Medicaid not meant to shoulder burden of care


By Sondra Shapiro

It’s an age-old problem — how to pay for long-term care.

Just consider these national averages from a 2010 government report: $205 per day or $6,235 per month for a semi-private room in a nursing home; $229 per day or $6,965 per month for a private room in a nursing home; $3,293 per month for care in an assisted living facility (for a one-bedroom unit); $21 per hour for a home health aide; $19 per hour for homemaker services; $67 per day for services in an adult day health care center.

The high cost forces most low and middle class families to turn to Medicaid to pay for care.

Keep in mind that Medicaid funds the care of nearly 70 percent of nursing home residents and 34 percent of home health clients, according to the Massachusetts Senior Care Association (MSCA), which represents the state’s nursing homes.

Since long-term care insurance is too costly for most, not to mention the market is rather unstable, Medicaid is the primary payer. Yet, the state/federal program that funds medical and health-related services for low-income individuals was never meant to shoulder the burden of care. The extent to which families rely on Medicaid to pay for long-term care means the program’s money is being stretched way too thin.

MassHealth payment rates to nursing facilities have been frozen for six years, according to Scott Plumb, senior vice president of MSCA. As a result, each facility is being under-funded at an average rate of $900,000 per year.

“We estimate that those rates now average $37 a day below the cost of care,” Plumb said. “This chronic underfunding cannot be shifted to other payer sources. The results have been sad but predictable; an inability to give wage increases to our dedicated and hard-working employees and an increase in the number of nursing home closures and sales.”

So far this year, four nursing homes in the Bay State have shut their doors. In human terms, that means 318 vulnerable elderly were displaced and 639 workers lost their jobs. MSCA warns that these closings are just the beginning.

sshapiro_headshotInadequate operating dollars also means less money to attract qualified workers, fairly compensate current employees — 70 cents out of every dollar goes toward wages and benefits — or make technological upgrades or structural improvements.

While nursing homes care for the sickest — those needing short-term acute care and dementia sufferers who will never return home — home care provides a sense of independence by offering elderly programs and services that allow them to live in the community. “We view home care as something that everyone is eligible for, with some people getting subsidies,” said Al Norman, the executive director of Mass Home Care. “The reality is someone making a few dollars over the state’s cut off limit may get no care at all. That punishes the middle class.”

Norman explained that income eligibility for the basic home care program in Massachusetts is based on family size and annual gross income (AGI). Very low-income individuals, including those on MassHealth, receive home care services without a co-pay fee. A one-person family with an AGI of $11,509 or less pays a $9 per month co-pay — but it is not mandatory.

In the course of a year, an average caseload of roughly 30,900 individuals is enrolled in the home care program.

The 2013 federal poverty guideline for a one-person family is $11,490. So people below that poverty level are not required to make a co-payment for home care. Individuals with an AGI from $11,510 to $26,168 are charged a mandatory co-payment for their home care services. This co-payment is a flat dollar rate based on income, irrespective of the amount of home care services the individual receives.

State-awarded dollars are not meeting the demand for care. The home care benefit package has been frozen at $8.76 a day since 2009. The home care network has had to wait-list sick elderly — even items such as meals on wheels are chronically underfunded.

Year after year, nursing facilities and home care agencies have fought for a fair share of government support to care for the frail elderly population. In Massachusetts the shortfall of money allotted to providers has compromised care to our loved ones.

Locally and nationally, nursing homes and home care agencies that depend on government funding have been forced to play catch up, all the while falling further and further behind in their ability to provide a full array of services necessary to care for the elderly. Families who don’t qualify for Medicaid, but do not have the money to pay for care, fall through the cracks.

It shouldn’t be this way.

The majority of us will likely require some type of long-term care during our lifetime. We and our parents, grandparents or spouse should be entitled to receive quality care in a safe and nurturing setting. The reliance on Medicaid and the unavailability of other financing options limit a family’s ability to make choices regarding care settings and services.

The dependence on the current Medicaid program is not the answer. Rather federal lawmakers must work toward a solution. Time after time, there have been missed opportunities. Two recent ones come to mind:

A voluntary public long-term care insurance program proposal, the Class Act, was included in early drafts of the Affordable Care Act, but fell victim to political wrangling. Though far from perfect, the idea should have provided a launch pad for further discussion and action.

Then, last year, a 15-member, non-partisan Federal Commission on Long-Term Care was tasked with developing comprehensive funding and implementation proposals that would lead to legislative action. Out of the group’s 28 recommendations, nothing sufficiently addressed the financing of care. This was not surprising since Washington-based commissions are traditionally a waste of time.

Yet this issue demands immediate attention since the national age demographic is ticking up. Here in Massachusetts, the population of those aged 65 and over will increase by over a half a million — expanding from 14 percent of the state’s total population in 2010 to 21 percent by 2030.

Inaction will result in an intolerable long-term care climate for families and the long-term care institutions that serve them. Bottom line: We, as caregivers, and our loved-ones, will ultimately pay the price.

Sondra Shapiro is the executive editor of the Fifty Plus Advocate. Email her at Follow her online at, or www.fiftyplus