long-term care - Legislative Reference Bureau

CONCEPT OF A SINGLE ENTRY POINT
and community-based (HCB) long-term care services. In addition, 32 states use the personal
care or case management option to provide at least one type of HCB long-term care; 30
states have opted to use both programs. 34
For 1993, Medicaid expenditures for nursing homes accounted for 62 percent of its
long-term care spending. Intermediate care facilities for the mentally retarded (ICF-MR)
spending accounted for 22 percent. The Home and Community Based waiver accounted for 7
percent, closely followed by 6 percent for personal care services. Home health services
accounted for the remaining 3 percent of Medicaid expenditures. 35 In 1990, the federal
government spent about $4.5 billion for all state Medicaid programs in Region 9 comprising
the four states of Hawaii, California, Arizona, and Nevada. About seven-eighths of this
amount was spent in California. Federal Medicaid expenditures for Hawaii in 1990 amounted
to $121,441,000 while California received $3,869,906,000. 36 Per capita federal expenditures
for Medicaid for the United States in 1990 was $161.94, but only $109.58 for Hawaii.
Corresponding per capita figures for the other three states in Region 9 amounted to: $130.04
for California, $111.40 for Arizona, and $61.24 for Nevada. 37
Almost one-third of the $450 billion spent annually on health care in the United States
goes towards treatment of the elderly aged 65 and older, who represent just 12% of the
population. The elderly represent two-thirds of the 8 million Americans who require long-term
care. Three-fourths of the disabled elderly live at home and rely on family members or other
unpaid caregivers. Some 1.6 million persons or 5% of the over-65 population lived in nursing
homes in 1985 at a cost of more than $35 billion. Half of the elderly who enter homes
eventually wind up on Medicaid. Private insurance covered only 1% of nursing home costs in
1985. 38
However, even though the subject is Medicare expenditures, according to a 1989
article in State Government News: 39
[I]t is not the elderly per se who are the heavy users of health care fmancing. It is
the very sick and terminally ill, many of whom are also very old. In fact, analysis
reveals that a very small percentage of the elderly are responsible for the high
Medicare bills. According to the Health Care Financing Administration, in 1983
.. , 2.3 percent of the 65 and older Medicare beneficiaries accounted for 33.9
percent of program expenditures. Less than 10 percent of the beneficiaries
accounted for more than 72 percent of the costs. A large portion of these
expenditures is laid out for the terminally ill: 28 percent of the Medicare budget -approaching
$25 billion -- is spent on patients who are in the final year of life.
Screening and Functional Eligibility: In addition to financial eligibility, preadmission
screening also involves functional eligibility determination. However, in addition to medical
need, many state programs also look at a person's functional, psychological, and social
status. In many states, one becomes eligible for community care programs only if one is
already nursing home-eligible and, in most cases, the community care costs no more or less
than nursing home care. The aim is to determine if a person can remain in the community
and function successfully with the benefit of formal and informal community support services.
Thus, community care programs -- of which screening is a part -- aim to integrate client
access to both community and institutional care. Preadmission screening determines
eligibility for nursing homes and informs of community alternatives. "Locating these
screening programs in the same local agency that serves as the entry point for community
care services increases the potential that clients will receive advice on a range of possible
alternatives. "40
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