State Aging and Disability
Policy: 50 years backwards,
50 years forward
John Michael Hall,
Senior Director of Medicaid Policy & Planning
NASUAD
12/11/2013
www.nasuad.org
“Quotes—use
quotes and other
50 years
of
over images to create
historyfacts
of aging
more visual interest, pauses
and disability
policy and color fields.”
—Name, title
Page 2
1960s—Older Americans Act
Page 3
1970s—establishing the
aging network
Arthur
Flemming,
Commissioner
on Aging
• Started congregate meal program
– Served 200,000 meals
– $100 million program
• Formed the Aging Network (AAAs)
Page 4
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
Page 5
1990s—Americans with Disabilities Act
Page 6
1990s—Olmstead Decision
Page 7
2000s--
Page 8
2011—First Boomer turns 65
2000
2020
Source of charts: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005.
9
Population 60+
National
58,000,000
56,000,000
2005 -2010
54,000,000
15.3% increase
52,000,000
50,000,000
48,000,000
46,000,000
44,000,000
2005
2006
2007
2008
2009
2010
Population 60+ 49,788,075 50,697,360 52,499,373 54,120,116 55,748,172 57,424,771
2010—Affordable Care Act
Page 11
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?
Page 13
What if funding continues to
slide?
Page 14
Compare where the beneficiaries are . . .
15
. . . to where the money is:
16
FUNDING FOR SENIORS
NOT KEEPING PACE NOW…
From 1980 to 2010
60%
POPULATION
INCREASE
ADULTS 65+
34%
FUNDING
DECREASE
AoA FUNDING
Page 17
FUNDING FOR SENIORS
NOT KEEPING PACE
Current Funding Levels Unable
to Meet Increased Need
$9.24
$3.85
PER
ADULTS 65+
PER
ADULTS 65+
1980
2010
Page 18
FUNDING FOR SENIORS
NOT KEEPING PACE
2030
2010
Percent of Seniors Continues to Grow
ONE IN EIGHT
ADULTS 65+
ONE IN FIVE
ADULTS 65+
Page 19
AGING SERVICES UNABLE
TO MEET DEMAND
57
MILLION
O N LY
11
MILLION
SERVED
ADULTS 60+
Page 20
AGING SERVICES UNABLE
TO MEET DEMAND
If these trends continue millions will
be eligible, few will be served.
1980
2010
2030
1980
2010
2030
36
57
92
236
155
???
MILLIONS OF SENIORS
MILLIONS OF DOLLARS
Page 21
AGING IN PLACE IS
COST EFFECTIVE
Annual Facility Care Cost
$42,600
$66,000
MEDICAID
FINANCED
NURSING
FACILITY
PRIVATE PAY
ASSISTED
LIVING
$81,030
PRIVATE PAY
NURSING FACILITY
Page 22
AGING IN PLACE IS
COST EFFECTIVE
Annual Facility Care Cost
$18,200$20,800
HOMEMAKER &
ADULT CARE
SERVICES
$24,675
HOME &
COMMUNITY
BASED MEDICAID
SERVICES
Page 23
OLDER AMERICANS ACT SERVICES
HELP SENIORS STAY AT HOME
Page 24
Will Aging and Disability Working
Together Make a Difference?
Page 25
States Restructuring State Aging and Disability Agencies
NH
VT
ME
WA
MA
MT
ND
MN
OR
ID
NY
WI
RI
MI
SD
CT
WY
PA
IA
NE
NV
IL
DE
IN
VA
WV
UT
CO
CA
MO
KS
NJ
OH
MD
DC
KY
NC
TN
AZ
OK
NM
SC
AR
MS
TX
AL
GA
LA
FL
AK
HI
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)
Factors Driving State Aging and Disability Agency Restructuring
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
0
5
Number of States
10
15
20
What changes will MMLTSS have
on the network?
Page 28
Medicaid Managed LTSS &
Medicare-Medicaid Care Coordination Initiatives
NH**
VT
(Current as of 10/3/2013)
ME
WA*
ND
MT
OR
(W)**
MN
(W)**
ID
WY
MI
IA
NE
NV
NY*
WI**
SD
IL*
CO
KS
PARI
OH*
UT
CA*
IN**
VA*
WV
OK
NM
(W)
MD
NC
AR
SC
MS
TX
RI
CT
NJ**
DE
DC
KY
MO
TN (W)
AZ
(W)
MA*
AL
GA
LA
AK
FL**
HI (W)
Medicaid Managed LTSS (MMLTSS)
Medicare-Medicaid Coordination Initiative
*
Source: NASUAD State
Medicaid Integration Tracker,
September 2013 edition
**
Financial Alignment (FA) demonstration
proposal approved by CMS
Initiatives other than FA demonstration
(W) No longer pursuing FA demonstration
Both MMLTSS and Medicare-Medicaid
Coordination Initiative
What impact will the Affordable
Care Act have?
Page 30
Medicaid Expansion
NH
VT
(Current as of 10/3/2013)
WA
ME
ND
MT
MN
OR
ID
NY
WI
MI
SD
WY
IA
OH
NE
NV
PARI
IL
UT
IN
VA
WV
CA
CO
KS
NC
TN
AZ
OK
NM
SC
AR
MS
TX
AL
GA
LA
FL
AK
Expanding Medicaid
Likely to Expand
HI
Alternative Expansion Approved
Unlikely to Expand
Not Expanding
Source: NASUAD Medicaid Expansion Tracker
MD
DC
KY
MO
RI
CT
NJ
DE
MA
Other LTSS Activities
NH
VT
(Current as of 10/3/2013)
WA
ME
ND
MT
MN
OR
ID
NY
WI
MI
SD
WY
IA
OH
NE
NV
IL
UT
CA
PARI
IN
VA
WV
CO
KS
NC
TN
AZ
OK
NM
SC
AR
MS
TX
MD
DC
KY
MO
RI
CT
NJ
DE
AL
GA
LA
FL
AK
More than One Activity
Balancing Incentive Program Only
HI
Section 1915(i) State Plan Amendment Only
Section 1915(k) Community First Choice Only
Health Homes Only
Source: NASUAD State Medicaid Integration Tracker, September 2013 edition
MA
Will we measure Quality?
Outcomes?
Page 33
If not…boomers don’t wait
patiently
Page 34
For more information, please visit: www.nasuad.org
Or call us at: 202-898-2583