Medicaid’s Role in Meeting Seniors’ Long-Term Services and Supports Needs Ninth Annual Symposium on Access to Health Care Beazley Institute for Health Law and Policy November 13, 2015 Erica L. Reaves Policy Analyst, Kaiser Family Foundation’s Commission on Medicaid and the Uninsured

Figure 1 LTSS needs are relatively common among seniors living in the community Share with: SOURCE: KCMU analysis of 2011 NHATS data; see Rachel Garfield et al., Serving Low-Income Seniors Where They Live: Medicaid’s Role in Providing Community-Based Long-Term Services and Supports (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), providing-community-based-long-term-services-and-supports/ providing-community-based-long-term-services-and-supports/.

Figure 2 NOTES: *Significantly different from age 85+ at p<0.05 level. ^Significantly different from male at the p<0.05 level. ~Significantly different from White, Non-Hispanic at the p<0.05 level. SOURCE: KCMU analysis of 2011 NHATS data. Multiple factors influence seniors’ risk of needing LTSS Age Gender Race/Ethnicity Non- Hispanic White, Non- Hispanic Black, Hispanic Share of community-based seniors with any need:

Figure 3 NOTES: Total LTSS expenditures include spending on residential care facilities, nursing homes, home health services, and home and community-based waiver services. Expenditures also include spending on ambulance providers and some post-acute care. This chart does not include Medicare spending on post- acute care ($74.1 billion in 2013). All home and community-based waiver services are attributed to Medicaid. SOURCE: KCMU estimates based on CMS National Health Expenditure Accounts data for Medicaid is the nation’s primary payer for LTSS Out-of- Pocket, 19% Total National LTSS Spending in 2013 = $310 billion

Figure 4 $93 $100 $113 $121 $123 68% 37% 63% 42% 58% 55% 45% 32% 55% 45% 54% 46% Medicaid LTSS spending is increasingly devoted to HCBS as opposed to institutional care NOTES: Home and community-based services (HCBS) include state plan home health, state plan personal care services and § 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals with intellectual/developmental disabilities, nursing facilities, and mental health facilities. SOURCE: KCMU and Urban Institute analysis of CMS-64 data. (in billions) $109 41% 59%

Figure 5 NOTE: Individuals who used both institutional and community-based services in the same year are classified as using institutional services in this figure. SOURCE: KCMU and Urban Institute estimates based on MSIS and CMS-64 FY 2011 data. Seniors are more likely than non-elderly people with disabilities to use institutional LTSS vs. HCBS

Figure 6 Per capita Medicaid LTSS spending is relatively high for seniors NOTE: Per capita calculations include only full-benefit enrollees. SOURCE: KCMU and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. In cases where 2011 MSIS data were unavailable, 2010 MSIS & CMS-64 data were used.

Figure 7 The majority of Medicaid HCBS are delivered via § 1915(c) waivers 3.2 million$55.0 billion 764, ,507 1,497,528 $5.8 billion $8.4 billion $40.8 billion SOURCE: Terence Ng et al., Medicaid Home and Community-Based Service Programs: 2012 Data Update (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2015), update/. update/ Total:

Figure 8 Section 1915(c) waiver enrollment and spending are disproportionate for the aged and disabled population NOTES: Percentages may not sum to 100 percent due to rounding. The “Other” enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain and spinal cord injuries. SOURCE: KCMU and UCSF analysis of 2012 CMS Form 372 data. Total = $40.8 billion Aged and Disabled Other Persons with Intellectual/Developmental Disabilities Aged and Disabled 163,638 (11%) 720,204 (48%) 613,685 (41%) $29.2B (72%) $8.5B (21%) Other$3.2B (8%) Total = 1.5 million Persons with Intellectual/Developmental Disabilities

Figure 9 NOTES: Percentages may not sum to 100 percent due to rounding. The “Other” enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain and spinal cord injuries. SOURCE: KCMU and UCSF analysis of CMS Form 372 data and program surveys. 53%47%45% Section 1915(c) waiver enrollment can be capped, resulting in waiting lists 64% 60% 45% 53% 68% 64% 26% 53% 41% 42% 26% 30% 14% 1% 6% 5% 6% 61% 10% 29% 63% 9% 28% 58% 62% 32% 10% 8% 60% 29% 11% 582, , ,916280, ,689393, , , ,174 Total: 523,710536,464 29%

Figure 10 NOTES: Total counts equal the number of states that were approved by CMS to participate in the option as of October States with planning grants, pending state plan amendments, and/or pending demonstration proposals are not captured in this figure. SOURCES: CMS, Medicaid.gov, and state websites. The Affordable Care Act offers states additional options to provide Medicaid HCBS

Figure 11 Mary Francis | Richmond, VA “My mom had Medicare at the time of her stroke but it did not cover long-term care. To us, Medicaid means being able to live with dignity, in the community, with friends and family.” Maxine | Kansas City, KS “Because she [Maxine] is able to stay in her own home, she feels a certain amount of independence.” Penny | Braintree, MA “Medicaid allowed me to have the same care as everybody else, in the same respiratory hospital and in this nursing home…there’s no discrimination.” SOURCE: KCMU, Faces of Medicaid (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), Personal stories highlight the diverse experiences of seniors who rely on Medicaid LTSS

Figure 12 No Wrong Door/Single Entry Point systems and universal functional needs assessment State take-up of Medicaid HCBS options Length and duration of HCBS waiver waiting lists HCBS provider payment rates and workforce adequacy Delivery system reforms including managed LTSS and initiatives to integrate acute care and LTSS Oversight and monitoring of HCBS programs and quality measures Looking ahead, Medicaid policymakers will be challenged to find innovative ways to meet seniors’ LTSS needs