Write a response to each Discussion Question.

Kuta 11.1

Long-term care can be provided at facilities, in an individual's home, and in the community. This type of care can be extremely expensive and, unfortunately, not many individuals can afford it. Medicaid has been the main funding source for long-term care for many years now, even after the implementation of the Affordable Care Act (ACA). When enrollment first opened for the ACA, there were 6 million individuals that enrolled in Medicaid coverage (CMS, 2014). Going forward, one of the key federal issues is addressing whether the ACA's coverage is stable and continuous for individuals enrolled. Income fluctuation affects Medicaid coverage and the ACA wants to make sure that individuals always have some type of coverage no matter their income, change in health status, or some type of major life event (Rosenbaum, 2015). Rosenbaum (2015) goes on to say that improving the level of integration between Medicaid and health insurance marketplace enrollment systems would be very helpful. The federal issue of making sure the ACA is stable and continuous is also a state issue, because states have the option of whether they want to integrate the Medicaid system to health insurance market place systems, or if they would rather keep Medicaid as an isolated pathway for coverage (2015). The ACA came into place assuring Americans that they all would have some sort of health coverage no matter their income. With gaps in the transition and whether or not states keep Medicaid as a separate entity of coverage is something that Congress needs to figure out. Of course the process of getting everything figured out so that the program runs smoothly and that everyone has affordable healthcare coverage at all points in their life, is a long one. It will take a great amount of time until everything is operating smoothly, and once that happens there will probably already be new changes occurring that will just have to make Congress and states re-evaluate again.

TURMAN DB 11.1

Long-term care (LTC) is expensive, a nursing home can cost $50,000 to $ 280,000 per year, and assisted living can cost $30,000 to $ 94,000 per year. Full time home care can over $150,000 per year (Frolick, 2016). Even more concerning is the uncertainty of future needs for long-term care based on the nations increasing life span. Long-term care insurance is an option that few purchase even though increased length of life and risk factors of dementia, chronic illness, and physical frailty can become a cost barrier in an individual's future.

Stage governments more commonly utilizing three improvement strategies for Long-term services and support. One of these three strategies is expanding on non-institutional care or home care which as seen above can be less costly than nursing home care (Naylor, Kurtzman, Miller, Nadash, & Fitzgerald, 2016). The second and third strategies are integrating payment and care delivery, and realigning incentives through market based reform (Naylor, Kurtzman, Miller, Nadash, & Fitzgerald, 2016). These strategies are being implemented by states as a way to address the large disproportionate share of Medicaid spending required by LTC.

Long-term care is primarily supported through Medicaid programs that are jointly financed by state and federal government to serve low income individuals (Naylor, Kurtzman, Miller, Nadash, & Fitzgerald, 2016). In an effort to reduce Medicaid spending states are focused on LTC spending, which continues to grow as the number of elderly increases along with life expectancy.

Disabled and older adults represent only 28% of Medicaid participants, but account for two thirds of Medicaid spending (Naylor, Kurtzman, Miller, Nadash, & Fitzgerald, 2016). The Medicare chief actuary questions the financial sustainability of subsidies mentioning that it would attract individuals with health problems and greater risk of functional limitations than those with better health resulting in adverse selection of participation (Inglehart). By 2020 it is estimated 15 million Americans will need some sort of LTC and fewer than 3% will have a policy (Inglehart, 2016). There is currently no bills on the table that are under consideration nor has there been much congressional dialogue around expansion of LTC coverage.

The biggest focus federally is trying to shift care to home-based services to reduce cost. States Medicaid reform when focused on the three strategies can improve effectiveness, efficiency, and comprehensiveness (Naylor, Kurtzman, Miller, Nadash, & Fitzgerald, 2016). I think that it is not a state or a federal issue it is a social and health issue that can be addressed by both state and federal. The Nation is aware that the end of life care is the most costly, therefore the federal and state need to both assist in the healthcare industry reducing cost in end of life care such as LTC. The cost of LTC is not sustainable for either state or federal programs. This subject is important to address now as the balance is shifting, because of longevity and population increases.

Langel DB 11.1

Advances in medicine and technology are allowing more individuals with chronic illnesses to live longer in their lives. When these individuals get older, we can expect that more individuals will require assistance from Long Term Care (LTC) resources. LTC refers to assistance with daily living activities such as eating, bathing, or dressing (Reaves, 2015). When an individual can no longer perform these tasks on their own, the individual will seek assistance. A few different types of LTC would be institutions (nursing homes), community-based settings (assisted living), or home health (Reaves, 2015). Usually, individuals will choose to remain in their home or move into an assisted living environment for the sense of community.

LTC can become a very significant cost to these individuals. In 2015, the average cost for one year of home health was about $45,800, daily adult care was about $18,000, and care in a nursing home was $91,250. (Reaves, 2015). Obviously, this would be an extremely high amount for a person to cover out of their own pocket. Luckily, there are a few different ways these services can be funded. An individual could purchase private insurance to help cover these costs. They would pay a monthly premium and the policy would usually grow by 3-5%. These policies were underestimated by the insurers so in recent years, the organizations have had rate increases of 50-60% (Lankford, 2016). Private insurance makes up only 8% of the spending on LTC services (Reaves, 2015).

The other ways an individual can pay for LTC is through Medicare and Medicaid. Medicaid is the primary payer for the institutional and the community-based care covering 51% of LTC services (Reaves, 2015). It is financed by both the states and the federal government, but is administered by the states. Medicare has limited coverage for these services. It only covers individuals that have a "qualifying work history and (1) are age 65 or older; (2) are under age 65 and have been receiving Social Security Disability Insurance for more than 24 months; or (3) have end-stage renal disease or Amyotrophic Lateral Sclerosis" (Reaves, 2015). Coverage is also limited under Medicare only covering beneficiaries that are homebound. No personal care services are covered.

I would consider the issue of LTC both a federal and a state issue. The federal government has a hand in helping to fund Medicaid. The states are doing the same as well as administering the programs. In the future, there needs to be more efforts to align Medicare and Medicaid financing. This can help integrate and coordinate primary care, acute care, behavioral health, and LTC for the beneficiaries (Reaves, 2015).

Epperson 11.1

What are the key federal issues related to funding Long Term Care that are being debated in Congress during the past three years. How is Long Term Care typically paid for (Medicare? Medicaid? Private insurance? Self-Pay?). Would you consider Long Term Care to be more of a Federal or State Issue? Why?

One of the issues being debated in Congress is the high cost of caring for the elderly. As baby boomers continue to age, more and more long term care service will be needed. Nursing homes are expensive with the private room costing $92,379 annually. The U.S. spends $725 billion on long-term care.

Many elderly people cannot afford to pay for long-term care and will end up seeking care from family members, or no care at all. Eight percent of the population has long term care insurance, and all others will have to drain their life savings before they are eligible for Medicaid. The burden of caring for the elderly will sit on the shoulders of many families ("Finding Common," 2016).

Some people pay for their own long-term care services, and often deplete their life savings doing so, but Medicaid is one of the largest payers of long-term care. Medicaid is not available to everyone unless that person is below the poverty level. I feel that long-term care is both a federal and state issue. A federal issue because Medicare, Veterans' benefits are federal programs.

Although Medicare and Veterans' benefits are limited coverage, they do provide some benefits for long-term care to those in certain situations. State issues because the state is heavily involved in state Medicaid and they pay once a person's finances have been exhausted and the person approved for Medicaid ("How Can I Pay for Nursing," n.d.).