November 5, 2013
Washington State has been a leader in seeking innovative, community-based approaches to meeting the Long-Term Care (LTC) needs of residents. Much of the funding for such care has come through the Medicaid program (now renamed Washington Apple Health (WAH) except for LTC coverage for individuals who are eligible as Aged, Blind or Disabled).
The Medicaid program has typically worked to support more community-oriented and responsive LTC options.
However, the financial stresses now acting on LTC, due to increasing numbers of individuals who require assistance in varying degrees, are going to require new ways of thinking about and meeting such needs at a sustainable cost.
The Affordable Care Act (ACA) originally included provisions for a publicly-run LTC insurance program called CLASS (Community Living Assistance Services and Supports). However, due to concerns that this program would not be actuarially viable, it was never implemented. This part of the ACA was later repealed by Congress.
The Medicaid programs in Washington State that apply to the Aged, Blind and Disabled categories of eligibility have not been changed by the Affordable Care Act (ACA).
At the same time, private LTC insurance coverage is becoming more difficult to obtain and more expensive.
There are a variety of options for the Health Care Authority (HCA) to consider in response to this situation. At one extreme might be tighter top-down restrictions on the availability of payment for LTC through Medicaid.
However, the HCA has demonstrated a preference for flexibility and simplified administration for expansion of the Medicaid program under the ACA. At another extreme, efforts could be made to apply these principles to Medicaid LTC.
What might such an alternative approach to LTC look like in Washington?
When the CLASS program was repealed, a national Commission on Long-Term Care was established by Congress on January 2, 2013. A short Report by the Commission was issued on September 12, 2013 (available at www.ltccommission.senate.gov).
The Commission concluded that emphasis should be placed on care in the least restrictive settings, located in “livable communities” whenever possible.
It was also stated that emphasis should be placed on better use of information technology to help arrange for such care, and on new financing strategies based on “services provided” rather than the setting.
They recommended that emphasis should be placed on “family-centered” services.
Against this backdrop, it is interesting to think about more decentralization as a possible approach to the redesign of LTC services. LTC needs might be approached through a “voucher system”, with the voucher value set according to the services required.
Individuals needing care could shop for the services that they prefer. Potential caregivers could compete to provide the needed services. And local supervision could be used to check up on the care that is being provided.
(This option is further discussed in the references provided below.)
Elder Law Practice in Washington is discussed by Cheryl and Ferd Mitchell of Mitchell Law Office in volumes 26 to 26B of Washington Practice. Further information about the ACA and LTC may be found in a series of blog postings and in a recent book by the authors.