Long-Term Care - Illinois General Assembly

The changes in occupancy seem to be related to medical advances. Services can be provided
in more settings. There are more things for people to choose, and they're choosing them. A lot
of it has to do with market forces — people choosing to have services in other settings, and
some of those settings being more available.
We have also seen a doubling of residential assisted living options in the last decade. Patterns
are not even from state to state, but essentially a doubling of residential and assisted living
options. We see many more Medicaid home and community-based waivers for all populations.
As of last year, 41 states use their Medicaid home and community-based waivers, which covers
care in the home and some services in residential settings.
Medicaid home and community-based waivers started out as an exception, something that was
different, but they are now mainstream. States are using Medicaid home and community-based
waivers for all of their people that have disabilities and frail elderly persons.
Another important element is that there have been some changes in Federal policy recently that
encourage consumer-direction in services. Most recently the federal government has put
together some templates that allow states to do more in consumer-direction.
About 2/3 of the expenses for long-term care are for persons with developmental disabilities.
The developmental disabilities field very early moved to the notion of building up services in the
community, so more of the expenditures are for the developmentally disabled. Those
individuals often have very extensive needs that increase the cost.
It doesn't seem that long-term care services have been disproportionately affected by the states’
budget shortfalls, but many states’ provider rates were frozen for a variety of providers,
including long-term care. Many states put a freeze on waiver-slots that they intended to open.
So there have been some impacts due to budget issues this year. It's going to be another tough
budget season, as states get ready for 2005.
The upside is that we've seen the budget crisis spur increased interest in planning for the future,
with most states restructuring service delivery and financing.
Legislatures everywhere and policy makers are discussing the Olmstead Supreme Court
decision. That decision is not about Medicaid. It was about the Americans with Disabilities Act.
It basically said that medically unjustifiable institutionalization is discrimination. What that
means in practice is playing out in courts all across the country. Most people looking at this
decision see it as something that will be affecting policy making for many years to come. It is
something that is very significant.
States are strategically planning around long-term care. They're also trying to sort out where
the Olmstead decision fits. The Olmstead decision used terms like "reasonable modification,"
and it said that courts can order states to make reasonable modifications in their public
programs to move toward community integration. Courts cannot order states to make
fundamental alterations in their services. Fundamental alterations are part of what legislatures
do.
Some recent decisions center on another phrase in the decision, which is “reasonable pace."
States need to move at a reasonable pace to assure community liberation for persons with
disabilities. Some of the decisions are looking at the cumulative picture of a state's effort to
achieve change, and when a state is making both reasonable modifications and fundamental
alterations, which shows a pattern of a reasonable pace of change.
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