Long-Term Care

Long-term care (LTC), also known as long-term care services and supports (LTSS), is a very large and rapidly growing part of the U.S. health care system, but it receives relatively little media attention.  This is likely to change, however, over the next two decades as the number of people needing LTC reaches 10 or more million persons and the amount of money, from both public and private resources, spent on LTC doubles to over 500 billion dollars.

Formal LTC includes a wide range of paid services from in-home services like home health care, personal care, homemaker assistance to community residential care, mainly assisted living, to nursing home care for those who are most impaired and dependent.  Informal care includes essentially the same kinds of services available through the formal in-home care part of the formal LTC system, but they are provided without pay by family members and friends.

Over the past 30-40 years people in need of LTC have been increasingly served through the formal care system, receiving services paid for either privately out-of-pocket or through private insurance, or publicly, mainly through the Medicaid program if the person meets fairly stringent eligibility criteria.  Even with the growth of the formal LTC system, the informal system still meets about two-thirds of the need for care.  The continuing shrinkage, however, of the informal system due to the decline in the availability of potential informal caregivers, is likely to increase the demand for formal care services and push up the future costs of the publicly funded LTC system beyond levels that would occur anyway with the unprecedented increases in the 65+ and 85+ population over the next three to four decades.

How will the state and federal governments meet this growing need for LTC starting from a current system of services that is far from adequate to meet the need for care that already exists in most states? This question is a major part of the organizing framework for the materials collected in this section.  We are committed to developing as accurate and useful a critique as possible of the current LTC system in Florida and across the country and to proposing policy initiatives we think might be best designed to meet current deficiencies and make LTC far better for those who will need care in the future.

The American long term care system has changed dramatically over the last several years as the need for care has increased steadily with the aging of the boomer generation. Arguably the most important change has occurred in the Medicaid funded part of the system as several states, with strong federal support, have moved toward contracting with large for profit insurance companies to provide overall administration of Medicaid Long-Term Care (LTC) services, largely displacing non-profit organizations from the administration of home and community based services. Private equity firms have also become increasingly active in the LTC space with investments in a wide range of LTC related industries. We have many concerns about the impact of these trends on both Medicaid beneficiaries and taxpayers. We are concerned that the displacement of the ethic of care, mission oriented model of aging network administered LTC by a more proprietary model will negatively affect access, quality, and cost in the Medicaid LTC programs. We are also concerned that the increasing participation of private equity firms in Medicaid funded LTC programs will threaten program quality and drive up costs.

We don’t claim to have all of the answers for the issues we are addressing, but we think it is critical to do what we can to help the public and policymakers understand more fully the urgency of these issues and the importance of responding to them more forcefully than we have for the past several years.

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Issue Briefs:


Overdoses, Bedsores, Broken Bones: What Happened When a Private-equity Firm Sought to Care for Society’s Most Vulnerable

Public Long-term care programs, including Medicaid funded programs, are increasingly being administered by for profit corporate health firms and funded through financial companies, especially private equity firm. This very revealing report from The Washington Post shows the connection between a private equity firm’s efforts to save costs and increase profits, mainly by cutting staff, which led to declining quality of care in nursing homes owned by ManorCare, the nation’s second largest nursing home chain.

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