Thursday, July 6, 2017
NPR recently ran a story about beneficiaries enrolled in Medicare Advantage plans. As Seniors Get Sicker, They're More Likely To Drop Medicare Advantage Plans discusses a recent "GAO report, released this spring, [that] reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to "preferred doctors and hospitals" or other medical care as the leading reasons for leaving." The article notes the positives to MA plans, but also some concerns: "some critics argue the plans can prove risky for seniors in poor or declining health, or those ... who need to see specialists, because they often face hurdles getting access." The GAO report referenced in the story is available here.
We have blogged on several occasions about the important role adult children play in family caregiving. Ever wonder just how much care the kids are providing? The Center for Retirement Research at Boston College looked at that specific question.
How Much Long-Term Care Do Adult Children Provide?, an issue brief, offered these key findings:
As people age and their health deteriorates, they begin to need more help with daily activities.
- While many formal long-term care services are available, cost concerns and personal preferences lead many to rely on informal care from adult children.
At any given point, 6 percent of adult children serve as caregivers, and 17 percent will take on this role at some point in their lives.
Those who do provide care devote an average of 77 hours per month, which can take a toll on both the finances and health of the caregiver.
The caregiving burden on adult children is likely to become a bigger concern as baby boomers move into their 80s.
Look again at the numbers. Seventeen percent of adult kids will be caregivers at some point and at almost 80 hours a month, it's almost like working half-time. Here is the conclusion to the brief:
At any point in time, few adult children are taking care of their parents. But, over the course of their lives, about 17 percent of adults end up providing care for their parents. And when children do care for par- ents, the commitment is large – 77 hours per month. As baby boomers enter their 80s, a large increase in the demand for long-term care is likely, with a commensurate rise in the reliance on care from their children. Since boomers had fewer children per household than the previous generation, this develop- ment will place an unprecedented burden on their children, with implications for their physical, mental, and nancial well-being. However, research also suggests that the issue may be more challenging than just the relative sizes of the generations. After all, divorced parents need more support from children, and those children are more likely to provide support if they live nearby. For a generation characterized by low fertility, unstable marriages, and far- ung children, this situation sug- gests that the informal care the boomers will need may not be there – and demand for formal care will soon increase beyond its historical levels. Policymakers and the private sector must confront this prospect, with its attendant burdens on the long-term care sector and insurers of long-term care – the largest of which by far is an already overburdened Medicaid system.
Consider the last sentence of the conclusion in light of the debated Congressional action on the Affordable Care Act.
The full brief is available here.
Thursday, June 29, 2017
The National Council on Aging (NCOA) posted a story on its blog explaining per capita caps and the impact on elders. Straight Talk for Seniors®: How Medicaid Caps Would Impact Seniors explains how Medicaid per capita caps would work.
Medicaid is funded jointly by the federal government and the states. Today, the federal government gives states matching funds to cover a percentage of their actual Medicaid costs. This keeps Medicaid affordable for states.
Under per capita caps, the federal government would limit, or cap, its contribution to the states based on a preset formula. This means states would be left paying the true cost of care for people in need. Many predict that states would face severe funding gaps and have to cut back on services to make up the difference.
If this is implemented, 5 states in particular would be hit hard as far as home and community based services funding, including my state of Florida. Those 5 states, besides Florida, are Alaska, Arizona, Georgia, and Nevada. The impact can be severe, as the article notes:
Medicaid per capita caps would hurt seniors in all states, but some states would fare worse than others. Here’s why.
First, the caps would be set based on each state’s 2016 Medicaid costs. This means states that were efficient and kept their costs low that year will be locked into a lower federal contribution. North Carolina, California, Nevada, Georgia, and Florida are examples of states that fall into this category.
Second, the caps would not adjust for an aging population. This means states whose 65+ population is growing faster than the national average will be locked into a smaller federal contribution that will not keep pace with growing costs. In fact, the caps would begin when baby boomers start turning 80. People aged 85+ are more likely to need long-term services and supports, and the cost of their care is 2.5 times more than people aged 65-74.
Tuesday, June 27, 2017
A recent story in the Toronto Star covers a ruling from a trial court judge about Canada's Medical Aid-in-Dying law. Advocates hail judge’s decision in woman’s assisted death appeal explains the judge's decision: "[a] 77-year-old woman seeking medical assistance in dying has a “reasonably foreseeable” natural death, a judge declared Monday in an attempt to clear up uncertainty that left her doctor unwilling to perform the end-of-life procedure for fear of a murder charge." The concern in the case was the meaning of "reasonably foreseeable" and the judge held "[t]o be reasonably foreseeable, the person’s natural death doesn’t have be imminent or within a specific time frame or be the result of a terminal condition...."
The judge went on to explain
“The legislation is intended to apply to a person who is “on a trajectory toward death because he or she a) has a serious and incurable illness, disease or disability; b) is in an advanced state of irreversible decline in capability; and c) is enduring physical or psychological suffering that is intolerable and that cannot be relieved under conditions that they consider acceptable,” ....
Monday, June 26, 2017
This week is a big one for the Senate as they consider the Republican version of a health care bill to "repeal" the Affordable Care Act. Now I confess that I've only skimmed portions of it, and I suspect that there will be some "deal making" going on to amend the proposal in an attempt to gather the necessary votes for it to pass. I don't intend this to be a political post, although the title probably makes you think I do. But depending on what happens, couldn't a crisis be looming as a result, at least for those individuals in nursing facilities whose stays are covered by Medicaid? Whether per capita caps or block grants, the potential remains that there may be less money to cover long term stays in nursing homes, right?
What got me thinking about this post was an article in the New York Times on June 24, 2017. Medicaid Cuts May Force Retirees Out of Nursing Homes asks the question, what happens if Medicaid cuts are enough to affect coverage for long term nursing home care? "Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage." One expert interviewed for the story suggested that even if the ACA isn't repealed, Medicaid is still an attractive target for cuts and don't forget that long term nursing home care makes up a significant amount of Medicaid spending, "long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them." The article considers the possibilities of cuts and the impact both on the facilities and the residents.
Justice in Aging released a blog post, issue brief and fact sheet focusing on the impact the Senate version of the bill will have on elders. The Fact Sheet, discussing Caps lists 5 downsides to the states and 3 ways elders will be harmed. Since the Times article was focused on nursing facility coverage, here's what the Justice in Aging Fact Sheet says about that: "Losing Coverage for Nursing Home Care. 62% of nursing home residents rely on Medicaid. For the vast majority of these 850, 000 nursing home residents, Medicaid coverage is provided through an eligibility category that is "optional" under federal Medicaid law. As states face insufficient funding, they will look for optional categories to cut, putting nursing home residents at particular risk." Both the Issue Brief and the Fact Sheet fail to take into account the aging of America by tethering the cap to "baseline years". As the Brief notes
[T]he fourth problem is that the Senate bill’s per capita cap fails to recognize how increasing age corresponds to a greater need for health care. In 2011, for example, persons aged 85 and over incurred average Medicaid costs that were 2.5 times higher than the average costs incurred by beneficiaries aged 65 to 74.35
Assume that a state currently has a large percentage of Medicaid beneficiaries in their early 70s. The base rate for that state will be weighted heavily towards the average health care needs of persons in their 70s, and that weighing will affect the cap amounts imposed in 2027, when the large group of beneficiaries will be in their early 80s — with different and more extensive needs for health care. Notably, such a shift in population from the young-old to the old-old is more likely than not, given the overall aging of America’s population. From 2025 and 2035, approximately two-thirds of the states will experience a rise in the share of seniors who are 85 and older. In most cases, the increase will be at least 25%. (citations omitted).
If these folks in nursing homes need a level of care that can't be provided by their families (if they even have families) and Medicaid is cut, what's the answer? Right now, all we can do is wait and see what happens with the Senate this week. Right now, the vote is projected to take place on Thursday.
Wednesday, June 21, 2017
According to a recent article in the Washington Post, not all family caregivers of vets are treated equally. Law makes VA treat some family caregivers better than others explains that for "veterans injured on duty, Uncle Sam pays more attention to some of their caregivers than others. The law allows the government to provide caregiver services for vets injured on Sept. 11, 2001, or after, but not those injured before that ...." On June 19, 2017, the Disabled American Veterans (DAV) organization released a report about its efforts, the "Unsung Heroes Initiative" to change the law. The DAV describes this, according to the article, as “a national campaign to raise awareness about the service and sacrifice of caregivers to America’s severely disabled veterans as well as the inequities of supports available, particularly for those injured before 9/11.” Bills are before Congress to change the law "that would make all veterans, no matter when they served, eligible for the caregiver support." The article also references a recent Veterans' Affairs Committee hearing on budgets, with testimony, etc. available here.
Tuesday, June 20, 2017
Consider those who need home health care but say no. Kaiser Health News recently ran a story on this very topic. Some Seniors Just Want To Be Left Alone, Which Can Lead To Problems explain that the percentage of those who want to be left alone is higher than you may think. "As many as 28 percent of patients offered home health care when they’re being discharged from a hospital — mostly older adults — say “no” to those services, according to a new report." The report is from a roundtable that was sponsored by the Alliance for Home Health Quality & Innovation and United Hospital Fund. The report, I Can Take Care of Myself: Patients' Refusals of Home Health Care Services runs 23 pages.
Here are highlights of the report (found on page 1):
Medical care is moving from hospitals and other institutions into the community, which for most people means care at home, where they want to be. With shorter hospital stays and more complex post-discharge needs, the importance of home health care services, including skilled care and personal care, in discharge planning and transitional care is increasing.
Some studies show that patients who receive home health care after hospital discharge are less likely to be readmitted. Other studies show that patients who receive home health care report better quality of life.
Although data are limited, approximately 6-28 percent of patients eligible for home health care refuse these services, for a variety of reasons.
Even less is known about the process by which hospital staff identify patients for referral to home health care, how they explain these services, and how well they address the full range of patients’ and family caregivers’ transitional care needs.
Patients and their family caregivers have similar goals but may have different needs and attitudes about home health care.
Policy and system barriers to accessing services include inflexible criteria for eligibility, inadequate payment for home health care agencies’ services for patients with complex conditions, and shortages of trained workforce.
Recommendations from Roundtable participants include interventions that improve communication about care challenges and home health care services, qualitative and quantitative research on all aspects of home health care refusals, policy changes to increase access and coordination, and continuity across providers and care settings.
Friday, June 9, 2017
Kiplinger's ran an article about less noticed veterans benefits. Vets, Don't Miss Out on 'Hidden Benefits' discusses life insurance, hearing aids, spouse and dependent benefits (DIC), health insurance, directed care, Agent Orange benefits, Aid & Attendance, home modification and coverage for conditions from the water at Camp Lejeune to name a few. The article offers information about eligibility, where to get help, how to apply for benefits and more.
Monday, June 5, 2017
I'm just going to start off with my opinion on this latest action by CMS: bummer. Now I'll tell you what CMS is doing and you can decide if you agree with their course of action, or not. As you may recall, last fall CMS issued the revised nursing home regs (which we've blogged about before-you can search the archives for them, if you want). One of the regs getting a lot of attention was the reg that prohibited the use of pre-dispute arbitration clauses in nursing home admission contracts. Now CMS has announced they are reversing course. They will no longer prohibit pre-dispute arbitration clauses under the proposed amendment to the rule. Instead the proposed rule allows the use of arbitration clauses if certain notice requirements are met. The summary explains that CMS
would revise the requirements that Long-Term Care (LTC) facilities must meet to participate in the Medicare and Medicaid programs. Specifically, it would remove provisions prohibiting binding pre-dispute arbitration and strengthen requirements regarding the transparency of arbitration agreements in LTC facilities. This proposal would support the resident’s right to make informed choices about important aspects of his or her health care. In addition, this proposal is consistent with [CMS] approach to eliminating unnecessary burden on providers.
The specific amendments to 42 C.F.R. 483.70(n) appear on pages 20-21 of the notice. The notice is scheduled to be published in the Federal Register on June 8 and the comment period closes 60 days thereafter.
Sunday, June 4, 2017
The New York Times ran an article giving an update on California's aid-in-dying law. The numbers are not from state officials but come from Compassion in Choices. They report "at least 504 terminally ill Californians have requested a prescription for life-ending drugs since a state law allowing physician-assisted deaths went into effect in June 2016... [representing] ... those who have contacted Compassion & Choices...." The article notes that once the state publishes the required data there will be a more accurate picture of the law's application. The article also references the number of facilities that have written policies on recognizing the prescriptions. The article also reminds us that a lawsuit had been filed some time back to challenge the law, with a hearing scheduled for June 16, 2017.
Thursday, June 1, 2017
Kaiser Health News ran an interesting story about the need for a team for aging. Putting In Place An A-Team Of Allies reports on elders who met to talk about those who would be "allies" going through the aging process, especially for those who have no nearby family. One participant, Mr. Gordon, described his allies system:
The setup has four tiers. In the first are three close friends who have powers of attorney for legal, financial and health care decision-making, should Gordon not be able to handle these responsibilities.
In the second are more than 25 friends and acquaintances whom Gordon — disabled by degenerative motor neuron disease — can call on for a ride to the doctor or a trip to the grocery store.
In the third tier are Gordon’s primary care doctor, lawyer and financial adviser, with whom he has close personal relationships. In the fourth are helpers he pays for services, including a driver and a handyman.
The article gives some examples of those who have organized their allies and recommendations for criteria in choosing allies.
Wednesday, May 31, 2017
Let's start June off with some good news, shall we? Some time ago we let you know that Medicare was going to remove Social Security Numbers from beneficiaries' Medicare cards (can you say identity theft?). I saw a progress report about this. Medicare plans to replace Social Security numbers on cards reports an announcement from Medicare on May 30, 2017 that they are on schedule to have the cards revised with a randomly generated number replacing a beneficiary's SSN. Mail outs are planned to being in April of 2018. The final design of the card is still unknown, according to the article. The new numbers will be known as "MBI, which stands for Medicare Beneficiary Identifier." To read the press release from CMS, click here.
Tuesday, May 30, 2017
Last week I received an email from the Hastings Center with the subject line "What Do We Owe the Frail Elderly?" This intrigued me because I often have a conversation with my students about what, if anything, we "owe" the generation before us. I typically have this conversation in the context of discussing funding of public benefits and other programs specifically for America's elders. Here is the information about the casebook
A woman juggles caring for her aged father at home and going to work. A volunteer cares for an 83-year-old man who lives alone and wonders why the man’s son doesn’t take more of an interest. Staff members at a nursing home, discussing a patient with dementia who hits staff members, consider whether it’s acceptable to control his behavior with antipsychotic medication, knowing that antipsychotics increase the risk of stroke in people with dementia. These are three of the 10 cases in Caring for Older People in an Ageing Society, the second edition of an online bioethics casebook launched this week. The casebook aims to support professional and family caregivers by helping them recognize and respond to situations that pose ethical uncertainty... The bioethics casebook was the product of a project with the National University of Singapore Centre for Biomedical Ethics, The Hastings Center, and Oxford University’s Ethox Centre. Explore the Casebook.
Additional information about the book is available from The Hastings Center website: "an innovative web-based casebook that focuses on ethical challenges of caring for people in an aging society. It is geared to those who provide community-based care to frail or chronically ill people living at home, in a family member’s home, or in a nursing home. The casebook will include fictional cases along with ethics commentaries, clinical perspectives, reflection and discussion questions, and other resources...."
This second volume of the casebook focuses on elders while the first volume focuses on difficult decisions. For more information, click here.
Wednesday, May 24, 2017
I was catching up on some reading last week when I ran into some information about the PREPARE project. PREPARE for your care provides folks with "a range of tools to help people discuss their wishes for medical care with family, friends, and medical providers." Voice over narration accompanies the web pages in either English or Spanish. The purpose of PREPARE is to help someone "make medical decisions for yourself and others... talk with your doctors ...[and] get the medical care that is right for you." PREPARE not only helps a person make decisions and talk to her doctors, it provides assistance with evaluating priorities, communicating one's wishes to others, and providing flexibility for the decision-maker. PREPARE also helps to ready the person for conversations with her doctors and to complete a 5-step interactive action plan.
Tuesday, May 23, 2017
Kaiser Health News ran a story about the impact of loneliness in elders. Like Hunger Or Thirst, Loneliness In Seniors Can Be Eased explains that loneliness is "fixable".
[L]oneliness is the exception rather than the rule in later life. And when it occurs, it can be alleviated: It’s a mutable psychological state... Only 30 percent of older adults feel lonely fairly frequently, according to data from the National Social Life, Health and Aging Project, the most definitive study of seniors’ social circumstances and their health in the U.S....The remaining 70 percent have enough fulfilling interactions with other people to meet their fundamental social and emotional needs.
There are significant physical and psychological manifestations of loneliness but the good news is that it can be resolved. The article discusses a study on loneliness, with one result worth mentioning here, "[w]hat helped older adults who had been lonely recover? Two factors: spending time with other people and eliminating discord and disturbances in family relationships." The study also examined loneliness prevention factors; the "study also looked at protective factors that kept seniors from becoming lonely. What made a difference? Lots of support from family members and fewer physical problems that interfere with an individual’s independence and ability to get out and about."
The article distinguishes between loneliness and isolation, an important point. The article discusses a couple of ways to alleviate loneliness: altering perceptions and investing in relationships. The article also mentions a project from The Netherlands, "a six-week “friendship enrichment program” [with the] goal is to help people become aware of their social needs, reflect on their expectations, analyze and improve the quality of existing relationships and develop new friendships."
As I reported here for the first time recently, Pennsylvania's Governor Wolf has proposed consolidation -- or as he prefers to call it -- unification -- of four separate administrative agencies, the Departments of Aging, Health, Human Services (formerly Public Welfare) and Drug & Alcohol Treatment Programs. Are similar budget-driven changes occurring in your state?
As I catch up with events in Pennsylvania, I'm learning from readers about growing concerns about the possible merger.
- As one recently retired PA legislator pointed out, there seems to be little in the way of a written plan for how services will be handled under this merger. Rather, the merger appears mostly as a description of budget items, with a lot of "minus" signs to indicate cuts. Perhaps by design, Pennsylvania government is often a bad example of transparency for governments. What is the real plan, if any?
- With the consolidation, at a minimum, older Pennsylvanians would be losing a cabinet level post, their singular, dedicated spokesperson. This would be likely to affect all future budget and programming battles.
- The timing is, to use a favorite Trump adjective, "sad." While the leading edge of the big wave of aging baby boomers began to be felt a few years ago when those born in in 1945 started turning age 65 in 2010, the "real" need for an effective advocate is when boomers start turning age 75, age 80 and so on, the higher ages when they are more likely to need or question access to services.
Perhaps of greatest significance is the potential impact of consolidation on the process for assessment of need for services and assistance, especially Medical Assistance.
Under the current allocation of resources, "assessment" of need is handled by individuals employed under the authority of Pennsylvania's Department of Aging.
However, the financial allocations are currently determined under the authority of the Department of Human Services. Consolidation might make sense on paper, but wait!
As one of my mentors in aging, Northern Ireland's former Commissioner of Older People Claire Keatinge, says, to be helpful, fair and effective, any individual assessment of need for health care, social care and security, should be exactly that -- individualized and focused on the client, and should not be simply a match to "what services (if any) are available." That process-based distinction is critical to determining current and future funding priorities.
In Pennsylvania, the lion's share of budget and personnel for aging services has long been housed in the Department of Human Services (formerly Public Welfare), but those workers -- perhaps by necessity and perhaps by design, have often functioned as dedicated bean counters, as in "here's what services we fund, so do you or don't you meet the eligibility criteria?"
By losing the aging assessment focus of the current Department of Aging, it seems likely the state would compromise, and perhaps lose entirely, the independent thinking and opportunity for critical needs-based assessment.
Several elder-focused organizations have raised these and other key points in opposition to the existing budget-based consolidation proposal. Those active in the debate include:
- The Pennsylvania chapter of the National Association of Elder Law Attorneys (PAELA) has asked thoughtful legislators to "oppose such consolidation" as presented in the current budget proposal. As Pittsburgh Elder Law attorney Julian Gray testified on May 1 in state Senate hearings, a "bigger" agency is not necessarily a "better" agency.
- Representatives for the service organization for Pennsylvania senior service workers, P4A, testified strongly in favor of the role of the Department of Aging as the advocate for the "unique needs of seniors." Speakers focused too on the Department's historical role in protecting and managing a unique funding stream dedicated to seniors, "lottery" funds.
- Long-time practitioner and elder law guru, Jeff Marshall, has a comprehensive commentary, with links, detailing the history and importance of Pennsylvania's Department of Aging. There's a simple bottom line expressed here -- "if it ain't broke, don't fix it."
- Related articles
Monday, May 22, 2017
In what is described as a "first" for the National Academy of Elder Law Attorneys (NAELA), the organization through its New York Chapter will present argument on behalf of individuals seeking to establish access to "aid in dying." On April 27, the New York Chapter was granted leave to appear as amicus curiae in Myers v. Schneiderman before the New York Court of Appeals. Oral arguments are scheduled in Albany on May 30, 2017.
At issue is New York's penal law prohibiting assistance in "suicides." The original suit, filed in February 2015, sought a ruling that the statute, characterized by opponents as "antiquated," should be interpreted as not reaching the conduct of a physician that provides aid-in-dying where the patient is terminally ill and mentally competent and voluntarily seeks "terminal medication." Alternatively, the opponents of the law argue that the statute violates the rights of privacy and/or equal protection guaranteed by the New York State Constitution. New York's trial level court dismissed the challenge as a matter of law, on the grounds that New York's penal law was "clear on its face."
In joining the challenge to the dismissal, which was affirmed by appellate division, New York NAELA wrote:
As an organization of lawyers who represent the elderly and persons with disabilities, the New York Chapter [of NAELA] believes that a proper interpretation of New York's "assisted suicide" laws and due consideration of Appellants' constitutional challenges should be based on a fully developed factual record. These are issues of great moment to the elderly and those who love them and to the administration of justice in this State. This Court should have the benefit of a hearing and findings of relevant evidence before deciding them. . . .
What would assist this Court in fairly construing the Penal Law are facts relating to aid-in-dying. While the language of the statute is the starting point for interpretation, its words do not exist in a vacuum.
For more on the arguments, including links to the various parties' appellate briefs in Myers, see the "End of Life Liberty Project."
May 22, 2017 in Advance Directives/End-of-Life, Cognitive Impairment, Discrimination, Ethical Issues, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Wednesday, May 17, 2017
Earlier this month Kaiser Health News (KHN) ran a story about Ombudsman volunteers. Volunteers Help Ombudsmen Give Nursing Home Residents ‘A Voice’ In Their Care discusses the local ombudsman volunteers and their importance regarding a resident's quality of care.
Ombudsman’s offices, which operate under federal law in all 50 states, Washington, D.C., Puerto Rico and Guam, investigated 200,000 complaints in 2015, according to the Administration on Aging, a part of the Department of Health and Human Services.
Of those, almost 117,000 were reported to have been resolved in a way that satisfied the person who made the complaint, and about 30,000 were partially resolved. At the top of the list were problems concerning care, residents’ rights, physical environment, admissions and discharges, and abuse and neglect.
Ombudsmen volunteers have a right to enter a long term care facility and talk to residents or anyone else. They investigate complaints and can find issues on their own, and maintain confidentiality. The article emphasizes the importance of volunteer ombudsmen to the success of the programs. There's more involved than putting your name on a list. Ombudsmen volunteers go through training, must pass background checks, are supervised on a few first visits and attend monthly meetings. The article notes the spectrum of experience held by the volunteers but identifies one commonality, "an abundance of compassion."
Monday, May 15, 2017
The Commonwealth Fund has released a new issue brief regarding Medicare out of pocket costs. Medicare Beneficiaries’ High Out-of-Pocket Costs: Cost Burdens by Income and Health Status examines the out of pocket costs faced by Medicare beneficiaries" "Fifty-six million people—17 percent of the U.S. population—rely on Medicare. Yet, its benefits exclude dental, vision, hearing, and long-term services, and it contains no ceiling on out-of-pocket costs for covered services, exposing beneficiaries to high costs." The issue brief concludes that
More than one-fourth of all Medicare beneficiaries—15 million people—spend 20 percent or more of their incomes on premiums plus medical care, including cost-sharing and uncovered services. Beneficiaries with incomes below 200 percent of the poverty level (just under $24,000 for a single person) and those with multiple chronic conditions or functional limitations are at significant financial risk. Overall, beneficiaries spent an average of $3,024 per year on out-of-pocket costs. Financial burdens and access gaps highlight the need to approach reform with caution. Already-high burdens suggest restructuring cost-sharing to ensure affordability and to provide relief for low-income beneficiaries.
The Commonwealth Fund used 2 "indicators" in doing the research, the "High total cost burden" and "underinsurance". The issue brief notes that lower-income beneficiaries may have significant out of pocket costs. "When premiums, cost-sharing, and spending on uncovered services are included, more than one-fourth of all beneficiaries (27%)—an estimated 15 million people—and two of five beneficiaries with incomes below 200 percent of the federal poverty level spent 20 percent or more of their income on health care and premium costs in 2016." As far as the other indicator, the Commonwealth Fund found "that one-fourth of beneficiaries are underinsured—that is, they spend at least 10 percent of their total annual incomes on medical care services, excluding premiums. Of beneficiaries with incomes below the poverty level, one-third spent 10 percent or more... Despite having Medicare or supplemental coverage, these people are effectively underinsured." (citations omitted).
The brief concludes with these observations:
Despite the substantial set of benefits that Medicare provides, many beneficiaries are left vulnerable because of financial burdens and unmet needs. As Medicare enters its sixth decade and the baby boom population becomes eligible, the costs of the program will increase, likely placing it on the policy agenda. Despite Medicare’s notable recent success in controlling costs per beneficiary, total spending will increase as the program covers more people.
The high financial burdens documented in this brief illustrate the need for caution. Half of Medicare beneficiaries have low incomes; one-third have modest incomes (200% to 399% of poverty). Any potential policy should first consider the impact on beneficiaries.
Access and affordability remain key concerns. In any discussions of potential Medicare reform, it will be important to pay particular attention to consequences for those vulnerable because of poor health or low income. Indeed, the findings point to the need to limit out-of-pocket costs and enhance protection for low-income or sicker beneficiaries.
As the single largest purchaser of health care in the country, Medicare policies directly influence insurance and care systems across the country. With a projected one-fifth of the population on Medicare by 2024, keeping beneficiaries healthy and financially independent is important to beneficiaries, their families, and the nation. (citations omitted).
Friday, May 12, 2017
On May 10, 2017, my research colleagues Gavin Davidson (Queens University Belfast) and Subhajit Basu (University of Leeds) participated in a policy briefing at Stormont, the Northern Ireland Assembly in Belfast. They appeared in support of recommendations by the Commissioner of Older People (COPNI) Eddie Lynch on a major plan for modernization of social care programs for vulnerable adults (of any age).
Professors Davidson and Basu focused on three key recommendations:
- Northern Ireland should have a single legislative framework for adult social care with accompanying guidance for implementation. This could either be new or consolidated legislation, based on human rights principles, bringing existing social care law together into one coherent framework.
- All older people in Northern Ireland, once they reach the age of 75 years, should be offered a Support Visit by an appropriately trained professional. This will be based on principles of choice and self-determination and is aimed at helping older people to be aware of the support and preventative services that are available to them.
- Increasing demands for health and social care reinforce the importance of considering how these services should be funded. All future funding arrangements must be equitable and not discriminate against any group who may have higher levels of need.
The audience, which included researchers, social service program administrators and elected officials (not only from Northern Ireland, but elsewhere, including the Isle of Man), reportedly responded strongly to the recommendations, especially to the concept of specially-trained "support visitors," offered to persons age 75 or older. The intent is to provide individuals with planning support and, where needed, medical assessment. Guidance and information is often needed for pre-crisis planning, thus moving in the direction of prevention of crises and reduction of need for last-minute response. The support visitor concept has been used successfully in Denmark and other locations in Europe. The next step for Northern Ireland would likely be a pilot or test project.
As a co-author of the research reports that led to the COPNI recommendations, working with Professors Gavin Davidson and Subhajit Basu as part of a team headed by Dr. Joe Duffy of Queens University Belfast, I found it an interesting coincidence that at almost the same time as the Northern Ireland government session, I was addressing similar interests in "preventative" planning while speaking on elder abuse in a "Day on the Hill" program at the Capitol in Pennsylvania, hosted by the Alzheimer's Association. It is clear that on both sides of the Atlantic, we are interested in cost-effective, proactive measures to help people stay in their homes safely.