Dr. Anthony Hill’s Policy Class Catholic University of America November 29, 2010 Who knows the music of Dick Dale – Dick Dale and the Del-Tones? He is the King of the Surf Guitar. He was my companion as I headed for Virginia Beach although the closest I got was hearing and seeing the surf from my hotel room – but sure enjoyed that.

The PPACA & Related Federal Policy Remarks by William F. Benson © Health Benefits ABCs

“Lovers of sausage and the law should watch neither made.”

What Will Be Highlighted A Bit of LTC Background Patient Protection and Affordable Care Act Long-Term Care Related Provisions Elder Justice Act Other Patient Protection and Affordable Care Act Long-Term Care-Related Provisions My Crystal Ball

Percentage of Population Over Age 65 2000 2015 2025 5%-9.9% 10%-14.9% 15%-19.9% 20-30% Source: U.S. Census Bureau

An Aging Population Percentage of U.S. Population over Age 65 Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population Copyright 1996, Watson Wyatt Worldwide. 5 10 15 20 25 1930 1950 1970 1990 2010 2030 2050 Year Percentage of Population

Older Population is Getting Older The fastest growing segment of the aging population is the “old old”, those over the age of 85: 1.6% to 3.8% in 2025 & in numbers from 4.2 million in 2000 to 6.1 million in 2010 – Population most likely to need long-term care

LTC Expenditures: A Lot Now & Much More in the Future In 1999, CBO projected that total LTC expenditures for seniors (including government and private spending but not the value of donated care) would rise from about $123 billion in 2000 to $346 billion by 2040. That estimate of a relatively modest increase in spending incorporated the assumption that the prevalence of impairment would decline at a rate of about 1.1 percent per year. CBO 2004

Health Care Expenditures for Chronic Conditions 83% of all Health Care Spending Involved People with Chronic Conditions in 2001 Medicare – 98% Medicaid – 83% Privately Insured – 74% Uninsured – 72% Source: Medical Expenditure Panel Survey, 2001, and Partnership for Solutions

Threats to Health Among Seniors 73% age 65 - 74 report no regular physical activity 81% age 75+ report no regular physical activity 61% - unhealthy weight ~35% - fall each year 20% - clinically significant depression; age group at highest risk for suicide Sources: State of Aging and Health, 2007; www.cdc.gov/nchs; www.cdc.gov/ncipc/olderadults.htm

What’s the health picture for Boomers? By 2030 More than 6 of every 10 will be managing more than one chronic condition 14 million (1 out of 4) will be living with diabetes >21 million (1 out of 3) will be considered obese Their health care will cost Medicare 34% more than others 26 million (1 out of 2) will have arthritis Knee replacement surgeries will increase 800% by 2030 “When I’m 64: How Boomers Will Change Health Care ”, American Hospital Association, May 2007

Diabetes Trends Among U.S. Adults, BRFSS 1990, 1996, and 2003 No Data <4% 4%–6% 6%–8% 8%–10% >10%

PPACA Nursing Home Provisions (Selected) Nursing facilities must report to HHS and certify as a condition of participation in Medicare and Medicaid that the following information is (“to the best of the facility’s knowledge”) accurate and current: Each member of the governing body; Each officer, director, member, partner, trustee, or managing employee; Each additional disclosable party; The organizational structure of each additional disclosable party to the facility and relationship of each to one another. Effective Immediately: Nursing homes must provide the information in this section to the state and state long-term care ombudsman in which the facility is located and to the Department of Health and Human Services and the HHS Office of Inspector General (OIG) upon request. June 2012: Facilities begin reporting information to HHS. March 2013: HHS makes information available to the public. Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

Nursing Home Compare Website Sec. 6103 Staffing data: By March 2012 The publicly reported data must include resident census; hours of care per resident day; and staff turnover and tenure. The format must be clearly understandable and allow consumers to compare differences between facilities and state and national averages. It must include concise, “plain English” explanations of how to interpret such data as “nursing home staff hours per resident day;” differences in types of staff; the relationship between nurse staffing levels and quality of care; and an explanation “that appropriate staffing levels vary based on patient case mix.” Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

Nursing Home Compare Website Sec. 6103 Standardized Complaint Form and Complaint Information – info on how complaint forms are used and how to file complaints with the state survey and certification agency and the state long-term care ombudsman program. NHC will include a summary of the number, type, severity, and outcome of substantiated complaints. Adjudicated Criminal Violations by a Facility or Its Employees – NHC will include the number of adjudicated criminal violations by a facility or employees of the facility that were: Committed inside the facility; and Violations or crimes of abuse, neglect, and exploitation; criminal sexual abuse; or other crimes that resulted in serious bodily injury. NHC will report the number of civil monetary penalties levied against the facility, employees, contractors, and “other agents.” Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

Nursing Home Compare Website Sec. 6103 The Special Focus Facility Program that was instituted during the Clinton Administration is now required by law for facilities identified as substantially failing to comply with the law. No additional guidance on the program is given other than that surveys of SFFs will be conducted at least once every six months. [Policy now in effect.] By March 2011 Nursing homes will be required to allow any individual to review their survey reports and complaint investigations for the preceding three years. They will be required to post a notice in prominent, accessible areas of the facility that the reports are available. (They cannot make identifying information about complainants or residents available. ) States are required to maintain a consumer-oriented website that provides information about all nursing homes in the state, including their Form 2567 inspection reports, complaint investigation reports, plans of correction, and other information that the state and HHS consider useful to the public in evaluating care in individual facilities. HHS will provide states guidance, and it will provide such information on Nursing Home Compare “if possible.” Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

Reporting of Expenditures Sec. 6104 Medicare cost reports will be modified to report separately skilled nursing facilities’ expenditures for wages and benefits for direct care staff. The date will be broken out (at minimum) for RNs, LPNs, CNAs, and other medical and therapy staff. (3/12) HHS will categorize SNFs’ expenditures annually from all payment sources into the following functional accounts (3/13): Spending on direct care services, including nursing, therapy, and medical services; Spending on indirect care, including housekeeping and dietary services; Capital assets, including building and land costs; and Administrative services costs. Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

PPACA Nursing Home Complaint Processes HHS will develop a standardized complaint form that residents or persons acting on their behalf can use in filing a complaint with the state survey and certification agency or the state long-term care ombudsman. (Sec. 6105) March 2011 States are required to establish complaint resolution processes that ensures that legal representatives of residents and other responsible parties are not denied access to residents or otherwise retaliated against if they complain about the quality of care or other issues. (Sec. 6105) March 2011 Source: PPACA & NCCNHR: The National Voice for Quality LTC © Health Benefits ABCs

Elder Justice Act – Tricky Riding But We Stayed Up

Source: Congressional Research Service

Elder Justice Act Patient Protection & Affordable Care Act (H.R. 3590), Sec. 6701 Authorized for FY 2011-2014 Amends Title XX of the SSA – Senate Finance Committee & House Ways & Means Only portion of original version of EJA (note Sestak’s Elder Abuse Victims Act of 2009) 13 individual authorizations of appropriations – $195 million authorized – without funding, “close but no cigar” Heavily LTC focused

EJA: Mandatory Reporting of Crimes in Facilities Reporting to Law Enforcement of Crimes Occurring in Federally Funded LTC Facilities (to Secretary & Law Enforcement) Includes owners, operators, employees, managers, agents, contractors of LTC facilities CMPs for failure to do so; higher CMPs when residents harmed by crime Additional Penalties for Retaliation No Appropriation – can start now

EJA: Other LTC Provisions Enhancement of Long-Term Care Grants & Incentives for LTC Staffing (Career Ladders, Wage & Benefit Increases, Technology, Adoption of Standards for Transactions re Clinical Data) Authorization -- $20M FY 11 (drops to $15 M in FY 13-14) Protecting Residents of LTC Facilities National Training Institute for Surveyors (with National Complaint Intake System) Authorization -- $12 M FY 11-14 Grants to State Survey Agencies re complaint investigations systems Authorization -- $5M FY 11-14

Other EJA Provisions National Nurse Aide Registry Study & report to Coordinating Council & Congress – 18 mos. Congress (Finance, W&Ms, E&C) “shall, as they deem appropriate, take action on the recommendations Authorization – such sums Forensics Centers (4 Stationary Centers, 6 Mobile Centers) Authorization -- $4M FY 11 (to $8 M) LTC Ombudsman Program Capacity & Training Grants

EJA and Adult Protective Services (APS) First dedicated federal funding for APS $100 million in new money to states for APS $25 million in new money for APS demo grants $3-4 million for HHS for a federal “home” for APS

What the EJA means for APS: State Funding Adult Protective Service Grant Program (State Formula Grants) Authorizes $100 million Funds may be used only by states and local governments to provide adult protective services & may only be used for APS. State receiving funds would be required to provide these funds to the agency or unit of state government having legal responsibility for providing adult protective services in the state. Each state would be required to use these funds to supplement and not supplant other federal, state, and local public funds expended to provide adult protective services. California: If $100 million: $9.958 milllion =170 FTEs at $60,000 each (85 FTEs at $120,000)

Implementation of the EJA “Show me the money” – the battle & challenges for appropriations Who will be responsible for what at HHS? What is the timetable especially sans appropriations – e.g., no action taken until appropriations? Those items not requiring appropriations – e.g., reporting of crimes in LTC facilities

The CLASS Act CLASS (Community Living Assistance Services and Supports) Act, a voluntary insurance program for employees to help pay for their future long-term care and support at home. CLASS differs from Medicaid waiver HCBS in that Medicaid requires the beneficiary to need nursing home-level care. CLASS does not. Also CLASS can cover people who are not low-income enough to be Medicaid eligible.

The CLASS Act: Hugh Potential Good But Many Questions Will premiums be low enough to attract buyers while providing sufficient money for benefits? How much? How to market to people 45+ who are struggling to pay college (or day care), home mortgage, and saving for retirement? Must convince people they need this (they are at risk of needing LTC). How do we prevent adverse selection? How will HHS determine level of disability? (Law says 2 OR 3 ADLs) How does the CLASS Act interact with LTCI plans. (Who pays first if a person has both?) Program is offered through employers, so will employers offer the program (not mandatory) so that employees can participate?

PPACA: New Options for States to Provide Long-Term Services and Supports (Subtitle E) Sec. 2401. Community First Choice Option (Medicaid). Authorizes states to offer home and community-based attendant services and supports to Medicaid beneficiaries with disabilities who would otherwise require care in a hospital, nursing facility, intermediate care facility for the mentally retarded, or an institution for mental diseases. Effective Oct. 1, 2011, but sunsets after five years (according to Family Caregiver Alliance) Sec. 2402. Removal of barriers to providing home and community-based services. Gives states the option of: (1) providing home and community-based services to individuals eligible for services under a waiver (instead of a state plan amendment); and (2) offering home and community-based services to specific, targeted populations. Creates an optional eligibility category to provide full Medicaid benefits to individuals receiving home and community-based services under a state plan amendment.

PPACA: New Options for States to Provide Long-Term Services and Supports (Subtitle E) Sec. 2403. Money Follows the Person Rebalancing Demonstration. Amends the Deficit Reduction Act of 2005 to: (1) extend through FY2016 the Money Follows the Person Rebalancing Demonstration; and (2) reduce to 90 days the institutional residency period. Sec. 2404. Protection for recipients of home and community-based services against spousal impoverishment. Applies Medicaid eligibility criteria to recipients of home and community-based services, during calendar 2014 through 2019, in such a way as to protect against spousal impoverishment.

PPACA: New Options for States to Provide Long-Term Services and Supports (Subtitle E) Sec. 2405. Funding ($10 million per year for five years) to expand State Aging and Disability Resource Centers. Sec. 2406. Sense of the Senate regarding long-term care. Expresses the sense of the Senate that: (1) during the 111th session of Congress, Congress should address long-term services and supports in a comprehensive way that guarantees elderly and disabled individuals the care they need; and (2) long-term services and supports should be made available in the community in addition to institutions.

PPACA: Selected Medicare Provisions Medicare Rx Drug “donut hole” to be phased out. (“Donut Hole” – the gap in coverage that occurs after an individual spends $2,830 on Rx drugs and must pay 100% of costs in 2010 $250 rebate in 2010 for those entering the donut hole 50% discount on brand name drugs & 7% on generics in donut hole in 2011 gap gradually disappears until gone in 2020

PPACA: Selected Medicare Provisions Eliminates c0-pays and deductibles for most Medicare preventive services (e.g., colorectal cancer screening and mammograms) -- 2011 Provides for an annual “wellness visit” and personalized prevention plans – 2011 Reduces payments for MA plans (due to concerns that plans receiving more money per beneficiary than Original Medicare benes Many fraud & abuse-related provisions

The Picture for Funding EJA, OAA, SSBG & Other?

OAA appropriations: Title III (in thousands) FY 1993 FY 2000 FY 2003 FY 2010 93-10 $ 93-10 % Supp. Serv. $313,708 $310,082 $355,673 $368,348 +$54,640 +17% Home meals $89,659 $146,970 $180,985 $217,676 +$128,017 +143% Cong. meals $363,236 $374,336 $384,592 $440,783 +$77,547 +21% OAA Total $1,372,700 $1,513,048 $1,784,469 $2,341,722 +$969,022 +70% Source: CRS Report for Congress: Older Americans Act: History of Appropriations, FY1966-FY2004 FY 2011 Administration on Aging Justification of Estimate for Appropriations Committees FY 2010 appropriations conference report, H.Rept. 111-366

OAA appropriations: Title VII (in thousands) FY 1993 FY 2000 FY 2003 FY 2010 93-10 $ 93-10 % Ombudsman $3,870 n/s $16,827 +$12,957 +335% Prev. abuse $4,348 $5,056 $708 +16% Title VII $8,218 $13,181 $18,559 $21,883 +$13,665 +166% OAA Total $1,372,700 $1,513,048 $1,784,469 $2,341,722 +$969,022 +70% n/s= not specified Source: CRS Report for Congress: Older Americans Act: History of Appropriations, FY1966-FY2004 FY 2011 Administration on Aging Justification of Estimate for Appropriations Committees FY 2010 appropriations conference report, H.Rept. 111-366

Social Services Block Grant Recent History Who has heard of it? Former Title XX of SSA -- HUGE importance to states for human services 1996 Welfare Reform: Congress & Governors reduced SSBG from $2.8 B to $2.38 B, promising restoration to $2.8 B in FY 2003 Agreement broken; SSBG further reduced to $1.7 B – its current level (over $1 B less than in 1996 - in 1996 dollars) Repeated efforts to restore funding have been unsuccessful – But may again be fighting against further cuts! 3/25/2017

Gazing Into My Crystal Ball

Thank you!