METODOLOGÍA HÍBRIDA

While some may believe that a true social insurance option financed through a broad-based tax, similar to the Medicare program, may be the most efficient and equitable means of financing LTSS, the current political and fiscal environment make that solution infeasible for the foreseeable future. As outlined below, BPC’s initiative seeks input from experts and stakeholders on how best to craft a series of solutions that include both publicly funded programs, such as Medicaid, and private insurance products. BPC has identified a series of issues with the current system as well as questions that will be explored in the coming months. While BPC does not expect to answer all of the questions raised here, this framework serves as a critical starting point. Further, these issues are not meant to be comprehensive, and BPC welcomes additional questions and guidance from stakeholders and policymakers.

Medicaid

The Medicaid program provides both acute care services and LTSS for a broad range of individuals, including children, pregnant women, and people eligible for cash assistance such as Supplemental Security Income (SSI) and Temporary Assistance for Needy Families

(TANF). Under the ACA, and at state option, Medicaid programs may also cover adults

without dependent children with incomes below 133 percent of the federal poverty level,12

as well as certain other low-income populations. The amount and type of income and assets subject to eligibility requirements vary by state. For example, assets typically counted for eligibility include checking and savings accounts, stocks and bonds, real property other than primary residence and motor vehicles other than primary vehicle. Assets not counted for eligibility include primary residence, household belongings, one motor vehicle, life insurance with a face value under $1,500, up to $1,500 in funds set aside for burial, and assets held

in certain kinds of trusts.13 _{Services are based on “medical necessity,” so not all Medicaid-}

eligible individuals receive LTSS. Although eligibility generally varies by state, Medicaid programs may provide an institutional level of care for individuals with incomes up to 300

percent of SSI income levels.14 _{Institutional care includes nursing homes, intermediate care}

facilities for individuals with mental retardation (ICFs/MR), and other residential facilities.

America’s Long-Term Care Crisis: Challenges in Financing and Delivery | 10

Distribution of Enrollment and Spending Among Medicaid LTSS Beneficiaries, by Population, 2009

Source: The Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 MSIS. Because 2009 data was unavailable, 2008 data was used for Pennsylvania, Utah, and Wisconsin.

Medicaid programs also continue to increase the availability of services in HCBS settings through a variety of waivers and demonstration programs. Experts have suggested that better coordination of services for those with chronic conditions who are eligible for both Medicare and Medicaid could reduce health care expenditures financed under the Medicare program, thus permitting health plans or affiliated provider groups, such as patient-

centered medical homes or primary care case management, to use savings to finance improved coordination and availability of LTSS under the Medicaid program. Potential health care savings, however, vary widely from state to state. We look forward to seeing the early results of these demonstrations. We also seek guidance on how the Medicaid program could be improved to provide limited LTSS to individuals whose incomes are above Medicaid- eligibility levels in order to prevent spending down into Medicaid, or to improve existing programs designed to prevent working individuals with disabilities from relinquishing their jobs in order to receive services.

• Presuming that there is agreement that a new public insurance structure is not

currently fiscally and politically viable, is there a role for public insurance, apart from the Medicaid program, for those who do not have access to private resources or private long-term care insurance? If so, what is it and how would it be structured in a politically and economically viable fashion?

• What is the appropriate division of responsibility between state and federal

programs?

• How could the current delivery system be improved to better coordinate care and

improve patient-centeredness and efficiency?

All LTSS Enrollees Institutional Services Community- Based Services Enrollment Expenditures Total: 3.38M $165B 1.9M $68B 1.6M $83B

Enrollment Expenditures Enrollment Expenditures Elderly LTSS Enrollees LTSS Enrollees with Disabilities Under Age 65 37% 63% 52% 48% 52% 48% 72% 28% 21% 79% 37% 63%

America’s Long-Term Care Crisis: Challenges in Financing and Delivery | 11

• Should health care services and LTSS be integrated? If so, for all populations, or only

for those with chronic health conditions?

• Should integration of health care services and LTSS be left to individuals and families

to decide?

• What lessons can be learned from the long history of waivers and demonstration

programs?

• What can be learned from other programs and plans such as the Program of All-

Inclusive Care for the Elderly (PACE) and Medicare Advantage Special Needs Plans?

• Should states be expected to better coordinate care for Medicaid-covered LTSS? If

so, what is the federal role in promoting better coordination?

• What are the pros and cons of proposals that would turn LTSS delivery over to state

governments with limits on federal funding, such as a block grant or per capita cap?

• How can lessons learned from public programs be applied to private LTC insurance?