Long Term Care: Elderly Individuals Could Find Significant Variation in the Availability of Medicaid Home and Community Services

Statement of Kathryn G. Allen, Director, Health CareMedicaid and Private Health Insurance Issues

My remarks will summarize findings of a report that we are releasing today that examines four geographically diverse states Kansas, Louisiana, New York, and Oregon that varied in their coverage of Medicaid home and community-based services. At your request, we examined how these states coverage policies affected long-term care services available to elderly individuals needing care. We focused on three specific issues:

(1) the extent to which home and community-based services were available for Medicaid-eligible elderly, (2) services that local case managers would offer to two hypothetical elderly individuals based on the levels of unpaid informal care provided by family members, and (3) the extent to which care offered to the same individual with the same level of informal support varied among the selected states.

The cornerstone of our work was the development of vignettes for two hypothetical elderly persons an 86-year-old woman with debilitating arthritis and a 70-year old man with moderate Alzheimer's disease. For each of these hypothetical individuals, we developed three scenarios where the individuals had varying levels of informal care available from their families and preferred to remain at home as long as possible. We then asked four Medicaid case managers in each of the four states to develop care plans for each scenario.

In summary, we found that a Medicaid-eligible elderly individual with the same disabling conditions, care needs, and availability of informal family support could find significant differences in the type and intensity of home and community-based services that would be offered for his or her care. These differences were due in part to the very nature of long-term care needs which can involve physical or cognitive disabling conditions and the lack of a consensus as to what services are needed to compensate for these disabilities and what balance should exist between publicly available and family-provided services. The differences in care plans were also due to decisions that states have made in designing their Medicaid long-term care programs and the resources devoted to them. The case managers we contacted did offer, in general, care plans that relied largely on in-home services rather than other residential care settings. However, there was considerable variation in the extent of in-home services offered. For example, for our hypothetical 86-year-old woman with debilitating arthritis, case managers recommended from 4.5 hours per week to 40 hours per week of in-home assistance to supplement the care she received from her daughter who lived with her but who also cared for her own infant grandchild. However, despite coverage for varying types and levels of home and community-based services in all four states Medicaid programs, two states had waiting lists that would at present preclude the availability of many of these services for elderly individuals seeking them.