ACP recommends finance reform to support long-term care services

Long-term services and support are critical to older Americans facing frailty, disability and other age-related complications, and the demand and cost of this care is expected to increase in the coming years, according to the ACP.

In a position paper published in Annals of Internal Medicine, Ryan Crowley, BSJ, senior associate for health policy at ACP, and colleagues said the number of Americans aged 65 years and older is estimated to grow from 56 million in 2020 to 73 million in 2030 — representing about 20% of the United States population.

As the aging population grows, so does the need for long-term services and supports (LTSS), which are typically delivered in assisted living facilities or the person’s home and include assistance with everyday tasks such as eating, dressing and bathing. More than half of people turning 65 years will develop a condition that requires paid LTSS, according to Crowley and colleagues.

Along with demand, the cost for LTSS “is expected to increase considerably over the coming decades, but policymakers have struggled to develop ways to ensure this need is met,” the authors wrote.

The LTSS sector already faces challenges like workforce shortages, coverage that is “complex and fragmented,” quality problems and keeping patients and providers alike safe from COVID-19, according to ACP.

“During the past few decades, policymakers have sought ways to make it easier for persons to receive LTSS in their homes and communities rather than nursing homes or other institutions; however, under Medicaid, states are required to provide institutional care, whereas home- and community-based services are covered as a state option and many enrollees do not have timely access to these services,” Crowley and colleagues wrote.

Short-term nursing home stays resulting from an acute illness are covered by Medicare, the authors explained, but enrollees who need additional LTSS “often spend down income and assets to qualify for additional coverage through Medicaid.” Many people who require LTSS are not eligible for public coverage and therefore pay for services out of pocket or rely on others for care.

In response to these barriers to access, the ACP stated that the LTSS sector “must be strengthened to ensure that patients can maintain quality of life and financial stability as they age” and that more must be done to improve LTSS.

The ACP offered several recommendations in this effort, the first being “a multipronged public-private sector approach to reforming LTSS financing.” According to the organization, this should include public and private entities developing “a nationwide information campaign to expand LTSS literacy and educate the public about preparing for future LTSS needs.”

The other specifics of this recommendation include the ACP’s support of:

• a publicly funded, universal catastrophic LTSS insurance program;

• policies to ensure front-end, private long-term care insurance (LTCI) is affordable, accessible and viable;

• standardizing insurance policies and policies allowing the sale of hybrid prices combining LTCI and other products and optional use of retirement funds for LTCI; and

• more funding and policy changes that expand home- and community-based services through Medicaid and other programs.

The ACP listed four more recommendations:

• Policymakers and employers should address workforce shortages in the LTSS sector by increasing wages and providing more benefits, comprehensive training and career advancement opportunities.

• Evidence-based interventions should be incorporated to improve LTSS quality, such as “robust monitoring, enforcement of quality reporting and improvement requirements” and “research and implementation of emerging alternatives to institutional care.”

• Research efforts should focus on the impact that ownership status has on the LTSS sector, including staff and patient safety, staffing ratios, cost and quality of care.

• Additional funding, staff support and assistance should be provided to LTSS organizations so they can implement emergency preparedness plans to better ensure patient and staff safety while also considering “the behavioral and social well-being of patients and staff ... to prevent unintended consequences, including depression and loneliness.”