Medicaid, Long Term Care and the Ryan Budget

As reported in the New York Times on Friday September 7, 2012, Center Attorney Toby Edelman writes to explain the importance of Medicaid to long-term care recipients, and how the Ryan Budget, which purports not to affect current Medicare beneficiaries, would actually have an "immediate and devastating impact" on those who rely on this vital program.

In March 2012, the House of Representatives passed the House Budget Committee Fiscal Year 2013 Budget Resolution, The Path to Prosperity: A Blueprint for American Renewal – called here, the Ryan Budget.[1]   In August 2012, the Republican Party adopted the Ryan Budget's principles for Medicare and Medicaid in its Platform for 2012, We Believe in America.[2]  Both the Ryan Budget and the Republican Platform purport not to affect current Medicare beneficiaries.  But the truth is that for current Medicare beneficiaries who live in nursing facilities, the overwhelming majority of whom rely on the Medicaid Program to help pay for their nursing home care, the impact of the Ryan Budget and the Republican Platform would be immediate and devastating.  Under both proposals, the Medicaid program would be immediately converted into block grants to states, threatening nursing home residents nationwide.  Fewer residents would be covered by Medicaid and more of the costs of nursing home care would be dramatically shifted to residents and states, and, for the first time, to residents' families.  Residents could be required to pay for prescription drug coverage under Medicare Part D, whereas, under current law, those with Medicaid have no cost-sharing.  Further, since the Ryan Budget specifically repeals "federally determined program requirements,"[3] all current federal standards of care for nursing home residents could disappear- a huge loss for residents and their families.

Nursing home care is expensive.  A study of the costs of nursing home care, released April 21, 2011 by John Hancock Financial, reports, "the national average annual cost of care in the U.S. is $85,775 for a private room in a nursing home; $75,555 for a semi-private room in a nursing home."[4]

Often forgotten, nursing home residents with Medicaid already pay for a considerable portion of the nursing home charges for their care.  They are required to contribute virtually all of their income toward the cost of their nursing home care, usually retaining only a small monthly personal needs allowance.[5]  In addition, states can recapture the cost of a Medicaid resident's nursing home care by placing a lien on the resident's property and by collecting from the resident's estate after the resident's death.[6]

The Kaiser Family Foundation reported in 2009 that "Direct out-of-pocket care spending by individuals and families accounts for 22 percent" of the $178 billion spent on nursing home care – more than $39 billion.[7]  Families already spend billions of dollars in caregiving that is never reimbursed by any public program.  AARP estimated the value of unpaid caregiving at $350 billion in 2006.[8] These families would face further financial hardships and even higher costs under the Ryan Budget.

Nursing Home Residents Could Lose Medicaid Coverage of Their Nursing Home Care

Nearly a million and a half people live in nursing facilities.  In June 2012, more than one million of them relied on Medicare or Medicaid to pay for their care in whole or in part – 14.4% (199,577 nursing home residents) relied on Medicare; 63.6% (881,467 nursing home residents), on Medicaid.[9]

However, while the Medicare program pays for many residents at the beginning of their stay,[10] Medicare actually provides a relatively short benefit for nursing home care.  On average, in 2009, Medicare paid for only 27.3 days of care in a benefit period and in 2010, 27.1.[11]  Most residents remain in a nursing home far longer than a month.  The National Nursing Home Survey (2004) reported, "The average length of time since admission for all current nursing home residents was 835 days," the median length of time since admission, 463 days.[12]  For most residents, Medicaid quickly becomes the primary payer for long-term care.  The Medicare Payment Advisory Commission (MedPAC) reported in March 2012 that in 2010, the median number of Medicare-covered days was 12% of total resident days;[13] Medicaid, 63% of total resident days.[14]

The Ryan Budget and the Republican Platform would unwind Medicaid, leaving nearly a million people without a secure source of funding for their care.

Even if States Choose to Pay for Nursing Home Care under a Block Grant Program, Medicaid's Current Financial Rules and Protections for Residents and Their Families Could Disappear

Although it is unlikely that states would stop providing at least some coverage for nursing home care, the specific services that would be covered, how much the state would pay for them, and how much residents and their families would be required to pay, would be likely to change drastically from current practice.

Under a Medicaid block grant program, states could reduce the types of services, or the duration of services, that they cover under a Medicaid nursing home benefit.  Many people who are currently entitled to comprehensive nursing home care could see their nursing home services reduced in scope or duration, or both.

States could also change the income, resource, and medical need eligibility rules.  Some residents could lose their eligibility for any Medicaid coverage of their nursing home stays.  Others could face new financial obligations since the Ryan Budget does not require states to continue current federal rules for Medicaid coverage of nursing home care.  Medicaid funding under block grants would not be Medicaid funding as it is known today.

The Republican Platform says, "Excessive mandates on [Medicaid] coverage should be eliminated."[15]  Four of the most significant current financial protections that have been enacted and mandated over the more-than-45-year history of the Medicaid program could be lost under a block grant.  They are:

• Relative Responsibility.  Since 1965, the Medicaid program has prohibited nursing facilities from requesting or requiring contributions from residents’ families.[16]  Adult children have never been legally responsible for paying for their parents' nursing home care under the Medicaid program.  That provision disappears if Medicaid is repealed.  States could require residents' families to contribute to the cost of their relatives' care, even as they address their own health care needs or seek to help a child attend college.
   
• Supplementation.  The Medicaid program requires that nursing homes accept the Medicaid rate as payment in full for covered services.[17]  The prohibition on supplementation means that nursing homes are not allowed to ask residents or their families to pay any amount above the Medicaid rate for services that are covered by Medicaid – to "supplement" the Medicaid rate.  Loss of this protection means that residents receiving Medicaid coverage could be asked to supplement the Medicaid payment with their (or their families') personal funds.  Inability to supplement the Medicaid rate could disqualify individuals from admission to, or continued stay in, a nursing home.
• Liens and Estate Recovery.  Under current law, states cannot place a lien on a home where a Medicaid beneficiary's spouse, dependent or disabled children, or certain siblings live.  States cannot foreclose on a lien on a beneficiary's home if adult children live there who cared for the Medicaid beneficiary before the beneficiary received Medicaid.  Similarly, states cannot recover from a deceased beneficiary's estate while a spouse or dependent child is living. These protections are lost if Medicaid becomes a block grant program.  States could place liens on residents' homes and force foreclosure, or recover from a deceased resident's estate, depriving the resident's spouse and dependent or disabled children of their home or other assets on which they may depend.
• Spousal Impoverishment.  Since 1987, the Medicaid law has recognized that the spouse of a nursing home resident needs to retain some of the couple's income and assets in order to be able to continue living in the community.[18]  The loss of this statutory protection could return the country to the time when all of a couple's money was used for nursing home care and the spouse in the community was left with, literally, no income at all.

Medicare and Medicaid Law Establish the Standard of Care in Nursing Facilities

The Medicare and Medicaid programs do more than provide funding for nursing facility residents' care.  The Nursing Home Reform Law,[19] which was enacted during the Reagan Administration as part of the 1987 Omnibus Budget Reconciliation Act, amended the Medicare and Medicaid statutes to set out a comprehensive framework for nursing home law – the standards of care that facilities must meet as well as a regulatory structure to ensure that the standards are met.  If Medicare and Medicaid are repealed, the Reform Law will be gone, with all of its provisions governing the care of residents and enforcement of those standards.[20]

Standards of care that will be lost if Medicare and Medicaid are restructured as planned in the Ryan Budget include:

• Requirements that facilities' multi-disciplinary teams comprehensively assess each resident and develop an individualized plan of care to meet each resident's medical, nursing, therapy, activities, and social services needs;
• The requirement that facilities actually provide each resident with care and services to maintain each resident's "highest practicable physical, mental, and psychosocial wellbeing;"
• The requirement that facilities respect residents' rights, including rights to privacy, access and visitation rights, protection from discrimination, protection of resident funds, and transfer and discharge rights;
• The requirement that nurse aides be trained and demonstrate competency before providing care to residents.

The Nursing Home Reform Law also requires annual surveys and investigations of complaints and sets out a system of remedies that may be imposed against facilities that fail to provide residents with the quality of care and quality of life they need. 

Conclusion

The Ryan Budget and the Republican Platform claim they will not affect current Medicare beneficiaries.  But the limited Medicare benefit for nursing homes means that many current Medicare beneficiaries rely primarily on the Medicaid program to help pay for their nursing home care.  Proposed block grants for Medicaid would eliminate the financial and quality of care protections that residents and their families have relied on for decades.  Further analysis of the Ryan Budget and the Republican Platform must await actual legislative language.  The implications for current nursing home residents and their families could be worse than the facts and predictions discussed here, but the broad proposals outlined in the Ryan Budget and republican Platform would likely raise costs and erase critical protections and rights of America’s nursing home residents.