1. 11 …to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshires future. Aging and the Health Care System Board of Directors William H. Dunlap, Chair David Alukonis Eric Herr Dianne Mercier James Putnam Todd I. Selig Michael Whitney Daniel Wolf Martin L. Gross, Chair Emeritus Directors Emeritus Sheila T. Francoeur Stuart V. Smith, Jr. Donna Sytek Brian F. Walsh Kimon S. Zachos New Hampshire House Long-Term-Care Commission March 18, 2014

2. Major Areas of Consideration Aging Service Demand Service Supply Financing Responsibility and Authority for Policy Flexible Systems (Peak Load)

3. Critical Questions How will demand for different services change as a result of aging and new disease burden (e.g. dementia)? Is the system of supports for aging sufficient to meet this growing demand (caretakers, institutions)? Is a state solution the right answer? How do regional differences impact the questions being asked? Does the growth of Medicare enrollment and changes in Medicaid (expansions to 55-64-year-old adults) provide opportunities? What does a long-term-care accountable care organization look like? How do these answers affect the states implementation of managed care for long term care services? How do national policy changes (Affordable Care Act) and potential recommendations out of the long term care commission impact New Hampshire? What role will the counties play in providing the services needed across the spectrum of long-term-care supports and services (Meals on Wheels to institutional care)? Long-term-care expenditures are projected to grow more quickly then revenues. How will the state and counties finance these changes?

4. 4 Are we old? Not yet, but getting there …

5. 5 Geography Matters

6. 6 The new 60? Significant growth of 75-79 population

7. 7

8. The Geography of Elderly Poverty

9. Predicting the Future in Spending

10. Private Pay – Tremendous growth in 45-64 y.o. range

11. Aging has real impacts on Medicare ….

12. Currently, much of the Medicaid spending is for those under the age of 65 (2009)

13. A very different picture in 2030

14. 14 Shifts in Medicaid Spending

15. 15 Driven by Age and Shifts in Demand for Services Nursing Home Care

16. 16 Can the current system support such demand for institutional and non-institutional services?

17. Large Growth in Spending

18. Medicare will play a growing role in driving the healthcare system

19. Workforce Issues will become more acute.

20. The Workforce Is Aging As Well!

21. Capacity Questions Home Health Home and Community Based Care slots Geriatric hospital services Assisted Living Facilities Alzheimer's Support (Hospital, Nursing Homes) Prisons Inpatient versus Outpatient services

22. What does a comprehensive assessment of the system of LTC supports look like?

23. Acute Medical Chronic Medical Community Based LTC Assisted Living Nursing Home What does a Long-Term-Care Accountable Care Organization Look Like?

24. 24 Support and Information Service Link (ADRC) Legal Services 211 Calls Other ?

25. 25 Financial Assistance (2012) TANF Grants for Lower Income Elderly –Household size of one must be under $712 per month and aged 65 or older; Average grant is $164.13 in July 2012 Property Tax Exemptions? –96% of cities and towns provide mandated base elderly exemption (94% provide additional value) –In 2006, 11,753 individuals received an exemption, average $1,727 for a total of $20.3 million across the entire state. Local welfare expenditures?

26. 26 Nutrition (2012) Food-stamps –Maximum grant is about $5.80 per day per person. Of a total 56,887 cases in July (2012), 5,944 or 5.1% are over age 65. Of these, 1,215 have a cash grant Meals Programs (Title III) –11,454 individuals received home delivered meals. –17,192 received congregate meals Local food kitchens

27. 27 Other Housing –Section 8 housing? –Other efforts Transportation –Title III – provided almost 19 visits per person over the age of 65 living in poverty in NH. –Medicaid provides transportation services Acute Healthcare –Medicaid –Local Welfare

28. 28 State (or county based) Long Term Care Supports Public Health (support for falls, chronic conditions for those 55 to 64) Medicaid Nursing Home Home and Community Based Care Title III –Adult Day Care – 654 individuals received support –Homemaker – 645 individuals received support –Personal Care Services – 523 received support

29. What about the impact of the budgetary changes from 2010 – 2013?

30. The National Long Term Care Commission The Commission identified the following problems with the current LTSS system: Currently, family caregivers are providing most of the care, but their responsibilities can be very overwhelming. Their availability will decline as more of the population ages.family caregivers Many Americans approaching retirement are unaware of how costly paid LTSS are and are not prepared for these expenses. There are training and retention problems within the direct care workforce that will affect the quality and accessibility of practiced employees in the future. Paid LTSS are fragmented and difficult to access. They often lack the focus and efficiency that would result in the best outcomes, all the while remaining a financial burden.

31. Critical Questions How will demand for different services change as a result of aging and new disease burden (e.g. dementia)? Is the system of supports for aging sufficient to meet this growing demand (caretakers, institutions)? Is a state solution the right answer? How do regional differences impact the questions being asked? Does the growth of Medicare enrollment and changes in Medicaid (expansions to 55-64-year-old adults) provide opportunities? What does a long-term-care accountable care organization look like? How do these answers affect the states implementation of managed care for long term care services? How do national policy changes (Affordable Care Act) and potential recommendations out of the long term care commission impact New Hampshire? What role will the counties play in providing the services needed across the spectrum of long-term-care supports and services (Meals on Wheels to institutional care)? Long-term-care expenditures are projected to grow more quickly then revenues. How will the state and counties finance these changes?

32. New Hampshire Center for Public Policy Studies Want to learn more? Online: nhpolicy.org Facebook: facebook.com/nhpolicy Twitter: @nhpublicpolicy Our blog: policyblognh.org (603) 226-2500 …to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshires future. Board of Directors William H. Dunlap, Chair David Alukonis Eric Herr Dianne Mercier James Putnam Todd I. Selig Michael Whitney Daniel Wolf Martin L. Gross, Chair Emeritus Directors Emeritus Sheila T. Francoeur Stuart V. Smith, Jr. Donna Sytek Brian F. Walsh Kimon S. Zachos