The Generation Project






Bring home the promise of choice for nursing care


April 17, 2005

The Indianapolis Star


Our position: Indiana should heed the success of other states and begin implementing its home- and community-based nursing care law.


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.


It’s motherhood and apple pie,” she observes. “Our preference would be for care to be delivered at home or in the community versus institutions.”


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 self-directed care.

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 at present.


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.