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Advisory Council October 2014 Meeting Presentation: Long-Term Services and Supports

Monday, October 27, 2014

Long-Term Services and Supports:An Overview

Helen Lamont, Ph.D.
Office of Disability, Aging, and Long-Term Care Policy
Office of the Assistant Secretary for Planning and Evaluation

Long-Term Services and Supports

  • aka “long-term care”
  • Assistance with routine daily activities provided to people with functional limitations because of physical, cognitive or mental disability
  • Measured with ADLs and IADLs
  • Most prevalent among 65+ population, but not exclusive
  • LTSS includes services like personal care, homemaker services meal assistance, transportation assistance, case management, etc.

Who uses LTSS?

Bar Chart: 65-69 smallest category; 90+ largest category.
Source: 2011 National Health and Aging Trends Study

Likelihood of needing LTSS

Bar Chart: 1-2 Years smallest category; None largest category.
Source: Kemper, Komisar and Alecxih (2005)

Who provides LTSS?

  • 95% of people get help from family and friends
  • 65% rely exclusively on family and friends
  • Only 1/3 use formal (paid) services and very few (5%) only use paid services As needs increase, paid care is more likely to be added

Source: 2011 National Study of Caregiving; Supplement to the National Health and Aging Trends Study

Informal caregivers

  • Estimated 17.9 million caregivers providing 1.3 billion unpaid hours annually
  • Most chronically disabled older adults have at least 2 people providing care-- increases with disability level
  • More likely to be women (62%)
  • Half are middle-aged (45-64)
  • 29% daughters, 21.2% spouses, 18% sons, 22% other relatives like grandchildren and daughters-in-law
  • Average 75 hours of help per month-- but lots of variability

Source: 2011 National Study of Caregiving; Supplement to the National Health and Aging Trends Study

Impacts of informal caregiving

  • Almost 70% of caregivers report substantial positive aspects of caregiving
  • 15% of caregivers report significant negative aspects like financial difficulties, stress, or physical strain-- higher among dementia caregivers
  • Caregiver stress associated with poor health and increased likelihood of nursing home placement for care recipient

Source: 2011 National Study of Caregiving; Supplement to the National Health and Aging Trends Study

LTSS settings

  • Provided in home, community settings, residential settings (assisted living), or nursing homes.
  • Nursing facilities
    • Compensatory, rehabilitative, psychosocial and social services to residents.
    • Regulated by states with federal rules because payment sources are largely Medicare and Medicaid
    • 2012: 1.4 million residents
  • Residential care
    • 24 hour supervision, assistance with ADLs, but not skilled nursing
    • Regulated at state level-- payment sources are mostly private pay and some Medicaid
    • 2012: 713,300 residents

Paid workforce

  • Direct care workers-- staff who deliver formal LTSS
  • Include nurse aides and home health aides
  • Estimated 1.9 million direct care workers
  • Demanding profession with low wages and limited benefits
  • Challenges with recruitment and retention

Sources of LTSS payments

  • In 2011, expenditures estimated at $425 billion.
    • $291 billion care in home and community
    • $134 billion institutional care
Figure 2. Percentage Share of Spending on Long-Term Care for the Elderly, 2011
Pie Chart: Informal Care (55%), Medicare (16%), Medicaid (14%), Other (3%), Private Insurance (3%), Out-of-Pocket (9%).
Source: Congressional Budget Office, 2013


  • Medicare*
  • Medicaid
  • Private out-of-pocket and long-term care insurance

Clarifying Medicare and LTSS

  • Medicare designed to cover post-acute care
  • Medicare does cover limited services
    • Up to 100 days in a skilled nursing or rehabilitation facility after a hospitalization
    • Home-health to the homebound meeting certain need requirements (recertified every 60 days)1
  • But Medicare does not cover most long-term services and supports!


  • Health care coverage for the poor and LTSS for disabled persons with limited financial resources
  • Many older Americans with income and assets above poverty “spend down” their resources by paying out-of-pocket for LTSS
  • Nursing home care is a required benefit
  • States can choose to cover home and community-based services (HCBS) through “waivers,” but states can also limit number and type of beneficiaries who receive these services
  • Medicaid financed by states and federal government; roughly 50:50

Out-of-pocket costs

  • Average annual costs
    • Nursing home: $85,235 single occupancy, $78,110 double occupancy
    • Assisted living: $41,724
    • Home care: $20/hr
      • 10hrs/week=$11,400
      • 8hrs/day=$58,240

Long-term care insurance

  • Policies mostly purchased by middle-aged and older adults
    • Healthy enough to pass underwriting
    • Higher than average incomes
  • 7.7 million policies in force
  • Insurance payments account for 3.3% of spending on LTSS annually

The Aging Network

  • Under Older Americans Act (OAA) through the Administration on Aging (part of ACL)
  • Formula grant funding to states, distributed to network of regional Area Agencies on Aging (AAAs) or Aging and Disability Resource Centers (ADRCs) to provide LTSS
  • Provide information & referral, HCBS, caregiver supports, congregate and home-delivered meals
  • Funding levels in FY2014:
    • HCBS: $347 million
    • Meals: $811 million
    • Caregiver supports: $146 million

Recent trends and developments

  • 1999: Supreme Court Olmstead decision
  • CLASS Act and Long-Term Care Commission
  • Planning for LTSS
  • HCBS Quality Measurement
  • Potential for technological solutions