Suppo pporting ng Choice i in a an Increa easing ngly C Complex W World: d: What at a a Great at T Time f for Sel elf-Direc ection! n! Sha haron L Lewis is May 2018 2018
B A C K G R O U N D DATA AND CONTEXT
HEALTHCARE AND THE U.S. ECONOMY For the majority of Health care costs A 30% increase in the past 40 years, constitute over 17% personal income health care costs of U.S. GDP; when over the past have increased we include human decade was annually at a services, the total effectively greater rate than is 35%. eliminated by a 76% the economy as a increase in health whole. care costs. Source: IOM, http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/Quality/LearningHealthCare/Release%20Slides.pdf 3
WE ARE SPENDING MORE ON HEALTHCARE AS A PERCENTAGE OF GDP 18 16 14 12 10 8 6 4 2 0 United States Netherlands Germany France Denmark Canada Australia United Kingdom Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor 4
WE HAVE LOWER LIFE EXPECTANCY 88 86 84 82 80 78 76 74 72 70 United States Netherlands Germany France Denmark Canada Australia United Kingdom Life Expectancy - females at birth (2013) Life Expectancy - Males at birth (2013) Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor 5
WHEN SOCIAL SERVICES SPENDING IS INCLUDED, WE’RE IN THE MIDDLE 50 45 40 35 30 25 20 15 10 5 0 United States Netherlands Germany France Denmark Canada Australia United Kingdom Health Spending as share (%) of GDP (2013) Public Social Spending as share (%) of GDP (2013) Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor 6
FEDERAL LTSS POLICY 1993 2010 Clinton Health Care Affordable Care Plan includes plans to 1935 1981 Act expands expand HCBS; plan is US enacts 1915(c) access to HCBS never enacted. 2001 Social Security 1974 establishes HCBS through BIP, CFC, New Freedom Act/Old Age Social services added waivers CLASS. Initiative Assistance to SSA, including 1995 established to program. Ban homemaker services, 1982 remove barriers HHS & RWJF on funding to transportation, adult Katie to community public day care, Beckett/TEFRA initiate the living for people institutions. employment training state plan Medicaid cash with disabilities. Gives rise to nutrition assistance. option for HCBS and counseling private nursing demonstration . facilities. 2001 1935 1965 1974 1980 1981 1990 1993 1999 2001 2005 2013 1990 2005 Pepper Commission Deficit Reduction 1980 makes Act: expands Mental Health recommendations 1965 HCBS funding; Systems Act provides on LTSS financing. Medicare and Medicaid MFP created; funding for added to the SSA; 2013 HCBS state plan community mental 1990 institutional bias (nursing CLASS Act 1999 option; self- health programs with Americans with facilities) memorialized in repealed,; Olmstead Supreme direction of an emphasis on Disabilities Act statute. bipartisan LTC Court decision personal care. deinstitutionalization. (ADA) becomes law. Commission promotes right to 1965 established. community Older Americans Act integration under enacted. LTC Commission the ADA unable to agree on recommendations. 7
LTSS: A HUGE PART OF OUR MEDICAID SYSTEM Over 5 million people depend on Medicaid-funded LTSS People who received Medicaid-covered LTSS, CY 2013, MEDICAID LTSS n = 5.2 million, (Data from CMS) 4.0 + 5.2 million persons received 3.5 LTSS = $158.2 billion Medicaid LTSS in CY 2013, based 3.5 across institutional on CMS estimates. Data is and HCBS settings Many individuals who 3.0 imperfect. receive Medicaid-funded LTSS are also dual eligible 2.5 individuals, who are + 1.5 million (28%) of people who 2.0 covered under both received LTSS from Medicaid Medicare and Medicaid. 1.5 1.5 received institutional services. 1.0 + 42% of full benefit dual eligible 0.5 0.2 individuals use Medicaid LTSS; - 87% of their Medicaid Institutions HCBS Both expenditure are LTSS 8
MEDICAID: THE PRIMARY PAYER Who pays for LTSS in the US? FEW OPTIONS Private Insurance + 8% Employer-sponsored and commercial healthplans rarely offer LTSS benefits Out of pocket + 19% 86% decline in private LTC Medicaid policies since 2000 – 52% fewer than + Private LTC insurance Other Public benefits relatively limited 21% and short-term 9
PEOPLE WITH DISABILITIES ARE DISPROPORTIONATELY EXPENSIVE 100% 14% 90% 9% 40% 80% 70% People with Disabilities 34% 60% Aged 50% 21% 40% Adult 30% 19% 43% 20% Children 10% 19% 0% Enrollment Spending Source: http://www.kff.org/medicaid/state-indicator/distribution-of-medicaid-enrollees-by-enrollment-group/; http://www.kff.org/medicaid/state-indicator/medicaid-spending-by-enrollment-group/ 10
WHY MEDICAID? LTSS is unaffordable for most individuals and families. HCBS & Institutional Care Compared to Income COSTS Median Household Income 65+, 2017 $40,000 + The national median annual cost of care for home health care is FPL Household (2 people), 2016 $16,240 $49,188. Cost of home care services is… • Nearly 3x higher than the income of a 2 person household $85,775 Institutional (Semi-Private Room), 2017 living at FPL. • 1.2x higher than the median household income for a $49,188 HCBS (Homemaker), 2017 HCBS (Home Health Aide) 2017 65+ household. Source data: HMA using cost data from $18,200 HCBS (Adult day), 2017 Genworth, 2017. Note: does not include IDD or BH-related LTSS system costs. $- $20,000 $40,000 $60,000 $80,000 $100,000 11
AGING POPULATION Future costs driven by aging of the over 65 population. DEMOGRAPHICS + Big age shift in the composition of the 65+ population between 2010-2050. + The elderly grow older: those over age increasing from 6% to 11.2% of the US population from 2010 – 2050. + By 2050, over 4% of U.S. population will be over age 85 Source: CBO, Rising Demand for LTSS for Elderly People, (June 2013). 12
AGE WAVE: “Oldest” States in 2030 + Map shows the % of each state’s population that will be 65+ in 2030. + What is the US average? + 20% of the US population will be 65+ in 2030. + What is the range for the US? + 13.2% (UT) – 27.1% (FL) + Top 5 “oldest” states by 2030: + MN, NM, WY, ME, and FL. + Key issues to note: + Oldest states will face the greatest imbalance between workforce and potential demand for LTSS. Source: HMA, based on US Census Bureau. 13
AGE WAVE: Highest Rate of Growth in 65+ + Map shows the annual population growth rate for individuals 65+ between 2015-2030. + What is the US rate of growth? + US population will grow by 3.5% from 2015-2030. + What is the range for the US? + <2% (DC and WV) – 6.7% (AZ) + Top 5 states, highest growth rates 2015-2030: + TX, AK, NV, FL, and AZ. + Key issues to note: + Lowest rates of growth across the Great Lakes and Norther/Southern Mid- West. Source: HMA, based on US Census Bureau. 14
INSTITUTIONAL CARE Heavy reliance on institutions by older adults in 2015. People who use Medicaid LTSS by Population Group Source data: CMS, April 2017. 86% 90% 1 in 2 adults 65+ use 77% 80% institutional LTSS 67% 70% 60% 48% 46% 1 in 5 adults <65 use 50% institutional LTSS 40% 28% 30% 18% 20% 13% 6% 4% 10% 4% 1% 0% Under 21 (1.2 m. or 22%) Adults, 21-64 (1.9 m. or 37%) Seniors 65+(2.1 m. or 41%) All (5.2 m.) Institutional Only HCBS Only Institutional and HCBS 15
SELF-DIRECTED SERVICES Participation in Self-Directed Services continues to grow. 300 1,200,000 250 1,000,000 SELF-DIRECTION Number of participants Number of programs 200 800,000 + Number of participants grew 40% between 2011-2016 150 600,000 + MLTSS states – 80% growth; 100 400,000 non-MLTSS states 110% growth + About 27 out of every 1000 50 200,000 Americans with disabilities participate in self-directed 0 0 services 2011 2013 2016 Programs Statewide Participants Source: AARP PPI Report, April 2018 16
SELF-DIRECTED SERVICES Participation in Self-Directed Services continues to grow. 300 1,200,000 250 1,000,000 SELF-DIRECTION Number of participants Number of programs 200 800,000 + Number of participants grew 40% between 2011-2016 150 600,000 + MLTSS states – 80% growth; 100 400,000 non-MLTSS states 110% growth + About 27 out of every 1000 50 200,000 Americans with disabilities participate in self-directed 0 0 services 2011 2013 2016 Programs Statewide Participants Source: AARP PPI Report, April 2018 17
STATE MANAGED LTSS STATUS, MARCH 2018 MLTSS has had little impact on self-direction enrollment. Active MLTSS Program as of 2016 Intends to Implement DC MLTSS by 2018 Active capitated Duals Demo (MLTSS for duals in demo) States to Watch for Potential MLTSS Activity Note: Though ID is largely a FFS Medicaid state, it offers a Medicare Source: HMA, March 2018. Medicaid Coordinated Plan for duals that includes MLTSS 18
HEALTH DISPARITIES: PEOPLE WITH DISABILITIES, 2015 19
WHAT IMPACTS HEALTH OUTCOMES? 10% Health Care 5% 40% Environmental Exposure Behavioral Patterns 30% Genetic Predisposition 15% Source: Schroeder, Steven A. We Can Do Better – Improving Social the Health of the American People. N Engl J Med Circumstances 2007;357:1221-8 20
W H A T I S I M P O R T A N T T O STATES
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