Health Affairs: The Middle Ground For Fixing Long-Term Care Costs: The WISH Act

Our Marc Cohen and co-author Stuart M. Butler published the following piece this week in Health Affairs, revisiting some of the issues we wrote about earlier while taking a deeper look at this long-standing problem.

The Middle Ground for Fixing Long-Term Care Costs: The WISH Act is Copyright © 2021 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

WISH Act and UMass Boston’s Marc Cohen Hope to Transform American Elder Care

Marc Cohen and other academics and policy analysts saw the writing on the wall years ago. With roughly 10,000 Americans turning 65 every day, a decades-old medical and financial storm is now on the horizon when it comes to how to provide and pay for long-term services and supports (LTSS) for elders.

The number of family members available to care for aging relatives is dwindling, most families can’t afford the time or expense of caring for an older relative, and divisive, uncompromising politics in the United States – despite these long-approaching clouds – have done little to tackle the issue head on. More than half of us will need LTSS in old age, yet less than 10 percent of us have insurance to help cover the costs.

“Everyone in their gut knows that there’s this issue out there,” said Cohen, co-director of the LeadingAge LTSS Center at UMass Boston, and research director of the Center for Consumer Engagement in Health Innovation at Community Catalyst. “But very little has been done about it.”

Marc Cohen, PhD

Marc Cohen, PhD

Cohen and his peers spent years working on an idea first put forward by academics and researchers that were part of the Long-Term Care Financing Collaborative, and then expanded on this idea in a paper presented at the Bipartisan Policy Center. At times, their suggestions gained traction, but not among the people who mattered most – the politicians who could enact legislation.

On June 30th, New York Congressman Tom Suozzi, a Democrat representing sections of Long Island and Queens, introduced the Well-being Insurance for Seniors to be at Home (WISH) Act, which addresses how to finance long-term care for older adults, the first new solution put forth in almost a decade.

“With the number of disabled elders expected to double in the coming years, fewer family caregivers are available for these aging Americans, and the market for long-term care insurance is not currently sufficient to address these demographic challenges,” Suozzi said in a press release when the legislation was released. “The WISH Act would save the Medicaid program and millions of Americans from financial ruin, would allow people to age at home with dignity, and would create millions of good-paying, middle-class jobs in the home health care industry.”

Private and public interests had always stood in the way of past legislation aimed at this issue. The WISH Act attempts to overcome this divide by creating a public-private partnership based on social insurance for catastrophic LTSS expenses, coupled with family help, savings and private long-term care insurance for early up-front costs.

The idea is that such a comprehensive insurance solution – built on well-defined public and private roles — would enable older adults to stay at home if they wish instead of needing to deplete their and their family’s life savings and enter Medicaid-funded nursing homes or access more limited Medicaid-financed home care services.

In addition, the legislation is aimed at helping low-income individuals and their families whose savings are often devastated when a loved one requires long-term care, forcing many to make tough decisions about work and incomes versus their relative’s long-term care needs.

In mending this dangerous trend, the legislation would also promote health equity by providing a financial parachute to those families that would suffer most under the current system – a system which leaves the Medicaid program financially stretched and unable to meet the needs of its beneficiaries and pay rates necessary to support a high-performing workforce.

Cohen also views the legislation through a feminist lens. For decades, working women – who are the primary family caregivers of disabled elders — have been forced to weigh their careers and income versus staying at home to care for an elderly relative. If successful, the WISH Act would empower more working women to stay in the workforce, because the costs associated with bringing in home care aides, for example, would be paid for through the insurance program.

The legislation would create a new Long-Term Care Insurance Trust Fund that would be used to pay for the “catastrophic” period of long-term care for adults requiring many years of help. At the same time, the legislation would have private insurance companies offer affordable coverage plans for older adult’s initial years of disability. And it would be paid for with a social insurance contribution by all workers and their employers, each contributing about 0.3 percent of wages.

The legislation was largely inspired by the 2018 paper written by Cohen, Judith Feder of Georgetown University and Melissa Favreault of the Urban Institute. Their work was funded in part by the Office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, among others.

The way that work came about mirrors the political headwinds the WISH Act legislation will face on a very divided Capitol Hill.

“We went back and forth for two years,” Cohen said. He came to the issue with a perspective shaped by his work with the private insurance sector, while Feder came from the public policy side, a big philosophical divide concerning what private industry and the government could and should do when it comes to such a challenging and difficult issue like long-term care financing.

“Very early on when we butted heads, we both agreed that we would not let “the enemy of the good be the best” and that ideological purity would have to be put aside so that we could focus on a practical solution that could do a lot of good,” Cohen said.

Their paper was published in January 2018, got some attention, but then languished until just before the pandemic hit in 2020. In late November 2019, Dr. Joanne Lynn, a geriatrician and hospice physician who is a senior analyst at Altarum and who was working at Congressman Thomas Suozzi’s office, invited Cohen to fly down to Washington, D.C., to meet with the Congressman and his team, where the initial sketches of the WISH Act were discussed. Throughout 2020 and the first six months of 2021, there were multiple meetings which were led by Dr. Lynn responding to concerns of stakeholders and dealing with the minute details that come with developing a new and major piece of legislation.

After a career spent touting the rationale for such legislation, this was the first time Cohen played a direct role in helping to shape legislation. “During that process it became clear to me that this is not a rich versus poor or Democrat versus Republican issue, but rather, a human issue that affects us all and really needs to be addressed,” Cohen said.

Valued Partnership

Internship benefits housing provider and doctoral student while supporting older adult residents

When a Boston-based affordable housing developer wanted to survey their residents to better support their health-related needs, they paused. What did they know about approaching older adults to inquire about their personal healthcare?

“We’re developers and project managers, not social workers or healthcare providers,” says Amarillys Rodriguez, Development and Policy Project Manager for the Planning Office for Urban Affairs (POUA). “We needed to bridge this gap and have the kind of expertise on hand to help us better understand our residents.”

Elisabeth Stam, gerontology doctoral student

POUA reached out to the Gerontology Institute at UMass Boston and the two organizations created a graduate assistantship. The opportunity allowed one doctoral student in UMass Boston’s distinguished Gerontology program to help POUA move forward on its Health & Housing Initiative while gaining useful work experience.

A social justice ministry of the Archdiocese of Boston, POUA has more than 3,000 housing units located in Eastern Massachusetts. About one-half of these apartments are homes for older adults. POUA wanted to learn about these residents’ health needs to better serve them by providing support such as preventive care. To accomplish this, POUA decided to develop a voluntary, confidential survey to collect demographic information and information about health conditions, insurance coverage and healthcare provider relationships.

“If we gather this information, we’ll be able to identify any patterns or clusters of particular issues to pay attention to and create on-site, health-targeted resident services,” says Rodriguez.

Elisabeth Stam, a first-year doctoral student studying Gerontology at UMass Boston, began her internship with POUA in the fall of 2020 continuing through the Spring 2021 semester. Among her responsibilities was helping to develop and structure the survey to describe respondents’ health needs. Having someone with an understanding of gerontology and knew how to word questions so residents felt comfortable to participate and respond, was key to a successful survey, notes Rodriguez. Continue reading

Reinvesting in home and community-based services

How the Biden Administration’s $1.9 trillion relief bill will impact Medicaid in Massachusetts

The American Rescue Plan Act (ARPA) — a COVID-19 relief and recovery package — was signed into law by President Joseph Biden last month. Among the $1.9 trillion relief bill’s provisions is a temporary enhanced federal matching percentage (FMAP) for Medicaid home and community-based services. The FMAP is the proportion of every Medicaid dollar spent paid for by the Federal government. Massachusetts could receive as much as $409.2 million during the one-year period covered.

Prof. Miller discusses COVID-19 relief bill

“One of ARPA’s goals is to strengthen state efforts to help seniors and people with disabilities live in their homes and communities rather than in nursing homes or other institutional settings,” said Edward Alan Miller, PhD, a fellow at the Gerontology Institute at UMass Boston and professor in the university’s Department of Gerontology. “The imperative to do so has been underlined by the COVID-19 pandemic which increased demand for safe, high quality alternatives to institutional settings where morbidity and mortality threats from the virus are greatest.”

Organizations serving vulnerable populations — AARP Massachusetts, the Dignity Alliance of Massachusetts and Disability Advocates Advancing our Healthcare Rights — gathered stakeholders statewide recently to look at how this new funding could be directed in Massachusetts and, in particular, expanding and strengthening home and community-based services. Miller was among the speakers to address the group.

The Centers for Medicaid and Medicare Services (CMS) had already allowed states certain flexibilities in meeting the COVID-19 crisis through the option to adopt temporary changes to their Medicaid programs covering home and community-based services. Furthermore, prior legislation had increased the federal matching rate by 6.2 percentage points across Medicaid services for the duration of the Coronavirus emergency. ARPA increased the federal matching rate by an additional 10 percentage points for home and community-based services (HCBS), specifically. The federal government typically pays for half of Massachusetts Medicaid costs. Combined with the early increase, 66.2% of the Commonwealth’s HCBS costs would be paid for by the federal government under ARPA for one year.

“Key stakeholders see the value of the flexibility ARPA provides to address needs across a range of services and populations needing home and community-based support,” says Miller. “There is particular interest in improving the work conditions of direct care workers, including raising wages and benefits to increase their quality of life and improve recruitment and retention. These are issues that directly impact the quality of care delivered.”

In addition, care recipients and advocates view the ARAP legislation as an opportunity to fund the additional services and supports necessary to maintain older adults and younger people with physical disabilities, developmental disabilities, and severe mental illness at home and in the community, not just during the pandemic but beyond.

One key area the legislation does not detail is whether changes considered by states need to be shared, reviewed, or approved in advance by the federal government. The Massachusetts Office of Health and Human Services is waiting for guidance from CMS before finalizing or implementing plans to take advantage of the enhanced federal match. Although the funding period began April 1, 2021, the state would not lose money if plans were not implemented by that date.

 “Developing strategies and processes that best enable states to take advantage of ARPA’s enhanced federal matching funds would give them a leg up should substantial additional resources become available through the American Jobs Plan and other potentially forthcoming federal legislation,” said Miller. Critical to success is consultation with community stakeholders to outline plans on how to expend the additional revenues in the most effective way possible to the greatest benefit of care recipients, their families, and the front-line staff who care for them.”

Nursing Home Reimbursement: A case study

The current financing structure of Pennsylvania nursing homes is not sustainable

Nursing homes play a critical role delivering long-term services and supports (LTSS) to older adults and individuals under the age of 65 with disabilities. Despite this, these facilities face serious threats to their financial viability. A new report documents the increasingly important role nursing homes play in Pennsylvania, the key demand and supply factors affecting nursing home performance, and highlight implications for the financial viability of nursing homes going forward.

Edward Alan Miller

Editor-in-chief Edward A. Miller

Using data from a variety of sources, the researchers demonstrate that the demand for nursing home care is expected to increase, but the reimbursement level from Medicaid — the growing source of payment for nursing home residents — is causing a financial strain on these institutions. The report, “The Case for Funding: What is Happening to Pennsylvania’s Nursing Homes,” was written by researchers with the LeadingAge LTSS Center @ UMass Boston and funded by The Jewish Healthcare Foundation.

Data between 2010 and 2018 indicate that nursing homes are serving lower income individuals with more challenging diagnoses, including more severe cognitive impairment and psychiatric illness, as length of stay and occupancy has declined. Coupled with Medicaid as a payment source for increasing numbers of residents, the researchers expect to see more nursing homes face financial challenges in the coming years.

“The current financing structure supporting nursing home care in Pennsylvania is not sustainable,” says Edward Alan Miller, PhD, one of the report’s authors and Professor of Gerontology at UMass Boston. “Unless the reimbursement rates paid by the Medicaid program are brought more in alignment with the costs of providing high quality care in a safe manner, providers will face increasing challenges caring for Pennsylvania’s most vulnerable residents.”

Data on professional and support staff in nursing homes also indicate a concerning trend:

  • Even as patients are presenting with more challenging diagnoses, overall staff hours among direct care workers have remained relatively unchanged over the last ten years and RN hours have declined slightly.
  • Compensation for direct care workers has remained relatively flat, increasing by only 1.9% per year from 2012 to 2019. When adjusted for the medical consumer price index, real wages have declined an average of .78% annually during the time examined.
  • While certain individual quality metrics have improved — such as declines in the numbers of bed sores — overall aggregated quality scores have not.Marc Cohen, PhD

“The growing gap between what facilities need, as reflected in charges, and the Medicaid reimbursement rate has come at a time when nursing homes are being asked to care for an increasingly complex and frail mix of residents,” says Marc Cohen, PhD, one of the report’s authors and Co-Director of the LeadingAge LTSS Center @ UMass Boston. “The result has been increased cost shifting to individuals and families who must pay for care privately or take on additional caregiving responsibilities. Nursing home services represent a critical component in Pennsylvania’s continuum of care. Our study demonstrates that more needs to be done to support them.”

Journal Special Edition Dedicated to COVID-19 and Older Adults: Lessons From the Pandemic

Edward Alan Miller

Editor-in-chief Edward Alan Miller

The impact of the COVID-19 pandemic on older adults around the world has been nothing short of breathtaking. Like any sudden crisis, it begs a few common questions: What actually happened and how did we respond? What lessons should we take from that experience? And, most importantly, what do we do now?

In a special double-issue of the Journal of Aging and Social Policy, dedicated to the COVID-19 pandemic crisis, leading gerontology researchers tackle those questions from a wide range of perspectives. The issue, Older Adults and COVID-19: Implications for Aging Policy and Practice, offers 28 scholarly articles available online free of charge.

“The COVID-19 pandemic has devastated populations and economies globally but older adults have been particularly hard hit, due both to direct exposure to the virus itself and to the adverse consequences of efforts taken to mitigate its effects,” said Edward Alan Miller, a University of Massachusetts Boston gerontology professor and JASP’s editor-in-chief. Continue reading

Institute Director Len Fishman: Ease Direct-Care Health Workforce Shortage by Improving Jobs

Len Fishman testifies before Legislative committee

Gerontology Institute Director Len Fishman testifies Feb. 5 before the Legislature’s Joint Committee on Elder Affairs

Gerontology Institute Director Len Fishman offered a simple suggestion to state legislators wrestling with the critical shortage of low-paid direct-care health workers: Make the jobs more attractive.

Fishman told the Legislature’s Joint Committee on Elder Services that two things – more money and a legitimate career path to better jobs – were overwhelmingly the most important factors that would attract more workers to the field.

“How can we convince more people to accept and remain in jobs that are physically and emotionally demanding, provide poor benefits, low wages and offer virtually no opportunity for career advancement? When you ask the question honestly, it answers itself,” he told the legislators at a Feb. 5 hearing. Continue reading

Institute Talk: A Conversation With Vince Mor on Alzheimer’s Care and the State of Nursing Homes

Len Fishman and Vince Mor

Len Fishman, left, and Vince Mor

Vincent Mor is a leading academic expert on eldercare issues and a national authority on research related to nursing homes. The Brown University professor has been principal investigator in more than 40 grants funded by the National Institutes of Health that focus on the use of health services and the outcomes experienced by frail and chronically ill persons.

Mor and Susan Mitchell of Hebrew SeniorLife are leading an ambitious new collaborative research incubator for “pragmatic clinical trials” that test and evaluate interventions for Alzheimer’s disease and related dementias. Last month, they received a grant from the National Institute on Aging expected to total $53.4 million to fund that work over the next five years. It was one of the largest federal grants ever awarded for Alzheimer’s care.

Gerontology Institute Director Len Fishman recently spoke with Mor to talk about his new project and discuss the state of the struggling nursing home industry. The following is an edited version of their conversation. Continue reading

Gerontology Institute Research Team Completes Report on Healthy Aging in New Hampshire

Mass. Heatlhy Aging Team

The Healthy Aging team, left to right: Wendy Wang PhD, Bon Kim, Nina Silverstein PhD, Jay Lee PhD, Sae Hwang Han, Shiva Prisad, Frank Porell PhD, Haowei Wang, Beth Dugan PhD. Team members not in photo: Natalie Pitheckoff and Evan Chunga.

A research team from the University of Massachusetts Boston has delivered a comprehensive new report on the health of older people in New Hampshire, along with detailed profiles of 244 communities in their state.

The first-ever New Hampshire Healthy Aging Data Report was prepared by researchers at the McCormack Graduate School’s Gerontology Institute, led by associate professor Beth Dugan. The report, funded by the Tufts Health Plan Foundation, was released April 2 at a legislative breakfast at the New Hampshire statehouse.

“We are all aging,” said Dugan. “Identifying and understanding the gaps in healthy aging will allow communities to continue to adapt, improving quality of life for all New Hampshire residents.” Continue reading

Gerontology PhD Student Shiva Prasad Studies How to Create Ideal LGBT Online Senior Center

By Caitlin Connelly

Imagine an online LGBT senior center. What would that look like and how would it serve visitors?

These are questions on Shiva Prasad’s mind. The third-year gerontology PhD student at UMass Boston recently presented preliminary research findings on the subject at the LGBT Elders in an Ever Changing World conference in Salem, Mass.

Nearly 200 people attended the one-day conference held to discuss the needs and desires of older adults and caregivers who are lesbian, gay, bisexual, or transgender. Organizations helping put on the event included the LGBT Aging Project, North Shore Elder Services and the Over the Rainbow LGBT Coalition, Salem State University School of Social Work, Care Dimensions, and AARP Massachusetts. Continue reading