Stephen Moses headshot
Stephen Moses

Long-term care’s caregiving sectors — assisted living, skilled nursing and home care — share problems and needs in varying degrees. But what they get from researchers in the field is seldom what would address their problems or meet their needs.

Only 18% of assisted living residents receive Medicaid, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. That is a net plus for the industry as it fills otherwise empty rooms until private payers appear. But why aren’t there enough private payers to fill those rooms in the first place? Medicaid’s income and asset rules divert many financially capable prospects into publicly subsidized nursing homes.

Nursing homes’ biggest problems are excessive dependency on low Medicaid reimbursement aggravated by too much unwarranted regulation, such as mandatory staffing levels. What nursing homes need is policy proposals and advocacy to reduce Medicaid census and increase private, market-rate payers. But is that what researchers deliver?

Hardly. Most long-term care analysts and special task forces recommend new, compulsory, social insurance programs on the model of Medicare and Social Security. They ignore those aging entitlements’ dubious financial prospects. They never explain how more government money and regulation would fix problems created by the same.

Medicaid allows higher-income people to qualify for long-term care benefits if their private medical and long-term care expenditures are high enough. Nor do assets interfere with Medicaid long-term care eligibility as most large wealth, such as home equity, is exempt. Allowing affluent people onto Medicaid converts their private payments into the welfare program’s meager rates for assisted living communities and nursing homes.

Does the research community propose solutions to this conundrum? Not often. It is more apt to join the Centers for Medicare & Medicaid Services, find fault and simply demand higher care standards without providing sufficient compensatory revenue. Expecting Ritz Carlton care at Motel 6 rates is a fantasy, not a plan.

The same problems affect the home care sector. Low Medicaid reimbursements create caregiver shortages. Easy Medicaid financial eligibility diverts people from private-pay home care to publicly subsidized nursing home, assisted living or home- and community-based care alternatives. Cost-shifting to private payers makes the home care and assisted living markets more expensive than they would otherwise be. But what does the home care sector get from researchers?

Nothing to address that problem. Rather, decades of advocacy for “rebalancing” Medicaid from nursing homes to home care. On the dubious premise that home care saves money, Medicaid gradually has tipped from mostly institutional to mostly home care (including HCBS provided in assisted living) over time. But that change did not save money as intended, because so many people who receive home care end up needing nursing homes eventually anyway. The net effect of rebalancing was to make Medicaid more attractive, induce more people to take advantage of its generous financial eligibility rules, crowd out potential private payers from unsubsidized, market-based home care and vastly increase Medicaid long-term care expenditures.

Finally, researchers steeped in the “long-term care narrative” — that only government can fix long-term care’s problems — routinely recommend “value-based care.” Value-based care is a long-term care delivery model based on paying for resident/patient outcomes, instead of for delivered services, with the goal to save money and improve care. But such a system makes government and its contractors, usually big insurance companies, the arbiters of care “value.” Both have conflicts of interest inclining them to define value in ways to maximize savings (to the government) or profits (for the insurers). People and their health needs are disvalued.

In a free, private care market, people demand value by vetting providers and walking away if they’re disappointed. People are empowered. But where is the research and advocacy favoring market-based reform? Mostly missing.

For long-term care research and recommendations that speak directly to the senior living and care industry’s actual problems and needs, see the Paragon Health Institute’s reports titled “Long-Term Care: The Problem” and “Long-Term Care: The Solution.” You will find market-based analysis and proposals that soon will be on the public policy agenda as debt and inflation continue to undercut government-based long-term care programs.

Stephen Moses is president of the Center for Long-Term Care Reform, a visiting fellow at the Paragon Health Institute and the author of Paragon’s “Long-Term Care: The Problem” and “Long-Term Care: The Solution.” Reach him at [email protected].

The opinions expressed in each McKnight’s Senior Living guest column are those of the author and are not necessarily those of McKnight’s Senior Living.

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