Social security, medicare & medicaid, and the ppaca fall 2011 abridged


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  • Fertility rate below replacement rate Increased life expectancy due to improvements in public health
  • The age structure of the overall population is projected to change greatly over the next four decades (Figure 1). Much of this change is driven by the aging baby boomers and trends in immigration. Figure 1 illustrates the importance of the baby boom generation in shaping the overall population. In 2010, the baby boom generation will be 46 to 64 years old.4 The echo of the baby boom is also evident in the 2010 population pyramid for the age groups near 20.5 By 2030, all of the baby boomers will have moved into the ranks of the older population. This will result in a shift in the age structure, from 13 percent of the population aged 65 and older in 2010 to 19 percent in 2030.In 2010, 60 percent of the U.S. population will be aged 20–64. By 2030, as the baby boomers age, the proportion in these working ages will drop to 55 percent. Green color – 2010 Dark purple – 2030 Light purple – 2050 The aging Baby Boomers are going to dramatically affect society for many decades to come.
  • Dependency ratio – number of people per 100 who are too old or too young to be working and must DEPEND on productive wage earners. This is a measure of burden placed on working age population age 20-64 to support older people and children over the next 4 decades. Indicator of potential burden on those in the working population. Greater number = greater burden. Smaller portion working Larger portion of population depending on government services (or family/ personal savings) to get by. 2010 – 67 per 100 2030 – for every 100 people age 20 to 64, there will be 83 people who are probably too old or too young to be working. More retirees + fewer workers = trouble for the system. Dependency ratio and stress on Social Security system increases dramatically when cohorts of retiring workers are replaced by smaller cohorts of active workers.
  • Social Security Act of 1935 – old-age pension. Franklin D. Roosevelt’s “New Deal.” Defines age of retirement. Social Security is most important because it provides a foundation for retirement income. Social Security is the public retirement pension system administered by the federal government, the largest domestic government program today. Social Security covers almost all US workers except for some state and local government employees. The biggest controversies over Social Security revolve around this core retirement program, which is essentially a tax on wages during working years followed by a wage subsidy during retirement years. Strengthened with addition of survivors’ and dependents’ benefits (1939), disability insurance (1956), Medicare (1965), and automatic adjustment of benefits for inflation and supplement income (1972). The Social Security Act provided a safety net of income in return for a lifetime of employment; it never was intended to be the sole source of retirement income. It also provided a standard age by which retirement could be defined. Participation in the Social Security system is mandatory through payroll taxes called “contributions.” No means test is required to receive benefits; rather, it is an earnings-related program . Benefits are financed by payroll taxes paid by employees and employers on income up to a certain level. The richest retiree will receive benefits alongside the poorest retiree. Social Security was never meant to entirely fund seniors' expenses. It was never intended to be the sole income source for people in retirement. In fact, the large majority of beneficiaries have other income from a pension, savings, or continued part-time employment. Not surprisingly, up to 80% of Boomers plan to continue to work in some capacity after the traditional retirement age of 65. It was designed with the typical family of the 1930s in mind and was only meant to be a supplement to other forms of retirement income. In fact, when Social Security was created in 1935, only 5% of the population reached age 65. The planners assumed the fund would remain solvent because the life expectancies of the era would prevent most people from living long enough to collect benefits. The rising life expectancy we see today is both a blessing and a challenge. Now, those who survive to age 65 can expect to live 15 (men) to 20 (women) years longer. The problem with most entitlement programs – ends up costing far more than originally envisioned. As such, it provides only a bare subsistence. Social Security retirement benefits would average $12,000 a year for a single individual in 2006 (usually 50% more for a couple – around $18,000). Federal spending for Medicare, Medicaid, and Social Security are expected to surge, nearly doubling by 2035, as people live longer and spend more time in retirement. Further, advances in medical technology and prescription drugs will likely keep pushing the costs of health care. For those individuals born before 1938, the full retirement age is 65 years. Since 2003, the full retirement age has been rising. For example, a person born in 1955 will reach full retirement age at 66 years and 2 months; an individual born in 1960 will not reach full retirement age until 67 years. Social Security has decreased poverty rates of the elderly, particularly for female elderly. Half of the older women in the US would live in poverty without their SS income. Approximately 75% of the poor elderly are women who depend on SS as the major source of income. Women represent 60% of all SS recipients at age 65; at age 85, women represent 71% of all SS recipients. Demographic pyramid – going to square and then to inversion. Not enough young working people to support the burgeoning elderly population through decades of retirement. Phenomenon of retirement – How will it be redefined by the Boomers? Finally, some analysts advocate means testing retirement benefits—reducing or eliminating benefits to retirees who have substantial private pensions, savings, and other sources of retirement income. Critics of means testing point out that this approach would alter the very nature of the system from one in which all benefit to a system targeted at low-income workers. Such a change could also reduce the political viability of the system by reducing the constituency with a stake in the program. Administrative costs as well as incentives for people to “game” the system would also increase. * Distinction here between a SOCIAL program which helps all equally or in proportion to their taxation and a POVERTY program which disproportionately helps the poor.
  • The Medicare program was created in 1965 as Title XVIII of the Social Security Act. Its primary purpose was to provide health care coverage for the elderly, who were defined at that time as anyone 65 years of age or older. In 1972 provisions were added to the act to include people who were permanently disabled and those with kidney disease. Before Medicare, as many as half of people over age 65 were without health insurance, whereas today almost all people are covered. Much has changed in the Medicare population in more than three decades. Since 1965, life expectancy has risen from 70 to 77, and the 65+ population grew from 9% to 13% of the total US population. Medicare has had a major impact on the health of the elderly population: Since 1965, half as many Americans die of heart attacks and a third as many die of strokes, and this is a tremendous accomplishment. Medicare is the chief federal government program that pays for health care for 35 million Americans over age 65 and another 5 million disabled people of all ages. Medicare has serious limitations: It doesn’t pay for the first day of hospitalization; it doesn’t cover hearing aids, eyeglasses, or dental care. It also excludes long-term care coverage, except for limited periods after hospital discharge. The two main elements of the program are Part A, which provides hospital insurance, and Part B, which provides supplementary medical insurance that covers physician care, along with limited home and outpatient services. Part B is purchased by beneficiaries with payment of a small premium. That separation pretty well defines the major thrust of the program. It is oriented to the acute care, medical model. There is no Part C covering long-term care. Although some limited forms of long-term care coverage have been added over the years, this was not the original intent of the Medicare program. In recent years, Medicare has expanded coverage of preventive services to encourage older people to stay healthy. Medicare does not pay for onoing routine physical examiniations, but a one-time “Welcome to Medicare” preventive exam is covered. This is given within the first 6 months of enrollment in Part B. It covers a medical and social health history with attention to modifiable risk factors for disease, education and counseling about preventive services, and referrals for care if needed. Services covered during this examination include measurement of height and weight and blood pressure, vision screening, an ECG, routine immunizations as needed, education and counseling on how to stay well, and a list of recommended screening tests and a timetable for when they should be obtained. The following screeening tests are recommended by Medicare: Screenings for breast, cervical, vaginal, colorecttal, and prostate cancer; bone mass screening (once every 2 yrs for those at risk); fasting blood glucsoe screening (q6mos for those at risk); diabetes monitoring; flu, pneumonia & hepatitis B vaccinations; nutriton assessment; glaucoma screening; smoking cessation counseling. Medicare is an entitlement program (like Social Security), meaning that anyone belonging to a particular population group is entitled to coverage. It is available primarily on the basis of age. here historically has been no requirement that recipients demonstrate financial need (as there is with Medicaid) (“means testing”). The wealthiest retiree has enjoyed the same rights to Medicare coverage as the poorest. This has become a major issue in recent years as the program struggles to provide coverage for a population that has grown many times faster than was predicted. In fact, the funding source for the program, the Medicare Trust Fund, is currently in considerable jeopardy. Like Social Security, Medicare is funded from payroll taxes, with additional funding from general revenues and premiums from beneficiaries. Unlike SS, whose problems lie many decades into the future, Medicare faces short-term financing problems. Overall, Medicare spending has risen much faster than the cost of living, and thus it presents government policymakers with a serious problem of cost control. The Trust Fund-Part A is headed for insolvency by the year 2019 or 2017 unless actions are taken to change either its funding source or the way in which those funds are spent. The Part B (Supplementary Medical Insurance Trust Fund) is projected to last longer because beneficiary premiums cover about 25% of it. Based on US Census Bureau middle-range population forecasts, it is estimated that the Medicare costs for the oldest-old (85+) could increase sixfold by the year 2040. In light of these troubling forecasts and trends, there is serious discussion about the rationing of health care for the elderly in the future. When the 2003 Medicare prescription drug bill was passed there was a little noticed provision tacked on that added a "means" test to the bill.  M eans testing —reducing, eliminating, or charging more for benefits to seniors who have substantial private pensions, savings, and other sources of retirement income. Medicare means testing was implemented for the first time on January 1, 2007. The Part B premium is "means tested," meaning the government determines the Medicare Part B premium based on a person’s income. Seniors with incomes of $80,000 per year or higher will pay more for services than lower-income seniors. It also introduced a scale of premiums which goes up as income rises. Starting in 2007 the premium for Medicare Part B increases substantially for high income individuals.  This has affect about 2 million people.  The increase is in the form of a premium surcharge that is to be paid in addition to the normal Part B premium. This surtax is owed even if the individual Medicare recipient has not sign up for prescription drug coverage. Means testing radically changes the nature of Medicare. The program was designed as universal social insurance with everyone paying a uniform premium and receiving a standard package of benefits. Supporters of means testing argue that it's needed to cut Medicare costs and make the program more sustainable. Government estimates, however, indicate that higher premiums for some will not save Medicare. In 1965, when it was first enacted, Medicare spent a little more than $3 billion. Today, it spends more than $200 billion each year. Nearly two thirds of that total goes to hospitals, where acute and often high-technology care are provided. If health care rationing on the grounds of age were ever to be introduced, it would probably take place in the Medicare program and would show up in the large sector of Medicare concentrated in hospitals. Although Medicare expenditures have climbed dramatically, Medicare still covers only about half of the out-of-pocket expenses of older people; roughly the same percentage as when the Medicare program was first enacted in 1965. Part of the reason is that Medicare B reimburses 80% of physicians’ “reasonable charges.” In fact, the amount reimbursed may or may not reflect actual charges in a specific geographic area. Because of what limits on what Medicare will pay, around 30% of Medicare beneficiaries also have private Medigap insurance policies to cover the remainder of their medical bills.
  • Medicare Part C, formerly known as "Medicare+Choice," is now known as "Medicare Advantage". MA was brought into existence by Part C of Medicare. It involves p rivatized corporate sponsored health insurance rather than traditional government sponsored, single payer health insurance which is what  Medicare is.  This section of Medicare allows private companies such as UnitedHealth, Blue Cross Blue Shield, Humana, Kaiser, and Coventry Health Care to arrange care for Medicare beneficiaries enrolled in the plan. To join a Medicare Advantage Plan, one must have Medicare Part A and Part B before being able to get Part C. In addition, the enrollee might have to pay a monthly premium to the Medicare Advantage Plan for the extra benefits that they offer. Medicare now serves 44 million elderly and disabled people. More than 10 million of the 44 million Medicare beneficiaries (23%) are in the private Medicare Advantage plans. Many of these plans offer extra benefits like vision and dental care. But independent studies have found that the private plans cost the government more per person than traditional Medicare. Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006. Medicare Prescription Drug Plan (Part D): The Medicare Prescription Drug, Improvement and Modernization Act of 2003 added Part D. Medicare Part D pays for outpatient prescription drugs. See handout for details of deductibles, copayments, and the “donut hole.”
  • “A”
  • Original Medicare covers many health care services and supplies, but there are many costs (“gaps”) it doesn’t cover. A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover (such as copayments, coinsurance, and deductibles). In 2006, 18% of Medicare beneficiaries were covered by a Medigap policy. A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. During the open enrollment period which begins within 6 months of turning 65 or enrolling in Medicare Part B at 65 or older, a person may obtain a Medigap plan on a guaranteed issue basis (i.e. no medical screening required). Outside of open enrollment, the issuing insurance company may require medical screening and may obtain an attending physician's statement if necessary. Medigap insurance is not compatible with other forms of private Medicare coverage, such as a Medicare Advantage plan. If a senior is in the Original Medicare Plan and has a Medigap policy, then Medicare and the Medigap policy will pay both their shares of covered health care costs. Medicare pays first; then the Medigap policy pays its share. If a person is enrolled in a Medicare Advantage Plan, then the person doesn’t need and can’t use a Medigap policy. Medigap offerings have been standardized by the Centers for Medicare and Medicaid Services (CMS) into twelve different plans, labeled A through L, sold and administered by private companies. Each Medigap plan offers a different combination of benefits. The coverage provided is roughly proportional to the premium paid.
  • Medicare covers: “Skilled nursing care” in nursing facilities or units in hospitals. Skilled nursing (SNFs) may be free-standing or they can be units in hospitals or nursing facilities. Skilled nursing care is health care given when skilled nursing or rehabilitation staff are needed to manage, observe, and evaluate the patient’s care. Examples of skilled care include changing sterile dressings and physical therapy. Other “unskilled” care in nursing facilities is not covered at all by Medicare. Skilled services must be certified as necessary by a physician, be related to a hospital admission (occur within 30 days of a hospital stay of at least 3 days for the same condition), and be needed on a daily period, with the patient paying a portion of the cost from day 21 through 100. Medicare coverage of skilled nursing services is limited to 100 days per benefit period. A benefit period is defined as beginning when the Medicare beneficiary first enters the hospital until there has been a 60-day break in hospital or SNF services. Subacute care is not a separate category under Medicare. It is generally provided in Medicare-certified SNFs or units and is reimbursed through the SNF mechanism. Medicare has embraced home health care services. To receive that reimbursement, these services must be provided by agencies certified by the Medicare program. Medicare covers hospice care for people who are certified to be terminally ill, with 6 months or less to live. The care must be palliative rather than curative, and as with other types of Medicare coverage, must be delivered by a provider organization that is certified by that program. Medicare does not regularly provide coverage in settings such as assisted living or adult day care.
  • “ Never events” – in 2007 accounted for $22 billion in expenses: Wrong site surgeries Transfusion with the wrong blood Pressure ulcers (stage III and IV) Falls or trauma Iatrogenic/ nosocomial infections involving surgeries or catheters The 10 categories of HACs include: Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity Catheter-Associated Urinary Tract Infection          (UTI) Vascular Catheter-Associated Infection Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) - Mediastinitis Bariatric Surgery Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery Orthopedic Procedures Spine Neck Shoulder Elbow Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)        Total Knee Replacement        Hip Replacement
  • “C”
  • Medicaid – At the same time that the Medicare program was developed to provide health care for the elderly, Congress also created Medicaid as a program to provide health care for the poor. Enacted as Title XIX of the Social Security Act, Medicaid is different from Medicare in several very specific ways. Medicaid serves the "medically indigent," those have no other coverage, and cannot afford to pay for their own care. Medicaid is managed by state governments under federal guidelines. First, it has no age limitations but covers people of all ages. Second, it does have income restrictions, covering only those who are “medically indigent” and who cannot pay for their own health care insurance. Third, Medicare is funded and operated by the federal government, but Medicaid is jointly funded by the federal and state governments and is run by the states under federal guidelines. Finally, whereas Medicare coverage is limited in terms of the types of services covered and the length of time they are covered, Medicaid essentially covers most services needed by its beneficiaries. Recently, some clinics and physicians are refusing to accept Medicare assignments; some will not treat Medicaid recipients; and some limit the number (ratio) of Medicaid patients they will service. The problematic financial situation has numerous causes: high cost of well developed and technologically advanced treatments; high costs of malpractice insurance, aggressive lawyers, and large settlements; large gaps between the wealthy and the poor; expensive and extensive research necessary for development of new treatments; and others. Add to all those variables the extensive and mind-boggling demands within the insurance agencies themselves. Medicare and Medicaid are not always necessarily separate programs. In some instances, Medicare recipients with low incomes may also be eligible to receive aid from Medicaid. If someone is covered by both, first Medicare will pay, then Medicaid. For those who are fully covered by Medicaid, the Medicare health care coverage is supplemented by services provided under their respective State's Medicaid program. Some such services include: Nursing facility care beyond the 100-day limit provided by Medicare. Prescription drugs. Eyeglasses. Hearing aids. Medicaid is the primary public medical assistance provider in the state of North Carolina. The N.C. Medicaid program has served about 19% of the total state population in 2007, or 1 out of 5 every resident in the state. Nearly 10% and 16.2% of the total recipients were seniors and residents with disability, respectively. These groups account for 65% of total Medicaid expenditures, amounting to about $5.6 billion combined. Medicaid enrollees have increased by 2.3%, compared with data of previous year. Major reimburser of long-term care. Costs for LTC consumer 1/3 of Medicaid funds. The elderly and disabled account for 2/3’s of Medicaid expenditures. 60% of Medicaid funds spent for LTC involves costs for nursing homes. 50% of Medicaid dollars spent for elderly – cost of nursing homes.
  • In most states, Medicaid coverage is extensive, particularly in long-term care. This makes it a major source of funding for long-term care consumers and providers. Medicaid also serves as a backup to Medicare, paying for services for low-income elders beyond those covered by Medicare. Because Medicaid is a welfare-type program, it is not intended as a reimbursement source for anyone with other resources. This means that consumers must not be eligible for other forms of health insurance, public or private. They must also use up all of their available resources before becoming eligible for Medicaid. Medicaid coverage for long-term care services ranges from none at all for some providers to being the primary funding source for others. Medicaid accounts for over 40% of all funding for most nursing facilities. Medicaid is also a provider of reimbursement for assisted living facilities and programs. The coverage is far from universal, varying from state to state, but it is growing. Medicaid is the second largest source of funding for home health care agencies, although it falls far behind Medicare. Other forms of long-term care, such as subacute care, hospice, and adult day care, are generally not covered by Medicaid, but may be covered as a supplement to Medicare or under some of the waiver innovations.
  • Approximately one in four older adults will spend some time in a nursing home during the last years of their lives. Another side product of the quandary caused by conflicting societal obligations is an ethical issue that has been gaining considerable attention. Related to financing, and therefore to access, it is the issue of “spending down” one’s resources to qualify for Medicaid coverage. This has produced one of the most urgent and pervasive ethical debates associated with long-term care. Many of those who do not qualify for Medicaid still do not have enough assets to pay for long-term car themselves. They face a cruel choice: struggle to provide home-based care or do what is necessary to obtain Medicaid. To qualify for Medicaid, it is necessary to “spend down” lifetime accumulated assets to become impoverished and therefore eligible for assistance. Under regulations of the Medicaid law, spouses of those thus impoverished may obtain some protection, but children and grandchildren lose their share of accumulated life savings. One major problem with Medicaid financing of long-term care is that it introduces inequities across families, age groups, and social classes. For example, should people who become poor in old age be treated the same as those with a lifetime of poverty? Should families that contribute their own labor for caregiving have that contribution taken into account? In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets. The spouse of a nursing home resident--called the "community spouse" -- is limited to one half of the couple's joint assets up to $109,560 (in 2009) in "countable" assets. This figure changes each year to reflect inflation. In addition, the community spouse may keep the first $21,912 (in 2009), even if that is more than half of the couple's assets. This figure is higher in some states, even up to the full maximum of $109,560 (in 2009). Most people who enter nursing homes as private-pay residents spend their assets by the end of 1 year and require government support for their care; one-third of the Medicaid budget is spent on long-term care. As the percentage of the advanced-age population grows, society will face an increasing demand for the provision of and payment for services to this group. In this era of budget deficits, shrinking revenue, and increased competition for funding of other special interests, questions may arise about the ongoing ability of the government to provide a wide range of services for older adults. To what extent does the government owe each of us coverage for our care, regardless of our ability to pay for it? Consumers faced with spending down ask why, after they have been paying their taxes all these years, have to lose all that they have saved just to be eligible for long-term care? After all, is it not the same care that is covered for those who were not so farsighted and prudent? Should coverage not be an entitlement as so many other government benefits? People feel that the savings that they put away over many years were meant to be passed on to children and grandchildren. They believe it is unfair to take all of that way from them, in effect penalizing them for being frugal, and point to others who either spent all they had frivolously or never bothered to provide for themselves in the first place. Where is the incentive to save if it is to be taken away by the government? Countering arguments, primarily coming from government entities that are hard-pressed to finance Medicaid programs, center on the unfairness of providing coverage to those who have their own resources. Which is more or less ethical – to take away an individual’s savings or to force government to pay for someone who has those savings? The issues also affects the children and grandchildren of the individual consumers of long-term care. If asset transference is not allowed, they may not receive the inheritance that they, and their parents, had anticipated. On the other hand, if today’s elderly are allowed to collect Medicaid while transferring their assets to their children and grandchildren, these later generations may not have a public system on which to fall back. According to public pinion surveys, 82% of the general public recognize that they cannot afford to pay the cost of long-term care either at home or in a nursing home. They also know that they cannot rely on the family alone; 86% want the government to help pay for long-term care instead of leaving it entirely up to the family. But despite such clear public sentiment, a universal public insurance program for long-term care is still not available in the US. On the contrary, Medicaid has become the public program of last resort to pay nursing home costs. In fact, it is the fastest-growing component of state budgets, and it is increasingly becoming an old-age program. Nearly 40% of all Medicaid benefits go to the elderly, chiefly for nursing home care.
  • With an average stay of 19 months and an average cost of $30,000 per year, most older adults cannot afford to pay out of pocket for nursing home stays. Consequently, an illness that results in a nursing home stay has the potential t bankrupt most middle-income older adults. Families who want to plan ahead for long-term care costs have another option: purchasing private long-term care insurance. Long-term care insurance may be appropriate for middle-income individuals and couples who have too many financial assets to qualify for Medicaid but not enough assets to pay for long-term care. More than 100 insurance companies now offer these policies, and more than 2.5 million policies are now in force. Still, present private long-term care insurance provides only 7% of total funding for long-term care in the United States while out-of-pocket expenditures cover nearly 25%. Long-term care insurance is a relatively new concept designed to meet the needs of the growing elderly population. Because it has not been available until recently, most of the current cohort of the older population would be charged high premiums for coverage. Thus, long-term care insurance is rarely used for paying for long-term health care among today’s older adults. Private LTC insurance typically covers nursing home care and sometimes other community-based services. Long-term care insurance generally provides coverage for approved care in nursing facilities and assisted lving. Care in the home by health care providers and community-based services such as care at adult day care cetners are usually covered. Because the policies vary greatly, some services in these facilities may not be covered by long-term care policies. The best of policies pay for medically necessary services for a period from 1 year up to a lifetime, but usually with a maximum period of coverage. Good policies are guaranteed to be revewable and need not require a prior hospital stay, as Medicare does. The best time to purchase LTC insurance is between the ages of 45 and 55 – reasonably affordable at this age. Premiums for LTC insurance are about as long as they ever will be during the period between 45 and 55, and rate increases from one year to the next during this period are relatively small. After the age of 55, premium costs start to accelerate more rapidly and they increase dramatically from year to year in a person’s mid-sixties. The age when a policy is first purchased is important because the premium paid, although it remains level once the policy is purchased, rises sharply with age at purchase. For example, the same policy that goes for $250 a year at age 50 would cost up to $2000 a year at age 70. Long-term care insurance is bought mainly by people over age 55; half the current policyholders are in their 60s. Less than 4% of the older population is covered by such policies. Many policies are simply not affordable when purchased at an advanced age. Only a tiny proportion of the older population can afford to buy private long-term-care insurance. Many consumers lack confidence in the products on the market. Long-term care policies have many exclusions and limitations that complicate comparisons of competing products. Some health conditions that one carrier may accept may be cause for rejection by another provider. Some older people and their families also mistakenly believe that Medicare will cover such expenses. Many people live in a state of denial about their need for LTC services in the future. This is often because they have always been relatively healthy; therefore, they find it hard to picture themselves in a state where they may need assistance with ADLs. Another alarming fact is North Carolina's low savings rate of about 4%. Currently, many residents rely on publicly-funded LTC programs. Medicaid is the primary public medical assistance provider in the state of North Carolina. The N.C. Medicaid program has served about 19% of the total state population in 2007, or 1 out of 5 every resident in the state. Nearly 10% and 16.2% of the total recipients were seniors and residents with disability, respectively. These groups account for 65% of total Medicaid expenditures, amounting to about $5.6 billion combined. Medicaid enrollees have increased by 2.3%, compared with data of previous year. Class Act – Community Living Assistance Services and Support Act – begins to take effect 1/1/2011. People begin to sign up in 2012 or 2013.
  • After a year of rancor and wrangling, partisan politics, strident public debate, rallies and protests, back-room deals, and media brawls, the Patient Protection and Affordable Care Act (PPACA) finally passed the House of Representatives in March 2010. It was amended into the final version by the Health Care and Education Reconciliation Act, which was signed into law by President Barack Obama on March 30, 2010. At first, few had any idea as to what sorts of provisions were included in the 2310 pages of this verbose historic legislation. It was quite the surprise to discover that the PPACA contains several provisions significantly affecting long-term care that will start taking effect over the next four years. The demographic shift in increased numbers of elderly in our society will cause a shift in focus from acute care to long-term care health services. The present long-term care system, however, is not prepared for the burgeoning elderly population and is in dire need of reform. Weaknesses are many and include: reimbursement-driven and inequitably-distributed services; a fragmented, uncoordinated, and "user-unfriendly" system; a confusing blend of health and social services; multiple entry points; domination by the acute care system; poor public image; and, inadequate support for informal caregivers.
  • On Tuesday, March 23, 2010, President Obama signed H.R. 3590, the Patient Protection and Affordable Care Act (PPACA), into law. However, the real impact, value, shortcomings and whatnot of this law has yet to be realized since it is being implemented over the next decade.
  • The following summary outlines key provisions of the PPACA for long-term care: 1) introduction of national long-term care insurance; 2) expansion of Medicaid options for community based services and supports; 3) mandating chronic care coordination; 4) more stringent criminal background check requirements for prospective long-term care employees; and, 5) nursing home reforms (the transparency provisions). The Community Living Assistance Services and Supports (CLASS) Act establishes a new federally administered voluntary long-term care insurance program that will be financed by participating enrollees. This program is an entirely new public-private enterprise to finance and access long-term services and supports in the home or in a facility. Individuals will be automatically enrolled if their employers agree to participate. Premiums will be paid through payroll deductions unless the employee opts out. Many details in the new program have yet to be determined. The CLASS Act may end up crowding out the private long-term care market, which was not that significant in the first place. Regulations must be issued by the Secretary of Health and Human Services no later than October 1, 2012, and will spell out the details of the CLASS program. Those regulations will specify the method of operation of the program, the premiums for each population group, how people will qualify for and obtain benefits, how decisions can be appealed, and a host of other program details. Enrollment in CLASS is restricted to actively employed individuals, or individuals on active duty with the military, regardless of their health status. Enrollees will pay premiums through a voluntary payroll deduction system; self-employed individuals through an alternate premium contribution system; and those on active duty with the military will pay their premiums through the military payroll deduction system. Individuals enrolled in the program must pay premiums for a minimum of 60 months (5 years), known as a vesting period, before they will be eligible for benefits, and have had earned income during 3 of the first 5 years of enrollment. Benefits of the CLASS Act are intended to help maintain independence and provide support for an impaired person living at home, in the community, or in an institutional setting of their choice. The program will pay a minimum daily cash benefit of $50 that can be used to purchase typical home and community-based long-term care assistance and other non-medical services and supports. The actual daily benefit amount a covered individual receives will be based on an assessment of their functional limitations or cognitive impairment. The PPACA expands Medicaid and Medicare community-based long-term care pilot and demonstration programs to improve quality and reduce the cost of care, with the ultimate aim of keeping frail elders in their homes longer. These payment and delivery arrangements, if successful, may be expanded nationally. These include community-based prevention and wellness pilot programs, individualized wellness plans, the National Pilot Program on Payment Bundling, the Community First Choice Option, the Programs for All-Inclusive Care of the Elderly (PACE), the Money Follows the Person demonstration, and the Independence at Home demonstration program. The PPACA also introduces a three-pronged structural reform: single point of entry; case management; and standardized eligibility/ need assessments. The chronic care coordination provisions are a diverse set of new initiatives offered through the PPACA with the goal of better coordinating the care of individuals with multiple chronic conditions. Addressing care coordination is a critical issue in health care payment reform, since many people with multiple chronic illnesses need expensive long-term care services. Presently, care for chronic conditions is poorly coordinated, and the costs of care are increasingly shifted to the client. Care coordination initiatives include: more closely aligning Medicare and Medicaid for dual enrollees; enhancing linkages between health care needs and long term care services; improving primary care provisions for persons with multiple chronic conditions; and, facilitating seamless transitions in care settings across the entire health care continuum. In accordance with these initiatives, the PPACA calls for the establishment of a federal coordinated health care office, Medicare Special Needs Plans, and medical health homes. The PPACA requires the establishment of a nationwide program for background checks of direct care employees in a wide variety of community and institutional long-term care entities. The new requirements cover employees of nursing facilities, assisted living facilities, intermediate care facilities, and providers of home health, hospice, and adult day care services. The nursing home transparency provisions are the most sweeping reforms in nursing home quality since the Omnibus Budget Reconciliation Act (OBRA) of 1987. The PPACA provisions require disclosure of ownership, governance, and indirect controlling interests. When fully implemented, the law will provide consumers a substantial amount of new information about individual facilities. The Medicare Nursing Home Compare website will contain staffing data; links with information regarding state surveys, inspection reports, and certification programs; information on accurately interpreting these reports; and, facility responses to these reports. Additionally, the Nursing Home Compare site will include a consumer rights information page.
  • Social security, medicare & medicaid, and the ppaca fall 2011 abridged

    1. 1. Social Security, Medicare & Medicaid, & the PPACA NURS 4100 Care of the Older Adult Fall 2011 Joy A. Shepard, PhD(c), MSN, RN, CNE
    2. 2. Objectives <ul><li>Analyze the benefits of Social Security </li></ul><ul><li>Compare and contrast the Medicare and Medicaid programs </li></ul><ul><li>List the benefits and barriers to long-term care insurance </li></ul><ul><li>Discuss the effects of the PPACA on long-term care in the United States </li></ul>
    3. 3. Changing Demographics
    4. 4. Changing Demographics <ul><li>Year 2001 </li></ul><ul><li>Year 2011 </li></ul><ul><li>Year 2021 </li></ul>
    5. 5. Age & Sex Structure of the US Population: 2010, 2030, & 2050
    6. 6. Shifting Composition of the Workforce
    7. 7. Social Security
    8. 8. Social Security <ul><li>Social Security Act of 1935 </li></ul><ul><li>Federal public retirement pension system </li></ul><ul><li>Full retirement age steadily rising (since 1980s) </li></ul><ul><li>Has decreased poverty rates </li></ul><ul><li>Major recipients female elderly </li></ul><ul><li>No means test </li></ul><ul><li>Text of the 1935 Social Security Act </li></ul>
    9. 9. Medicare & Medicaid
    10. 10. President Lyndon Johnson Signing Medicare Bill: July 30, 1965
    11. 11. Medicare <ul><li>Title XVIII of the Social Security Act (1965) </li></ul><ul><li>Covers elderly and some disabled </li></ul><ul><ul><li>Part A – Hospital insurance </li></ul></ul><ul><ul><li>Part B </li></ul></ul><ul><ul><ul><li>Supplemental medical insurance (physician care) </li></ul></ul></ul><ul><ul><ul><li>Preventive services </li></ul></ul></ul><ul><li>Limited means test </li></ul><ul><li>Only covers ~ 45% of elders’ medical care bills </li></ul>
    12. 12. Medicare <ul><li>Medicare Advantage </li></ul><ul><ul><li>Part C </li></ul></ul><ul><li>Voluntary Prescription Drug Benefit </li></ul><ul><ul><li>Part D </li></ul></ul>
    13. 13. Question <ul><li>Hospital insurance for Medicare recipients is funded under: </li></ul><ul><ul><li>A. Medicare Part A </li></ul></ul><ul><ul><li>B. Medicare Part B </li></ul></ul><ul><ul><li>C. Medicare Part C </li></ul></ul><ul><ul><li>D. Medicare Part D  </li></ul></ul>
    14. 14. Medigap – Medicare Supplemental Insurance Policies <ul><li>Medicare Supplemental Insurance </li></ul><ul><li>Private insurance – helps seniors pay for costs not covered by Medicare </li></ul>
    15. 15. Medicare <ul><li>Covers (with some limitations): </li></ul><ul><ul><li>Skilled nursing in nursing facilities and subacute care </li></ul></ul><ul><ul><li>Home health care </li></ul></ul><ul><ul><li>Hospice </li></ul></ul>
    16. 16. Medicare no longer covers the cost of 10 hospital-acquired conditions <ul><li>Foreign object retained after surgery </li></ul><ul><li>Air embolism </li></ul><ul><li>Blood incompatibility </li></ul><ul><li>Stage III & IV pressure ulcers </li></ul><ul><li>Falls & trauma </li></ul><ul><li>Poor glycemic control </li></ul><ul><li>Catheter-assoc UTI </li></ul><ul><li>Vascular catheter-associated infection </li></ul><ul><li>Certain surgical site infections (CABG, bariatric, orthopedic) </li></ul><ul><li>DVT or PE following TKR, hip replacement </li></ul>For more information, please see http://www. cms . hhs . gov /apps/media/press/ factsheet .asp?Counter=3227&intNumPerPage=10&checkDate=& checkKey =& srchType =1&numDays=3500&srchOpt=0&srchData=& keywordType =All& chkNewsType =6&intPage=& showAll =& pYear =&year=& desc =& cboOrder =date
    17. 17. Question <ul><li>Medicare recently issued a new ruling. It will cease paying for 10 preventable hospital-acquired conditions. Which of the following conditions are included in the new ruling? </li></ul><ul><ul><li>A. Hematoma after venipuncture </li></ul></ul><ul><ul><li>B. Skin tear after being turned and repositioned </li></ul></ul><ul><ul><li>C. Cellulitis after IV infusion </li></ul></ul><ul><ul><li>D. Pneumonia after aspirating on meal tray   </li></ul></ul>
    18. 18. Medicaid <ul><li>Title XIX Social Security Act (1965) </li></ul><ul><li>Covers “medically indigent” </li></ul><ul><li>Funded partly by federal and partly by state governments </li></ul><ul><li>Run by states under federal guidelines </li></ul><ul><li>North Carolina statistics </li></ul>
    19. 19. Medicaid <ul><li>Covers (depending on state’s program): </li></ul><ul><ul><li>Nursing care facilities </li></ul></ul><ul><ul><li>Assisted living </li></ul></ul><ul><ul><li>Home health </li></ul></ul>
    20. 20. Ethical Issue: Transfer of Assets & “Spend Down” <ul><li>Is transferring assets to qualify for Medicaid ethical? </li></ul><ul><li>Right to leave assets to children? </li></ul><ul><li>Should wealthy be subsidized? </li></ul><ul><li>Punished for being frugal? </li></ul>
    21. 21. Long-Term Care Insurance
    22. 22. Long-Term Care Insurance <ul><li>Plan ahead for LTC costs </li></ul><ul><li>Mainly people over age 55 </li></ul><ul><li>Less than 4% older population covered </li></ul><ul><li>Provides 7% of total funding for LTC </li></ul><ul><li>CLASS Act (PPACA) </li></ul>
    23. 23. The Patient Protection and Affordable Care Act ( PPACA) and Long-Term Care
    24. 25. The Patient Protection and Affordable Care Act ( PPACA) & LTC <ul><li>The PPACA affects LTC in the following ways: </li></ul><ul><ul><li>Introduces national LTC insurance (Community Living Assistance Services and Supports [CLASS] Act) </li></ul></ul><ul><ul><li>Enhances Medicaid options for community services & supports </li></ul></ul><ul><ul><li>Mandates chronic care coordination demonstrations </li></ul></ul><ul><ul><li>Increases nursing home ownership transparency </li></ul></ul><ul><ul><li>Increases LTC staff background check requirements </li></ul></ul>