www.nasuad.org

State Aging and Disability Policy: 50 years backwards, 50 years forward

John Michael Hall, Senior Director of Medicaid Policy & PlanningNASUAD

12/11/2013

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“Quotes—use quotes and other facts over images to create more visual interest, pauses and color fields.”

—Name, title

50 years of history of aging and disability policy

1960s—Older Americans Act

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1970s—establishing the aging network

• Started congregate meal program – Served 200,000 meals– $100 million program

• Formed the Aging Network (AAAs)

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Arthur Flemming,

Commissioner on Aging

1980s -- Creating the Waiver

• Omnibus Reconciliation Act of 1981 created §1915(c) waiver, states were slow to take up the option in part because of the “cold bed” rule. Now, every state has some form of HCBS waiver.

• Permits states to provide HCBS to individuals who require the level of care provided in institutional settings.

• Most states have several HCBS waivers, different populations

• Often administered in different agencies

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1990s—Americans with Disabilities Act

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1990s—Olmstead Decision

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2000s--

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2011—First Boomer turns 65

Source of charts: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005.

2000 2020

9

Population 60+National

44,000,000

46,000,000

48,000,000

50,000,000

52,000,000

54,000,000

56,000,000

58,000,000

Population 60+ 49,788,075 50,697,360 52,499,373 54,120,116 55,748,172 57,424,771

2005 2006 2007 2008 2009 2010

2005 -2010

15.3% increase

2010—Affordable Care Act

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HCBS Provisions in the ACA

• Balancing Incentive Program (BIP)

• Extending Money Follows the Person (MFP)

• Consumer First Choice -- §1915(k)

• Moving HCBS Into the Mainstream – State Plan Option §1915(i)

• Waiver Consolidation

• Health Homes

What will the next 50 years bring?

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What if funding continues to slide?

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Compare where the beneficiaries are . . .

15

. . . to where the money is:

16

FUNDING FOR SENIORS

NOT KEEPING PACE NOW…

From 1980 to 2010

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60%POPULATION

INCREASEADULTS 65+

34%FUNDING

DECREASEAoA FUNDING

FUNDING FOR SENIORS

NOT KEEPING PACECurrent Funding Levels Unable

to Meet Increased Need

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$9.24PER

ADULTS 65+

1980 2010

$3.85PER

ADULTS 65+

FUNDING FOR SENIORS

NOT KEEPING PACEPercent of Seniors Continues to Grow

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20

10

ONE IN EIGHT ADULTS 65+

20

30

ADULTS 65+ONE IN FIVE

AGING SERVICES UNABLE

TO MEET DEMAND

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57M I L L I O NADULTS 60+

11M I L L I O NSERVED

O N LY

AGING SERVICES UNABLE

TO MEET DEMAND

If these trends continue millions will

be eligible, few will be served.

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1980 2010 2030 1980 2010 2030

MILLIONS OF SENIORS MILLIONS OF DOLLARS36 57 92 236 155 ???

AGING IN PLACE IS

COST EFFECTIVE

Annual Facility Care Cost

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$66,000MEDICAIDFINANCED NURSING FACILITY

$42,600PRIVATE PAY

ASSISTEDLIVING

$81,030PRIVATE PAY

NURSING FACILITY

AGING IN PLACE IS

COST EFFECTIVE

Annual Facility Care Cost

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$18,200-$20,800

HOMEMAKER & ADULT CARE

SERVICES

$24,675HOME &

COMMUNITY BASED MEDICAID

SERVICES

OLDER AMERICANS ACT SERVICES

HELP SENIORS STAY AT HOME

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Will Aging and Disability Working Together Make a Difference?

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States Restructuring State Aging and Disability Agencies

AK

HI

OR

NV

UT

AZ

SD

NE

KS

AR

LA

WI

IN

KY

TN

GA

SC

VA

ME

MS AL

WV

CA

ID

MT

WY

NM

TX

ND

OK

MN

IA

MI

IL

MO

OH

FL

PA

NY

CO

NC

WA

VTNH

MA

MD

DE

NJ

DC

RI

States restructuring since 2011(CT, DE, HI, IA, IN, KS, ME, NC, NH, OH, OR, PA, VT, VA, WA, WY)

States with plans for restructuring (CO, DC, LA, NV, WV)

States both restructuring since 2011 and with plans (AL, MD, NJ)

CT

Factors Driving State Aging and Disability Agency Restructuring

0 5 10 15 20

Number of States

Comprehensive vision

Consistent policy making

Administrative simplification

Improved access to services (no wrong door)

Accountability

Quality management

Consolidation of program authority

Budget and personnel reductions

Preparation for managed long-term services and

supports

Other

Reduction of institutional bias

Global budgeting

Address functions that present conflict of interest

What changes will MMLTSS have on the network?

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Medicaid Managed LTSS (MMLTSS)

Medicare-Medicaid Coordination Initiative

Both MMLTSS and Medicare-Medicaid Coordination Initiative

RI

AK

HI (W)

OR (W)**

NV UT

AZ (W)

SD

NE

KS

AR

LA

WI**

IN**

KY

TN (W)

GA

SC

VA*

ME

MS AL

WV CA*

ID

MT

WY

NM (W)

TX

ND

OK

MN (W)**

IA

MI

IL*

MO

OH*

FL**

PA

NY*

CO

NC

WA*

VTNH**

MA*

MD

DE NJ**

DC

RICT

* Financial Alignment (FA) demonstration proposal approved by CMS

** Initiatives other than FA demonstration (W) No longer pursuing FA demonstration

Medicaid Managed LTSS & Medicare-Medicaid Care Coordination Initiatives

(Current as of 10/3/2013)

Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

What impact will the Affordable Care Act have?

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RI

AK

HI

OR

NV

UT

AZ

SD

NE

KS

AR

LA

WI

IN

KY

TN

GA

SC

VA

ME

MS AL

WV CA

ID

MT

WY

NM

TX

ND

OK

MN

IA

MI

IL

MO

OH

FL

PA

NY

CO

NC

WA

VTNH

MA

MD

DE NJ

DC

RICT

Expanding Medicaid

Likely to Expand

Alternative Expansion Approved

Unlikely to Expand

Not Expanding

Medicaid Expansion (Current as of 10/3/2013)

Source: NASUAD Medicaid Expansion Tracker

RI

AK

HI

OR

NV

UT

AZ

SD

NE

KS

AR

LA

WI

IN

KY

TN

GA

SC

VA

ME

MS AL

WV CA

ID

MT

WY

NM

TX

ND

OK

MN

IA

MI

IL

MO

OH

FL

PA

NY

CO

NC

WA

VTNH

MA

MD

DE NJ

DC

RICT

More than One Activity

Balancing Incentive Program Only

Section 1915(i) State Plan Amendment Only

Section 1915(k) Community First Choice

Only

Health Homes Only

Other LTSS Activities(Current as of 10/3/2013)

Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

Will we measure Quality? Outcomes?

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If not…boomers don’t wait patiently

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