To the surprise of absolutely nobody, the Obama administration today walked away from the CLASS — Community Living Assistance Services and Supports — Act, the landmark long-term care insurance program included in the 2010 health reform law. But while CLASS may have disappeared, the challenge of financing the long-term care needs of 20 million Americans over the next few decades has not.

Health and Human Services Secretary Kathleen Sebelius killed CLASS in a letter to Congress today. “I do not see a viable path forward for CLASS implementation at this time,” she wrote.

Congressional critics of CLASS are gleeful. After all, they have their first Obamacare scalp on their belts. But there is a far more important question at stake now: What happens next? Medicaid, which pays for nearly half of all long-term care, is itself under immense financial pressure. And hardly anyone buys private long-term care insurance — only 7 million Americans own policies. As a society, we are simply unprepared for the crushing financial burden of frail old age or disability at younger ages due to accident or illness.

Where do we go from here? Most independent analysts recognize that the model most likely to succeed for long-term care insurance is a system of universal coverage. Every developed nation on the planet — except for the U.S. and the U.K. — has gone this route. And most programs have been extremely successful. But we just had a national debate about universal health insurance as Congress considered the 2010 health law and the returns are in — people don’t want it.

Perhaps there is a way out. Suppose Congress designed a system built on private insurance rather than government coverage? Suppose also that instead of a dreaded mandate, it included a combination of penalties and rewards to encourage people to buy insurance at a relatively young age.

Such a model already exists. Several do, in fact. Think about the Medicare Part D drug benefit, for instance. Insurance is sold by private companies in a regulated, transparent environment. Consumers can compare policies and prices. Premiums are relatively inexpensive for people who buy when they are first eligible. But they are penalized for delaying their purchase since premium prices rise rapidly.

Also imagine a choice of long-term care insurance options, much like Medicare Supplemental (Medigap) insurance. You might buy a lifetime cash benefit of $50-a-day that looks like CLASS would have. Or you could buy a policy that paid $200-a-day for three years. Or one with a $100,000 deductible and a lower premium.

There are many options. But advocates, long-term care providers and insurance companies must sit down and work out a consensus plan. Advocates have to understand they are not going to get the government plan they wanted. Insurance companies must recognize their business is dead in the water and desperately needs a jump-start. And providers such as nursing homes, assisted living facilities and home health agencies must find a steady source of revenue as Medicaid begins to shrink.

I know that consensus is out of fashion in Washington. But if people who care about long-term care issues — and we all should — don’t act quickly, this issue will end up back in the closet. And that will be a personal and financial disaster for tens of millions of Americans and their families.

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Since the 1990s, nearly every developed country on the planet has reformed the way it finances long-term care for the frail elderly and adults with disabilities. Among the handful of exceptions: The U.S. and the United Kingdom.

In 2010, Congress took a small step in the direction of reform when it passed the Community Living Assistance Services and Supports Act, a voluntary public insurance program that would provide a modest daily benefit for life. But even before the first policy is ever issued, a bipartisan group of senators has targeted it for repeal as part of a broad-based deficit reduction plan that has already won the support of President Obama.

While CLASS would represent a lost opportunity, the program’s vulnerability highlights the challenges the U.S. faces as it tries to find a way to finance long-term care for its aging population, as well as younger people with disabilities.
Currently, the U.S. model is built on the means-tested Medicaid program, which pays for more than 40 percent of all long-term care costs and is itself under tremendous financial pressure. Only about 7 million Americans own private long-term care insurance, which is costly and unattractive to many. CLASS would take a small step toward a public insurance-based system where people would be responsible for financing a share of their own care. But because CLASS is both voluntary and open to nearly all who want to buy, regardless of their medical status, its premiums may be unaffordable for many and the program may not be sustainable.

The problem is that while Congress seems on its way to both dumping CLASS and further shredding the already-tattered Medicaid safety net, it has no ideas for an alternative. Meanwhile the U.S. struggles with the fate of CLASS, a high-profile government commission in the U.K. laid out a reform plan July 4 to address its long-term care needs. And this blueprint heads in a very different direction.

The panel, chaired by economist Andrew Dilnot, ripped Britain’s existing Medicaid-like system as “confusing, unfair, and unsustainable.” Echoing the sentiments of studies over the past 13 years, the Report of the Commission on the Funding of Care said the means-tested system is “not fit for purpose” and needs “urgent and lasting reform.”

As an alternative, it proposed a new universal social insurance plan. This one, though, would provide only catastrophic benefits for many middle-class and wealthy seniors. Those with limited assets would continue to receive Medicaid-like assistance while everyone else would be expected to pay about the first $55,000 in personal care costs. In addition, those living in nursing homes would be responsible for their room and board, on the theory that they’d have these expenses wherever they lived. This approach, by the way, is a common feature in most European systems and the panel estimated it would increase the cost to seniors by about $15,000 a year.

While British middle-class and wealthy seniors would receive only catastrophic assistance, the number of people eligible for unlimited public long-term care support would increase. Currently, the eligibility cutoff for such benefits is about $37,000 in personal assets. In the new proposal, public support would be available to seniors with assets of as much as $160,000 — including, importantly, their home. Young people with disabilities would be eligible for first-dollar benefits, no matter what their wealth.

The panel estimated the new system would increase government spending by about $2.5 billion, or about 0.25 percent of current outlays. In the U.S. budget, that would be equal to about $80 billion.

While the Dilnot panel said very little about how those needing care would finance their share, I could imagine them using home equity, annuities or private long-term care insurance. Although such an insurance product barely exists in the U.K., it should be relatively inexpensive to purchase a basic $55,000 policy that would cover would cover about nine months of nursing home care.

The Dilnot plan is in stark contrast to the CLASS Act. Instead of full coverage after a big deductible, CLASS would provide modest first-dollar insurance (probably about $50 to $75 a day) for life. Such a “long-and-skinny” benefit is also very different from a typical private long-term care insurance policy, which normally includes a 90-day deductible and has a more generous daily benefit for three to five years.

Could such a catastrophic plan work in the U.S.? Several researchers, including Christine Bishop at Brandeis University, Anne Tumlinson at Avalere Health, and Bill Galston at the Brookings Institution, have proposed similar ideas. But they’ve never gotten much traction.

Dilnot’s plan would protect those who most need financial support — the poor and those with true catastrophic costs, such as people with dementia. But by requiring those who can finance some of their own care to do so, it could hold down public costs, making the plan both fiscally and politically more acceptable. As universal insurance, it would avoid all of the problems that go with a voluntary program such as CLASS.

The plan’s biggest downside is probably the opportunity for people to game the system by shifting assets so they can claim those generous public benefits. And its failure to recommend a specific source of funding is a huge omission.

I don’t understand enough about British politics to know if this idea has a chance, although the government response has so far been noticeably cool. Still, advocates seem to like it, and given the jeopardy CLASS is in on this side of the pond, some form of a catastrophic insurance system might be worth a look.

Congress can repeal CLASS but it can’t slow the aging of America and the growing need to provide personal care for the frail elderly or others with disabilities. Much as it might try, it cannot walk away from the problems of long-term care by trashing the only options available to many Americans.

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As the federal and state governments struggle to address their severe budget shortfalls, the assistance these women and millions like them need for long-term care services will certainly be cut. But by how much? And how will our society deliver care to those who desperately need it but cannot afford it?

Families, already the backbone of the care system, will take on greater burdens. But many frail elderly people have no children and their spouses are unable to care for them. As government’s role shrinks, community groups and nonprofits will have to take on more responsibility as well. But some care requires skills beyond the ability of relatives and neighbors. How will it be funded in an era of budget constraints?

While Medicaid was created mostly to provide medical care to low-income moms and their kids, two out of every three Medicaid dollars is spent on the elderly and disabled. Last year, the program spent one-third of its budget — more than $100 billion federal dollars — on long-term care, either in nursing facilities or in the community. States, which share the program’s cost, spent tens of billions more.

Overall, Medicaid pays more than 40 percent of all long-term care costs. The advocacy group FamiliesUSA estimates that more than 6 million seniors and nearly 10 million younger people with disabilities rely on the program for assistance.

I knew Natalie and Lisa. I told their stories in my book on long-term care, Caring for Our Parents. Like many Medicaid long-term care beneficiaries, both were once solidly middle class. But the cost of the medical and personal care they required ruined them financially. Over a decade, Natalie spent nearly all of her assets — more than $500,000 — on meeting these needs. A year before she died, she ended up on Medicaid. While critics often claim wealthy people exploit the system by giving away assets so they can enroll in Medicaid, there is no evidence that this is a widespread problem.

Now both Medicaid and many non-Medicaid programs for the frail elderly are in the fiscal cross-hairs. The House-passed 2012 budget would cut the projected federal share of Medicaid by nearly $800 billion over the next decade — mostly by turning the program into a block grant. In April, President Barack Obama suggested cutting planned Medicaid spending by $100 billion. And lawmakers of both parties are considering a blanket cap on all federal spending — a scheme that also would lead to deep reductions in elder and disability care under Medicaid.

More immediately, cash-strapped states are urging Congress to give them new flexibility in how they manage the program. Currently, federal “maintenance of effort” rules curb a state’s ability to limit enrollment. House Republicans would eliminate those restrictions, a move supported by at least 28 governors.

Individual states would respond to this new flexibility in different ways, but many frail seniors will have less access to Medicaid. In addition, states are likely to cut benefits themselves, especially for home and community programs — the services most popular among the elderly and disabled. For instance, states may cut the number of hours a home health aide may assist a Medicaid beneficiary. Already, even blue state governors such as Andrew Cuomo of New York and Jerry Brown of California have proposed deep reductions in programs such as adult day care, which are optional under current Medicaid rules.

At the same time, a wide range of non-Medicaid government programs for seniors such as transportation, home delivered meals programs (such as Meals on Wheels), information services and subsidized housing also face an uncertain future. Last month, Congress froze or cut spending for all those programs for the remainder of 2011. With House Speaker John Boehner, R-Ohio, demanding $2 trillion in additional spending reductions, even deeper cuts are on the horizon. And they will create an enormous gap in long-term care.

In the face of a shrinking government role, community efforts such as senior villages and elder care programs based in churches, synagogues, and mosques need to step up. But who will pay for those services that require care workers, or for nursing facilities?

And that leaves me with one more question. Many lawmakers who would cut Medicaid would also repeal the CLASS Act that would create a national, voluntary long-term care insurance system. If they oppose direct government spending for personal care, and oppose a transition to an insurance-based system, I wonder how they propose to assist those elderly and disabled who do not have the means to care for themselves.

Howard Gleckman is a resident fellow at The Urban Institute and author of Caring for Our Parents.

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But congressional critics want to kill CLASS long before the first policy is ever sold. Rep. Phil Gingery, R-Ga., who has sponsored legislation to repeal the program, calls it “a Bernie Madoff-fraudulent investment scheme run by the Secretary of Health and Human Services.” And the House GOP leadership’s 2012 budget proposal, released on April 5, would eliminate CLASS, along with much of the rest of the 2010 health law.

Overheated rhetoric aside, critics have two substantive聽objections to this obscure health law measure. They are offended that, under the conventions of budget accounting, CLASS premiums are counted as revenues that help “pay for” health reform. And they fear that if the program fails as self-funded insurance, it eventually will be bailed out with general tax revenues.

Their concerns are important, and there is no doubt the program needs to be significantly revised if it is to have any chance of success. But without CLASS, or something like it, millions of disabled adults, frail seniors and their families will be left with only Medicaid’s tattered safety net to support their personal care needs.

That’s why CLASS should be revamped, not repealed.

If CLASS is murdered in its crib, many families will have no resources to pay for long-term care services. Fewer than half of us will have sufficient savings. Most retirement nest eggs will fall far short of what we’ll need for nursing home care that costs more than $200 a day or home health aides who cost $20 per hour. Even fewer of us — about 7 million Americans — have private long-term care insurance.

As a result, many of the 10 million Americans who need long-term care will go broke paying out of pocket and then turn to Medicaid, a woefully underfunded entitlement program that pays for nearly half of all long-term services. This joint federal-state program spends one-third of its funds — more than $110 billion annually — on both home-based and nursing facility personal care.

But Medicaid is busting both the federal and state budgets, and many states are slashing already skimpy benefits.

CLASS could be an alternative. It would provide an average minimum benefit of $50 per day for life — in cash. This feature would let families decide how to structure care, a vast improvement over Medicaid that too often forces the frail elderly into nursing homes.

Unfortunately, as designed, CLASS will be unaffordable for the vast majority of potential buyers, with average monthly premiums well in excess of $100. HHS Secretary Kathleen Sebelius vows to fix the program’s many flaws. And while the repairs she has suggested don’t go nearly far enough, she is on the right track.

Here are a few ways to make CLASS more attractive to buyers:

— Narrow the focus. Today, CLASS attempts to achieve two goals at once. It tries to provide a personal care benefit for working people with disabilities and, at the same time, sell insurance to healthy people looking to hedge against the risk of needing assistance sometime in the future. The result: those who buy insurance will end up subsidizing those with disabilities. That will drive up premiums and discourage healthy people from participating. CLASS needs to be an insurance program only. Congress should make personal assistance benefits available to working people with disabilities — but not through CLASS.

— Second, encourage employers to include this insurance in their employee benefit plans. CLASS will succeed only with robust enrollment, but people must be nudged to participate. That will only happen if employers offer policies to their workers.

— Third, start premiums low, but gradually increase them as people age. This structure will make policies far more attractive to younger buyers.

— Finally, Congress should create an independent insurance fund to collect and invest CLASS premiums. This would assure participants that they are buying real insurance and not just exchanging their premium dollars for government IOUs.

Someday, perhaps, the U.S. will join nearly every other major developed nation in the world and create a universal long-term care insurance system funded by some mix of taxes and premiums. Coverage could be provided by private insurers — just as the Medicare Part D drug benefit is today — or it could be run by the government. Monthly premiums for a universal CLASS-like program could average as little as $40. And such a program could cut Medicaid long-term care costs in half — by as much as $60 billion.

Given our current anti-government, anti-tax climate, Congress won’t pass a universal long-term care insurance program any time soon. But as 77 million baby boomers age, the nation’s care needs will only grow. Two out of three seniors and many younger people with disabilities will need some personal assistance before they die. They won’t be able to count on a crumbling Medicaid program, and they have not saved. Insuring against this risk makes perfect sense. And CLASS, for all its flaws, is a step in that direction. It deserves a chance.

Howard Gleckman is a resident fellow at The Urban Institute and author of Caring for Our Parents. 聽

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And this squeeze may only be just beginning. Faced with an historic deficit, the federal government could opt to reduce its future Medicaid payments, forcing states to choose between cuts in acute care for young families or long-term care. This tenuous future is why the U.S. must begin to consider broad-based insurance to finance long-term care.

The Medicaid long-term care benefit is a critical safety net for the frail elderly and others with disabilities. Many recipients are once middle-class people who went broke paying for their own medical and personal care. Now, without financial resources, they must turn to Medicaid.

For those who cannot afford the nearly $80,000-a-year price tag for nursing facility care or the $20 an hour tab for home health aides, Medicaid is often the only option. Currently Medicaid spends more than $100 billion, or one-third of its total budget, on long-term care services. It is by far the biggest payer of long-term nursing facility and home health services. By contrast, private long-term care insurance pays less than 10 percent of these expenses. Medicare only pays for nursing care for a limited period after a patient has been discharged from the hospital.

But the Medicaid safety net is fraying. Facing their own massive budget shortfalls, states have already begun trimming benefits, many occurring in Medicaid’s home and community based programs. That’s because states are required to provide assistance in a nursing facility, but not at home. Thus, states cut where they can, even though beneficiaries prefer home care and some research suggests the states themselves can save money by helping Medicaid long-term care recipients stay in the community.

Until now, those benefit cuts have been relatively modest. The Kaiser Family Foundation estimates that 18 states reduced long-term care benefits in 2010 and another 10 plan to do so this year while more than 30 expanded their programs. The main reason: The huge 2009 economic stimulus included $87 billion in additional federal Medicaid payments to states through December 2010. In August, Congress reluctantly added another $16 billion and extended the additional payments through June 2011. (KHN is a program of the foundation.)

But that money is about to dry up. With Republicans winning control of the House and picking up seats in the Senate, and with worries about the federal deficit growing, there is little chance Congress will provide any additional Medicaid dollars.

The long-run future is even dicier. To start, the new health law will add an estimated 16 million more acute care patients to the Medicaid rolls starting in 2014. Congress promised to pick up most of the cost of those added beneficiaries, though the federal payment will slowly decline. If states pay more for those acute care patients, the extra dollars must come from somewhere. And one possibility is Medicaid funding for long-term care.

The real risk to states, however, is that Washington will fail to keep its commitment. Given the growing fiscal crunch, I’d worry about that promise if I were a governor.

Some conservative lawmakers in Texas and elsewhere have floated the idea of pulling out of Medicaid entirely. But since a state can’t withdraw from only part of Medicaid, this decision would leave long-term care beneficiaries with no safety net at all.

While states can’t change the rules, Congress can. Already, influential deficit hawks are suggesting how that might happen.

For instance, the co-chairs of President Obama’s , former Clinton Administration chief of staff Erskine Bowles and former Sen. Alan Simpson, R-Wyo., have proposed capping the federal share of Medicaid long-term care costs — a step that could reduce federal payments by nearly $90 billion over 10 years.

A second deficit commission would go much further. The privately-funded Bipartisan Policy Center’s panel suggested major changes in Medicaid long-term care assistance. The most far-reaching suggests states and Congress fundamentally renegotiate their Medicaid responsibilities. For instance, one level of government could take full responsibility for all long-term care while the other handles al acute care.

These proposals won’t become law any time soon. But they are evidence that Medicaid could be on the fiscal chopping block. In that environment, it makes sense to get the program out of the long-term care business. And a way to do that would be to replace it with a broad-based insurance system. The Community Living Assistance Services and Support Act, which was created by the health overhaul, will create a voluntary national long-term care insurance program. Program participants would begin contributing in 2012, but wouldn’t b eligible for benefits for at least five years. But there are real doubts about whether CLASS insurance will attract enough middle-class buyers to reduce the burden on Medicaid. If it can’t, Congress should begin to think about what insurance design can, and do so before the Medicaid safety net for long-term care is in tatters.

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CLASS takes a step towards moving long-term care financing from the welfare-like Medicaid program to an insurance-based system. But CLASS alone won’t get the nation there. Private insurance, currently a niche product that covers only about seven million Americans, will have to play an important role as well.

A key question remains: Will private coverage fill the gaps left by CLASS? Top industry executives are deeply divided over how to respond to the new law. Some are anxious to design products that would supplement CLASS insurance, much like Medigap insurance currently enhances basic Medicare. But others see little benefit in selling such products, and suggest they may try to compete with CLASS. This could doom the new government program. And it could leave the industry stuck with the same limited market it has today.

While many details of CLASS insurance won’t be worked out for at least two years, daily benefits will be relatively modest-probably about $50 or $75. That’s very valuable for the many elderly and disabled who live at home. But for those worried about having to move to a nursing home, which costs an average of more than $200 a day, CLASS insurance will fall far short of their needs.

That’s where private insurance fits in. Today, buyers of commercial policies typically purchase a daily benefit of more than $100. That suggests many consumers may want to top off the government’s modest daily benefit with private coverage. This, in fact, is what has happened in France. There, government benefits are very modest for middle- and upper-income individuals. So about 25 percent of those 60 and older have purchased extra private coverage-far more than the seven percent who currently own long-term care insurance in the U.S.

But CLASS coverage may not be easy for private companies to complement. For instance, while the daily benefit is modest, CLASS coverage is available for life. Private companies effectively dropped lifetime benefits years ago, and are unlikely to return to them.

Private companies also worry about how people would qualify for benefits. Under CLASS, it takes only the approval of a patient’s own doctor, who is likely to approve most claims. And private companies fear it will be impossible to deny payments for somebody who is already receiving CLASS benefits. As a result, they may be reluctant to sell policies to complement government policies.

But the biggest industry worry is price. It will be a few years before anyone knows how much CLASS premiums will be, but they may very likely exceed an average of $100 a month (younger people will pay lower premiums and older people will pay more). A new study by the SCAN Foundation and the consulting firm Avalere Health figures that a CLASS-like policy will cost the average buyer about $115 monthly. (SCAN funding supports some KHN coverage of aging.)

Insurers worry that once consumers buy the government plan, they’ll have little money left to pay for a supplemental private policy. That was a big reason why much of the industry opposed CLASS in the first place.

Now, some companies think those potentially high CLASS premiums may give them an opening to compete with government insurance. Here’s why: Private carriers can keep their premiums relatively low by refusing to sell to people with pre-existing health issues. But CLASS will be available to everyone who holds at least a part-time job and thus will cover many high-risk buyers. That threatens to drive up CLASS premiums which, in turn, may push more buyers to cheaper private insurance. By cherry-picking the healthiest buyers, private companies could kill CLASS.

Why wouldn’t they? Because CLASS offers one huge potential benefit to private companies: It opens the door to a large government-funded marketing campaign that promotes the need for long-term care insurance. The industry has never been able to make that case on its own but, with federal promotional dollars, long-term care insurance could become a more widespread product, and that would be good for everyone.

So maybe there is a deal to be struck: As long as private companies agree to sell CLASS supplemental policies, government agrees to promote the need for long-term care insurance, whether government or private. Now that would be a public/private partnership worth watching.

Howard Gleckman is a resident fellow at the Urban Institute, author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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But Americans do have a way to fund this care: their home. Last year, we had more than $7 trillion in real estate equity, even after the crash. In 2007, nearly two-thirds of American families headed by people 62 or older owned a home free and clear But 20 percent were “cash-poor,” according to the MetLife Mature Market Institute, and could have used that equity to improve the quality of their lives.

Trouble is, two-thirds of retirees have no intention of using their homes to fund their old age. Some want to leave houses to their kids. Others don’t understand how they can tap their home equity, and others misunderstand the rules about home ownership and Medicaid.

So here’s a possible solution. What if your state, in effect, helped you turn unused home equity into cash to pay for the care you need when you become old and frail? To sweeten the deal, what if the state let you have easier access to Medicaid to supplement your own long-term care contributions?

You could use the money to make your home wheelchair accessible, or pay for a special van, or even for adult day care or that home health aide. You’d have far more flexibility than with regular Medicaid. In return for this upfront cash, your heirs would repay the state with modest interest after you die, usually by selling your house. The state wins by saving the cost of caring for you in a nursing home. You win by easily accessing the equity that could allow you to stay at home.

This program would look a lot like a reverse mortgage. With those, if you are at least 62, you can take out a loan against the equity in your home. You get either a lump sum in cash, access to a line of credit, or a regular check each month. When you move or die, you or your heirs sell the house and repay the loan plus interest.

But reverse mortgages have been a bust. In 2007, fewer than 1 percent of eligible homeowners had one. People have trouble understanding them. And they are weighed down by high fees (there is a servicing fee, an origination fee, mortgage insurance premiums, closing costs, and, of course, the interest). At the same time, a troubling number of users are relatively young borrowers who are tapping reverse mortgages to pay off credit cards or fund vacations. The perverse result: They will have even less home equity available when they really need it to pay for long-term care.

Normally, I’m no fan of the government’s doing what the market could do. Unfortunately, like long-term care insurance, private reverse mortgages are failing. A quasi-government agency might allow consumers to tap unused home equity more easily and cheaply.

In truth, states can already recover some Medicaid benefits by putting liens on the homes of Medicaid enrollees after they (and their spouses) die. But this practice is poorly understood and applied inconsistently at best. As a result, this scheme usually produces more angry families than revenue to the state.

A government reverse mortgage program would accomplish the same thing, but in a much more transparent and attractive way. States could even encourage seniors to participate in such a program by allowing them to supplement their home equity with Medicaid. Several states already operate the Partnership Program that links long-term care insurance with Medicaid. They could do the same with home equity and Medicaid.

The United Kingdom is experimenting in three localities with a somewhat different way of tying that nation’s Medicaid-like long-term care system with home “equity release.” But the idea is the same: reducing the financial burden on government-funded long-term care while giving people greater control over these services by encouraging them to use some home equity to pay for this assistance.

A few analysts are beginning to think about this in the U.S., but the idea remains half-formed. There is a lot to work out with such an arrangement, but given the poor alternatives, it may be worth thinking about.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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It is not clear why it’s happening, but some hospice officials blame both a bad economy and Medicare rules that unintentionally discourage doctors from referring all but those who are about to die.

Even though hospices have been operating in the U.S. for three decades, they remain widely misunderstood. Hospices provide medical care, pain management, spiritual and social care and volunteer support for those nearing the end of their lives. And their patients often live longer than if they were still receiving full-blown medical treatment.

Nearly all hospice care is paid by Medicare, but unlike most providers, hospices are paid a fixed daily rate (on average about $140-a-day for home care patients). If a hospice provides care for less, it keeps the difference. If a patient requires very costly care, the hospice can lose money. The number of patients served by hospices increased from about 1 million in 2004 to nearly 1.5 million in 2008, while the number of hospices grew from 3,600 to almost 5,000. Most of this explosive growth has been driven by for-profit companies.

But in recent months, hospice officials have seen a downturn. In some states, such as Oklahoma, heavy competition has forced consolidation, and at least 10 hospices have closed in the past year.

Elsewhere, hospice officials blame the bad economy. Patients who have lost jobs–and insurance-may be waiting longer to visit the doctor and consequently are diagnosed with terminal illnesses at a very late stage.

Some hospice executives say the poor economy may also be driving doctors to hold on to patients longer. Here’s why: Once a patient joins hospice, she’s likely to see her physician far less often. Her doctor can usually order tests and treatments only to keep her comfortable, and not to try to cure her terminal disease. And while it may still be appropriate for, say, cancer patients to receive costly drugs or even radiation therapy to relieve pain, hospices must pay for these treatments out of their daily Medicare rate. That inevitably can create tension between the hospice and the physician.

And it may add up to less money for doctors at a time when they are already feeling squeezed. One physician I spoke to strongly rejected this argument, insisting that declining compensation does not slow referrals. But another-an oncologist who frequently refers to hospice-acknowledged the problem. “There is a financial deterrent,” she says.

At the same time, new Medicare rules may be further discouraging physician referrals. Medicare has begun cracking down on a handful of hospices that are making big profits by taking on chronically ill, but not terminally ill, patients. While hospice patients are normally expected to have six months or less to live, some hospices have many on their rolls for a year or more. In one attempt to stop this practice, Medicare now requires doctors to write a brief narrative describing why a patient is appropriate for hospice. Trouble is, says one hospice official, “We’re getting a lot of pushback” from doctors.

In 2008, more than one-third of patients were enrolled in hospice for a week or less, and some organizations are seeing the number of short stays increase, perhaps because these requirements may be making already reluctant doctors even less willing to refer to hospice until their patients are actively dying.

Mark Murray, president of the Center for Hospice and Palliative Care in South Bend, Ind., says that in the past year, eight percent of his referrals died before they could even be admitted, and 20 percent died within 48 hours. Those last-minute decisions put enormous financial pressure on hospices and make it impossible for patients to get the full benefit of end-of-life care.

These disincentives come on top of a long-standing reluctance on the part of many doctors to even talk about hospice. In a 2009 study, more than half of patients with stage IV lung cancer said their physicians never even raised the option.

I am a huge fan of hospice: My wife is a hospice chaplain and both my father and father-in-law were hospice patients. These organizations are a model for coordinated care that other health care providers would do well to copy. But doctors need to be persuaded to use hospice. And that may mean changing a payment system that may be discouraging them from using this valuable service.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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This story was produced in collaboration with our partner

In Washington D.C., Councilwoman Mary Che visits Palisades Village, an aging-in-place community where neighbors help neighbors with basic services so that seniors can stay in their homes longer. (Evy Mages for The Washington Post)

Nearly three years ago, Harry Rosenberg and his wife, Barbara Filner, met with nine of their neighbors about starting an aging-in-place “village” in the Burning Tree community of Bethesda, Maryland. The idea: If neighbors could help one another with basic services such as transportation and simple home maintenance and with friendly visits, people could stay in their homes longer as they aged. It took 19 months of planning and organizing, but accepted its first request for assistance in November of 2008: helping an 81-year-old widow take out her trash and driving her to the doctor.

The group is still suffering growing pains. It receives only a handful of requests for help. Like some similar organizations, it charges no dues and it has about 65 “friends”: people who volunteer, people who receive help, people who just want to be associated. It operates on a shoestring $4,000 budget raised from donations, but it has held a series of well-attended community events, including neighborhood walks and restaurant outings. “We are,” says Rosenberg, 73, “a viable presence in the neighborhood.”

The Washington D.C. area has become a hotbed for these villages. There are six in the city itself,聽 at least two in the Virginia suburbs聽and eight in various stages of development in the Maryland suburbs. “The idea has spread like wildfire,” says Naomi Kaminsky, president of one, .听

Still, organizing a village is difficult, say those who try. It can easily take two to three years before a new aging-in-place community can roll out services. And many groups are still struggling after five years. Fundraising, squabbles over priorities, legal and insurance issues, and the challenges of building a network of volunteers all make the process lengthy and difficult.

“It is a lot of work,” says Nancy Intermill, executive director of Midtown Village in Lincoln, Neb. “You need a group of people committed to the concept, and committed to working together.”

Most villages aim to recruit at least 200 members, often 60 or older. The process generally starts with a neighborhood survey, followed by visits to promote it at local schools, houses of worship and community associations. Finally, neighbors are approached one at a time or in small groups. Flyers or e-mail won’t do it, organizers say.

“No one has ever joined unless they were asked by a human being,” says Andrew Mollison, 70, president of the 65-member in Northwest Washington. Still, he adds, when encouraged to join, many elderly neighbors are likely to respond, “I’m not ready yet.”

Nonetheless, village organizers say, people seem instinctively attracted to the idea of neighbors helping neighbors stay at home as they age. Today, there are at least 48 fully functioning villages around the country and more than 600 in development, says Candace Baldwin, senior policy adviser at ,聽a nonprofit that has created an informal association of these groups called the .听

‘No Rule Book’

There may be as many variations on the village theme as there are communities. Each village attempts to meet the needs of its community in its own way. Some are intergenerational, while others are for seniors only. Some charge hundreds of dollars in annual dues and have paid staff; others assess members little or nothing. Some arrange exclusive deals with a single agency to provide home health aides or companions, while others provide lists of member-recommended firms. Some rely on informal volunteering, while others keep records so that members receive free services in exchange for giving their own time. “The nice thing about villages is there is no rule book,” says Mollison.

However, villages seem to be evolving around three basic designs. The first was pioneered by in Princeton, N.J.,聽in 1992. Today, it has more than 450 members who belong to one of six “houses.” Annual dues are $30 for a couple. Much of what it does is social: There is a bird-watching club and even a theater group. Nearly all of its services, such as rides to the doctor or the store, are provided by volunteers. For those who need more assistance, the group has arranged for a local nonprofit to coordinate care and provide access to a 24-hour-a-day emergency hotline. For this higher level of assistance, singles pay $300 annually and couples pay $350, plus fees for any services they require, such as a home health aide.

The second model is based on Boston’s ,聽which also started in the 1990s. Beacon Hill charges annual dues and delivers both volunteer and paid help. In Washington, , which has about 200 members, is probably the best example of this model. Capitol Hill began providing services about two years ago and has about 200 members who generally pay annual dues of $530 for individuals and $800 for households; about 30 low-income members pay less.

A third model, championed by a nonprofit called ,聽is built on the model of time banking, or service exchange. The idea: You agree to pick up groceries for a neighbor and, in return, another volunteer fixes your leaky faucet. Begun in 1993 and based in Anne Arundel County, Maryland, Partners in Care has 2,600 volunteers around the state.

Volunteers Are Key

Many experts believe the Beacon Hill/Capitol Hill model will be the most lasting because a professional staff buttresses the efforts of volunteers. Capitol Hill has an executive director and full-time social worker and offers a concierge service that arranges for paid assistance from preselected vendors. Yet it relies on social events and volunteers to thrive. In one recent month, nearly 90 percent of more than 200 requests for help were filled by volunteers. Most were for rides or for help changing a light bulb or hooking up a TV.

Palisades Village is copying much of that design. The village, which began with a small group of neighbors in early 2006, hired a part-time executive director in 2008 and offered its first services to 31 members in January of 2009. “We wanted to hire her full time,” says Mollison, “but we didn’t have enough money.” Mollison figures he puts in 25 hours a week as unpaid president.

The village raised about $60,000 last year from dues, gifts and start-up grants from the city and local foundations. Dues are similar to Capitol Hill’s, and to help reach its goal of about 200 members, the group has expanded to include a聽nearby聽neighborhood. Mollison believes a key to sustainable financing is attracting younger residents who can join at reduced dues or simply volunteer.

Chevy Chase at Home also favors the dues-and-staff route but is still in the early stages of development. Kaminsky, who says she is in her early 70s, says her group is not yet ready to recruit members or think about a budget. For now, they are working to raise their profile with twice-a-month informal gatherings. “An active social component is very important,” says Ken Hartman, a county employee who advises the villages.

In contrast to Palisades and Chevy Chase, Burning Tree Village has chosen an all-volunteer, dues-free model. “Philosophically, it feels right to not charge neighbors for this,” Rosenberg says. But he worries about the group’s sustainability as its founders age: “If they move or die, what is viable one day may disappear the next.”

But Rosenberg has already learned the value of his effort. A year ago, as his wife was dying of cancer, people he had not known just months before were offering help. “Barbara and I were getting neighborly support we would never have gotten,” he remembers. By that measure, Burning Tree Village is already a success.

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Government assistance for those who suffer from chronic illness is both terribly underfunded and deeply disorganized. There are programs run by Medicaid and Medicare and the federal Administration on Aging. There are programs run by states and similar projects run out of Washington. This is a particular nightmare for those with disabilities who are struggling to stay at home. If you don’t believe me, try to find a local phone number for elder care assistance.

I live in Montgomery County, Md., and a quick look at my phone book shows 18 different numbers for various senior services. If I need help that is not provided though the county, I need to call the state, which requires yet another frustrating search. Over the years, offices on aging and disabilities have tried to create one-stop shopping to make it easier to find help. And Maryland has a pretty good Web site that tries to pull together all these resources in one place. But the various programs go on for screen after screen. Imagine trying to navigate this if you are 75 years old and caring for a spouse with dementia.

The respite care program Obama wants to expand is typical of the problem.听 Respite care is temporary assistance for families who are helping the frail elderly or those with disabilities live at home. It may be a home health aide who visits for a few hours so a spouse can get a break. Or it may be an adult day program or transportation aimed at helping the person receiving care get out of the house.听

The Lifespan Respite Care Act was passed by Congress in 2006. And its laudable goal was to encourage states to coordinate services aimed at giving family members a temporary break from their often stressful responsibilities. For instance, states could use the funds to make more information available to caregivers about respite services or to train care workers.听聽

But the new law ran into two problems: Individual state agencies trying to protect their turf-and no money. For instance, the original law allowed up to $71 million for the program this year. But in its most recent budget, Congress agreed to make only $2.5 million available to states. The president now says he wants to increase this to about $50 million next year. At a time when the $1.4 trillion federal deficit is putting enormous pressure on spending programs like this, I’m willing to bet he’ll never get it all. And even if he does, he’d still only be spending a bit more than half of the $91 million the original law allowed.

For some sense of how little this is, think about it this way: By the administration’s own count, there are 38 million caregivers in the U.S. (others estimate there are many more). Even if Congress gave Obama the full $50 million, that works out to $1.31 per family. Of course, that’s a lot better than the six cents being spent today.

Worse, cash-strapped states are slashing their subsidies for the very adult day programs Lifespan is trying to promote. In a states such as California, for example, a federal program to promote these services won’t help much if the programs themselves are shuttered-an idea now being debated in Sacramento. And no small federal grant program will save them.听

In today’s awful budget environment, financial pressure on government services for the elderly and others with disabilities will only get worse. The president has already proposed freezing overall spending for social programs exactly like Lifespan for the next three years. If more is spent on Lifespan, don’t be surprised to see funds cut for other badly needed assistance aimed at exactly the frail elderly and younger adults with disabilities.

At the same time, Medicaid-the primary long-term care support program for the sickest and poorest among us-faces its own budget crisis, both in Washington and in the states that pay about half its costs.

The best solution is to free families from the whims of politicians and the inevitable battles over government dollars. National long-term care insurance, such as the proposed CLASS Act, would help in two ways. First, it would give people cash benefits they could use however they want. They would not need to rely on underfunded and possibly inaccessible government programs. If a wife wanted to enroll her husband in an adult day program, she could just do it. Second, because millions of consumers would, for the first time, have the financial resources to pay for these services on their own, new private services would spring up that might do a better job than today’s diffuse and underfunded government programs. It is at least worth a try.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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To the surprise of absolutely nobody, the Obama administration today walked away from the CLASS — Community Living Assistance Services and Supports — Act, the landmark long-term care insurance program included in the 2010 health reform law. But while CLASS may have disappeared, the challenge of financing the long-term care needs of 20 million Americans over the next few decades has not.

Health and Human Services Secretary Kathleen Sebelius killed CLASS in a letter to Congress today. “I do not see a viable path forward for CLASS implementation at this time,” she wrote.

Congressional critics of CLASS are gleeful. After all, they have their first Obamacare scalp on their belts. But there is a far more important question at stake now: What happens next? Medicaid, which pays for nearly half of all long-term care, is itself under immense financial pressure. And hardly anyone buys private long-term care insurance — only 7 million Americans own policies. As a society, we are simply unprepared for the crushing financial burden of frail old age or disability at younger ages due to accident or illness.

Where do we go from here? Most independent analysts recognize that the model most likely to succeed for long-term care insurance is a system of universal coverage. Every developed nation on the planet — except for the U.S. and the U.K. — has gone this route. And most programs have been extremely successful. But we just had a national debate about universal health insurance as Congress considered the 2010 health law and the returns are in — people don’t want it.

Perhaps there is a way out. Suppose Congress designed a system built on private insurance rather than government coverage? Suppose also that instead of a dreaded mandate, it included a combination of penalties and rewards to encourage people to buy insurance at a relatively young age.

Such a model already exists. Several do, in fact. Think about the Medicare Part D drug benefit, for instance. Insurance is sold by private companies in a regulated, transparent environment. Consumers can compare policies and prices. Premiums are relatively inexpensive for people who buy when they are first eligible. But they are penalized for delaying their purchase since premium prices rise rapidly.

Also imagine a choice of long-term care insurance options, much like Medicare Supplemental (Medigap) insurance. You might buy a lifetime cash benefit of $50-a-day that looks like CLASS would have. Or you could buy a policy that paid $200-a-day for three years. Or one with a $100,000 deductible and a lower premium.

There are many options. But advocates, long-term care providers and insurance companies must sit down and work out a consensus plan. Advocates have to understand they are not going to get the government plan they wanted. Insurance companies must recognize their business is dead in the water and desperately needs a jump-start. And providers such as nursing homes, assisted living facilities and home health agencies must find a steady source of revenue as Medicaid begins to shrink.

I know that consensus is out of fashion in Washington. But if people who care about long-term care issues — and we all should — don’t act quickly, this issue will end up back in the closet. And that will be a personal and financial disaster for tens of millions of Americans and their families.

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Since the 1990s, nearly every developed country on the planet has reformed the way it finances long-term care for the frail elderly and adults with disabilities. Among the handful of exceptions: The U.S. and the United Kingdom.

In 2010, Congress took a small step in the direction of reform when it passed the Community Living Assistance Services and Supports Act, a voluntary public insurance program that would provide a modest daily benefit for life. But even before the first policy is ever issued, a bipartisan group of senators has targeted it for repeal as part of a broad-based deficit reduction plan that has already won the support of President Obama.

While CLASS would represent a lost opportunity, the program’s vulnerability highlights the challenges the U.S. faces as it tries to find a way to finance long-term care for its aging population, as well as younger people with disabilities.
Currently, the U.S. model is built on the means-tested Medicaid program, which pays for more than 40 percent of all long-term care costs and is itself under tremendous financial pressure. Only about 7 million Americans own private long-term care insurance, which is costly and unattractive to many. CLASS would take a small step toward a public insurance-based system where people would be responsible for financing a share of their own care. But because CLASS is both voluntary and open to nearly all who want to buy, regardless of their medical status, its premiums may be unaffordable for many and the program may not be sustainable.

The problem is that while Congress seems on its way to both dumping CLASS and further shredding the already-tattered Medicaid safety net, it has no ideas for an alternative. Meanwhile the U.S. struggles with the fate of CLASS, a high-profile government commission in the U.K. laid out a reform plan July 4 to address its long-term care needs. And this blueprint heads in a very different direction.

The panel, chaired by economist Andrew Dilnot, ripped Britain’s existing Medicaid-like system as “confusing, unfair, and unsustainable.” Echoing the sentiments of studies over the past 13 years, the Report of the Commission on the Funding of Care said the means-tested system is “not fit for purpose” and needs “urgent and lasting reform.”

As an alternative, it proposed a new universal social insurance plan. This one, though, would provide only catastrophic benefits for many middle-class and wealthy seniors. Those with limited assets would continue to receive Medicaid-like assistance while everyone else would be expected to pay about the first $55,000 in personal care costs. In addition, those living in nursing homes would be responsible for their room and board, on the theory that they’d have these expenses wherever they lived. This approach, by the way, is a common feature in most European systems and the panel estimated it would increase the cost to seniors by about $15,000 a year.

While British middle-class and wealthy seniors would receive only catastrophic assistance, the number of people eligible for unlimited public long-term care support would increase. Currently, the eligibility cutoff for such benefits is about $37,000 in personal assets. In the new proposal, public support would be available to seniors with assets of as much as $160,000 — including, importantly, their home. Young people with disabilities would be eligible for first-dollar benefits, no matter what their wealth.

The panel estimated the new system would increase government spending by about $2.5 billion, or about 0.25 percent of current outlays. In the U.S. budget, that would be equal to about $80 billion.

While the Dilnot panel said very little about how those needing care would finance their share, I could imagine them using home equity, annuities or private long-term care insurance. Although such an insurance product barely exists in the U.K., it should be relatively inexpensive to purchase a basic $55,000 policy that would cover would cover about nine months of nursing home care.

The Dilnot plan is in stark contrast to the CLASS Act. Instead of full coverage after a big deductible, CLASS would provide modest first-dollar insurance (probably about $50 to $75 a day) for life. Such a “long-and-skinny” benefit is also very different from a typical private long-term care insurance policy, which normally includes a 90-day deductible and has a more generous daily benefit for three to five years.

Could such a catastrophic plan work in the U.S.? Several researchers, including Christine Bishop at Brandeis University, Anne Tumlinson at Avalere Health, and Bill Galston at the Brookings Institution, have proposed similar ideas. But they’ve never gotten much traction.

Dilnot’s plan would protect those who most need financial support — the poor and those with true catastrophic costs, such as people with dementia. But by requiring those who can finance some of their own care to do so, it could hold down public costs, making the plan both fiscally and politically more acceptable. As universal insurance, it would avoid all of the problems that go with a voluntary program such as CLASS.

The plan’s biggest downside is probably the opportunity for people to game the system by shifting assets so they can claim those generous public benefits. And its failure to recommend a specific source of funding is a huge omission.

I don’t understand enough about British politics to know if this idea has a chance, although the government response has so far been noticeably cool. Still, advocates seem to like it, and given the jeopardy CLASS is in on this side of the pond, some form of a catastrophic insurance system might be worth a look.

Congress can repeal CLASS but it can’t slow the aging of America and the growing need to provide personal care for the frail elderly or others with disabilities. Much as it might try, it cannot walk away from the problems of long-term care by trashing the only options available to many Americans.

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As the federal and state governments struggle to address their severe budget shortfalls, the assistance these women and millions like them need for long-term care services will certainly be cut. But by how much? And how will our society deliver care to those who desperately need it but cannot afford it?

Families, already the backbone of the care system, will take on greater burdens. But many frail elderly people have no children and their spouses are unable to care for them. As government’s role shrinks, community groups and nonprofits will have to take on more responsibility as well. But some care requires skills beyond the ability of relatives and neighbors. How will it be funded in an era of budget constraints?

While Medicaid was created mostly to provide medical care to low-income moms and their kids, two out of every three Medicaid dollars is spent on the elderly and disabled. Last year, the program spent one-third of its budget — more than $100 billion federal dollars — on long-term care, either in nursing facilities or in the community. States, which share the program’s cost, spent tens of billions more.

Overall, Medicaid pays more than 40 percent of all long-term care costs. The advocacy group FamiliesUSA estimates that more than 6 million seniors and nearly 10 million younger people with disabilities rely on the program for assistance.

I knew Natalie and Lisa. I told their stories in my book on long-term care, Caring for Our Parents. Like many Medicaid long-term care beneficiaries, both were once solidly middle class. But the cost of the medical and personal care they required ruined them financially. Over a decade, Natalie spent nearly all of her assets — more than $500,000 — on meeting these needs. A year before she died, she ended up on Medicaid. While critics often claim wealthy people exploit the system by giving away assets so they can enroll in Medicaid, there is no evidence that this is a widespread problem.

Now both Medicaid and many non-Medicaid programs for the frail elderly are in the fiscal cross-hairs. The House-passed 2012 budget would cut the projected federal share of Medicaid by nearly $800 billion over the next decade — mostly by turning the program into a block grant. In April, President Barack Obama suggested cutting planned Medicaid spending by $100 billion. And lawmakers of both parties are considering a blanket cap on all federal spending — a scheme that also would lead to deep reductions in elder and disability care under Medicaid.

More immediately, cash-strapped states are urging Congress to give them new flexibility in how they manage the program. Currently, federal “maintenance of effort” rules curb a state’s ability to limit enrollment. House Republicans would eliminate those restrictions, a move supported by at least 28 governors.

Individual states would respond to this new flexibility in different ways, but many frail seniors will have less access to Medicaid. In addition, states are likely to cut benefits themselves, especially for home and community programs — the services most popular among the elderly and disabled. For instance, states may cut the number of hours a home health aide may assist a Medicaid beneficiary. Already, even blue state governors such as Andrew Cuomo of New York and Jerry Brown of California have proposed deep reductions in programs such as adult day care, which are optional under current Medicaid rules.

At the same time, a wide range of non-Medicaid government programs for seniors such as transportation, home delivered meals programs (such as Meals on Wheels), information services and subsidized housing also face an uncertain future. Last month, Congress froze or cut spending for all those programs for the remainder of 2011. With House Speaker John Boehner, R-Ohio, demanding $2 trillion in additional spending reductions, even deeper cuts are on the horizon. And they will create an enormous gap in long-term care.

In the face of a shrinking government role, community efforts such as senior villages and elder care programs based in churches, synagogues, and mosques need to step up. But who will pay for those services that require care workers, or for nursing facilities?

And that leaves me with one more question. Many lawmakers who would cut Medicaid would also repeal the CLASS Act that would create a national, voluntary long-term care insurance system. If they oppose direct government spending for personal care, and oppose a transition to an insurance-based system, I wonder how they propose to assist those elderly and disabled who do not have the means to care for themselves.

Howard Gleckman is a resident fellow at The Urban Institute and author of Caring for Our Parents.

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But congressional critics want to kill CLASS long before the first policy is ever sold. Rep. Phil Gingery, R-Ga., who has sponsored legislation to repeal the program, calls it “a Bernie Madoff-fraudulent investment scheme run by the Secretary of Health and Human Services.” And the House GOP leadership’s 2012 budget proposal, released on April 5, would eliminate CLASS, along with much of the rest of the 2010 health law.

Overheated rhetoric aside, critics have two substantive聽objections to this obscure health law measure. They are offended that, under the conventions of budget accounting, CLASS premiums are counted as revenues that help “pay for” health reform. And they fear that if the program fails as self-funded insurance, it eventually will be bailed out with general tax revenues.

Their concerns are important, and there is no doubt the program needs to be significantly revised if it is to have any chance of success. But without CLASS, or something like it, millions of disabled adults, frail seniors and their families will be left with only Medicaid’s tattered safety net to support their personal care needs.

That’s why CLASS should be revamped, not repealed.

If CLASS is murdered in its crib, many families will have no resources to pay for long-term care services. Fewer than half of us will have sufficient savings. Most retirement nest eggs will fall far short of what we’ll need for nursing home care that costs more than $200 a day or home health aides who cost $20 per hour. Even fewer of us — about 7 million Americans — have private long-term care insurance.

As a result, many of the 10 million Americans who need long-term care will go broke paying out of pocket and then turn to Medicaid, a woefully underfunded entitlement program that pays for nearly half of all long-term services. This joint federal-state program spends one-third of its funds — more than $110 billion annually — on both home-based and nursing facility personal care.

But Medicaid is busting both the federal and state budgets, and many states are slashing already skimpy benefits.

CLASS could be an alternative. It would provide an average minimum benefit of $50 per day for life — in cash. This feature would let families decide how to structure care, a vast improvement over Medicaid that too often forces the frail elderly into nursing homes.

Unfortunately, as designed, CLASS will be unaffordable for the vast majority of potential buyers, with average monthly premiums well in excess of $100. HHS Secretary Kathleen Sebelius vows to fix the program’s many flaws. And while the repairs she has suggested don’t go nearly far enough, she is on the right track.

Here are a few ways to make CLASS more attractive to buyers:

— Narrow the focus. Today, CLASS attempts to achieve two goals at once. It tries to provide a personal care benefit for working people with disabilities and, at the same time, sell insurance to healthy people looking to hedge against the risk of needing assistance sometime in the future. The result: those who buy insurance will end up subsidizing those with disabilities. That will drive up premiums and discourage healthy people from participating. CLASS needs to be an insurance program only. Congress should make personal assistance benefits available to working people with disabilities — but not through CLASS.

— Second, encourage employers to include this insurance in their employee benefit plans. CLASS will succeed only with robust enrollment, but people must be nudged to participate. That will only happen if employers offer policies to their workers.

— Third, start premiums low, but gradually increase them as people age. This structure will make policies far more attractive to younger buyers.

— Finally, Congress should create an independent insurance fund to collect and invest CLASS premiums. This would assure participants that they are buying real insurance and not just exchanging their premium dollars for government IOUs.

Someday, perhaps, the U.S. will join nearly every other major developed nation in the world and create a universal long-term care insurance system funded by some mix of taxes and premiums. Coverage could be provided by private insurers — just as the Medicare Part D drug benefit is today — or it could be run by the government. Monthly premiums for a universal CLASS-like program could average as little as $40. And such a program could cut Medicaid long-term care costs in half — by as much as $60 billion.

Given our current anti-government, anti-tax climate, Congress won’t pass a universal long-term care insurance program any time soon. But as 77 million baby boomers age, the nation’s care needs will only grow. Two out of three seniors and many younger people with disabilities will need some personal assistance before they die. They won’t be able to count on a crumbling Medicaid program, and they have not saved. Insuring against this risk makes perfect sense. And CLASS, for all its flaws, is a step in that direction. It deserves a chance.

Howard Gleckman is a resident fellow at The Urban Institute and author of Caring for Our Parents. 聽

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And this squeeze may only be just beginning. Faced with an historic deficit, the federal government could opt to reduce its future Medicaid payments, forcing states to choose between cuts in acute care for young families or long-term care. This tenuous future is why the U.S. must begin to consider broad-based insurance to finance long-term care.

The Medicaid long-term care benefit is a critical safety net for the frail elderly and others with disabilities. Many recipients are once middle-class people who went broke paying for their own medical and personal care. Now, without financial resources, they must turn to Medicaid.

For those who cannot afford the nearly $80,000-a-year price tag for nursing facility care or the $20 an hour tab for home health aides, Medicaid is often the only option. Currently Medicaid spends more than $100 billion, or one-third of its total budget, on long-term care services. It is by far the biggest payer of long-term nursing facility and home health services. By contrast, private long-term care insurance pays less than 10 percent of these expenses. Medicare only pays for nursing care for a limited period after a patient has been discharged from the hospital.

But the Medicaid safety net is fraying. Facing their own massive budget shortfalls, states have already begun trimming benefits, many occurring in Medicaid’s home and community based programs. That’s because states are required to provide assistance in a nursing facility, but not at home. Thus, states cut where they can, even though beneficiaries prefer home care and some research suggests the states themselves can save money by helping Medicaid long-term care recipients stay in the community.

Until now, those benefit cuts have been relatively modest. The Kaiser Family Foundation estimates that 18 states reduced long-term care benefits in 2010 and another 10 plan to do so this year while more than 30 expanded their programs. The main reason: The huge 2009 economic stimulus included $87 billion in additional federal Medicaid payments to states through December 2010. In August, Congress reluctantly added another $16 billion and extended the additional payments through June 2011. (KHN is a program of the foundation.)

But that money is about to dry up. With Republicans winning control of the House and picking up seats in the Senate, and with worries about the federal deficit growing, there is little chance Congress will provide any additional Medicaid dollars.

The long-run future is even dicier. To start, the new health law will add an estimated 16 million more acute care patients to the Medicaid rolls starting in 2014. Congress promised to pick up most of the cost of those added beneficiaries, though the federal payment will slowly decline. If states pay more for those acute care patients, the extra dollars must come from somewhere. And one possibility is Medicaid funding for long-term care.

The real risk to states, however, is that Washington will fail to keep its commitment. Given the growing fiscal crunch, I’d worry about that promise if I were a governor.

Some conservative lawmakers in Texas and elsewhere have floated the idea of pulling out of Medicaid entirely. But since a state can’t withdraw from only part of Medicaid, this decision would leave long-term care beneficiaries with no safety net at all.

While states can’t change the rules, Congress can. Already, influential deficit hawks are suggesting how that might happen.

For instance, the co-chairs of President Obama’s , former Clinton Administration chief of staff Erskine Bowles and former Sen. Alan Simpson, R-Wyo., have proposed capping the federal share of Medicaid long-term care costs — a step that could reduce federal payments by nearly $90 billion over 10 years.

A second deficit commission would go much further. The privately-funded Bipartisan Policy Center’s panel suggested major changes in Medicaid long-term care assistance. The most far-reaching suggests states and Congress fundamentally renegotiate their Medicaid responsibilities. For instance, one level of government could take full responsibility for all long-term care while the other handles al acute care.

These proposals won’t become law any time soon. But they are evidence that Medicaid could be on the fiscal chopping block. In that environment, it makes sense to get the program out of the long-term care business. And a way to do that would be to replace it with a broad-based insurance system. The Community Living Assistance Services and Support Act, which was created by the health overhaul, will create a voluntary national long-term care insurance program. Program participants would begin contributing in 2012, but wouldn’t b eligible for benefits for at least five years. But there are real doubts about whether CLASS insurance will attract enough middle-class buyers to reduce the burden on Medicaid. If it can’t, Congress should begin to think about what insurance design can, and do so before the Medicaid safety net for long-term care is in tatters.

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CLASS takes a step towards moving long-term care financing from the welfare-like Medicaid program to an insurance-based system. But CLASS alone won’t get the nation there. Private insurance, currently a niche product that covers only about seven million Americans, will have to play an important role as well.

A key question remains: Will private coverage fill the gaps left by CLASS? Top industry executives are deeply divided over how to respond to the new law. Some are anxious to design products that would supplement CLASS insurance, much like Medigap insurance currently enhances basic Medicare. But others see little benefit in selling such products, and suggest they may try to compete with CLASS. This could doom the new government program. And it could leave the industry stuck with the same limited market it has today.

While many details of CLASS insurance won’t be worked out for at least two years, daily benefits will be relatively modest-probably about $50 or $75. That’s very valuable for the many elderly and disabled who live at home. But for those worried about having to move to a nursing home, which costs an average of more than $200 a day, CLASS insurance will fall far short of their needs.

That’s where private insurance fits in. Today, buyers of commercial policies typically purchase a daily benefit of more than $100. That suggests many consumers may want to top off the government’s modest daily benefit with private coverage. This, in fact, is what has happened in France. There, government benefits are very modest for middle- and upper-income individuals. So about 25 percent of those 60 and older have purchased extra private coverage-far more than the seven percent who currently own long-term care insurance in the U.S.

But CLASS coverage may not be easy for private companies to complement. For instance, while the daily benefit is modest, CLASS coverage is available for life. Private companies effectively dropped lifetime benefits years ago, and are unlikely to return to them.

Private companies also worry about how people would qualify for benefits. Under CLASS, it takes only the approval of a patient’s own doctor, who is likely to approve most claims. And private companies fear it will be impossible to deny payments for somebody who is already receiving CLASS benefits. As a result, they may be reluctant to sell policies to complement government policies.

But the biggest industry worry is price. It will be a few years before anyone knows how much CLASS premiums will be, but they may very likely exceed an average of $100 a month (younger people will pay lower premiums and older people will pay more). A new study by the SCAN Foundation and the consulting firm Avalere Health figures that a CLASS-like policy will cost the average buyer about $115 monthly. (SCAN funding supports some KHN coverage of aging.)

Insurers worry that once consumers buy the government plan, they’ll have little money left to pay for a supplemental private policy. That was a big reason why much of the industry opposed CLASS in the first place.

Now, some companies think those potentially high CLASS premiums may give them an opening to compete with government insurance. Here’s why: Private carriers can keep their premiums relatively low by refusing to sell to people with pre-existing health issues. But CLASS will be available to everyone who holds at least a part-time job and thus will cover many high-risk buyers. That threatens to drive up CLASS premiums which, in turn, may push more buyers to cheaper private insurance. By cherry-picking the healthiest buyers, private companies could kill CLASS.

Why wouldn’t they? Because CLASS offers one huge potential benefit to private companies: It opens the door to a large government-funded marketing campaign that promotes the need for long-term care insurance. The industry has never been able to make that case on its own but, with federal promotional dollars, long-term care insurance could become a more widespread product, and that would be good for everyone.

So maybe there is a deal to be struck: As long as private companies agree to sell CLASS supplemental policies, government agrees to promote the need for long-term care insurance, whether government or private. Now that would be a public/private partnership worth watching.

Howard Gleckman is a resident fellow at the Urban Institute, author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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But Americans do have a way to fund this care: their home. Last year, we had more than $7 trillion in real estate equity, even after the crash. In 2007, nearly two-thirds of American families headed by people 62 or older owned a home free and clear But 20 percent were “cash-poor,” according to the MetLife Mature Market Institute, and could have used that equity to improve the quality of their lives.

Trouble is, two-thirds of retirees have no intention of using their homes to fund their old age. Some want to leave houses to their kids. Others don’t understand how they can tap their home equity, and others misunderstand the rules about home ownership and Medicaid.

So here’s a possible solution. What if your state, in effect, helped you turn unused home equity into cash to pay for the care you need when you become old and frail? To sweeten the deal, what if the state let you have easier access to Medicaid to supplement your own long-term care contributions?

You could use the money to make your home wheelchair accessible, or pay for a special van, or even for adult day care or that home health aide. You’d have far more flexibility than with regular Medicaid. In return for this upfront cash, your heirs would repay the state with modest interest after you die, usually by selling your house. The state wins by saving the cost of caring for you in a nursing home. You win by easily accessing the equity that could allow you to stay at home.

This program would look a lot like a reverse mortgage. With those, if you are at least 62, you can take out a loan against the equity in your home. You get either a lump sum in cash, access to a line of credit, or a regular check each month. When you move or die, you or your heirs sell the house and repay the loan plus interest.

But reverse mortgages have been a bust. In 2007, fewer than 1 percent of eligible homeowners had one. People have trouble understanding them. And they are weighed down by high fees (there is a servicing fee, an origination fee, mortgage insurance premiums, closing costs, and, of course, the interest). At the same time, a troubling number of users are relatively young borrowers who are tapping reverse mortgages to pay off credit cards or fund vacations. The perverse result: They will have even less home equity available when they really need it to pay for long-term care.

Normally, I’m no fan of the government’s doing what the market could do. Unfortunately, like long-term care insurance, private reverse mortgages are failing. A quasi-government agency might allow consumers to tap unused home equity more easily and cheaply.

In truth, states can already recover some Medicaid benefits by putting liens on the homes of Medicaid enrollees after they (and their spouses) die. But this practice is poorly understood and applied inconsistently at best. As a result, this scheme usually produces more angry families than revenue to the state.

A government reverse mortgage program would accomplish the same thing, but in a much more transparent and attractive way. States could even encourage seniors to participate in such a program by allowing them to supplement their home equity with Medicaid. Several states already operate the Partnership Program that links long-term care insurance with Medicaid. They could do the same with home equity and Medicaid.

The United Kingdom is experimenting in three localities with a somewhat different way of tying that nation’s Medicaid-like long-term care system with home “equity release.” But the idea is the same: reducing the financial burden on government-funded long-term care while giving people greater control over these services by encouraging them to use some home equity to pay for this assistance.

A few analysts are beginning to think about this in the U.S., but the idea remains half-formed. There is a lot to work out with such an arrangement, but given the poor alternatives, it may be worth thinking about.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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It is not clear why it’s happening, but some hospice officials blame both a bad economy and Medicare rules that unintentionally discourage doctors from referring all but those who are about to die.

Even though hospices have been operating in the U.S. for three decades, they remain widely misunderstood. Hospices provide medical care, pain management, spiritual and social care and volunteer support for those nearing the end of their lives. And their patients often live longer than if they were still receiving full-blown medical treatment.

Nearly all hospice care is paid by Medicare, but unlike most providers, hospices are paid a fixed daily rate (on average about $140-a-day for home care patients). If a hospice provides care for less, it keeps the difference. If a patient requires very costly care, the hospice can lose money. The number of patients served by hospices increased from about 1 million in 2004 to nearly 1.5 million in 2008, while the number of hospices grew from 3,600 to almost 5,000. Most of this explosive growth has been driven by for-profit companies.

But in recent months, hospice officials have seen a downturn. In some states, such as Oklahoma, heavy competition has forced consolidation, and at least 10 hospices have closed in the past year.

Elsewhere, hospice officials blame the bad economy. Patients who have lost jobs–and insurance-may be waiting longer to visit the doctor and consequently are diagnosed with terminal illnesses at a very late stage.

Some hospice executives say the poor economy may also be driving doctors to hold on to patients longer. Here’s why: Once a patient joins hospice, she’s likely to see her physician far less often. Her doctor can usually order tests and treatments only to keep her comfortable, and not to try to cure her terminal disease. And while it may still be appropriate for, say, cancer patients to receive costly drugs or even radiation therapy to relieve pain, hospices must pay for these treatments out of their daily Medicare rate. That inevitably can create tension between the hospice and the physician.

And it may add up to less money for doctors at a time when they are already feeling squeezed. One physician I spoke to strongly rejected this argument, insisting that declining compensation does not slow referrals. But another-an oncologist who frequently refers to hospice-acknowledged the problem. “There is a financial deterrent,” she says.

At the same time, new Medicare rules may be further discouraging physician referrals. Medicare has begun cracking down on a handful of hospices that are making big profits by taking on chronically ill, but not terminally ill, patients. While hospice patients are normally expected to have six months or less to live, some hospices have many on their rolls for a year or more. In one attempt to stop this practice, Medicare now requires doctors to write a brief narrative describing why a patient is appropriate for hospice. Trouble is, says one hospice official, “We’re getting a lot of pushback” from doctors.

In 2008, more than one-third of patients were enrolled in hospice for a week or less, and some organizations are seeing the number of short stays increase, perhaps because these requirements may be making already reluctant doctors even less willing to refer to hospice until their patients are actively dying.

Mark Murray, president of the Center for Hospice and Palliative Care in South Bend, Ind., says that in the past year, eight percent of his referrals died before they could even be admitted, and 20 percent died within 48 hours. Those last-minute decisions put enormous financial pressure on hospices and make it impossible for patients to get the full benefit of end-of-life care.

These disincentives come on top of a long-standing reluctance on the part of many doctors to even talk about hospice. In a 2009 study, more than half of patients with stage IV lung cancer said their physicians never even raised the option.

I am a huge fan of hospice: My wife is a hospice chaplain and both my father and father-in-law were hospice patients. These organizations are a model for coordinated care that other health care providers would do well to copy. But doctors need to be persuaded to use hospice. And that may mean changing a payment system that may be discouraging them from using this valuable service.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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This story was produced in collaboration with our partner

In Washington D.C., Councilwoman Mary Che visits Palisades Village, an aging-in-place community where neighbors help neighbors with basic services so that seniors can stay in their homes longer. (Evy Mages for The Washington Post)

Nearly three years ago, Harry Rosenberg and his wife, Barbara Filner, met with nine of their neighbors about starting an aging-in-place “village” in the Burning Tree community of Bethesda, Maryland. The idea: If neighbors could help one another with basic services such as transportation and simple home maintenance and with friendly visits, people could stay in their homes longer as they aged. It took 19 months of planning and organizing, but accepted its first request for assistance in November of 2008: helping an 81-year-old widow take out her trash and driving her to the doctor.

The group is still suffering growing pains. It receives only a handful of requests for help. Like some similar organizations, it charges no dues and it has about 65 “friends”: people who volunteer, people who receive help, people who just want to be associated. It operates on a shoestring $4,000 budget raised from donations, but it has held a series of well-attended community events, including neighborhood walks and restaurant outings. “We are,” says Rosenberg, 73, “a viable presence in the neighborhood.”

The Washington D.C. area has become a hotbed for these villages. There are six in the city itself,聽 at least two in the Virginia suburbs聽and eight in various stages of development in the Maryland suburbs. “The idea has spread like wildfire,” says Naomi Kaminsky, president of one, .听

Still, organizing a village is difficult, say those who try. It can easily take two to three years before a new aging-in-place community can roll out services. And many groups are still struggling after five years. Fundraising, squabbles over priorities, legal and insurance issues, and the challenges of building a network of volunteers all make the process lengthy and difficult.

“It is a lot of work,” says Nancy Intermill, executive director of Midtown Village in Lincoln, Neb. “You need a group of people committed to the concept, and committed to working together.”

Most villages aim to recruit at least 200 members, often 60 or older. The process generally starts with a neighborhood survey, followed by visits to promote it at local schools, houses of worship and community associations. Finally, neighbors are approached one at a time or in small groups. Flyers or e-mail won’t do it, organizers say.

“No one has ever joined unless they were asked by a human being,” says Andrew Mollison, 70, president of the 65-member in Northwest Washington. Still, he adds, when encouraged to join, many elderly neighbors are likely to respond, “I’m not ready yet.”

Nonetheless, village organizers say, people seem instinctively attracted to the idea of neighbors helping neighbors stay at home as they age. Today, there are at least 48 fully functioning villages around the country and more than 600 in development, says Candace Baldwin, senior policy adviser at ,聽a nonprofit that has created an informal association of these groups called the .听

‘No Rule Book’

There may be as many variations on the village theme as there are communities. Each village attempts to meet the needs of its community in its own way. Some are intergenerational, while others are for seniors only. Some charge hundreds of dollars in annual dues and have paid staff; others assess members little or nothing. Some arrange exclusive deals with a single agency to provide home health aides or companions, while others provide lists of member-recommended firms. Some rely on informal volunteering, while others keep records so that members receive free services in exchange for giving their own time. “The nice thing about villages is there is no rule book,” says Mollison.

However, villages seem to be evolving around three basic designs. The first was pioneered by in Princeton, N.J.,聽in 1992. Today, it has more than 450 members who belong to one of six “houses.” Annual dues are $30 for a couple. Much of what it does is social: There is a bird-watching club and even a theater group. Nearly all of its services, such as rides to the doctor or the store, are provided by volunteers. For those who need more assistance, the group has arranged for a local nonprofit to coordinate care and provide access to a 24-hour-a-day emergency hotline. For this higher level of assistance, singles pay $300 annually and couples pay $350, plus fees for any services they require, such as a home health aide.

The second model is based on Boston’s ,聽which also started in the 1990s. Beacon Hill charges annual dues and delivers both volunteer and paid help. In Washington, , which has about 200 members, is probably the best example of this model. Capitol Hill began providing services about two years ago and has about 200 members who generally pay annual dues of $530 for individuals and $800 for households; about 30 low-income members pay less.

A third model, championed by a nonprofit called ,聽is built on the model of time banking, or service exchange. The idea: You agree to pick up groceries for a neighbor and, in return, another volunteer fixes your leaky faucet. Begun in 1993 and based in Anne Arundel County, Maryland, Partners in Care has 2,600 volunteers around the state.

Volunteers Are Key

Many experts believe the Beacon Hill/Capitol Hill model will be the most lasting because a professional staff buttresses the efforts of volunteers. Capitol Hill has an executive director and full-time social worker and offers a concierge service that arranges for paid assistance from preselected vendors. Yet it relies on social events and volunteers to thrive. In one recent month, nearly 90 percent of more than 200 requests for help were filled by volunteers. Most were for rides or for help changing a light bulb or hooking up a TV.

Palisades Village is copying much of that design. The village, which began with a small group of neighbors in early 2006, hired a part-time executive director in 2008 and offered its first services to 31 members in January of 2009. “We wanted to hire her full time,” says Mollison, “but we didn’t have enough money.” Mollison figures he puts in 25 hours a week as unpaid president.

The village raised about $60,000 last year from dues, gifts and start-up grants from the city and local foundations. Dues are similar to Capitol Hill’s, and to help reach its goal of about 200 members, the group has expanded to include a聽nearby聽neighborhood. Mollison believes a key to sustainable financing is attracting younger residents who can join at reduced dues or simply volunteer.

Chevy Chase at Home also favors the dues-and-staff route but is still in the early stages of development. Kaminsky, who says she is in her early 70s, says her group is not yet ready to recruit members or think about a budget. For now, they are working to raise their profile with twice-a-month informal gatherings. “An active social component is very important,” says Ken Hartman, a county employee who advises the villages.

In contrast to Palisades and Chevy Chase, Burning Tree Village has chosen an all-volunteer, dues-free model. “Philosophically, it feels right to not charge neighbors for this,” Rosenberg says. But he worries about the group’s sustainability as its founders age: “If they move or die, what is viable one day may disappear the next.”

But Rosenberg has already learned the value of his effort. A year ago, as his wife was dying of cancer, people he had not known just months before were offering help. “Barbara and I were getting neighborly support we would never have gotten,” he remembers. By that measure, Burning Tree Village is already a success.

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Government assistance for those who suffer from chronic illness is both terribly underfunded and deeply disorganized. There are programs run by Medicaid and Medicare and the federal Administration on Aging. There are programs run by states and similar projects run out of Washington. This is a particular nightmare for those with disabilities who are struggling to stay at home. If you don’t believe me, try to find a local phone number for elder care assistance.

I live in Montgomery County, Md., and a quick look at my phone book shows 18 different numbers for various senior services. If I need help that is not provided though the county, I need to call the state, which requires yet another frustrating search. Over the years, offices on aging and disabilities have tried to create one-stop shopping to make it easier to find help. And Maryland has a pretty good Web site that tries to pull together all these resources in one place. But the various programs go on for screen after screen. Imagine trying to navigate this if you are 75 years old and caring for a spouse with dementia.

The respite care program Obama wants to expand is typical of the problem.听 Respite care is temporary assistance for families who are helping the frail elderly or those with disabilities live at home. It may be a home health aide who visits for a few hours so a spouse can get a break. Or it may be an adult day program or transportation aimed at helping the person receiving care get out of the house.听

The Lifespan Respite Care Act was passed by Congress in 2006. And its laudable goal was to encourage states to coordinate services aimed at giving family members a temporary break from their often stressful responsibilities. For instance, states could use the funds to make more information available to caregivers about respite services or to train care workers.听聽

But the new law ran into two problems: Individual state agencies trying to protect their turf-and no money. For instance, the original law allowed up to $71 million for the program this year. But in its most recent budget, Congress agreed to make only $2.5 million available to states. The president now says he wants to increase this to about $50 million next year. At a time when the $1.4 trillion federal deficit is putting enormous pressure on spending programs like this, I’m willing to bet he’ll never get it all. And even if he does, he’d still only be spending a bit more than half of the $91 million the original law allowed.

For some sense of how little this is, think about it this way: By the administration’s own count, there are 38 million caregivers in the U.S. (others estimate there are many more). Even if Congress gave Obama the full $50 million, that works out to $1.31 per family. Of course, that’s a lot better than the six cents being spent today.

Worse, cash-strapped states are slashing their subsidies for the very adult day programs Lifespan is trying to promote. In a states such as California, for example, a federal program to promote these services won’t help much if the programs themselves are shuttered-an idea now being debated in Sacramento. And no small federal grant program will save them.听

In today’s awful budget environment, financial pressure on government services for the elderly and others with disabilities will only get worse. The president has already proposed freezing overall spending for social programs exactly like Lifespan for the next three years. If more is spent on Lifespan, don’t be surprised to see funds cut for other badly needed assistance aimed at exactly the frail elderly and younger adults with disabilities.

At the same time, Medicaid-the primary long-term care support program for the sickest and poorest among us-faces its own budget crisis, both in Washington and in the states that pay about half its costs.

The best solution is to free families from the whims of politicians and the inevitable battles over government dollars. National long-term care insurance, such as the proposed CLASS Act, would help in two ways. First, it would give people cash benefits they could use however they want. They would not need to rely on underfunded and possibly inaccessible government programs. If a wife wanted to enroll her husband in an adult day program, she could just do it. Second, because millions of consumers would, for the first time, have the financial resources to pay for these services on their own, new private services would spring up that might do a better job than today’s diffuse and underfunded government programs. It is at least worth a try.

Howard Gleckman, a resident fellow at the Urban Institute, is author of “Caring For Our Parents” and a frequent writer and speaker on long-term care issues.

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