Post on 27-Oct-2020
Changing Demographics and Funding Trends
Leadership Institute June 25, 2012 Nancy Thaler National Association of State Directors of Developmental Disabilities Services NASDDDS
Aging Baby Boomers Driving Entitlements
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Baby Boomer Tsunami Every day 10,000 Baby Boomers qualify for Social Security
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Current Policies Are Not Fiscally Sustainable: Change is Coming No Matter Who Wins the Next Election
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Ryan Plan
Replaces Medicaid with a block grant
Grows each year with inflation and U.S. population growth but at more than 3.5 percentage points less than current projected annual growth in Medicaid.
States get expansive new flexibility in areas such as eligibility and benefits. States could cap enrollment, charge significant premiums, offer vouchers to purchase private insurance, and cut some currently required services
CBO has estimated that by 2050, combined federal funding for Medicaid, the Children’s Health Insurance Program (CHIP), and federal subsidies provided through ACA would be cut by more than 75 percent
Toomey Plan
Similar block grant structure to Ryan proposal
Reduces Medicaid by about $990 billion over the next ten years — $180 billion more than under the Ryan budget
President’s Proposal
Cuts more than $50 billion from Medicaid
$17 billion over 10 years by establishing a “blended rate” for Medicaid and CHIP in 2017
Blends FMAP, CHIP match, and Medicaid expansion match into one number, and reduces it by as much as 5 percent.
Would increase automatically if an economic downturn forced enrollment to rise and state costs to increase
States Can’t Make UP the Difference
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Baby Boomers - Not Enough Workers to Take Care of the Baby Boomers
15,000,000
30,000,000
45,000,000
60,000,000
75,000,000
2000 2005 2010 2015 2020 2025 2030
Source: U.S. Census Bureau, Populat ion Division, Interim State Populat ion Project ions, 2005
Females aged 25-44 Individuals 65 and older
Larson, Edelstein, 2006
Confronting Reality
The Waiting List
Growth in public funding will slow
Workforce will not keep pace with demand
People Waiting
For Services
Residential
Capacity
Growth
Needed
155,059 Lakin
240,000 Kaiser 466,809 24.6%
15,000,000
30,000,000
45,000,000
60,000,000
75,000,000
2000 2005 2010 2015 2020 2025 2030
Source: U.S. Census Bureau, Populat ion Division, Interim State Populat ion Project ions, 2005
Females aged 25-44 Individuals 65 and older
State Responses to the Challenge In the worst times, service reductions
When there is time for thought:
1. Focus on rebalancing
2. Focus on sustainability Supporting Families Getting people a job
3. Focus on Equity Individual Budget Allocation
4. Managed care
Rebalancing
Focus on Where the Big Bucks Are
States are Rebalancing
@29,000
2011
Source: UMN RTC/ICI
12 States Have No Public Institutions >16
Closure Date State General
Population
1 1991 New Hampshire 1,315,000
2 1991 District of Columbia 582,000
3 1993 Vermont 624,000
4 1994 Rhode Island 1,068,000
5 1996 Maine 1,322,000
6 1997 Alaska 670,000
7 1997 New Mexico 1,955,000
8 1998 West Virginia 1,818,000
9 1999 Hawaii 1,285,000
10 2009 Oregon 3,641,000
11 2010 Michigan 10,079,985
12 2011 Alabama 4,779,736
UMinn RISP Rpt. 2010
States are Rebalancing
State Popula
tion
1 Texas 4,207 x
2 New Jersey 2,703 x
3 Illinois 2,111 x
4 Calif. 2,070 x
5 New York 1,981
6 North Carolina 1,598
7 Virginia 1,153 x
8 Ohio 1,329 x
9 Mississippi 1,324 DOJ
10 Pennsylvania 1,189
11 Louisiana 1,124 x
12 Arkansas 1,052
State Popul
ation
1 Alaska 173
2 Arizona 115
3 Colorado 67
4. Delaware 70
5 Idaho 62
6 Indiana 192
7 Kentucky 169
8 Maryland 144
9 Minnesota 29
10 Montana 55
11 Nebraska 173
12 Nevada 47
13 North Dakota 115
14 Rhode island 17
15 South Dakota 144
16 Wyoming 83 Source: UMN RTC/ICI
16 States have <200 people in large facilities
12 states have over 1,000 people in large facilities
x downsizing initiatives
UMinn. RISP Rpt. 2010
Thinking for the Long Term About Cost
Sustainability depends on how good we are at supporting families and getting
people jobs.
Highest Cost
Lowest Cost
People with Developmental Disabilities
(1% of the population)
Big House State Op
ICF-MRs
Community
ICF-MRs
HCBS Waivers
Comprehensive &
Specialty Waivers
Supports
Waivers
State Funded
Family Support
Services
DEMAND
Nudging the System
Source: John Agosta
Human Services Research Institute
The idea is to nudge a system down the incline to reduce per person expenditures.
The idea is to nudge a system
to be person-centered, to
support families, and involve
people in their community.
Employment
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Family Home 325,6 355,1 391,8 446,2 482,4 500,0 503,6 533,0 569,0 552,5 588,5 599,1
Own/Host Home 90,79 96,89 110,5 120,9 128,9 136,3 147,0 136,5 139,6 152,6 154,1 162,8
1-6 Community 108,8 114,5 124,4 135,3 135,5 135,5 142,9 156,6 157,0 157,7 160,4 158,6
7+ and Nursing Homes 78,08 78,66 85,01 89,50 88,08 89,35 83,67 83,03 88,75 84,93 79,50 88,05
16 + PRF 52,45 50,03 47,32 45,94 44,06 42,83 41,65 39,09 38,17 36,65 35,03 32,90
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1,100,000R
es
ide
nts
wit
h I
DD
Year
Residence of all IDD Service Recipients 1998 to 2009
Sustainability Means Supporting Families
Arizona 86% Calif. 71% Florida 70% Idaho 75% S.C. 72%
Nevada 69% Delaware 68% NJ 68% Wash 67% Louisiana 66% Hawaii 65% Mass. 62% NY 62% West Virg.60%
57.5%
Lakin et.al. RISP 2009 –UMinn.
States are Focusing on Employment
0%
20%
40%
60%
80%
100%
2009 –UMass Boston ICI ID/DD Agency Survey
Success in employment varies widely 2009
Washington State (88 %)
Oklahoma (60%)
Connecticut (54%)
Louisiana (47%)
New Hampshire (46%)
Sustainability depends on how good we are at supporting families and getting
people jobs.
Individual Resource
Allocation
Searching for Equity and Fairness - Individual Allocations with Consumer-Directed Options
Individual Resource Allocation Equity and Fairness Predictable costs
Consumer-Directed Services Hire and Fire Staff Hire relatives Control a budget
Thirteen states offered individual budgets and consumer control statewide for at least some individuals in Jan. 2009
Colorado** R.I.
Oregon** New Mexico
LA.** North Dakota
Georgia** Maine
Conn.** N.C.
Wyoming** Virginia
NJ** Maryland
Arkansas** DC
Indiana** New York*
Florida
Mississippi
Managed Care
Managed Health Care Brings Opportunities
Opportunities:
Reduce reliance on facility based services
Integration with medical, behavioral and long term care services and supports
Control costs
Address the waiting list
Innovation
Better transitions in ages and stages
Medicaid Managed Long Term Care -does not include all the states that have acute managed care
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Arizona -1115 Michigan-B/C counties Vermont-1115 Wisconsin-B/C counties Texas Star Plus-B/C North Carolina - B/C counties New York-1115 New Hampshire
Kansas ?
Kentucky ?
Illinois -1115 delayed
New Jersey -1115 delayed
Managed Care for the Duals
Dual Eligibles
Individuals dually eligible for Medicare and Medicaid
The most vulnerable, highest-need, and highest cost beneficiaries in the US health care system
Dual eligible beneficiaries account for
21% of Medicare enrollees but 36 percent of the expenditures
15% of Medicaid enrollees but 40% of the expenditures
(Kaiser Foundation)
Dual Eligibles as a Percent of Medicare and Medicaid Enrollment and Spending, 2006/2007
Medicare Medicaid
People People Cost Cost
State Demonstrations to Integrate Care for Dual Eligible Individuals
Test different delivery system and payment models that integrate care for dual eligibles
15 states received $1 million contracts to design new systems but 20 + additional states expressed interest
State proposals must cover the full range of health care services, the entire dual eligible population, and are administered statewide
The state can propose a new model, expand existing pilots, or a combination of both
Demonstration Requirements
Funding models
Capitated Model: A State, CMS, and a health plan enter into a three-way contract that will provide a new savings opportunity for both States and the Federal government.”
Managed Fee-for-Service Model: A State and CMS enter into an agreement by which the State would be eligible to benefit from savings
*Map Courtesy of National Senior Citizens Law Center
• Green-15 State Demo • Maroon – Financial Alignment
State Expressed Initial Interest in Dual Eligibles Integration Models
The Dual Eligibles in Managed Care
Medicare Eligibles
Developmental
Disabilities
Medicaid
Eligibles
State Responses to the Challenge
1. Focus on rebalancing – reducing reliance on facility based programs
2. Focus on sustainability Supporting Families Getting people a job
3. Focus on Equity Individual Budget Allocation
4. Managed care
What Does it Mean to Focus on Families as Our Core Service?
Can we reach out rather than wait for crisis?
Can we start early and continue on the journey
rather than try to make a life plan?
Do support coordinators have the skills?
Do we know how to help them navigate the world beyond the public system?
Do support agencies have the skills?
Do we know what families need?
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Does Everyone Have to Live with Their Family to Have a Sustainable System?
No. It means we have to maximize the extent to which as many people as possible can live great lives without 24 hours of paid supports using RELATIONSHIP BASED OPTIONS
Family
Extended Family
Friends
Shared Living
Independently or with a friend
Paid Companion
Nuclear Family
Aunts &
Uncles
Siblings
Cousins
Shared Living
It doesn’t matter with whom people live, the supports should match what they need so that…………………………...
Own Home/ Roommate/ Companion
$ Job And a
Does Everyone Have to Live with Their Family to Have a Sustainable System?
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Nancy Thaler
National Association of State Directors of Developmental Disabilities Services
113 Oronoco Street Alexandria, VA 22314
703-683-4202 nthaler@nasddds.org