1. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 0 Long-Term Care: Exploring the Possibilities Diane Rowland, Sc.D. Executive Vice President, Henry J. Kaiser Family Foundation and Executive Director, Kaiser Commission on Medicaid and the Uninsured for Alliance for Health Reform Washington, DC March 9, 2009

2. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 1 Who Pays for Long-Term Care? Total = $124.9 billion Note: Total LTC expenditures includes only spending on nursing home and home health services. Some community-based services financed primarily through Medicaid home and community-based waivers and delivered in other settings are not represented here. SOURCE: KCMU estimates based on CMS National Health Accounts data, 2008. Total = $177.6 billion Nursing Home Care ExpendituresTotal Long-Term Care Expenditures

3. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 2 Medicaid Long-Term Care Users Account for 7 Percent of Enrollees But Over Half of Spending 33% 48% 93% 4% 3% Total = 51.4 millionTotal = $228.2 billion EnrolleesExpenditures 19% Note: Data include spending on acute and long-term care services by users. Source: KCMU and Urban Institute estimates based on MSIS 2002. 52%

4. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 3 Dual Eligibles’ Share of Medicaid Enrollment and Spending, FFY 2005 49.8 million $ 287.3 billion Source: Urban Institute estimates based on data from MSIS and CMS Form 64, prepared for the Kaiser Commission on Medicaid and the Uninsured, 2008.

5. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 4 Comparison of Dual Eligible and Other Medicare Beneficiaries, 2006 SOURCE: KFF analysis of the Medicare Current Beneficiary Survey 2006 Access to Care File. 61% Total = 7.5 Million Dual Eligible Medicare Beneficiaries

6. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 5 Growth in Medicaid Long-Term Care Expenditures, 1991-2006 $32 $54 $75 87% 80% 70% In Billions: 13% 20% 30% 32% 68% $92 Institutional care Home & community- based care 63% 37% $100 $109 41% 59% Note: Home and community-based care includes home health, personal care services and home and community-based service waivers. SOURCE: KCMU and Urban Institute analysis of HCFA/CMS-64 data.

7. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 6 Reform Options at the State Level Home and community-based services (HCBS) waivers Demonstration grants with enhanced matching funds HCBS State Plan Options –Allows states to offer HCBS services as a state plan option rather than through a 1915(c) waiver Self-direction of personal assistance services –Medicaid beneficiary has greater control over hiring, scheduling and paying personal care attendants Long-term care Partnership Programs –Allow persons who purchase qualified LTC insurance policies to shelter some or all of their assets when applying for Medicaid after exhausting their policy benefits

8. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 7 Number of States with Medicaid Long-Term Care Expansions Note: State actions to expand HCBS waivers include those receiving Money Follows the Person demonstration grants. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, September 2008.

9. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 8 Increased Flexibility with DRA Long- Term Care Options SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, September 2008. Number of States

10. K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 9 Key Challenges in Long-Term Care Medicare coverage for long-term care is limited –Provides limited nursing home care (100 days) for those recently discharged from a hospital Better coordination of dual eligibles is needed Private sector options are still limited and often costly The demand for long-term care will continue to grow and families will continue to play a critical role in provision of care and financing home care and nursing home care