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Population-Based Health Policy: Elderly


The elderly population in the United States is growing significantly. People who are 80 years and older most likely need long-term care due to severe disabilities.

The elderly population in the United States is growing significantly. In 2000, the population 65 years of age and older was estimated 35 million; however, this figure is expected to reach 72 million by 2030. Similarly, the number of individuals 85 years and older is predicted to be doubled from 4.2 million in 2000 to 8.7 million in 2030.

People who are 80 years and older most likely need long-term care due to severe disabilities. Long-term care includes health, social, housing, transportation, and an any other services that are required by individuals with physical, mental, or cognitive disabilities that hinder them to have independent living. The urgency for long-term care services is characterized by assessing an individual’s impairment of activities of daily living (ADLs), such as eating, dressing, bathing, toileting, and getting in and out of bed; and instrumental ADLs, such as laundry, housework, meal preparation, grocery shopping, transportation, financial management, taking medications, and communication through telephone. It is estimated that 12 million individuals in the United States need assistance with one or more ADLs or instrumental ADLs.1

Changes to Long-Term Under the Affordable Care Act

In 2010, the Affordable Care Act (ACA) provided new opportunities for elderly, caregivers, and individuals with disabilities. The law provides superior care by better coordinating medical care with easy accessible and participant-centered home and community-based services (HCBS); promotes better health through health education, assessment, disease prevention, and health promotion programs; and reduces cost through high-quality services, payment system reform, and fraud education and prevention.2

The ACA incorporated few programs and funding improvements to guarantee that people can receive long-term care services in their home or the community, which enhances existing tools and develops financial incentives for states to provide HCBS. The law enables states to target home and community-based supports to particular groups of individuals, to services that are available to more people, and to make sure the quality of the services provided. The ACA builds on successful models and provides incentives to states to extend efforts in order to offer people with disabilities more opportunities to receive long term supports and services they require in their communities with the help of programs, such as community first choice (CFC), state balancing incentive payments program, money follows the person (MFP) and demonstration grant for testing experience and functional assessment tools (TEFT).3

Community first choice

The CFC increased federal funding to states that choose to provide person-centered HCBS. The CFC helps to increase individuals’ abilities to live in the community,3 allows states to provide statewide HCBS with no enrollment caps, and assists people who would otherwise need an institutional level of care. States that decide to take this option receive a 6% increase in their medical assistance percentage for CFC services. In order to be qualified for CFC, beneficiaries must otherwise need an institutional level of care and meet the criteria for financial eligibility.

State balancing incentive payments program

As of October 1, 2011, the state balancing incentive payment program authorized grants to enhance access to non-institutional long-term services and supports (LTSS). The incentive payment program provides states that launch structural reforms to increase access to LTSS, which will ultimately increase the federal medical assistance percentage (FMAP). As a result, states that undertake less structural reforms have lower FMAP increases.3

Money follows the person

The MFP assists states to rebalance their Medicaid long-term care systems. Since December 2013, almost 40,500 individuals with chronic conditions and disabilities have been converted from institutions into the MFP program. The ACA encouraged more states to apply for the MFP program. The goals of MFP include increasing the use of HCBS and decreasing the use of institutionally-based services, eliminating barriers that prohibits the utilization of Medicaid funds in order to let people earn long-term care in the settings of their choice, reinforcing the capability of Medicaid programs to supply HCBS, and putting procedures in effect to provide quality assurance and improvement of HCBS.4 The MFP assists individuals to move out of institutions and into the HCBS. The MFP was set to expire in 2011; however, it was extended by the ACA for an additional 5 years. The MFP offers states 50% increase in federal matching for 1 year.3

Demonstration grant for testing experience and functional assessment tools

The TEFT program is created to test quality measurement tools and validate e-health in Medicaid LTSS. The TEFT aims to demonstrate personal health records and create a standard electronic LTSS record. With the help of the grant program, which is approximately $42 million, the Centers for Medicare & Medicaid Services is advocating the use of health information technology in the LTSS system. The TEFT grant program will provide important feedback on how electronic infrastructure as a means of improving health information exchange can be implemented in this component of the Medicaid system. In the US, states that are currently receiving the grant awards include Arizona, Colorado, Connecticut, Georgia, Kentucky, Louisiana, Maryland, and Minnesota.3

Costs of Long-Term Care

In 2009, the United States spent $205 billion on long-term care. In 2006, one-year nursing home stay cost an average of $76,000. In 2009, out-of-pocket payments by individuals and their families financed 22% of long-term care in the United States. Medicaid and Medicare pay 34% and 28% of U.S. long-term care expenditure respectively. In 2005, average out-of-pocket costs for healthcare paid by the Medicare beneficiaries estimated to be 20% of family income. One-fifth of these expenses went in nursing homes. Medicare pays for skilled care and not custodial care. Some of the examples of skilled services include changing the dressing on a wound, taking blood pressure, listening to the individuals’ heart and lung to identify heart failure or pneumonia, increasing patients’ awareness about diabetes, hypertension, heart failure, and other ailments, occupational therapy sessions for people with stroke, hip fracture, and other individuals to assist them reach their maximum potential level of functioning, and speech therapy for patients with speech deficits. On the other hand, Medicaid does not cover 24-hour custodial services that include assistance with ADLs and instrumental ADLs. In order to be entitled for Medicaid long-term coverage, families are forced to spend their savings. However, with the help of HCBS 1915(c) waivers, Medicaid recipients receive more care services than before. In 2005, Oregon assigned 71% of its long-term Medicaid dollars to HCBS program, whereas nationally Medicaid spent 35% of its money for this program.1

Access to Quality Care

One of the successful long-term care program that enhanced access to quality care is the On Lok program in San Francisco that was implemented in 1971. On Lok, which is a certified Program of All-Inclusive Care for the Elderly (PACE) amalgamates adult day services, in-home care, home-delivered meals, housing assistance, extensive medical care, respite care for caregivers, hospital care, and nursing care into one program. All of the services that are provided by the On Lok program are coordinated by a multidisciplinary team that include physicians, nurses, social workers, occupational therapists, and nutritionists. However, PACE sites care for fewer than 25,000 of the three million vulnerable elderly and disabled population in the United States.1

Expanding Program of All-Inclusive Care for the Elderly

The ACA had a significant role in creating few programs, including CFC, state balancing incentive payments programs, MFP, and TEFT to ensure that people can receive long-term services and support. However, the United States has not acquired a social health insurance program for long-term care. Such insurance programs will emphasize access to healthcare services on the basis of individual’s medical needs and essentially redistribute the wealth from the rich to the poor, well to the sick. These programs ensure that all residents, including the elderly, have reasonable access to medically necessary services and enhances long-term viability of the healthcare system. It is essential to expand the PACE to provide solutions to the existing problems of long-term care.


1. Bodenheimer T, Grumbach K. (2012). Understanding health policy: A clinical approach (6th ed.). New York: McGraw Hill Medical.

2. U.S. Department of Health and Human Services. (n.d.). Administration for community living. Retrieved from http://www.aoa.gov/aging_statistics/health_care_reform.aspx

3. Medicaid. gov. (n.d.a). Community-based long-term services & supports. Retrieved from http://www.medicaid.gov/AffordableCareAct/Provisions/Community-Based-Long-Term-Services-and-Supports.html

4. Medicaid.Gov. (n.d.b). Money follows the person. Retrieved from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/balancing/money-follows-the-person.html

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