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Unmet Long-Term Care Needs: An Analysis of Medicare-Medicaid Dual Eligibles

Posted on: Tuesday, 20 September 2005, 03:01 CDT

People who are dually eligible for Medicare and Medicaid are the focus of fiscal struggles between federal and state governments. Drawing on a survey of community-based elderly "dual eligibles," this paper examines how well their medical and long-term care needs are being met under the current combination of Medicare and Medicaid policies. While few people report difficulty getting medical care, 58% of people needing long-term care (help with activities of daily living) report unmet needs. As a result, many experience serious consequences, such as falls. Although unmet needs are substantial in all six states surveyed, we find the greater the use of paid home care in a state, the lower the likelihood of unmet needs, suggesting states' policies can make a difference.

Whether the focus is on Medicare or Medicaid, "dual eligibles"- low-income older people and individuals with disabilities who are covered by both Medicare and Medicaid-loom large in policy discussions. This population is relatively small in number, consisting of about seven million people in 2000, less than one- fifth of each program's total number of beneficiaries (Kaiser Commission on Medicaid and the Uninsured 2003, 2004). Yet this group of beneficiaries consumes a substantial portion of each program's resources-24% of Medicare's total spending in 2000, and 42% of Medicaid's in 2002 (KCMU 2004). Given their fiscal importance, it is no surprise that dual eligibles capture the attention of policymakers grappling with program costs.

This attention has made dual eligibles a "hot potato" in a fiscal struggle between the federal government and the states. Simply put, each level of government would like to shift its responsibility for dual eligibles to the other. The federally run Medicare program is responsible for insuring health care for virtually all people age 65 or older, regardless of income, and for people with disabilities two years after they qualify for Social security's disability benefit. Funding comes from a mix of the Medicare Trust Fund, tax revenues, and beneficiary premiums. Medicaid-which is run by the states with state and federal governments sharing the financing-is responsible for filling Medicare's gaps in coverage for low-income enrollees.

Recent policy debates have turned a spotlight on these overlapping federal and state responsibilities. The newly enacted Medicare Modernization Act reduced but did not eliminate limits to Medicare coverage that leave the states financially responsible for prescription drug costs of dual eligibles. Under the new law, Medicare will be responsible for drug benefits for dual eligibles beginning in 2006, but states must pay the federal government a specified proportion of the estimated amount they would have spent had they continued to provide drug coverage for dual eligibles (Health Policy Alternatives 2004). Even more costly to states than drug coverage, however, is Medicaid's responsibility for long-term care. This responsibility is not only for the poorest elderly and people with disabilities, but also for middleincome people who exhaust their resources purchasing acute or long-term care services. Fiscally strapped governors argue that both long-term care and health care expenses for the Medicare population should be a federal, not a state, responsibility (National Governors Association 2005).

Current governors are not the first to raise the question of which level of government should be responsible for low-income elderly people and low-income people with disabilities. The question has been integral to debates about public spending and the size of government for decades. Its appearance on the current political agenda arises from both federal and state fiscal concerns. The federal government's interest is in limiting the expense of a new Medicare drug benefit and the federal contribution to Medicaid spending. State governments-facing extraordinary budget pressures- want relief from existing obligations and are understandably resistant to be left holding the bag for a costly and growing population.

This fiscal struggle between levels of government tends to obscure what is really at stake in policy proposals for both Medicare and Medicaid: the capacity to meet the service needs of vulnerable elderly and disabled people. This article aims to redress the balance by focusing directly on the people at risk. Drawing on data from a 1999 survey of community-based (that is, people not living in nursing homes) elderly dual eligibles, this paper describes who these elderly dual eligibles are and examines how well- under current policy arrangements-their needs are being met.1

In brief, we find that community-based elderly dual eligibles are disproportionately poor, sick, and living alone, compared with other community-based elderly Medicare beneficiaries. Despite their significant need for health care, few report difficulty getting medical care when they need it. But a large proportion of dual eligibles who need long-term care (that is, help from another person with fundamental tasks of life) report they do not get such care- and, as a result, experience serious consequences (falling, soiling or wetting themselves, or being unable to bathe or wear clean clothing). Fortunately, policy appears to make a difference to these outcomes. Although unmet needs are substantial in all states surveyed, analysis indicates that the broader the access to paid (publicly supported) care in a state, the lower the incidence of unmet needs. If the nation's goal is to assure adequate care and quality of life for its most vulnerable citizens, the policy debate should emphasize the importance of promoting, rather than avoiding, responsibility for adequate service.

Medicare and Medicaid Responsibilities for Dual Eligibles

For the full Medicare population, regardless of income, Medicare pays, on average, just over half of each enrollee's health care costs (excluding long-term care) (CMS 2002). The remaining expenses are paid for out of pocket by the enrollee, or by Medicaid, private supplemental insurance, or other sources. Medicare's current benefits include inpatient and outpatient hospital, physician, diagnostic laboratory, and other professional medical services. Medicare requires enrollees to pay a premium toward the cost of some of these benefits ($78.20 per month in 2005) and to pay deductible or coinsurance amounts for most covered services (CMS 2005). For example, for most physician services, the enrollee is responsible for an annual deductible of $110 plus coinsurance equal to 20% of the Medicare-approved amount for services (after the deductible).

Medicare does not cover most long-term care or, until 2006, outpatient prescription drugs. However, it does provide limited coverage of skilled nursing facility care and home health care for enrollees who have skilled care needs and meet certain other criteria. Among elderly Medicare enrollees, out-of-pocket expenses (for Medicare cost-sharing and uncovered medical and long-term care services) absorbed on average about one-fifth of income in 2000.2

In general, Medicare enrollees can qualify for Medicaid if they have very low incomes and assets or have somewhat greater resources but medical or long-term care expenses high enough to exhaust those resources. Because states have considerable flexibility in designing their Medicaid programs, benefits and eligibility criteria differ from state to state. Medicaid eligibility rules and benefits also may vary among categories of individuals (for example, nursing home residents).3

Most dual eligibles qualify for full Medicaid benefits under their state's program-that is, they satisfy the income and other Medicaid eligibility criteria that would apply in their state regardless of their Medicare status. There are a number of ways elderly people may qualify for full Medicaid benefits (Schneider 2002). Under federal rules, most states are required to provide Medicaid coverage to recipients of the Supplemental security Income (SSI) program; for an individual in 2004, the income limit to qualify for SSI is equivalent to 74% of the federal poverty threshold, and the limit on non-housing assets is $2,000 (KCMU 2004). In addition, many states (19 states as of April 2001) cover elderly people who have incomes up to 100% of the federal poverty threshold and assets that do not exceed the SSI threshold (Schneider 2002). There are two other major ways people qualify for full Medicaid benefits. One is by qualifying under statespecific "medically needy" programs that allow people to exclude medical and long-term care expenses from income in determining whether they meet specified income limits. The other is for nursing home residents who have incomes below a state-designated cap of up to three times the SSI income eligibility level and meet the SSI asset test.

For dual eligibles with full Medicaid benefits, Medicaid pays for services that Medicare does not cover and, for the most part, the Medicare premium and some cost-sharing amounts. The predominant services that Medicaid covers for dual eligibles are long-term care (nursing home and home and commu\nity-based care) and prescription drugs. For example, in a study of four states, 78% of Medicaid's spending for elderly dual eligibles in 1995 was for long-term care and 8% was for prescription drugs (Komisar, Feder, and Gilden 2000). These were also the top categories for community-based elderly dual eligibles; home care accounted for 61% of Medicaid's spending for this group and prescription drugs accounted for 15%. Medicaid also pays for other services not covered by Medicare, such as transportation for medical care, eyeglasses, hearing aids, and dental care.

For a minority of dual eligibles-about 15% in 2000-Medicaid provides more limited assistance, paying only for Medicare's premiums and some cost-sharing, or assisting only with premiums (KCMU 2003). These are Medicare enrollees who are eligible under federal rules for Medicaid assistance as Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicare Beneficiaries (SLMBs), or Qualifying Individuals (QIs), but who do not meet their state's rules for full Medicaid benefits.4

Dual eligibles have been a focus of attention for some time, but few empirical studies have examined the extent to which their needs for medical and long-term care are being met. Several studies have drawn attention to dual eligibles' above-average needs for medical and long-term care services and their relatively high Medicare and Medicaid spending, and have underscored the importance of Medicaid's role in filling gaps in coverage for low-income Medicare beneficiaries (for example, KCMU 2004; Feder 1997). Some have focused on the potential interaction between Medicare home health and Medicaid home care use or spending (for example, Kenney and Rajan 2000). Few studies, however, have assessed the adequacy of care in addressing dual eligibles' needs. Merrell, Colby and Hogan (1997) found that dual eligibles (of all ages) may experience greater barriers to obtaining medical care than other Medicare beneficiaries. Other research has examined unmet needs for long- term care among a broader population of people with disabilities, but has not focused on dual eligibles (for example, Laplante et al. 2004; Lima and Alien 2001). Our study provides two unique, as far as we are aware, contributions to the literature. First, it takes a close look at unmet needs for long-term care and the consequences for a dually eligible population. second, it examines how the prevalence of unmet needs varies among states with differing policy environments.

Survey of Dual Eligibles' Experiences

To assess the needs of dual eligibles and how well those needs were being met, the Robert Wood Johnson Foundation and the Commonwealth Fund supported a survey, in 1999, of community-based (that is, people not living in a nursing home) elderly dual eligibles in six states: Georgia, Iowa, Massachusetts, New Jersey, Washington, and Wisconsin. The states were chosen to reflect variation with respect to Medicaid home care (including both personal care and home health care) spending and Medicare home health spending, along with variation generally in Medicaid programs and geographic location. Further, the range of state characteristics reflects the range that exists among states nationwide.

The sample for the survey came from Medicare enrollment data for 1997, the most recent full year of enrollment data available at the time. The sample was restricted to people with a full year of dual enrollment, so individuals turning 65 in 1997 were not included. At the time of the survey (1999), the people in the sample were age 67 and older. Dual eligibility status was based on monthly indicators in the Medicare record that the person's Medicare premiums were paid by Medicaid (often referred to as state buy-in). Medicare enrollment data do not indicate whether people are eligible for full Medicaid benefits in their state or only for limited Medicaid assistance; however, as described previously, the overwhelming majority of dual eligibles are eligible for full benefits. Enrollment data also do not indicate whether a person resides in the community or in a nursing home. Of the people in the original sample, two-thirds were determined to be eligible for the survey; the rest were living in a nursing home or other facility (27%), had died (5%), or had moved to another state (1%).

Interviewers collected data primarily by phone, but one-fifth of completed interviews were conducted "face to face" to include people who did not have a phone (or an obtainable phone number) or who were only willing to participate in person. Among the 2,777 eligible people, the response rate was 77%. The response rate ranged among the six states from lows of 60% in Massachusetts and 70% in Washington to highs of 87% in Georgia and 88% in Iowa.6 Overall, about one-fourth of the completed interviews were with proxy respondents. Proxy respondents were interviewed when the subject person was unable to participate because of illness, cognitive impairment, or other reasons. Previous literature suggests that the use of proxy respondents for elderly adults may lead to somewhat overstated estimates of disability level (Todorov and Kirchner 2000). Based on previous literature, we do not expect significant biases in our results from the use of both telephone and face-to- face interviews; for example, in a study of older adults, Herzog and Rodgers (1988) found little difference in responses between those collected by phone and during face-to-face interviews.

After excluding a small number of participants because they had missing answers to a preponderance of questions, the sample size for this study was 2,123 people.7 Sample sizes in the individual states ranged from 298 in Massachusetts to 450 in Georgia. Data were adjusted to be representative of the community-based, elderly dual- eligible population in each of the six states.8

Characteristics of Dual Eligibles

Based on the combined data for the six survey states, community- based elderly dual eligibles are more likely to be female, widowed, living alone, and have low income than other communitybased elderly Medicare enrollees in these states (Table 1). In the six states, women constitute 77% of community-based elderly dual eligibles (compared with 57% of community-based elderly Medicare enrollees). Over half the dual eligibles (52%) are widowed and one-fifth (19%) are divorced or separated. Over half-53%-live alone (compared with 30% of all community-based elderly Medicare enrollees in the six states). Nearly one-third live with relatives or others (and not with a spouse). Among respondents reporting income, nearly one- quarter report that their household income is less than $5,000 a year and 87% have annual incomes of less than $10,000. In contrast, 10% of all community-based elderly Medicare enrollees in the six states had incomes below $10,000 in 2000. Overall, the characteristics of all community-based elderly Medicare enrollees in the six states are similar to those of community-based elderly enrollees nationwide.

The characteristics of elderly communitybased dual eligibles vary somewhat among the states, reflecting the differences in the states' general populations and, probably to a lesser degree, differences in their eligibility criteria for Medicaid. For example, these dual eligibles are relatively older in Iowa, where 33% are age 80 or older, and relatively younger in Washington, where 25% are age 80 or older (data are not shown). The distribution by race and ethnicity differs significantly, reflecting variations in the composition of the states' overall populations. The majority of elderly community- based dual eligibles are white, non-Hispanic in Iowa, Massachusetts, Washington, and Wisconsin. In Georgia, the black, non-Hispanic population is the largest group (54%). In New Jersey, 43% of elderly community-based dual eligibles are white, non-Hispanic; 24% are black; 23% are Hispanic; and 10% are of other, or unreported, racial or ethnic backgrounds. Georgia and New Jersey have the highest proportions of people with incomes less than $5,000-39% and 27%, respectively, compared with 11% to 13% in the other four states.

Health and Long-Term Care Needs of Dual Eligibles

Health care problems are prevalent among dual eligibles. Half of these elderly dual eligibles are in fair or poor health (Table 2). Chronic diseases are common-92% report at least one chronic condition and half the population has three or more chronic conditions. The most commonly reported conditions are: arthritis (65%), high blood pressure (62%), and heart conditions (40%).

Consistent with their relatively poor health status, dual eligibles use a lot of health care services. Forty-five percent of these community-based elderly dual eligibles reported using hospital care (emergency room, inpatient care, or both) in the previous year- 35% used the emergency room and 29% had a hospital stay of at least one night (19% did both). The overwhelming majority88%-take prescription medications. Over onethird (35%) are taking five or more prescription drugs.

In addition to medical care, one-third (32%) of these community- based elderly dual eligibles need long-term care-that is, the help of another person with fundamental, routine tasks such as bathing and getting in and out of bed. Specifically, people with long-term care needs include both individuals who receive help from another person and those who do not but report a need for assistance with one or more activities of daily living (ADLs): bathing, dressing, eating, using the toilet, getting out of bed or chairs, and moving around inside the house.9 One in seven people (14%) needs help with at least three ADLs. Bathing is the activity for which help is most often needed (among people who need long-term care, 85% need help with this activity), followed by dressing (53%), getting in and out of bed or chairs (46%), moving around inside the house (42%), using the toilet (23\%), and eating (13%).

Table 1. Characteristics of communitybased dual elderly eligibles in six states compared with all community-based elderly Medicare enrollees in the six states and nationwide

Dual Eligibles' Access to Medical Care

The results of the survey suggest that, overall, community-based elderly dual eligibles encounter few problems obtaining medical care. Only 3% report not having a regular physician or other regular source of care, a commonly used indicator of access to care. Similarly, very few people (4%) report that, because of their insurance, their doctor refused to treat them or they had to change providers. Access to medical specialist care is also good overall: among people who were referred for specialist care or thought they needed it (39%), only 1 % were unable to arrange this care. However, another 7% did not try to arrange this care because they did not know how, did not have a referral, or were concerned about the cost.10

Table 2. Health status and long-term care need of community- based elderly dual eligibles

Although 29% reported having problems paying for basics, such as rent, during the past yearand 15% expressed difficulty in paying medical bills-financial problems generally do not appear to be preventing people from getting the medical care or drugs they need. Only 4% said they delayed getting medical care or went without medications because of financial problems.11

Dual Eligibles' Access to Long-Term Care

The results of the survey are more troubling in their implications for the adequacy of long-term care services for dual eligibles. Access to longterm care typically is assessed differently from access to medical care because much of longterm care is not purchased but instead is provided by family members. To assess how well the combination of paid services and unpaid assistance was meeting people's long-term care needs, the survey identified individuals receiving help with ADLs from another person, and asked both people receiving help and those not receiving help whether they needed more assistance with ADLs. We denned a person to have unmet needs for help with a specific ADL if that individual received some help with the activity but needed more, or received no help but needed some. A person was denned as having any unmet need if unmet need existed for one or more of six ADLs.

The survey results indicate widespread shortfalls in people's ability to get needed care. Among elderly community-based dual eligibles needing assistance with ADLs, over half (58%) have some unmet need (Table 3). About 28% report that they "frequently" need more help. Another 24% "occasionally" need more help and 5% "seldom" need more. The proportion of people reporting unmet needs rises with disability level, with 72% of people who need help with five to six ADLs reporting unmet need, compared with 48% of people who need help with one to two ADLs.

The survey indicates that unmet needs can have serious consequences for the people reporting it. Overall, 56% of people with any unmet need for help with ADLs report at least one of five serious consequences because of a lack of assistance (Table 4). Among the people with any unmet ADL need, 33% are not able to bathe or shower as often as they want, 28% have fallen out of a bed or chair, and 15% have wet or soiled themselves, all because of a lack of help. Among people with unmet need for specific activities: 42% of those who need more help bathing have been unable to bathe, 48% of those who need more help getting in and out of bed or chairs have fallen, and 56% of those who need more help using the toilet have wet or soiled themselves.

Table 3. Prevalence of unmet need for help with activities of daily living (ADL)

Table 4. Prevalence of adverse consequences because of a lack of help among people with unmet need for help with ADLs

Impact of Public Policy on Adequacy of Long-Term Care

Given their very low incomes, dual eligibles' access to paid services likely depends heavily on state Medicaid policies- specifically, the degree to which they support service provision. Medicaid's role in supporting these services, along with the limited availability of family members in the dual population, is apparent from the importance of paid services for this population. According to the six-state survey, among community-based dual eligibles needing long-term care, over half (54%) receive assistance from home care agencies or other paid sources (such as independent home care aides). Two-thirds of these also receive unpaid assistance, while the other one-third (or 17% of the overall group who need long-term care) receive only paid help. Among the 46% of dual eligibles with long-term care needs who do not receive paid care, the overwhelming majority are assisted by unpaid family members or friends. Still, 4% of all people needing long-term care report receiving no help at all.

Some unmet needs are probably inevitable, but the high level of unmet needs and the fact that 46% of those with needs receive no paid care indicate that the Medicaid and Medicare programs are falling short of adequate service for a large number of people. For policy purposes, a key question is whether paid home care-primarily the scope of Medicaid support-makes a difference to unmet needs.

The answer appears to be yes. Although unmet need is prevalent among both people with and without paid care, the survey results indicate that the receipt of paid care substantially reduces the level of unmet need. Holding disability level constant, people with paid care are significantly less likely to have unmet needs than those who do not get paid care. For example, for people needing help with three to four ADLs, the proportion reporting unmet need is one- fifth lower among those receiving paid care (63% have unmet needs) than those who do not receive paid care (79% have unmet needs). Significantly, the difference paid care makes is greatest among people with the most severe disabilities: for people needing help with five to six ADLs, paid care reduces the likelihood of unmet needs by one-quarter (from 87% to 66%).

Recent studies have demonstrated the substantial differences across states (and communities within states) in the people who get Medicaidfinanced long-term care and how much they actually receive (U.S. GAO 2002; Summer 2003). Among the six states in the survey, there are considerable differences in the proportions of people receiving paid care at home. Consistent with the finding that paid care matters, the data indicate a pattern of lower unmet need for assistance with ADLs in states where a higher proportion of people get paid care (Figure 1). The proportion of people receiving paid care is lowest in Georgia (31 %)-and the proportion of people with unmet need is highest (65%) there. At the other end of the range, in Iowa 68% of people with long-term care needs receive paid care (the highest of all the states) and 47% have unmet need (the second lowest after Wisconsin at 42%). This pattern suggests that state policies that result in greater use of paid care may lead to more people obtaining the long-term care they need.

Lessons from Dual Eligibles' Experience for the Policy Debate

The characteristics of the elderly dual eligible population demonstrate how much both Medicare and Medicaid matter to this highly vulnerable population. Their multiple chronic conditions, high use of medical services and prescription drugs, and impairments in activities of daily living-along with the low incomes that qualify them for Medicaid-are evidence of their needs for the medical and long-term care services that it currently takes both programs to provide.

With respect to medical care, the finding that the vast majority of elderly dual eligibles report little difficulty getting medical services provides evidence of Medicare's effectiveness-in conjunction with Medicaid's supplementation of cost-sharing-in serving this population.

By contrast, the prevalence of unmet need for long-term care (assistance with ADLs) at home is striking. Although "unmet need" is subjective and reflects diverse situations, its association with significant consequences-falling, soiling oneself, or being unable to bathe or put on clean clothes-requires that it be taken seriously as an indication of inadequate care. Inadequate care may potentially lead to greater costs for medical care if a person becomes injured or sick as a result. It may be difficult to assure that all of a person's needs are met; however, that the same type of person would be much more likely to face unmet need in one state than in another is evidence that states' Medicaid policies can make a major difference to the quality of life for people who depend on Medicaid.12

Figure 1. Use of paid home care and prevalence of unmet need, by state (Source: Authors' analysis of data from the 1999 Survey of Dual Enrollees in Six States. N = 738 people who need help with ADLs. Sample sizes for individual states are: 160 in Georgia; 124 in New Jersey; 149 in Washington; 96 in Massachusetts; 106 in Wisconsin; and 103 in Iowa. LTC = long-term care.)

What do these findings mean for the current policy debate over federal versus state responsibility for dual eligibles? Perhaps most important, the findings indicate that the focus should be directed more toward serving than avoiding the dual eligible population. Medicare-in combination with Medicaid's supplementation-assures access to medical service for its lowest income beneficiaries just as it does for the financially better off. Medicaid, a means-tested program, on its own has never provided the same guarantee of access. In particular, access to home and community-based services has always been explicitly limited, provided primarily through "waivers" from Medicaid requirements that allow, among other things, limits on the size of the population being served.

In recent years, states have expanded signif\icantly their support for home and communitybased services. Between fiscal years 1990 and 2002, Medicaid spending on home and community-based care increased from $3.9 billion to $24.7 billion, and from 13% to 30% as a share of total Medicaid spending for long-term care (and from 5.6% to 10.2% of total Medicaid spending) (Burwell, Sredl, and Eiken 2003). Fiscal pressures on the states, however, may challenge further movement in this direction, or even lead to deterioration in the provision of home and community-based services.

The availability of home care benefits-as much if not more than other Medicaid benefits-will inevitably vary across states, given the autonomy states have to establish both the eligibility for, and scope of benefits. Evidence beyond this study (GAO 2002; Summer 2003) demonstrates the way specific policies create that variation, with the result that services available to a person in need of care in one state may not be available to a person in identical circumstances in another. Given differences across states in the aging of their populations, variation in the availability of long- term care services is likely to widen (Merlis 2004).

Assurance of support for dual eligibles in need of long-term care, regardless of the state in which they live, clearly will require a change in federal policy. One such change could substitute a universal, federally defined benefit, in or out of Medicare, for the varied benefits that Medicaid now provides. Perhaps more likely, given fiscal concerns about Medicare's future and controversy over the still-to-be-implemented prescription drug benefit, Medicaid could be altered to establish greater uniformity across states- through increased if not full federal responsibility for financing service to the dual eligible population, accompanied by federal standards for benefits and eligibility.

Even accomplishing this limited reform, however, runs counter to current federal efforts to constrain federal Medicaid expenditures. The Bush administration has actively pursued the substitution of fixed or "block grant" funding for the current open-ended federal matching of states' Medicaid spending-a policy likely to exacerbate rather than reduce variation in service across states.

From a fiscal perspective, either level of government-federal or state-would be better off if the other were to bear responsibility for this highly vulnerable, expensive population. However, from the perspective of dual eligibles, enhancement-not retraction-of federal responsibility is essential to better meet critical longterm care needs.

Notes

The Commonwealth Fund supported the preparation of this paper. The Robert Wood Johnson Foundation and the Commonwealth Fund jointly supported the survey used in this research. The authors are grateful to Barbara Cooper and Cathy Schoen at the Commonwealth Fund and Susan Rogers Mathieu, formerly at Georgetown University, for their contributions to this research, and to Donald Jones at Georgetown University for programming and research support. The views expressed here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.

1 Community-based elderly dual eligibles represent about half of all dual eligibles. About two-thirds of all dual eligibles are age 65 or older and, among elderly dual eligibles, about three-quarters live in the community (that is, not in nursing homes) (CMS 2002; Health Care Financing Administration 1997).

2 Estimated by the authors based on data in CMS 2002.

3 For a detailed description see Schneider 2002.

4 QMBs are Medicare beneficiaries with incomes at or below 100% of the federal poverty level (FPL) and assets up to $4,000 for individuals (or $6,000 for couples); SLMBs have incomes between 100% and 120% of the FPL and meet the same asset test as QMBs; and QIs have incomes between 120% and 135% of the FPL and meet the same asset test. For more information on these eligibility categories, see Schneider 2002.

5 The survey was designed by Judith Kasper and conducted by Westat, a research company in Rockville, Md.

6 The number of eligible people, response rate, and number of completed surveys are shown in the table.

7 Rates of missing responses to survey items for the remaining sample were generally low. When data were missing, we did not impute values. Instead, we generally used logically conservative approaches, such as not attributing a need for help or an unmet need to a person with missing information. Income is an exception; as indicated in the footnote to Table 1, we computed the distribution by income after excluding the approximate 15% of the sample with missing values.

8 Sample weights were provided by the survey contractor.

9 This definition enables us to focus on people with fundamental needs for personal assistance. Excluded from this definition are people who require assistance with instrumental activities of daily living (IADLs) only (such as help with housework, shopping, and preparing meals) or who rely solely on special equipment.

10 Niefeld and Kasper (2005) provide a detailed analysis of the survey's findings regarding barriers to access to medical and long- term care services.

11 This estimate may somewhat understate the total proportion of people who delayed or went without care (because of cost) because these questions were not asked of the 71% of the surveyed population who, in responding to a previous question, said they "never" had problems paying for basics such as rent and utilities.

12 To get a sense of how the patterns observed in our analysis compare with state spending for home care services, we examined Medicaid data from 1999. We summed: Medicaid home health and personal care spending for people age 65 (using Medicaid Statistical Information System [MSIS] data, available from CMS 2003); Medicaid spending for waiver services for "aged" eligibility category (available from Eiken, Burwell, and Schaefer 2004); and Medicaid spending for waiver services for "aged/disabled" eligibility groups, which we adjusted to roughly estimate the portion for people age 65 and over. (To adjust, we multiplied aged/ disabled waiver spending by the ratio of the number of aged enrollees to the sum of aged plus disabled enrollees.) We then divided the sum by the number of Medicaid enrollees age 65 or older in the state (available in MSIS data from CMS 2003) to roughly estimate state Medicaid spending for home care per person age 65 or older. The results were: $600 in Georgia, $720 in Iowa, $1,110 in Wisconsin, $1,230 in Washington and New Jersey, and $1,280 in Massachusetts. The rank among the six states differs from the results of our analysis in some interesting ways-in particular, Iowa has relatively low spending, but we found it to have high use of paid care; New Jersey has relatively high spending, but we found it to have relatively more limited use of paid care. Medicaid spending data provide an incomplete indication of how access to paid care varies among states. For example, in states where most spending is for home health, access to personal care may be quite limited. Similarly, in states where spending is dominated by waiver services, many people may not have access to this care because they do not meet eligibility rules or do not live in the areas where it is offered.

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Komisar, H. L., J. Feder, and D. Gilden. 2000. The Roles of Medicare and Medicaid in Financing Health and Long-Term Care for Low- Income Seniors. New York: The Commonwealth Fund.

LaPlante, M., H. Kaye, T. Kang, and C. Harrington. 2004. Unmet Need for Personal Assistance Services: Estimating the Shortfall in Hours of Help and Adverse Consequences. J\ournals of Gerontology 59(2):S98-S108.

Lima, J., and S. Allen. 2001. Targeting Risk for Unmet Need: Not Enough Help Versus No Help At All. Journals of Gerontology 56B(5):S302-S310.

Merlis, M. 2004. Medicaid and an Aging Population. Fact Sheet. Washington, D.C.: Georgetown University Long-Term Care Financing Project.

Merrell, K., D. Colby, and C. Hogan. 1997. Medicare Beneficiaries Covered by Buy-In Agreements. Health Affairs 16(1):175-184.

National Governors Association. 2005. Policy Position HHS-27. Medicaid Reform Principles Policy. Available at: http:www.nga.org/ nga/ legislativeUpdate/policyPositionDetailPrint/ 1,1390,5113,00.html Accessed May 16.

Niefeld, M. R., and J. D. Kasper. (2005). Access to Ambulatory Medical and Long-Term Care Services among Elderly Medicare and Medicaid Beneficiaries: Organizational, Financial, and Geographic Barriers. Medical Care Research and Review 62(3):300-319.

Schneider, A. 2002. The Medicaid Resource Book. Washington, D.C.: The Henry J. Kaiser Family Foundation.

Summer, L. 2003. Choices and Consequences: The Availability of Community-Based Long-Term Care Services to the Low-Income Population. Washington, D.C.: Georgetown University Long-Term Care Project.

Todorov, A., and C. Kirchner. 2000. Bias in Proxies' Reports of Disability: Data From the National Health Interview Survey on Disability. American Journal of Public Health 90(8):1248-1253.

U.S. General Accounting Office (GAO). 2002. Long-Term Care: Availability of Medicaid Home and Community Services for Elderly Individuals Varies Considerably. Report no. GAO-021121. Washington, D.C.: General Accounting Office.

Harriet L. Komisar, Ph.D., is an associate research professor, and Judith Feder, Ph.D., is the dean of public policy, both at Georgetown University. Judith D. Rasper, Ph.D., is a professor in the Department of Health Policy and Management at the Bloomberg School of Public Health, The Johns Hopkins University. Address correspondence to Prof. Komisar at Health Policy Institute, Georgetown University, Box 571444, 3300 Whitehaven St., N.W., Suite 5000, Washington, DC 20057-1485. Email: komisarh@georgetown.edu

Copyright Blue Cross and Blue Shield of the Rochester Area Summer 2005

Source: Inquiry - Blue Cross and Blue Shield Association

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