Health Policy Center, independent research for better health policy: The Urban Institute

Long term care—how to provide, pay for, and monitor it—will continue to be a pressing social and policy issue for the foreseeable future.  Comprising mainly less skilled help with ordinary activities like bathing, getting around, and meal preparation, long term care provides supportive services for a vulnerable segment of the population who have functional problems and typically substantial medical needs as well.  Informal care by family and friends is the mainstay of long term care, but spending on formal, paid services continues to rise, financed primarily by out-of-pocket payments and the Medicaid program.  Despite declines in the rate of old age disability in recent years, increasing longevity, the aging of Baby Boomers, and recent trends in obesity and chronic disease among the younger population assure that long term care and associated health care issues will remain high on the policy agenda.

The Affordable Care Act of 2010 contains provisions that are highly significant for disability and the long term care system.  Chief among these is Community Living Assistance Services and Supports (CLASS), a new voluntary employment-based public long term care insurance program intended to provide a private financial base for disability-related services and supports during working years and in old age.  Other important provisions are Medicare demonstrations designed to test new organization and provider payment systems for chronic illness and post-acute care that may be able to contribute to improved functional outcomes, and enhanced incentives for states to expand community-based Medicaid long term care benefits.

Nursing homes continue to be an important part of the long term care system, accounting for 68% of the $72 billion spent on long term care for the aged and disabled by the Medicaid program alone in 2008.  Increasingly, however, nursing homes care for the sickest and most frail, with a growing proportion of both publicly and privately paid long term care provided at home or in community-based residential care settings.  Both CLASS and enhanced Medicaid incentives are intended to support this trend.

The Urban Institute’s long term care and disability research agenda continues to inform policy by addressing pressing issues in disability and long term care, including trends; the implications of delivery system innovations for quality of care and costs; managing public long term care costs in the face of increasing strains on Medicaid programs; private financing options; and understanding how disability and long term care relate to the rest of the health care system and health spending.  Projects conducted by UI researchers alone or with colleagues at other institutions have employed a wide range of qualitative and quantitative methods and data to examine:

o  Trends in disability and implications for future long term care demand and costs;
o  Strategies for promoting continued declines in disability;
o  Lifetime risk of disability and long term care;
o  The relationship between long term care needs and other health care spending;
o  Long term care and other spending for persons dually eligible for Medicaid and Medicare;
o  Transitions between long term care settings;
o  Trends and innovations in long term care settings and formal and informal care;
o  Innovations in Medicaid benefits for long term care recipients;
o  Public and personal financing of long term care, including private insurance strategies;
o  Implications of informal caregiving for caregivers, care recipients, and use of paid services.