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Louisiana Must Continue Progress with In-home Long-Term Care for the Elderly
by David Hood
Senior Healthcare Policy Analyst, Louisiana Public Affairs Research Council
PUBLISHED: November/December 2011
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Those of us who follow the procession of national health surveys each year
can’t help being disheartened by Louisiana’s poor showings, typically ranking
last or next to last among the 50 states. So it was rewarding to find a recent
survey that documented significant progress for our state and also placed us
43rd overall in a comparison of long-term care systems.
The survey was a collaborative between
AARP, the Commonwealth Fund, and the
SCAN Foundation to produce a scorecard
that measures state-level performance of
long-term services and supports (
LTSS) that assist
the elderly, adults with physical disabilities, and family
caregivers. The scorecard is intended to help states
improve these systems in order to maximize independence
and well-being for those who depend on them.
While nursing home care is an essential segment of
the long-term care system, in-home care is often preferred
by those who are able to continue to live independently
or with their family. In some cases, the nursing
home is the logical choice when a disability requires the
attention and care found in an institutional setting or
there is no family or other caregiver available. Many
nursing home residents choose to leave once sufficient
supports and services for in-home care are available.
In-home and community-based care is less expensive
than institutional care, an important fact for budget
planning in these austere times.
In-home care includes a wide range of supports and
services geared toward individuals who live in their
own homes, the homes of relatives or other types of
residential care facilities. Examples of these services are
bathing, dressing, eating, and assistance with household
chores such as meal preparation and house cleaning.
Adult day health care provides meals, basic health
care, and recreational activities at community locations.
Home health care may also be available to elderly and
disabled Medicaid recipients who require specialized
nursing, therapeutic services or other medical care.
The AARP long-term care scorecard provides ample
evidence that Louisiana has made substantial progress
over the last decade. For example, the state ranks 18th
overall in affordability and access to all types of longterm
care, including 6th place for the relatively low cost
of private nursing home care.
The state also ranks 23rd in the proportion (32%) of
Medicaid long-term care dollars that are spent on inhome
and community-based care. That statistic is proof
of Louisiana’s accomplishment in providing choices for
people who wish to maintain their independence in
the community rather than be institutionalized. The
settlement of a lawsuit in 2002 opened the door to an
expansion of in-home care from less than 2,000 elderly
or disabled persons utilizing these services in 2003 to
almost 15,000 by 2009. Despite this forward progress,
however, more than 18,000 persons, including many
nursing home residents, were still on a waiting list for
in-home care in 2010. Many of them will wait two or
more years before services are available.
Ten years ago, spending for in-home and community-
based care was less than 2% of the long-term care
budget for the elderly and adults with disabilities. To
provide some perspective, nursing homes received
$583 million (98.6%) of the entire $591 million longterm
care budget for the elderly in Fiscal Year 2002. For
the current Fiscal Year 2012, nursing homes will receive
about $790 million (72%) of the elderly long-term care
budget of $1.1 billion.
Of course, there are problems within the 25 indicators
that make up the scorecard. Louisiana received a
few last-place rankings, including very low
participation in private long-term care insurance
policies (28 per 1,000 population) and a
high rate of nursing home residents with pressure
sores (17%). There is reason for optimism
for the future and satisfaction about accomplishments
of the last few years, but there is
also much that needs attention.
Although there has been recent progress
in expanding Medicaid non-institutional care
for the elderly and adult population with disabilities,
Louisiana still ranks highest in the
rate of beds and residents in the key population
served, as shown by the following statistics
(Source: Health Care State Rankings
2011, CQ Press):
• 357 residents in nursing homes per 1,000
population 85 years and older. Rank 1st in U.S. (2009)
• 297 beds per 1,000 population 85 years and older.
Rank 1st (2011)
• 34,965 nursing home beds. Rank 17th (2011)
• 70% occupancy rate for nursing home beds (10,000
beds empty). Rank 44th (2009)
Even with 10,000 empty beds, the high rate of
residents over 85 puts the state more than 40% above
the national average (249 residents per 1,000 population)
and more than 150% above 46th ranked Florida
(139 residents per 1,000). Figure 2 shows the volume
of nursing home care shrinking while spending has
climbed rapidly.
In conclusion, abandoning expansion of in-home
and community-based services should not be an option.
The state should commit to continuing that expansion
to ensure Medicaid recipients have access to highquality
services provided by well-trained caregivers.
High-quality care should be available throughout the
continuum of long-term care, including institutional as
well as home and community-based services. Therefore,
special attention should be devoted to nursing homes
as well, in order to right-size the amount of unused
resources while improving effectiveness and efficiency.
Using other states as models, savings can be achieved
by reducing numbers of empty beds (10,000) and the
savings applied to incentive payments for nursing
homes in order to upgrade performance and quality.
The Administration should lead the effort to bring all
parties together to confect a plan that hopefully all participants
can agree to.
National Long-Term Care Program Scrapped. The
federal Affordable Care Act of 2010 contains an important
provision that could have benefitted middle income
persons in Louisiana and other states by providing cash
benefits to defray a portion of expenses for in-home
or community-based care, as well as care in a nursing
home or assisted living facility when needed. Known as
Community Living Assistance Services and Supports
(CLASS), the program was designed as a voluntary public
insurance program that would be wholly financed by
premium payments from enrolled members. Use of federal
funds would not be allowed. Now defunct, CLASS
could have provided an alternative for middle-income
persons in most states, including Louisiana, who often
have to “spend down” their assets to be eligible for Medicaid
long-term care programs.
However, actuarial studies of the program prior to
implementation raised concerns that voluntary enrollment
would consist mainly of persons with severe disabilities
or at high risk of developing them. This would
result in high premiums that would discourage young
and healthy people from participating. Ultimately,
premiums would fail to cover costs and produce large
deficits that could require public funds. On October 14,
2011, Kathleen Sebelius, secretary of Health and Human
Services, announced that the department would
not be implementing CLASS because it appeared to be
“financially unsustainable.”
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