9 REFERENCES Brookings-ICF Long-Term Care Financing Model, Version 2, 1989. Unpublished estimates. Carpenter, L., 1983. "Medicaid Eligibility for Persons in Nursing Homes." Health Care Financing Review, 10(2):67-78. Cohen, M., Tell, E., and Wallack, S., 1986. "The Lifetime Risks and Costs of Nursing Home Use Among the Elderly." Medical Care, 24(12):1161-72. Friedland, R., 1989. "Issues Concerning the Financing and Delivery of Long-Term Care." EBRI Issue Brief,, No. 86. July. Kemper, P., Applebaum, R., and Harrigan, M., 1987. "Community Care Demonstrations: What Have We Learned?" Health Care Financing Review, 8(4):87-100. Murtaugh, C., Kemper, P., and Spillman, B., 1989. "The Risk of Nursing Home Use in Later Life." Rockville, Md.: National Center for Health Services Research. May. National Center for Health Statistics, Hing, E., Sekscenski, E., and Strachan, G., 1989. The National Nursing Home Survey 1985 Summary for the United States, Series 13, No. 97, DHHS Pub. No. (PHS) 89-1758, Public Health Service. Washington, D.C.: U.S. Government Printing Office. Rice, T., 1989. "The Use, Cost, and Economic Burden of Nursing Home Care in 1985." Medical Care, 27(12):1133-47. Rivlin, A. and Wiener, J., with Hanley, R. and Spence, D., 1988. Caring for the Disabled Elderly: Who Will Pay?, Washington, D.C.: The Brookings Institution. Spence, D. and Wiener, J., 1990a. "Estimating the Extent of Medicaid Spend-Down in Nursing Homes." Journal of Health Politics, Policy and Law, 15(3):607-626. Spence, D. and Wiener, J., 1990b. "Nursing Home Length of Stay Patterns: Results from the 1985 National Nursing Home Survey." Gerontologist. 30(1):16-20. Weissert, W., Cready, C. and Pawelak, J., 1988. "The Past and Future of Home and Community Based Long-Term Care." The Milbank Quarterly, 66(2):309-88. Zedlewski, S. et al. August 1989. the 21st Century." Washington, D.C.: "The Needs of the Elderly in The Urban Institute. 10 Mr. MARTINEZ. Thank you, Dr. Wiener. Dr. Hudson. Dr. HUDSON. Thank you, Mr. Chairman. I have followed the development and growth under the Older Americans Act for a number of years and I am pleased to be able to speak to you on the role of the Older Americans Act in long-term care. The act historically has performed a number of very useful functions. It has spawned an array of important social services throughout the country. It has provided a network of advocacy and planning agencies, it has been able to highlight the needs of older Americans, and it has been, I think, a relatively important player in recent years in helping get community-based, long-term care on the political agenda. However, it is important to note that the Older Americans Act has never served as a reliable guide to those charged with implementing it, ever since the passage of the act in 1965. In the matter of eligibility, there is a constant tension between serving all elders and targeting benefits. On the matter of benefits, there has been constant tension between whether the network agencies are to plan, advocate, deliver services, plan for services, pool resources, and a series of other important functions. On the matter of administration, there have been tensions over the years between whether the network out to be fairly autonomous and free standing or whether it ought to be more widely integrated into long-term care and other services. On the matter of financing, there is a growing tension between public and private financing and the notion of contributions from beneficiaries. Let me make four points on the matter of long-term care and the Older Americans Act. First of all, it is important, as Dr. Wiener has just suggested, that the Older Americans Act is not the principal factor shaping the community-based, long-term care delivery system in the U.S. It was key in developing social services but not in the long-term care context. Medicaid is obviously the principal player and, increasingly, major appropriations from State governments are playing a role as well. The Older Americans Act has noticeable limits when it comes to playing this role. As I say, the mission is not agreed to, that it ought to be in long-term care, and obviously that's one of our principal topics today. The dollars are very limited. An important point that I think has to be kept in mind is that the agencies under the act, particularly at the State level, have uneven political standing in the State capitals. Some are enormously important players and others are not nearly so, and that has to be kept in mind. Building on that, the second point is to highlight the enormous variability in the aging network. It is important to make the selfevident comment perhaps that the Older Americans Act is not the aging network. The Older Americans Act is a statement of intent; the aging network is a series of agencies at the State and sub-State level that are charged with a variety of functions, have a series of organizational needs, and increasingly are relying on funding from non-Older Americans Act sources. On average now, Area Agencies on Aging receive about a third of their funding through the Older Americans Act, and with the figure weighted that high, it has been heavily toward rural and smaller area agencies. My third point would be that it is important to remember as well that long-term care, which has become a catch phrase in some ways, is not a singular system; it is not well-defined. It is all over the place, as the number of introductory statements suggested. In fact, to think we have a single system in which we can insert an aging network is somewhat misleading. The system is not a system in any meaningful sense of that word and, frankly, the network, which is a term that has grown up over the last ten years, in some ways is not truly a network. It's a series of agencies operating under the vaguest of umbrellas, and to imply that there is broadbased and deep commonality among all these agencies is really quite misleading. As to what the Older Americans Act might do in the area of long-term care, I would suggest that to continue the important areas of access services and some amount of in-home services are important. They fill gaps and they're important in an of themselves. Yet, as Dr. Wiener has indicated, they are relatively small in terms of their funding. I would not favor legislation or mandates under the Older Americans Act that would mandate participation of State and Area Agencies in some punitive long-term care system. We simply don't know what that system would look like, and there is the issue of the variability within the network. There is the possibility-and perhaps we can discuss this laterof a quite different role, the possibility of taking some portion of substantial Title III dollars and, in fact, charging State and maybe Area Agencies with planning and design functions, management functions, if such long-term care systems were developed. But again, that would be something of a long shot and I wouldn't want to be in your shoes as you explained taking service dollars away and putting them into administration. Let me also make an important side comment which ties very directly to the previous testimony we've had. If we are seriously interested in long-term care, we have to remember the Older Americans Act is a very, very small player. I would urge you, as the committee and the subcommittee try to make a statement on long-term care, that we recognize that chronicity or long-term care needs is the great contingency of modern life. It is as contingent an event in the late 20th century as unemployment was in 1935, as health care needs were in 1965, and as disability was in 1956. I think we have to understand that this is an insurable event, it is something that can happen, it's a high-risk proposition, there can be a risk pool, and the great advantage of insurance is you fund out of a risk pool and you don't fund out of a beneficiary pool. That makes issues of equity and financing much more manageable, if not politically easy to accomplish. Let me conclude by simply saying I would not force the Older Americans Act into so-called long-term care in any monolithic fashion. I think we have to recognize the diversity and the interest and the capacities of the network agencies. At the same time there are a number of States and a large number of Area Agencies that can and have played important community-based long-term care roles, and they certainly should not be discouraged from continuing to do that. |