long-term care - Legislative Reference Bureau

CONCEPT OF A SINGLE ENTRY POINT
determining whether informal supports combined with formal community services could meet
the individual's long term care needs. "23
First, a potential consumer's financial eligibility is determined. States have not opted
for universal long-term care systems that offer care for all regardless of income. Rather, they
have consistently chosen to address the long-term care needs only of those, in general, with
the greatest financial need: 24
In none of the six states was there a philosophical inclination to provide universal
public support for community based care without regard to a client's income ....
There were no protracted debates over whether services should be provided on an
ability to pay basis; the only question was how to translate this philosophy [that
excludes universal community care] to operational policy.
States have rarely enjoyed the luxury of adequate funding for long-term care,
especially community- and home-based care. During a time of federal cuts, initiatives to
replace entitlement programs with capped block grants, and struggling state economies, it is
hard to imagine extending publicly-funded services to those who can afford them. Aside from
financial constraints, some object on philosophical grounds to the government's role in linking
consumers to services purchased in the private market. However, some states do partly
subsidize sliding-scale fee programs in which private-pay individuals not ordinarily financially
eligible may participate. For example, Justice, et al. (1988) argue for the publicly-supported
use of case management services by private-pay clients. Case management can help family
caregivers sustain their informal care to delay the eventual need of individuals, incomeeligible
or not, for more intensive, publicly-funded care. Such use of case management
services will also avoid a two-class system with two separate entry points. 25
Nonetheless, screening programs,26
[are] part of an organized access point for long term care services ... [and] are a
logical component of state policies designed to curb the growth of Medicaid
institutional expenditures [by avoiding inappropriate placements in nursing homes]
and [by apply[ing] the cost savings to an expanded community care system.
In some states, preadmission screening determines financial eligibility not only for
persons eligible for Medicaid, but also for those estimated .soon to be Medicaid-eligible.
Typically, the "countdown" to Medicaid eligibility is set at 60, 90, or 180 days, thus "90-day
eligibles" and "180-day eligibles." For example, Maryland's target population is screened for
both Medicaid- and 180-day eligibles. Screening in Oregon targets both Medicaid- and 90-day
eligibles. 27
(Note: According to the Select Committee on Aging of the United States House
of Representatives in a 1987 publication, 50 percent of persons aged 75 and
older and living alone would spend down income and assets to federal poverty
guidelines within 13 weeks of entering a nursing home. Within one year, almost
70 percent would be impoverished. For married couples aged 75 and older, 28
percent would reach poverty income levels within 13 weeks and 51 percent
within one year. The vast majority of persons entering a nursing home is over
age 75 and live alone. f28
Table 2-1 outlines how six states screen clients; whether participation is mandatory or
voluntary; and whether findings are binding or advisory only.29
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