1. www.nasuad.org State Aging and Disability Policy: 50 years backwards, 50 years forward John Michael Hall, Senior Director of Medicaid Policy & Planning NASUAD 12/11/2013

2. Page 2 “Quotes—use quotes and other facts over images to create more visual interest, pauses and color fields.” —Name, title 50 years of history of aging and disability policy

3. 1960s—Older Americans Act Page 3

4. 1970s—establishing the aging network Started congregate meal program –Served 200,000 meals –$100 million program Formed the Aging Network (AAAs) Page 4 Arthur Flemming, Commissioner on Aging

5. 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

6. 1990s—Americans with Disabilities Act Page 6

7. 1990s—Olmstead Decision Page 7

8. 2000s-- Page 8

9. 2011—First Boomer turns 65 9

10. 2005 -2010 15.3% increase

11. 2010—Affordable Care Act Page 11

12. 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

13. What will the next 50 years bring? Page 13

14. What if funding continues to slide? Page 14

15. Compare where the beneficiaries are... 15

16. ... to where the money is: 16

17. FUNDING FOR SENIORS NOT KEEPING PACE NOW… From 1980 to 2010 Page 17 60 % POPULATION INCREASE ADULTS 65+ 34 % FUNDING DECREASE AoA FUNDING

18. FUNDING FOR SENIORS NOT KEEPING PACE Current Funding Levels Unable to Meet Increased Need Page 18

19. FUNDING FOR SENIORS NOT KEEPING PACE Percent of Seniors Continues to Grow Page 19

20. AGING SERVICES UNABLE TO MEET DEMAND Page 20 57 MILLION ADULTS 60+ 11 MILLION SERVED ONLY

21. AGING SERVICES UNABLE TO MEET DEMAND If these trends continue millions will be eligible, few will be served. Page 21 1980 2010 2030 MILLIONS OF SENIORS MILLIONS OF DOLLARS 36 57 92 236 155 ???

22. AGING IN PLACE IS COST EFFECTIVE Annual Facility Care Cost Page 22 $66,000 MEDICAID FINANCED NURSING FACILITY $42,600 PRIVATE PAY ASSISTED LIVING $81,030 PRIVATE PAY NURSING FACILITY

23. AGING IN PLACE IS COST EFFECTIVE Annual Facility Care Cost Page 23 $18,200- $20,800 HOMEMAKER & ADULT CARE SERVICES $24,675 HOME & COMMUNITY BASED MEDICAID SERVICES

24. OLDER AMERICANS ACT SERVICES HELP SENIORS STAY AT HOME Page 24

25. Will Aging and Disability Working Together Make a Difference? Page 25

26. States Restructuring State Aging and Disability Agencies AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI 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) CT

27. Factors Driving State Aging and Disability Agency Restructuring 05101520 Number of States 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

28. What changes will MMLTSS have on the network? Page 28

29. Medicaid Managed LTSS (MMLTSS) Medicare-Medicaid Coordination Initiative Both MMLTSS and Medicare-Medicaid Coordination Initiative RI AK HI (W) OR (W)** NV UT AZ (W) SD NE KS AR LA WI** IN** KY TN (W) GA SC VA* ME MS AL WV CA* ID MT WY NM (W) TX ND OK MN (W)** IA MI IL* MO OH* FL** PA NY* CO NC WA* VT NH** MA* MD DE NJ** DC RI CT * Financial Alignment (FA) demonstration proposal approved by CMS ** Initiatives other than FA demonstration (W) No longer pursuing FA demonstration Medicaid Managed LTSS & Medicare-Medicaid Care Coordination Initiatives (Current as of 10/3/2013) Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

30. What impact will the Affordable Care Act have? Page 30

31. RI AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT Expanding Medicaid Likely to Expand Alternative Expansion Approved Unlikely to Expand Not Expanding Medicaid Expansion (Current as of 10/3/2013) Source: NASUAD Medicaid Expansion Tracker

32. RI AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT More than One Activity Balancing Incentive Program Only Section 1915(i) State Plan Amendment Only Section 1915(k) Community First Choice Only Health Homes Only Other LTSS Activities (Current as of 10/3/2013) Source: NASUAD State Medicaid Integration Tracker, September 2013 edition

33. Will we measure Quality? Outcomes? Page 33

34. If not…boomers don’t wait patiently Page 34

35. For more information, please visit: www.nasuad.org Or call us at: 202-898-2583