End of the Line
'Not a Pretty Picture'
By Christine Bahls
Jan. 29, 2001 -- So what is the proper prescription for solving the ills of the nursing home industry?
It might not exist.
"Nobody knows how to get to that point, so nobody is talking about it," says the Rev. Garth Brokaw, president of Fairport Baptist Home near Rochester, N.Y. Speaking before the presidential election, he added: "I haven't heard [the words] 'long-term care' coming out of Gore's mouth, or Bush's mouth."
"I don't think anyone has any answers to this," says Robin Kennedy, MD, director of geriatric medicine at Maimonides Medical Center in Brooklyn. "When you have 26% and more of those over 85 who will be in a nursing home [eventually], we need to examine whether 'nursing home' as such is the right term. That's why I use [the term] chronic care hospital."
"We are made up of 17,000 parts," says Tom Burke, spokesman for the American Health Care Association, referring to the number of nursing homes nationwide. "It's tough to say what would make anyone happy."
Indeed, it's hard to fix something that defies definition, says Don Redfoot, a senior policy advisor for the AARP, formerly known as the American Association of Retired Persons.
"What is this thing?" he asks, speaking of long-term care. "What is the appropriate public role versus the appropriate role of individuals to take care of themselves? ... What are the appropriate roles of the states versus the federal government, housing versus health care, public and private roles? They all get mixed in here."
So much of long-term care is just housing, or helping an elderly friend or relative get through the day, Redfoot says. About 75% of those who need care get it from family and friends.
It seems unlikely, then, to expect a one-size-fits-all solution. The services needed are not always like the rungs of a ladder, with patients stepping from one to another as their health deteriorates. Rather, the solutions are shaping up as an array of choices.
Don't expect a national conversation on it now. It's never happened before, says Redfoot.
When Medicaid was created in 1965, Congress added the nursing home benefit just to have a mechanism that would shorten hospital stays. "It's an adjunct to the hospital policy that's an adjunct to the welfare policy."
And certainly, don't expect quick answers on how to finance the system.
"Most people think you'd have to spend significantly more money to resolve problems," says Joshua Wiener, PhD, principal research associate for long-term care at the Urban Institute. "People are generally not willing to do that, and prescription drugs seem to have eaten away money for long-term-care benefit."
Nor is there an easy solution to the problem of understaffing.
"The overall staffing [problem] is a huge issue," says Bob Mollica, deputy director, National Academy of State Health Policy. "We don't have the people now to do the services. As we get along the demographic curve, it's just going to get worse."
Indeed, the elderly population is growing dramatically. By 2030, soon after the first wave of baby boomers reaches 80, the number of Americans 85 and older is expected to be close to nine million people, according to census estimates. In July 1995, there were 3.7 million people 85 or older.
"Every year we put it off, our situation becomes a little more dire," says Joy Johnson Wilson, health committee director for the National Conference of State Legislatures.
The future will be shaped largely by two factors, says Bruce C. Vladeck, former Health Care Financing Administration director and currently the director of the Institute for Medicare Practice and professor of health policy and geriatrics at the Mount Sinai Institute of Medicine in New York City. Those factors are how quickly a cure might be found for Alzheimer's disease and the impact of the women's movement on income.
Today, nearly half of all nursing home residents have some type of dementia, Vladeck says, and "there is a lot of optimism in the scientific community to cure this." And the women's movement, he says, with its demands for equal pay, could mean that elderly women -- who far outnumber men in nursing homes -- might be financially better off in 30 years.
"Women in the upper half of the income distribution will be much more affluent than women retiring today," Vladeck says. "But those in the lower half will be worse off. They are less likely to have had many years of marriage that would have produced survival benefits. And there are fewer children to support them."
Industry professionals believe that as baby boomers reach retirement age, they will force solutions. "When the baby boomers get there," says Wiener, "it will be on the covers of Time and Newsweek every other week."
Says Joe Luchok, spokesman for the Health Insurance Association of America: "One of the main things driving this is this mass of people approaching retirement. What's happening here, people are becoming aware of the fact that if they are going to take care of this problem, they are going to have to take care of it themselves."
The marketplace, meanwhile, is coming up with some interim answers, such as assisted living and home health care as replacements for nursing homes. Some states are testing programs that give Medicaid recipients monthly stipends to pay for their personal-assistance needs, while giving them control over who provides their care. In most states, Medicaid is helping with assisted living and home-care needs; the costs to taxpayers for such care have grown from $2.6 billion in 1989 to $13.9 billion in 1999, according to government estimates.
Yet the elimination of nursing homes altogether is highly unlikely. Odds are they might look different, and be more specialized, and most likely be connected to assisted living facilities, but they will be needed, and this will only further intensify the funding and staffing problems.
"As change occurs in one segment [of health care], it has a ripple effect on the whole spectrum," says Redfoot. "We won't get away from the necessity of long-term care. I think nursing homes will look more like assisted living. We'll see more private rooms. Consumer demand is just going to drive this."
Three states -- Arkansas, New Jersey, and Florida -- have been chosen for a pilot program called "cash and counseling" in which Medicaid-eligible people receive funding and develop their own plans to stay in their homes. National program director Kevin J. Mahoney, PhD, an associate professor at Boston College's graduate school of social work, says the plan must be tailored to individual needs.
"One person used the money to buy a washing machine," Mahoney recalls. "He was blind, and he lived in a bad neighborhood. He was able to tie how buying a washing machine would allow him to stay in the community."
So far, the results of the program have been so promising, "I think there would be a very good chance" of it being expanded nationwide, Mahoney says.
Long-term care insurance is another potential solution, if it can be afforded -- something only a minority of people likely can do. While premiums for a basic policy are about $274 per year at age 40, they are about $4,100 per year by age 79, says Luchok.
"Long-term care insurance doesn't get you anywhere," says Vladeck. "It can be valuable to middle class families as a way of protecting their estates. [But] in terms of otherwise altering long-term care, the likely impacts on it are very, very minimal."
That still leaves the problem of workable solutions for nursing homes.
"I have no idea where we will be [in the future]," says Charlene Harrington, PhD, a professor of nursing at the University of California, San Francisco, and an industry researcher. "I am hoping that quality will have improved, as unlike the last 25 years. If you extrapolate from the past, it's not a very pretty picture."
Christine Bahls is a WebMD staff member. She is an award-winning investigative reporter and editor who previously worked for newspapers including the Philadelphia Inquirer and the Philadelphia Daily News.
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