers supported insurers’ declines in nearly 90% of the cases², which also suggests claims are resolved fairly. A 2016 study³ found that 98% of LTCi claimants were satisfied with their claim payments and an earlier federally-funded study⁴ found large satisfaction as well. (Footnotes are below my signature block.)

Our society spawns a significant number of fraudulent insurance claims in every line of insurance, including LTCi. Insurers have a responsibility not to raise premiums in order to pay fraudulent claims. Their efforts to avoid fraudulent claims can contribute to (but not fully explain) frustrating claims processes (16% of claimants do not consider the claims process to be easy.⁵)

Ms. Scism wrote “some policyholders complain that it [the industry] has nothing to lose by denying legitimate long-term-care claims”. She failed to address that complaint appropriately. One of the key risks of denying a LTCi claim is the huge risk of a (possibly class action) law suit. In my view, insurers too often pay claims because the cost of defending a lawsuit would be expensive, even if successful. Perhaps that contributed to a federally-funded study concluding that insurers overpaid LTCi claims by 3.4%⁶.

Ms. Scism’s title refers to “Millions… Face An Awful Choice” and her second paragraph starts “Now, though, the industry is in financial turmoil, causing misery for many of the 7.3 million people who own a long-term-care policy, equal to about a fifth of the U.S. population at least 65 years old.” This sentence is inaccurate and misleading in several respects:

There were 47.8 million above age 65 as of July 2015⁷, obviously even more today. Dividing the “7.3 million” by 47.8 million produces less than 15% (still overstated), not “about a fifth” as she wrote.
She is including people below age 65 in the numerator but not in the denominator. If she did an apples-to-apples comparison, the ratio would be significantly lower than even 15%.
She is also including policyholders who no longer pay premiums (generally because they are on claim) and those who have purchased more recently-priced policies.
She wrote “Credit Suisse analysts tallied more than 4,500 rate-increase requests nationwide from 2009 to early 2017 by 16 once-big sellers of long-term-care insurance. The proposed increases affected hundreds of thousands of policyholders.” Even if all those “hundreds of thousands” are over age 65, the Credit Suisse data suggests probably less than 10% of people age 65+. Did she make any effort to reconcile the conflict between her statements and her Credit Suisse source?

Policyholders getting huge price increases is worthy of attention and discussion, but focusing solely on the plight of policyholders who bought LTCi long ago leads readers to infer that LTCi is not a good alternative for them today. The past problems have caused today’s products to be much more stably priced. Furthermore, Ms. Scism dismisses the popular combo products (“But such products are often costlier”), without mentioning that many of those combo products are entirely guaranteed, which protects against the “misery” she cites. By the way, of course it costs more if you add a potential death benefit to LTCi coverage. I believe articles about price increases on old policies should make strong efforts to explain that the situation is tremendously better today.

Best wishes,

Claude Thau
Director of Long Term Care Insurance Funding Solutions, Target Insurance Services
We're in it for the Long-Term... We Care^SM11020 Oakmont St., Overland Park, KS 66210
Phone direct: 913-403-5824; WATS line: 800-999-3026, x2241
claudet@targetins.com
Click here to connect with Claude on LinkedIn

¹ NAIC Experience Exhibit Reports through 2014 show LTCi claims compounded 12% per annum from 2001-2014. The author did not seek more recent information; growth clearly has continued albeit at a rate that the author can’t quote. See also the subsequent proof that claimants are satisfied, etc..
²Thau, Claude; Schmitz, Allan; and Giese, Christopher, Milliman LTCi Survey, Broker World Magazine, July 2017, p. 3 of the reprint.
³LifePlans, “Experience and Satisfaction Levels of Long-Term Care Insurance Customers: A Study of Long-Term Care Insurance Claimants”, September 2016, p. 14. “…only six percent of claimants had a disagreement with their insurance company about policy coverage, and the majority of these disagreements (65 percent) were resolved to the satisfaction of the claimant. Put another way, for every 100 people making claims under their insurance policy, only two are likely to have had a disagreement about coverage that was not solved to their satisfaction.” A table on page 22 shows that 70% of claimants were “very satisfied” with their policy, 27% were somewhat satisfied, 2% were somewhat dissatisfied and 1% were very dissatisfied. The lower satisfaction rate in this table appears to reflect the claims process as well as the amount paid, whereas the 98% statistic is related solely to the amount paid.
⁴ U.S. Department of Health and Human Services, Office of Disability, Aging, and Long-Term Care Policy (2006 and 2008). “Service Use and Transitions: Decisions, Choices, and Care Management Among an Admissions Cohort of Privately Insured Disabled Elders” (2006); “Following an Admission Cohort over 28 Months to Track Claim Experience, Service Use, and Transitions” (2008); “Care Management, Claim Experience, and Transitions Among an Admissions Cohort of Privately Insured Disabled Elders over a 28-Month Period” (2008). This study found that 14% of home care claimants, 5% of assisted living facility (ALF) claimants and 11% of nursing home claimants were dissatisfied. It differed from the 2016 study in that this older study dealt with people earlier in the claims process. Satisfaction apparently increases with time on claim, perhaps because the paperwork hassle is concentrated at claim initiation and because the monthly payment tends to increase and cumulative payments definitely increase.
⁵ LifePlans, “Experience and Satisfaction Levels of Long-Term Care Insurance Customers: A Study of Long-Term Care Insurance Claimants”, September 2016, chart p. 15 shows that 78% said it was easy; 15% said it was difficult and 7% did not know. Of those who expressed an opinion, 15/93=16.2% thought it was difficult)
⁶National Long-Term Care Insurance Claims Decision Study: An Empirical Analysis of the Appropriateness of Claims Adjudication Decisions and Payments, April 2010; Figure 5; p. 11 Total Paid/Total that should have been paid = Total Paid/((Total paid - (Amount that auditors would have denied – amount that auditors would have approved)) = $155,925,300/(155,925,300 – ($5,905,708 -$719,999)) = 3.4%
⁷ See https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html

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Updated, Monday, January 22, 2018, 9:39 AM (Pacific)

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LTC E-ALERT #18-004: LTC NEWS AND COMMENT

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:

One Day Your Mind May Fade. At Least You’ll Have a Plan
Long-Term Care Insurance Claim Payments Rise 6.4%
Only 7% of Caregivers Prefer to Work in Nursing Homes, Report Finds
Alzheimer's Association issues new guidance for dementia care in nursing homes
Mutual of Omaha plans to sell Medicare Advantage health plans in 2019
Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill
If you’re caring for Mom or Dad, your own retirement is in danger
Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice
Caring for young children and elderly parents, and wrestling with resentment
5 Notes on GE's $15B in LTCI Reserve Contributions
GE CEO Renews Pledge to Study Breakup After $6.2 Billion Stumble
Skilled Nursing Providers Sue Illinois Over Medicaid Rates

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Updated, Friday, January 19, 2018, 10:08 AM (Pacific)

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LTC BULLET: THREE TO GET READY

LTC Comment: Three seemingly unrelated Wall Street Journal articles this week are ominous for long-term care financing. Explanation after the ***news.***

*** SAMPLE LTC CLIPPING:

1/18/2018, “Long-Term Care Insurance Claim Payments Rise 6.4%,” by Allison Bell, ThinkAdvisor

Quote: “Long-term care insurance (LTCI) providers paid about $9.2 billion in U.S. long-term care claims in 2017, or about 6.4% more than they paid in 2016, according to the American Association for Long Term Care Insurance. . . . The number of people on claim increased 5.4% between 2016 and 2017, to 295,000, according to AALTCI.”

LTC Comment: Something tells me we won’t see these findings on the front page of the Wall Street Journal. ***

LTC BULLET: THREE TO GET READY

LTC Comment: “One for the money; two for the show; three to get ready; and four to go.” I recall that expression from my childhood. It came to mind as I contemplated three WSJ articles this week. They seem to bear no relationship to each other, but taken together they’re ill omens for long-term care financing. So, here we go . . .

Article number one is “How Millionaires Collect Food Stamps,” by Kristina Rasmussen, published January 15. She writes

Consider the food stamp program’s longstanding policy of “broad-based categorical eligibility.” You probably assume that food stamps go to poor people only. But this policy . . . allows state food-stamp programs to grant benefits to anyone who has moderately low wage income, regardless of net worth. A family with a seven-figure bank account can be eligible for food stamps.

Sound familiar? The same phenomenon occurs with eligibility for Medicaid long-term care benefits, only worse. Most assets are exempt from eligibility consideration, but even low-income isn’t necessary for Medicaid LTC, only cash flow insufficient to pay for costly nursing home care. For a complete explanation of Medicaid long-term care eligibility, why the affluent often qualify, and dozens of references to legal publications explaining how, see my monograph “How to Fix Long-Term Care Financing,” published by the same Foundation for Government Accountability that employs the food-stamps-article author Rasmussen.

Article number two is an op-ed titled “The Case for Medicaid Work Requirements,” by WSJ editorial board member Jason L. Riley, published January 16. He writes

[F]ew things are more important to America’s financial health than entitlement reform, and last Thursday the Trump administration backed state work requirements for recipients of Medicaid, which covers more Americans than any other health-care program. . . . In a major policy shift . . . the Trump administration told states that they could impose modest work or job-training requirements on childless adults without disabilities who receive Medicaid.

Imagine having to work or show signs you’re trying to find work before qualifying for free taxpayer-financed health care. Heaven forfend! Opposition was quick, widespread and strident.

But this was just a baby step in the direction of targeting Medicaid to the genuinely needy, because, as Riley observes, most Medicaid recipients are elderly, disabled or children, not able-bodied adults. A much bigger problem remains: gaping loopholes that trap many otherwise responsible affluent people on Medicaid unnecessarily. Specifically, the program’s huge home equity exemption--between $572,000 and $858,00 as of 2018--and its policy of allowing Medicaid-friendly annuities and “spousal refusal” create a slippery slope onto Medicaid for people who could, would and should have prepared privately for long-term care risk and cost.

A smart next step for the Centers for Medicare and Medicaid Services, which administers Medicaid, would be to apply the same “1115 Waiver” authority it used to enable states to impose work requirements on able-bodied applicants, to empower state Medicaid programs to reduce or eliminate the federally imposed home equity exemption and the annuity and spousal refusal dodges. I explained the need and made the case for such a move in “How to Fix Long-Term Care Financing.”

Article number three is a front-page, above-the-fold news article titled “Millions Bought Insurance to Cover Retirement Health Costs. Now They Face an Awful Choice,” by Leslie Scism, published January 17. She writes

Long-term-care insurance was supposed to help pay for nursing homes, assisted living and personal aides for tens of millions of Americans when they became unable to take care of themselves. Now, though, the industry is in financial turmoil, causing misery for many of the 7.3 million people who own a long-term-care policy, equal to about a fifth of the U.S. population at least 65 years old. Steep rate increases that many policyholders never saw coming are confronting them with an awful choice: Come up with the money to pay more—or walk away from their coverage.

Here’s how I replied to Ms. Scism:

“There is a critical aspect of the LTC insurance issue that your otherwise fair and well-researched article missed entirely.

“When LTC insurance carriers recognized their reserves were inadequate to pay future claims, they did the honorable thing. They raised premiums to ensure future claimants would receive full benefits.

“Compare that with the federal government’s failure to fund Social Security and Medicare adequately, leaving those programs with upwards of $100 trillion dollars in unfunded liability. What’s more, government policy actually impaired private LTC insurance.

“Beyond the reasons you cited for LTC insurance problems (actuaries’ errors regarding lapse rates and utilization, plus the Federal Reserve’s forcing interest rates to near zero, for which actuaries should not be blamed) there is another cause. Medicaid is the dominant payor of long-term care. Easy access to Medicaid for middle class and affluent people after they already needed care crowded out up to 90% of the potential market for LTC insurance, according to authors of peer-reviewed research published in the American Economic Review.

“In other words, government policy impaired demand for and profitability of private long-term care insurance, while itself, leaving most aging Americans vulnerable to social insurance and public assistance programs that are hopelessly unprepared financially for the coming age wave.

“It is a tragedy to blame private insurers and the dedicated people who’ve tried to make the LTC insurance product work for problems caused by poor public policy. Blame the culprits, not the victims.

“For a full explanation, evidence and documentation of these facts and this analysis, please see my monograph “How to Fix Long-Term Care Financing,” published by the Foundation for Government Accountability (also the source of yesterday’s WSJ op-ed about millionaires on food stamps, a very similar problem.)

“If you would like to follow up on these aspects of this complicated problem, please contact me.”

Steve Moses, President
Center for Long-Term Care Reform

LTC Comment: OK, let’s tie these three articles and the key points they make together. Article one exemplifies the problem. Perverse incentives in public policy lure affluent people onto welfare for whom our safety net programs were never intended. Article two shows an example of how public policy can be modified to discourage overuse of public assistance by able-bodied non-needy people. Finally, article three demonstrates how the private sector, in this case long-term care insurance, gets blamed for problems caused, exacerbated and prolonged by counterproductive government rules.

Takeaway: “There are people, who the more you do for them, the less they will do for themselves.” (Jane Austen, Emma) We’d better rid public policy of the pernicious tendency to do too much for too many or we’ll fail the few genuinely needy Americans who need help the most.

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Updated, Tuesday, January 16, 2018, 10:08 AM (Pacific)

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LTC E-ALERT #18-003: LTC NEWS AND COMMENT

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 Millionaires Collect Food Stamps
Anxiety: An early indicator of Alzheimer's disease?
Sad News, RIP Josh Wiener
Stan Hinden, Washington Post retirement columnist, dies at 90
Trump Administration Will Let States Require People To Work For Medicaid
How are Social Security benefits and the Part B premium changing?
Senior living might want to reconsider its superiority complex
Medicare Advantage Enrollees More Likely to Enter Low-Quality SNFs
Wisconsin considers tax-protected long-term care accounts
Millennials flock to nursing at twice the rate of baby boomers, staving off shortage

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Updated, Friday, January 12, 2018, 9:18 AM (Pacific)

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LTC BULLET: DON’T BUY LTCI?!

LTC Comment: Bad advice by the unknowing spread by the unwitting refuted by understanding after the ***news.***

***RIP, Josh Wiener: I’m forwarding with permission this announcement from the Long-Term Care Discussion Group of Joshua Wiener’s passing. Josh was a superlative and indefatigable researcher and author on long-term care services and financing. He was also a friend I’ll miss. Rest in peace.

“The Long Term Care Discussion Group is saddened to share the news with our members of the passing of our dear friend and colleague Joshua Wiener. Many of you may have heard the news. But friends and family have asked us to pass along information about the funeral and Shiva observance to be held to honor and remember Josh. He has been an important thought leader and innovator contributing so richly to our knowledge and understanding in the long term care field. He will be truly missed as a friend, colleague and as a scholar. The funeral will be Sunday January 14th at 10 am at Temple Sinai, 3100 Military Road NW, Washington DC, 202-363, 6394. Shiva will follow on Sunday, Monday and Tuesday evenings at the home Josh shared with his wife Susan Klinger at 5419 41st St, NW, Washington DC, 20015. When we know more about the family's wishes for memorial contributions or charities we will post it on the Calendar page of www.ltcdiscussiongroup.org.” ***

*** ILTCI EARLY-BIRD REGISTRATION deadline extended: When Inter-Company Long-Term Care Insurance Conference organizers announced the end of special early-bird registration fees effective January 11, we asked for an extension so that LTC Bullet readers could have one more chance to get in at the lower charge. They agreed. You can register here at the extended reduced rate through Sunday, January 14. Grab it. There is no better way to stay abreast of the LTCI business, meet its movers and shakers, and refresh your commitment to improving long-term care financing than to attend this annual industry convocation. ***

LTC BULLET: DON’T BUY LTCI?!

LTC Comment: Two of the long-term care experts I admire most brought the subject of today’s LTC Bullet to my attention this week. Both nationally syndicated columnist Terry Savage and Senior Care Investor Editor Steve Monroe forwarded the article “Long-Term Care Insurance Is a Poor Buy, CFP Says.” My first reaction was that this poorly reasoned diatribe against LTCI was unworthy of serious rebuttal. But evidently the purveyor, Henry Stimpson of Stimpson Communications, sent this item to a wide mailing list of financial advisors. So . . .

Start by reading the whole article below “The Fold.” Then come back to here, where I’ll address and correct several of the more egregious errors in the piece.

CFP Says: “Long-term care is a big financial risk, but unfortunately, it’s not one that lends itself to insurance.”

LTC Comment: Nonsense. The purpose of insurance is to replace the small risk of a catastrophic loss with the certainty of an affordable premium. Although most people will experience some need for long-term care during their lifetimes, relatively few require expensive care for an extended period of time. That’s why most real experts agree long-term care is an insurable risk. This fact has not been seriously in doubt since Mark Meiners’ path-breaking research in the 1980s.

CFP Says: “Long-term care insurance is an investment that doesn’t make sense,” she says. “It’s better to plan for long-term care on your own by saving and investing, and in some cases, using a trust.”

LTC Comment: Long-term care insurance is not an investment. It is a contract that permits an insured to transfer a risk to an insurer legally bound to compensate the insured if and only if the insured event occurs. The value of insurance is the financial leverage it provides against an unpredictable, unlikely, but possible calamity. Neither saving nor investing provide such protection. Even a high net worth can be wiped out quickly by long-term care for an individual or a couple.

CFP Says: “What about giving your assets to your adult children so you’ll be eligible for Medicaid? It can work for some people, but Kibler says there are a lot of drawbacks to that strategy.”

LTC Comment: Well, now we’re getting to the nub of the matter. So this is why she recommends “using a trust.” What exactly are the “drawbacks” of self-impoverishing to qualify for Medicaid?

CFP Says: “One big problem is that there’s a look-back period of five years on assets you gave away. If you apply for Medicaid within 60 months of transferring your assets, you’ll pay a prorated penalty based on the average monthly cost of care in your area, she says.”

LTC Comment: This is the “Medicaid trap.” You can avoid the transfer of assets problem by putting your wealth in a trust five years before you need care. But the problem with Medicaid is not that it is hard to get. Most people who require expensive long-term care get it paid for by Medicaid whether they’re poor or not. See my “How to Fix Long-Term Care Financing” for the evidence and the preferred solution. The problem with Medicaid is that it is a means-tested public assistance program, welfare, and has a dismal reputation for problems of access, quality, reimbursement, discrimination and institutional bias. The most important reason people need long-term care insurance is not to protect assets, but to ensure access to quality care at the most appropriate level if and when they need it. For that, they need to be able to pay privately.

CFP Says: “If your goal is to leave money to your heirs, consider buying a life insurance policy, she says. Term life policies are inexpensive for middle-aged buyers, but they’re costly for people above 65, who are usually better off with a whole life policy.”

LTC Comment: Life insurance, term or whole, gives no leverage against the small probability of an unlikely, but large long-term care expense, unless it’s combined with a LTC benefit. Such combination or hybrid products are a good choice for people concerned about possible future premium increases on traditional long-term care insurance. Most experts familiar with long-term care insurance doubt, however, that the traditional product is as vulnerable to premium increases in the future as in the past. Why is that? The Federal Reserve caused most of the problem with premium increases by forcing interest rates to near zero thus compelling LTC insurance carriers to make up for their handicapped reserves by raising premiums so they’ll be able to pay future claims. Now, finally, interest rates are headed back up so the pressure on premiums will abate.

Closing LTC Comment: Investment, even with historically high returns that are unlikely to continue indefinitely, is no substitute for the financial leverage against risk that insurance delivers. Implying that consumers can evade the dire financial consequences of a catastrophic long-term care episode by purchasing life insurance or putting money in a trust to facilitate Medicaid eligibility is inaccurate and irresponsible. Hopefully, readers will convey this message to Mr. Stimpson and CFP Kibler, thoughtfully and respectfully, but firmly and authoritatively.

---------------------------------- The Fold -----------------------------------

From: Henry Stimpson [mailto:henry@stimpsoncommunications.com]
Sent: Wednesday, January 10, 2018 4:17 PM
Subject: Long-Term Care Insurance Is a Poor Buy, CFP Says

Long-Term Care Insurance Is a Poor Buy, CFP Says
Better solutions: saving and investing, life insurance, and perhaps a trust

“Don’t buy long-term care insurance.”

That’s certified financial planner Melinda Kibler’s surprising advice.

Long-term care is a big financial risk, but unfortunately, it’s not one that lends itself to insurance. LTCI can increase rather than reduce risk in retirement, says Kibler, with Palisades Hudson Financial Group in Ft. Lauderdale.

“Long-term care insurance is an investment that doesn’t make sense,” she says. “It’s better to plan for long-term care on your own by saving and investing, and in some cases, using a trust.”

Mathematics works against LTCI because most people will need long-term care eventually. For insurance to make economic sense, the risk must be spread across a pool of participants, Kibler says. With other types of insurance, only a portion of the population collects, while the others continue to pay their premiums, covering expenses paid out and keeping premiums manageable.

Since the bulk of buyers will eventually collect, LTCI insurers will have to raise premiums. This, in turn, will cause the healthier portion of the population to opt out, leaving a pool of less-healthy participants who all believe they will need to collect on this insurance sooner than later.

“Instead of paying into a policy with rising premiums that may empty your retirement savings, it is better to plan for long-term care by saving and investing,” Kibler says.

The conundrum of long-term care is that people with few assets can “afford” it best. They’ll burn through their assets quickly and then Medicaid will pay for their care, she says. If one spouse needs care and the other doesn’t, Medicaid rules provide for a reasonable level of assets and income for the healthy spouse.

On the other hand, wealthy people don’t need the product because they have the money to pay for care.

It’s the bulk of people in the middle who are most vulnerable to long-term care costs, Kibler says. And for them, there are no magic solutions.

“The best solution is to save up for care using a balanced approach, investing in a comfortable mix of U.S. and foreign stock funds and bonds,” she says.

A certified financial planner can run various scenarios and stress test them to show if you’re ready for retirement and can afford long-term care eventually. Kibler regularly runs such cash flow projections for her clients.

What about giving your assets to your adult children so you’ll be eligible for Medicaid? It can work for some people, but Kibler says there are a lot of drawbacks to that strategy.

One big problem is that there’s a look-back period of five years on assets you gave away. If you apply for Medicaid within 60 months of transferring your assets, you’ll pay a prorated penalty based on the average monthly cost of care in your area, she says.

Because of that disadvantage and the fact that you lose control of the assets you give up, Kibler doesn’t usually recommend giving away your money.

But if you do decide to, set up an irrevocable trust. Without a trust, your former assets could be lost if your child is hit with a costly divorce settlement, or has big debts he or she can’t pay, or is sued.

“A lifetime of savings could be lost quickly,” she says.

Have a lawyer who specializes in elder law and estate planning draw up the trust so it won’t jeopardize Medicaid eligibility, Kibler points out. Find a reputable lawyer, not one who’s engaged in fearmongering.

If your goal is to leave money to your heirs, consider buying a life insurance policy, she says. Term life policies are inexpensive for middle-aged buyers, but they’re costly for people above 65, who are usually better off with a whole life policy.

“Life insurance is a good way to leave assets to survivors,” she says. “It’s more predictable and has more reasonable costs than LTCI.”

In addition, you can set up an irrevocable life insurance trust (ILIT) to purchase a life insurance policy. As the beneficiary of the policy, the trust can protect the proceeds.

Palisades Hudson Financial Group is a fee-only financial planning firm and investment manager based Fort Lauderdale, Florida, with more than $1.4 billion under management. It offers financial planning, wealth management, and tax services. Its Entertainment and Sports Team serves entertainers and professional athletes. Branch offices are in Stamford, Connecticut; Atlanta, Georgia; Portland, Oregon; and Austin, Texas.

The firm’s monthly newsletter covering financial planning, taxes and investing is online at www.palisadeshudson.com/insights/sentinel. Social media: Twitter; LinkedIn; Facebook; Instagram.

Contact: Henry Stimpson, Stimpson Communications, 508-647-0705, Henry@StimpsonCommunications.com

[If you wish to unsubscribe, please reply…thanks.]

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Updated, Monday, January 8, 2018, 9:35 AM (Pacific)

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LTC E-ALERT #18-002: LTC NEWS AND COMMENT

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:

Pfizer Ends Hunt for Drugs to Treat Alzheimer’s and Parkinson’s
What happens when retirement expectations meet reality
Genworth Says China Oceanwide Deal Is Moving Forward
Giving States A Tool To Improve Long-Term Services and Supports
A physician homebuilder tries to upend the nursing home industry — and give seniors back their independence
Investors excited about independent and assisted living: report
Gene Wilder's widow on what it's like to care for someone with Alzheimer's
New Tax Law Enhances Life Settlements Market
LTC Costs Continue to Rise in 2018, but Some Buyers See a Drop
CMS Mulls Ways to Address Improper Skilled Nursing Discharges
To Help Others, One Couple Talks About Life With Early-Onset Alzheimer's

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Updated, Friday, January 5, 2018, 9:18 AM (Pacific)

Seattle—

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LTC BULLET: THE LTCI ROLLER COASTER

LTC Comment: The LTCI industry’s lowest lows are history, but its highest highs lie ahead. Why and how, after the ***news.***

*** HEROES: I have a lot of them in the LTCI industry and at least two of them were in the audience for the speech recounted below. Author and super-agent Harry Crosby is one. Another is Barbara Franklin, a pioneer who shunned leads early and built successful businesses in two related fields, LTCI and reverse mortgages. Here’s her feedback on the speech and on our LTC Clippings service.

Hello Steve - It was great to hear your optimistic view from 40,000 feet today as I remain in the “foxhole.” Actually I am relatively optimistic too - currently have five (!) long term care policies (traditional) on my desk awaiting delivery. I’m talking a lot more about hybrids too! I spend the bulk of my time servicing current policyholders which I take very seriously. Thanks again for all of your work and especially for the articles and news pieces you send as LTC Clippings. I am complimented frequently by the “centers of influence” I communicate with on my ability to keep them informed. Little do they know I have a “secret weapon” in the form of the Center for Long Term Care Reform to keep ME informed. ***

***SAMPLE LTC CLIPPING:
1/3/2018, “LTC Costs Continue to Rise in 2018, but Some Buyers See a Drop,” by Melanie Waddell, ThinkAdvisor
Quote: “While long-term care insurance costs increased slightly in 2017, some coverage can be less expensive depending on the insurer, according to new data from the American Association for Long-Term Care Insurance. The 2018 Long-Term Care Insurance Price Index, an annual compendium of pricing prepared by the AALTCI, found that some costs have actually declined since a year ago.”
LTC Comment: Onward and upward.

Subscribe to LTC Clippings by contacting Damon at 206-283-7036 or damon@centerltc.com ***

*** ILTCI CONFERENCE special early bird registration discounts expire January 11. Jump on the special rate before it disappears. This year’s upbeat conference theme is “A Matrix of Opportunities.” The LTCI industry’s premier event convenes March 18-21, 2018 in Las Vegas, Nevada at the Paris Hotel. For details and registration go to iltciconf.org. Remember: “what happens in Vegas stays in Vegas” . . . unless it’s what you learn and the networking you do at this conference and put to work back home. ***

***ATTABOY: Hearty congratulations to Bob Vandy of Center-corporate-member Advisors Insurance Brokers (AIB), a New York Long Term Care Brokers, Ltd. (NYLTCB) Company, which just announced:

Robert M. Vandy, CLU, ChFC, LUTCF, CLTC, formerly Vice President, Marketing with the firm, has been promoted to President, effective January 1, 2018. Current President and CEO, Kevin J. Johnson, LTCP, CLTC, will remain at the firm, and focus his efforts in the CEO role, helping to provide vision and guidance to the AIB/NYLTCB management team, as they continue to build their brand as the preeminent provider of fixed insurance and annuity product and support to the insurance and financial services community. ***

*** ATLAS RISING: The Future of Applied Objectivism: Here’s another conference for which the early-bird registration rate is expiring soon (January 8!). Check out the details here. If you’ve ever been inspired by Ayn Rand’s Atlas Shrugged or The Fountainhead, this is a meeting not to miss. I’ll speak on “Objectivist Ethics: the Hazards of Morality” and there will speakers from the Atlas Society, Students for Liberty, Wikipedia, the Foundation for Economic Education (FEE), Freedom Fest, Reason, the Libertarian Party, Transhumanists, and Silicon Valley. Intrigued? This program happens over Presidents Day Weekend, February 16-18, 2018 in San Jose, CA, venue to be announced. I hope to see you there. ***

LTC BULLET: THE LTCI ROLLER COASTER

LTC Comment: I was privileged to address a large webinar audience brought together by Center-corporate-member GoldenCare this week. I thank the whole GoldenCare team for giving me that opportunity, for the critical work they do in pursuit of our common mission, and for the invaluable support the company has given the Center for Long-Term Care Reform for so many years. The speech I delivered follows.

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The LTCI Roller Coaster
by
Stephen A. Moses

We were way up; we came way down; and now we’re on the upswing again. What happened? Why? and What’s next?

That’s what I’m going to explain today.

I’ve been watching long-term care insurance for over 30 years. I saw it grow from a budding, small business opportunity into a big, thriving industry with over a hundred carriers, rapidly growing sales, and a promising future.

Then something happened. What?

Well, it was kind of ugly, wasn’t it?

Carriers had no choice but to increase premiums; consumers rebelled; negative press followed; companies started leaving the market; some specialized distributors expanded their offerings beyond LTCI; many producers looked for other employment opportunities.

It was brutal there for a while. But that’s all behind us now, right? There’s nowhere to go but up, and fast.

The LTCI industry has shown remarkable resilience and ethical leadership. LTCI’s best years are ahead of it. You’re in on the ground floor of a huge opportunity.

Whoa! Wait a minute? Say again?

Resilience?

Isn’t long-term care insurance on the ropes, struggling for survival?

Ethical leadership?

Aren’t private insurance companies, the profit motive and capitalism, in a word, greed, the source of all our problems? Think Bernie Sanders and Elizabeth Warren, not to mention all the academic studies insisting we need a new government entitlement program for long-term care.

LTCI’s best years are still coming?

Steve, are you out of your mind?

I don’t think so and I’ll prove all of this to you before I conclude my remarks today.

But first, let’s withdraw from the daily push and pull of industry challenges and personal professional trials. Let’s broaden our perspective. Let’s get out of the trees and look at the forest.

I’ve been surveying the forest of long-term care financing since 1981.

Back then, I worked for the HCFA, predecessor of CMS that now run Medicare and Medicaid.

I got interested in LTC when I found a program in Oregon that purported to recover 5% of Medicaid nursing home expenditures from the estates of deceased recipients.

That blew my mind. If Medicaid is welfare and you have to be poor to get it, how did a little state like Oregon recover millions of dollars from the estates of supposedly impoverished people?

I started researching Medicaid eligibility and found to my surprise that high income doesn’t disqualify as long as LTC costs exceed income. Most assets are exempt, so seemingly draconian spend-down requirements usually don’t matter.

This got me thinking. If you can ignore the risk of long-term care, avoid the premiums for private insurance, and shift the cost to tax payers if you ever need long-term care, why would people plan to save, invest or insure against the risk and cost of long-term care?

I predicted as much in national studies for HCFA and the HHS Inspector General in the late 1980s.

Despite some successes we’ve had in 1993 closing Medicaid eligibility loopholes and making estate recoveries mandatory and in 2005 capping the home equity exemption and unleashing the long-term care partnership program, the perverse incentives I identified over 30 years ago continue to obstruct the market for private long-term care financing.

I’m not going to dwell on this. It’s well-established in the peer-reviewed academic literature that Medicaid crowds out up to 90% of the potential market for LTC insurance.

If you want to learn more about all that, read just about anything I’ve ever written, most of which you can find on the handout you’ve been provided and on our website: www.centerltc.com.

Now if your reaction is “no wonder we’ve had problems, it must be hopeless” then you’ve got it all wrong.

The right way to think about it is “look at how successful we’ve been even dragging that ball and chain.”

And “just think what it will be like when those obstacles are out of our way.”

Well, now, I can practically hear you thinking: “OK, Steve, what makes you think those obstacles are going away?”

And, “incidentally, you’ve been predicting it would happen for a long time. So why not yet?”

Fair questions. First the why; then the why not yet.

Why do I think it’s inevitable that the government will have to stop crowding out private long-term care insurance?

In a nutshell, public expenditures, mostly for entitlements, have gone through the roof. The national debt has doubled in less than a decade and is on course to double again as quickly.

We’re on a course that Social Security, Medicare, Medicaid and other such programs plus interest on the national debt will consume all federal revenue within a decade or two.

Trees don’t grow to the sky, and neither do economies. As the late economist Herb Stein used to say “Trends that can’t continue, won’t.”

Now let’s relate this specifically to long-term care. What do we know for an absolute certainly?

The long-anticipated “age wave” is finally cresting and will soon crash on the U.S. economy.

Baby boomers began retiring and taking Social Security benefits at age 62 in 2008.

At age 65 in 2011, they turned the Social Security and Medicare programs cash-flow negative.

Boomers began taking Required Minimum Distributions (RMDs) from their tax-deferred retirement accounts in 2016, depleting the supply of private investment capital.

They will start reaching the critical age (85 years plus) of rising long-term care needs in 2031, around the time Social Security and Medicare are expected to deplete their trust funds, forcing them to reduce benefits.

That’ll be a disaster for Medicaid, which depends on collecting most of the Social Security of its LTC recipients and on Medicare’s far more generous reimbursements.

Just to explain. When you’re on Medicaid, you have to contribute most of your income to offset Medicaid’s cost for your care. Half of the so-called “out of pocket” costs for nursing home care are really just spend-through of Medicaid recipients’ Social Security benefits. When those benefits decline as they’re expected to do in the 2030s, it will be a devastating loss to Medicaid that will have to be made up by increased taxes or even lower provider reimbursements.

LTC providers make profits on Medicare patients that help make up for losses on the majority of their residents who rely on Medicaid’s reimbursements that are on average less than the cost of the care. So when Medicare hits the wall in the 2030s, that will devastate Medicaid too.

Reduce either or both of those sources and Medicaid’s ability to fund LTC (and crowd out private LTCI) goes south fast.

In other words, there’s a perfect gerontological and economic storm coming and to see it on the horizon, all you have to do is look.

OK, so why not yet?

For most of the time I’ve followed long-term care financing, there has been a clear economic pattern.

The government would spend way beyond its means in good times, then a recession would happen. Budgets would get tight and suddenly politicians and bureaucrats would struggle to control costs.

That’s when we made progress closing Medicaid loopholes, requiring estate recoveries, encouraging private LTC planning, and supporting LTC insurance with programs like the LTC Partnership. We even had a shot at getting above-the-line tax deductibility or cafeteria plan coverage in some years.

But then the business cycle would turn. Tax receipts would go up; welfare rolls would go down and all of a sudden no one cared any longer about controlling spending, until the next downturn happened.

I’ve traced this whole history in detail in our latest major report titled “How to Fix Long-Term Care Financing.” You can find a link to it on the handout too.

Now, this economic pattern prevailed until the last recession, the Great Recession, the worst since the Great Depression.

That economic downturn ended in June 2009. But it didn’t cause serious constraints on government spending like earlier recessions did. Federal and state budgets continued to explode. We got no traction on reforming public policy to discourage Medicaid dependency and encourage responsible LTC planning.

What’s different? Why did Uncle Sugar have to behave with good budget sense before or face dire fiscal consequences, but he can spend with impunity now?

The answer is critical because it is the same reason that nearly ruined the long-term care insurance industry.

After each recent recession, the Federal Reserve forced interest rates artificially low, trying to encourage economic recovery.

What happened instead as a result of this exceptionally careless monetary policy is that with interest rates so low, the federal government was able to spend without the usual constraints.

The consequences have been very serious including economic malinvestment by businesses; individuals, families and pension funds chasing higher, but unsafe investment returns; expanding asset bubbles especially in real estate and stocks; greater wealth inequality; and an historically slow recovery with few wage gains for the working and middle classes.

We’re experiencing the biggest economic bubble in the history of the United States. When this bubble pops, like earlier ones created by similar but less egregious interest rate policies resulting in the internet bust of 2000 and the real estate bust of 2008, the consequences will be far more dire than what followed those recessions.

But our focus here is on long-term care insurance and that’s where the Fed’s artificially low interest rates caused tremendous damage to our industry.

Unable to get the returns on reserves that the actuaries originally anticipated, carriers had to raise premiums to compensate.

That led directly to the consequences we mentioned earlier: consumer rebellion, negative press, declining sales, company attrition, etc.

So, bottom line, folks. You have the government to thank for all the problems we’ve faced. Medicaid crowded out demand for your product. The Fed’s monetary policy of near-zero interest rates made LTCI unprofitable without premium increases that started the industry down a slippery slope.

But here’s the good news. There are only two likely outcomes going forward, both of which are highly favorable to the LTC insurance industry.

The Fed has begun to increase interest rates. As those increases ramify through the economy, which they are already beginning to do, the short term impact on the long-term care insurance business will be highly beneficial.

Having already taken the unpopular measures to adapt to lower returns on reserves, LTCI carriers will benefit directly and disproportionately from higher returns going forward.

They’ll be able to make marketing the product more attractive to distributors and producers than ever before.

If on the other hand, the government’s profligate monetary and spending policies drive the economy into a disastrous tailspin, the market for LTC insurance will rapidly expand exponentially.

That’s because Medicaid will have to stop being the primary payor for long-term care for the middle class and many of the affluent in addition to the poor. Eligibility loopholes will close. The home equity exemption will disappear. Medicaid planners, who artificially impoverish people to get them on Medicaid, will have to file for unemployment or seek other, more responsible means of gainful employment.

When consumers actually have to face the true risks and cost of long-term care; when they really do have to spend down their life’s savings; when their biggest asset, their home equity, is at risk; then they’ll see the value proposition in long-term care insurance much more clearly.

They’ll beat a path to your door instead of vice versa.

It’s been a rough ride, but it’s over. The evidence is all around us. Let’s close by returning to the points I made at the beginning. The LTCI industry is resilient; its ethical leadership is noteworthy; and its best years are ahead.

What do I mean by resilience?

I’m so proud of the industry I joined when I left government in 1989 to become research director for an LTCI marketing company.

You’ve shown amazing resilience.

You’ve stabilized the LTC insurance market against all the odds.

Faced with challenges to the market not of your own making nor your own fault, you’ve responded with creative new products and policies.

Carriers that stayed the course adapted to lower-than-expected interest rates and higher-than-expected utilization, positioning themselves for a bonanza when interest rates turn up.

Experts agree future premium increases, if any, will likely be moderate, thus relieving consumers’ concerns in that regard.

You AMGs, “altruistic masochistic geniuses,” who out of a passion for protecting your fellow Americans from the risks and costs of long-term care, have successfully sold this product even though the government was giving away an inferior alternative, you deserve high praise and our unstinting thanks.

More good news stories are being published, both warning of the consequences of unanticipated long-term care expenses and more-often-than-ever-before actually recommending long-term care insurance as the solution.

AALTCI just reported that “A couple in their 60s purchasing new long term care insurance coverage can expect to pay $3,490 for a potential benefit of over $666,000 in coverage should they begin needing care at age 85” and that “some costs have actually declined compared to a year earlier.”

New products linked with life insurance or annuities answer common objections such as “what if I don’t need it.”

Chronic illness policies bridge the features of traditional and combination LTC policies. Insureds pay an annual premium instead of a large single premium, but they’re still guaranteed to get all their money back over time whether they ever need long-term care or not.

In this new, exciting environment, opportunities abound to do well for yourself while doing good for others.

Want an example? Just consider the potential of Genworth’s expertise and experience informing and supercharging long-term care insurance in China, the world’s biggest market. China is doing everything wrong so far in LTC insurance; Genworth could set them straight.

What about my claim that you’ve shown tremendous ethical leadership?

Ignore the specious criticism you get for selling a product, making a profit, participating in capitalism and enjoying its fruits. That’s what makes the world go around and makes everyone in it better off.

Compare how your industry handled its challenges with the way the federal government has operated.

When you faced rising costs and declining revenues, caused as I explained by government policies to cut interest rates and pump trillions into your biggest competitor, Medicaid, you responded by raising premiums to ensure adequate reserves so you could pay the future claims you contracted to pay.

Compare how government has handled its similar responsibility. Social Security and Medicare face upwards of $100 trillion of unfunded liabilities backed by nothing more than IOUs in their “trust funds” for money the federal government has already spent on other priorities.

Medicaid, the biggest obstacle to fixing long-term care and unleashing the power of private financing, doesn’t even have a phony trust fund and is doomed to continue trapping otherwise responsible people on welfare, causing excessive dependency on nursing homes, and impairing access and quality of long-term care until the program collapses entirely.

Finally, what about my claim that the best times for LTCI are ahead of you?

The problem of long-term care risk and cost hasn’t gone away.

Two in three aging Americans will need long-term care.

Alzheimer’s Disease is a huge and growing plague. Research breakthroughs are few and far between.

Most people don’t think about long-term care until they or their loved ones need it.

Then their options are few: provide care themselves, pay for professionals, or seek Medicaid’s low-cost, uncertain care.

Suddenly needing care for parents or spouse can ruin lives and tear families apart.

You’ll be in the bulls-eye if you haven’t prepared your clients for this likelihood when the government programs most have relied on in the past no longer meet their needs.

If I’ve assessed the problem, the likely eventualities, and the solution correctly, you, my friends are in the cat-bird seat going forward.

All you have to do is stay the course, persevere.

Just remember these immortal words of Calvin Coolidge, a rare, free-market capitalist in the White House:

“Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan Press On! has solved and always will solve the problems of the human race.” Calvin Coolidge

If you need encouragement to stay the course, go see the movie “Darkest Hour,” in theaters right now. It’s the story of Winston Churchill’s struggle to mobilize Great Britain against a seemingly unstoppable Nazi scourge.

Compared to that our struggles to overcome the obstacles government has placed in the way of private long-term care insurance are a walk in the park.

Thanks for your dedication, hard work, collegiality and friendship in our common mission to improve long-term care for all Americans.

Before I conclude, I’d like to tell you a little bit about how we pursue that mission at the Center for Long-Term Care Reform.

We conduct state-level and national studies of long-term care financing with a focus on the problems created by government interference in that market.

You can find and read dozens of our reports at our website, www.centerltc.com, and on the handout you’ve been given for today’s presentation.

We publish a weekly essay, usually on Fridays, called the LTC Bullets. The Bullets discuss and analyze current topics related to long-term care service delivery and financing. We’ve done over 1200 of them and you can find them archived chronologically and by topic on our website.

We publish a weekly compendium of long-term care news called the LTC E-Alerts designed to keep members abreast of everything they need to know to remain on the forefront of professional knowledge and expertise.

Our daily LTC Clippings give premium members access in real time to the latest stories, articles, reports and data as these are released along with our “take” on what they mean in a sentence or two.

Our Members-Only website, AKA “The Zone,” is full of invaluable resource material including our voluminous “Almanac of Long-Term Care,” where we archive all important news about long-term care organized within 11 sub-topics.

Finally, I want to thank GoldenCare and its staff and management for this opportunity to share some ideas with you today and for their long and invaluable support for our work at the Center for Long-Term Care Reform.

I’ll be glad to take questions now.

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Updated, Wednesday, January 3, 2018, 9:18 AM (Pacific)

Seattle—

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LTC E-ALERT #18-001: LTC NEWS AND COMMENT

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:

Home Equity Insurance (That Thing We Sell)
Why Tax Hospitals? It’s a Medicaid Shell Game
Rising Number Of Older Americans Carrying Debt Into Retirement
LTCI Policyholders May Get Broader Guaranty Association Protection
Trump Administration Eases Nursing Home Fines in Victory for Industry
Daily Serving of Leafy Greens May Boost Brain Health
CDC: More than 20% of 85+ adults need ADL assistance
Smaller personal care homes are a growing senior living option
Completing the Retirement Planning Puzzle: Where Long-Term Care Fits In
How Care for Elders, Not Children, Denies Women a Paycheck
CDC: More than 20% of 85+ adults need ADL assistance
Interventions Unproven for Preventing Late-Life Dementia
Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015

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Updated, Monday, December 18, 2017, 10:09 AM (Pacific)

Seattle—

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LTC E-ALERT #17-043: LTC NEWS AND COMMENT

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:

Why Affluent Clients Need LTC Coverage
Skilled nursing occupancy hits 5-year low
Manulife exits the Long Term Care insurance market
Don’t Count on FEHB to Cover Long-Term Care Costs
Genworth Posts LTCI Rate Hike Update
Waiting Your Turn: Wait Times for Health Care in Canada, 2017 Report
Married and protecting assets from Medicaid | Biz Brain
'Village Movement' Allows Elderly To Age In Their Homes
Americo Introduces a Single-Premium Immediate LTCI Policy
Critics say pressure to lower hospital readmissions may be backfiring
We haven’t prepared for the aging monster
Past efforts point way to future success of Medicaid LTSS reform: report

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Updated, Friday, December 15, 2017, 9:46 AM (Pacific)

Seattle—

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LTC BULLET: WHY COUPLES WORRY SO LITTLE ABOUT LONG-TERM CARE

LTC Comment: If long-term care is such a huge risk and cost, devastating families’ life’s savings across America, how come so few people, even otherwise financially responsible couples, plan, save, invest or insure for LTC? Answers after the ***news.***

*** 2018 ILTCI CONFERENCE REGISTRATION IS OPEN: The Intercompany Long-Term Care Insurance Conference will convene at the Paris Hotel & Casino in Las Vegas, March 18-21, 2018. Register here: https://www2.bravuratechnologies.com/iltcireg/register. Through January 11, take advantage of the individual Early Bird registration rate of $895. If you are attending for the first time, you can qualify for special Early Bird pricing of just $395! This is the premier industry event of the year with outstanding educational and networking opportunities. For more details and to register, visit iltciconf.org. ***

*** NOMINATIONS ARE OPEN: Something new this year. ILTCI Conference organizers are asking “Who are the stars in the long term care industry that are demonstrating out-of-the-box thinking? Who are the best and brightest? Who demonstrates passion for our industry each day? Who is embracing innovation to pursue new business strategies to advance the industry and the vision of the ILTCI?” Do you know someone who should be recognized and acknowledged at the 18th Annual Intercompany Long Term Care Insurance Conference? If so, please fill out a nomination! Here’s the form. ***

*** WHAT HAVE YOU DONE FOR ME LATELY? 2017 was a prolific year for your Center for Long-Term Care Reform. In July we co-published with the Foundation for Government Accountability a major study by Stephen Moses titled How to Fix Long-Term Care Financing. We published 43 LTC Bullets (check them out here), 43 LTC E-Alerts (check them out in The Zone here), and 552 LTC Clippings. We’ve tried hard to keep members abreast of everything that happened in the current year affecting long-term care services and financing. We’ll do the same for members in the coming year. So if you’re not a Center member yet, consider the following benefits of membership and join. ***

*** MEMBERSHIP BENEFITS. Let’s take a moment to review the benefits of individual and corporate membership in the Center. For more details, see our “Membership Levels and Benefits Schedule.”

In a nutshell, as a regular member of the Center ($150 per year or $12.50 per month), you’ll get our weekly LTC Bullets and LTC E-Alerts and a user name and password for access to our “Members-Only Zone.”

In “The Zone,” you’ll find the “Almanac of Long-Term Care,” our compendium of LTC news, reports and statistics stretching back more than a decade with links to critical research materials covering eleven topics from “Aging Demographics” to “Unfunded Liabilities.”

Other features in The Zone include key Medicaid and Medicare numbers updated yearly and archived, a transcription of our highly regarded “Long-Term Care Graduate Seminar,” links to the major current and past “Long-Term Care Cost Surveys,” a couple dozen reasons why veterans should not rely on VA benefits for long-term care and much more.

If you’re really serious about a career in long-term care financing, then join the Center as a “Premium Member” ($250 per year). At that level, you’ll have all the benefits of regular membership plus email and phone access to Steve Moses with a 24-hour turnaround and a subscription to our “Clipping Service,” placing you on the pioneering forefront of up-to-the moment news, data and analysis in your field.

Premium Elite members ($500 per year) get all of the above plus a complimentary LTC Bullet or LTC E-Alert sponsorship with a banner ad, complimentary Center membership for one assistant, and quickest-turnaround email and phone access to Steve Moses.

Regional Representative members ($500 per year) get all of the above and, after they meet all the qualifications—including five years qualified experience and completion of our LTC Graduate Seminar—the status of Regional Representative of the Center for Long-Term Care Reform.

Every member of the Center gets the “Big Benefit”: the knowledge and personal satisfaction that you're supporting the indefatigable research and public policy advocacy of the Center for Long-Term Care Reform.

Corporate membership at the Bronze, Silver, Gold and higher levels is also available. Each level includes the same benefits individual members receive for increasing numbers of employees or producers plus additional benefits exclusively for corporate members. ***

LTC BULLET: WHY COUPLES WORRY SO LITTLE ABOUT LONG-TERM CARE

LTC Comment: Conventional wisdom warns long-term care risk and costs are huge. People all across the country are supposedly spending down their life’s savings paying for caregivers, assisted living, and nursing homes. Yet most folks don’t worry enough about that ostensibly highly likely outcome to prepare in advance. Policy wonks, academics and public officials scratch their heads in wonderment at this seeming illogic, but we know what’s going on, don’t we?

Medicaid pays for most expensive long-term care. Despite the common belief that Medicaid long-term care eligibility rules require financial devastation, the truth is that income rarely stands in the way as long as it’s less than the monthly cost of a nursing home. Excluded assets, including home equity, exempt as of 1/1/18 up to $858,000 in some states and no less than $572,000 everywhere else, plus, in unlimited amounts, one car, business, IRAs, prepaid burial expenses, term life insurance, home furnishings and other personal belongings, enable affluent people to qualify easily. Anyone who still owns too much can hire a Medicaid planning attorney to slip in under the income and asset eligibility screen. Given these facts, no one should wonder why (1) the public is asleep about long-term care, (2) home equity rarely pays for LTC, and (3) too few consumers buy private insurance for this risk.

But what about the special case of couples? Medicaid planners often defend the practice of artificially impoverishing an ill spouse for the purpose of Medicaid qualification by pointing to the healthy spouse’s future financial well-being. Until the Medicare Catastrophic Coverage Act of 1988 (MCCA ’88) was passed, that was a serious problem. Nearly all of an ill spouse’s income had to go to offset Medicaid’s cost for his care. In that generation, it was nearly always the husband who had most of the income and needed care first. The healthy wife was left in the community, often in a home owned free and clear, but with little or no income. Some survived on cat food according to media reports at the time.

All that ended with passage of MCCA ’88. Although that law was mostly about Medicare, it included some very important measures bearing on Medicaid LTC eligibility. For example, MCCA ’88 required state Medicaid programs for the first time to penalize asset transfers for less than fair market value done for the purpose of qualifying for Medicaid long-term care benefits. Previously asset transfer penalties were voluntary. But in the same legislation, Congress and President Reagan balanced that more restrictive measure with a generous provision ending spousal impoverishment. Instead of devastating healthy wives remaining in the community when their husbands entered nursing homes on Medicaid, MCCA ’88 allowed them to keep up to $1,500 per month of the institutionalized husband’s income (which would before have gone to offset Medicaid’s cost for his care) plus up to half the couple’s joint assets not to exceed $60,000. These "spousal impoverishment" protections were set to increase with inflation each year.

On January 1, 2018, the comparable figures, updated for inflation, rise to a Maximum Monthly Maintenance Needs Allowance of $3,090 per month for income and a Community Spouse Resource Allowance of up to $123,600 for assets, more than double their original levels. Medicaid's spousal impoverishment protections may be below today's middle class income and asset standards, but that's why they're called "spousal impoverishment" protections. The purpose of Medicaid was never to replace personal savings, investments or insurance for long-term care, nor has it been to protect middle-class inheritances from the risk of parents' needing long-term care. The goal of these protections was to prevent community spouses from financial devastation without featherbedding their failure to prepare for long-term care costs. Premium members of the Center for Long-Term Care Reform with access to “The Zone,” our members-only website, can review increases in the spousal impoverishment numbers for every year since 1991 here.

Here’s another major benefit married couples enjoy when they rely on Medicaid for their long-term care. Prior to the Deficit Reduction Act of 2005 (DRA’05), Medicaid imposed no limit on home equity. A Medicaid recipient could own one home and all contiguous property of any value without its affecting his or her eligibility for long-term care benefits. The DRA ’05 capped the home equity exemption at between $500,000 and $750,000 with the limit set by state legislatures. Those limits were also pegged to inflation. In 2018, they’ll increase to $572,000 and $858,000, respectively. But, not to worry. “There are some exceptions to this rule. If your spouse or your child who is under 21 or blind or lives in the home, this rule does not apply. Also, the state can choose not to apply this rule if it determines that applying the rule would be an undue hardship.” In other words, there are still no dollar limits on the home equity exemption for married couples.

Finally, married couples enjoy other special “loopholes.” Medicaid-compliant spousal annuities enable couples to shelter hundreds of thousands of dollars from Medicaid eligibility limits immediately before an ill spouse becomes eligible for care. In some states, notably New York and Florida, healthy spouses routinely refuse to share in the ill spouse’s cost of care, defying federal and state requirements, but dodging litigation because state Medicaid programs usually refuse to prosecute.

Get the picture? It’s no mystery why so many consumers fail to plan for long-term care. In most cases, most of the time, if they’re stricken by high and extended long-term care expenditures, the worst of the financial liability is picked up by tax payers. People don’t know ahead of time that they’re not at risk; they just don’t take warnings about losing their life’s savings seriously. Their denial has been enabled for 52 years by easy access to Medicaid after the insurable event occurs. There is nothing peculiar about consumers,’ especially couples’, seeming obliviousness about long-term care. They respond predictably to the perverse incentives created by government policy. We all pay the price for this poor public policy, both in taxes, and in a system that traps so many unnecessarily in welfare-under-financed long-term care.

SEASON’S GREETINGS. We wish all our friends in every aspect of the long-term care business unbounded happiness in this joyous time of year. Except for keeping up with our daily LTC Clippings, we’ll be offline now until the start of 2018. See you then!

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Updated, Monday, December 11, 2017, 9:55 AM (Pacific)

Seattle—

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LTC E-ALERT #17-042: LTC NEWS AND COMMENT

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:

5 Things an Asset-Based LTC Veteran Sees Today
Past efforts point way to future success of Medicaid LTSS reform: report
We haven’t prepared for the aging monster
National Health Expenditure Report Shows We Have Not Solved the Cost Problem
What You Could Learn About a Successful Retirement From Current Retirees
Tools added to insurance portfolio
Big 5 insurers depend on Medicare, Medicaid for growth in enrollment, profits
SUNY study: Nursing homes in minority neighborhoods provide poorer quality care
Debunking Five Common Myths About Long-Term Care Planning
Kansas Nursing Homes May Refuse Patients Waiting on Medicaid
Healthcare prices hard to find online
The cost of caregiving: ‘A sacrifice for our entire family’
What if the elderly could swap home equity for long-term care?

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Updated, Friday, December 8, 2017, 10:13 AM (Pacific)

Seattle—

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LTC BULLET: SO WHAT IF THE GOVERNMENT PAYS FOR MOST LTC?, 2016 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?, 2016 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 2016 statistics on its website at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Tables.zip. You’ll need to choose the data tables of interest and “unzip” them.

Health Affairs has published a summary and analysis of the new data titled “National Health Care Spending In 2016: Spending And Enrollment Growth Slow After Initial Coverage Expansions." Registered subscribers to Health Affairs can access the full text of that article at www.healthaffairs.org. The “Abstract” is available free.

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

Heads Up: This may be the most important LTC Bullet we publish all year. It is the fifteenth 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 if the Government Pays for Most LTC.” You’ll find our yearly analyses of the data going back to "So What If the Government Pays for Most LTC, 2002 Data Update."

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"So What If the Government Pays for Most LTC?, 2016 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 $162.7 billion on nursing facilities and continuing care retirement communities in 2016. The percentage of these costs paid by Medicaid and Medicare has gone up over the past 45 years (from 26.8% in 1970 to 53.7% in 2016, up 26.9 % of the total) while out-of-pocket costs have declined (from 49.2% in 1970 to 26.9% in 2016, down 22.3% 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 1970-2016.

So What? Consumers' liability for nursing home and CCRC costs has declined by nearly half, down 45.3% in the past four decades while the share paid by Medicaid and Medicare has doubled, up 100.4%.

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 $560,000 and in some states up to $840,000 of home equity (as of 1/1/17). No wonder nursing homes are struggling financially--their dependency on parsimonious government reimbursements is increasing while their more profitable private payers are disappearing.

Unfortunately, these problems are even worse than the preceding data suggest. Over half of the so-called "out-of-pocket" costs reported by CMS are really just contributions toward their cost of care by people already covered by Medicaid! These are not out-of-pocket costs in terms of ASSET spend down, but rather only INCOME, most of which comes from Social Security benefits, another financially struggling government program. Thus, although Medicaid pays less than one-third of the cost of nursing home care (30.7% of the dollars in 2016), it covers nearly two-thirds (62%) of all nursing home residents. Because people in nursing homes on Medicaid tend to be long-stayers, Medicaid pays something toward nearly 80 percent of all patient days.

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

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

Private Health Insurance

Don't be fooled by the 9.1% of nursing home costs that CMS reports as having been paid by "private health insurance" in 2016. That category does not include private long-term care insurance. (See category definitions here.) No one knows how much LTC insurance pays toward nursing home care, because many LTCI policies pay beneficiaries who then pay the nursing homes. Thus, a large proportion of insurance payments for nursing home care gets reported as if it were "out-of-pocket" payments. This fact further inflates the out-of-pocket figure artificially.

Assisted Living

How does all this affect assisted living facilities? ALFs are 85% private pay (Source: AHCA/NCAL Data) and they cost an average of $45,000 per year (Source: Genworth 2017 Annual Cost of Care Survey: Costs Continue to Rise Across All Care Settings). 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 $560,000 or $840,000 depending on the state), plus—in unlimited amounts—one business, one automobile, prepaid burials, term life insurance, personal belongings and Individual Retirement Accounts not to mention wealth protected by sophisticated asset sheltering and divestment techniques marketed by Medicaid planning attorneys. Income rarely interferes with Medicaid nursing home eligibility unless such income exceeds the cost of private nursing home care.

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

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

Home Health Care

The situation with home health care financing is very similar to nursing home financing. According to CMS, America spent $92.4 billion on home health care in 2016. Medicare (40.5%) and Medicaid (36.8%) paid 77.3% of this total and private insurance paid 10.4%. Only 8.7% 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 1970-2016.

So What? Only one out of every eleven 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:

“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-Cassandra-Quandry.pdf.

“How to Fix Long-Term Care,” 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" here (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 on Medicaid's home equity exemption and several of the more egregious Medicaid planning abuses were ended. But much more remains to be done. With the Age Wave starting to crest and threatening to crash over the next two decades, we can only hope it isn't too late already.

* 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