Bring home the promise of choice for nursing care
Our position: Indiana should heed the success of
other states and begin implementing its home- and community-based nursing
It’s a “motherhood and apple
pie” issue to state officials and a win-win in the eyes of
advocates for the elderly and disabled.
It’s also the law, and has been for two
years. The legislation signed by Gov. Frank O’Bannon in 2003,
passed without a single dissenting vote by the Indiana General Assembly,
mandates a “rebalancing” of long-term care toward home- and
community-based services and away from nursing homes.
It is time for the state, cautiously but
nonetheless decisively, to get moving. A burgeoning population of seniors
demands and deserves options to institutionalization, and recent history
says it’s good for society and good for the bottom line.
Other states have done it. They’re
assisting more people at lower cost, enabling thousands to postpone or
outright avoid the move to the most expensive and least popular setting
for nursing care. They have the support of the Bush administration, which
is boosting in-home care funding even while many social services are
facing cuts. They have the expressed support of the Daniels
administration as well.
So why isn’t it happening here? Why
does this state continue to rank near the bottom of the nation in the
percentage of Medicaid dollars (source of more than half of Indiana’s long-term care
funding) going to alternatives to nursing homes?
One factor is the changing of the guard. The
O’Bannon-Kernan administration had barely
over a year to work with Public Law 493 before plunging into an election.
The winners of that election have been in charge less than four months.
They have gone so far as to create a separate Bureau of Aging and In-Home
Services; but its director, Jackie Bouyea, says
“We’re still in the thinking-about-it stage” as far as
rebalancing is concerned.
motherhood and apple pie,” she observes. “Our preference
would be for care to be delivered at home or in the community versus
John Cardwell, director of the Generations Project,
the multi-agency advocacy group that crafted the legislation, says fare
more interest has been shown already by Bouyea
and her boss, Family and Social Services Administration Secretary Mitch Roob, than ever was evident from the previous regime.
Still Cardwell and his allies with AARP
Indiana, United Senior Action of Indiana and other groups feel the same
impatience as last year with a state government that frets about taking a
financial hit from the transition.
They are meeting with Bouyea
and Roob to find ways to obey a law that
prescribes, among other things, these specifics:
Raising the income eligibility threshold for
non-institutional care to the same level as that for nursing home care.
Now, someone taking in more than $545 per month is not poor enough for
Medicaid for in-home care; he can earn three times that and get Medicaid
to move into a nursing home, which will probably cost more and eventually
mean loss of his house.
Developing a system of non-nursing home services,
including assisted living, adult foster care, adult day care and
Seeking from the federal
government 20,000 new Medicaid “waiver slots” to fund
alternatives for persons who would otherwise enter nursing homes or
remain in nursing homes out of financial rather than medical necessity.
Roob warns that a large-scale
shift from brick-and-mortar institutions to widely scattered service
delivery might cause a business disruption that would leave some needy
people unserved unless taxpayers filled the gap
left by the market. Quality assessment fees, or “bed taxes,”
now being paid by nursing homes might cover some of that transition, Roob says; but questions remain as to who would get
the home- and community-based services and which investors and workers
would provide them.
Fair enough, say the advocates; but states
such as Vermont, Oregon, Colorado, Washington and Texas have more than managed. The
nursing industry already has demonstrated its adaptability to the market
for individual house calls and assisted-living apartment developments; in
fact, that’s a healthier sector of the business than nursing homes
Indiana has its own model and
mechanism to work with as well. For nearly two decades, with only state
funding, the nationally respected CHOICE program has been serving seniors
at home as an alternative nursing homes; it has a three-year waiting list
that Public Law 493’s Medicaid changes could whittle down.
Meanwhile, the state’s Area Councils on Aging already are
performing the job of matching recipients and services.
Roob and Cardwell agree that
implementation of Public Law 493 is roughly a four-to-five-year
proposition. Cardwell submits the nursing home population receiving
Medicaid, now about 27,000, could be cut nearly in half by then. Roob ventures no number.
Both men note that the state must brace for a
spike in the over-65 population. Those people will not be inclined to
settle for an outmoded system of late-life care that divests them of
their homes and independence before they’ve lost the capacity to
participate in society at large. The government cannot give all of them
all they want, but it is demonstrating growing recognition that their
assertiveness makes economic and social sense. Indiana stamped its recognition
with Public Law 493, and now must send clear signals it intends to obey.