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NASUAD-Presentation-MWC-012011-mike-cheek

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Weathering the Storm:
The Impact of the Great Recession
On Long Term Services and Supports

Presented by: Mike Cheek, NASUAD
             Funded by AARP under direction of
                 the Public Policy Institute

            Built on 5 prior NASUAD state surveys


                        Final Report




9/27/2010                                           2
NASUAD is an Executive Branch Organization

 • National Association of States United for Aging and
   Disability (NASUAD) formerly was the National
   Association of State Units on Aging (NASUA)
 • Core membership is the nation’s 56 officially designated
   state and territorial agencies on aging, but …
 • In June 2010, the membership voted to change the
   name and revise the mission to recognize
    – Approximately 75 percent of the members already were serving
      individuals 60 and older as well as adults with disabilities
      regardless of age (i.e., PD, TBI)
    – Role and importance of family caregivers



                                                                     3
             Research Methodology

            E-Survey to 50 states, DC, and 4 territories
Medicaid Agencies and State Units on   Targeted programs for aged and
              Aging                          physically disabled




                   Follow up telephone interviews


                     Response: 49 states and DC
41 from both Medicaid and State Unit
                                         9 State Units on Aging only
         on Aging Agencies


9/27/2010                                                               4
                Primary Findings

        The Great   • Remains a sustained and growing concern
                    • States using as opportunity to balance services
        Recession     from institutional to non-institutional settings



 ARRA enhanced      • Allowed states to continue Medicaid and non-
                      Medicaid HCBS
     FMAP           • Phase-down may force additional cuts in LTSS



 Affordable Care    • Offers additional opportunities to expand
                      HCBS services
       Act          • States need federal guidance on requirements


9/27/2010                                                            5
   States Continue to Struggle through Tough Economy

   BUDGET CONTEXT


1/18/2012                                              6
       Recession Remains a Significant Factor

Major revenue sources (PI, Corp, and Sales
Tax) below pre-recession levels for most
states

         Only 9 states and DC project 2011 levels at or above
         2007 collections
         5 expect 2011 revenue to be 25% or more below
         2007 collections



               While revenues are down, states must
               contend with increasing service demand

 9/27/2010                                                      7
                       Percent Change in State Tax Revenue
                                             2007 (actual) to 2011 (projected)
                                       Personal Income, Corporate, and Sales Taxes
               WA
                                                                                                                                             NH
                                                                                                                                   VT                  ME
                                        MT                     ND

                                                                              MN                                                                                  MA
             OR
                            ID                                 SD                            WI                                         NY
                                                                                                        MI                                                   RI
                                             WY
                                                                                                                                                        CT
                                                                                                                              PA
                                                                NE                 IA                                                                  NJ
                  NV
                                                                                                       IN     OH                                   DE
                                  UT                                                              IL
                                                  CO                                                                    WV                        MD
        CA                                                          KS                                                        VA
                                                                                    MO                       KY

                                                                                                                              NC
                                                                                                        TN
                                 AZ                                      OK
                                             NM                                         AR                               SC

                                                                                                  MS               GA                    Percent Change
                                                                                                        AL
                                                                                        LA                                                         -33.7% to -16%
                                                               TX

                                                                                                                                                   -14.8% to -10.1%
                       AK                                                                                                    FL
                                                                                                                                                   -9.8% to -5.9%

                                                                                                                                                   -4.5% to -.8%

                                                       HI                                                                                          +.1% to 11.5%


    Source: HMA analysis of data from National Association of State Budget Officers (NASBO), Spring Fiscal Survey of States, 2007-2011 reports.
    Notes: 2011 figures are estimates. For Illinois, this map uses projected revenue from NASBO’s 2006 report because 2007 data was not available.
1/18/2012                                                   DRAFT: NOT FOR DISTRIBUTION                                                                                8
   Impact of the Recession on non-Medicaid funded LTSS

AGING AND DISABILITY PROGRAMS


1/18/2012                                                9
                               Non-Medicaid State Expenditure Cuts
                                                               FY 2010
      WA
                                                                                                                                       NH
                                                                                                                             VT                  ME
                                 MT                  ND
                                                                                                                                                              MA
                                                                    MN
     OR
                    ID                               SD                            WI                                             NY
                                                                                              MI                                                         RI
                                      WY
                                                                                                                                                    CT
                                                                                                                        PA
                                                      NE                 IA                                                                      NJ
          NV                                                                                            OH
                                                                                             IN                                               DE
                          UT                                                            IL
                                           CO                                                                 WV                            MD
CA                                                        KS                                                            VA
                                                                          MO                       KY                                          DC

                                                                                                                        NC
                                                                                              TN
                         AZ                                    OK
                                      NM                                      AR                               SC

                                                                                        MS               GA
                                                                                              AL
                                                                              LA
                                                     TX                                                                                     Expenditure Cut

                                                                                                                                                      More than 25%
                                                                                                                   FL
                                                                                                                                                      21-25%
               AK
                                                                                                                                                      16-20%

                                                                                                                                                      11-15%

                                                                                                                                                      6-10%
                                                HI
                                                                                                                                                      Less than 5%

                                                                                                                                                      None

                                                                                                                                                      Data not available

               Notes: Washington, D.C. (not shown) had a cut of less than 5%.
                                    States Use A Variety of Strategies to Make Reductions
                               16
 Number of States Responding


                               14

                               12

                               10

                                8

                                6

                                4

                                2                                                                                                     SFY 10
                                                                                                                                      SFY 11
                                0




                                                        Types of Strategies

Other includes: local provider cuts, reducing administrative costs, staffing reductions, limiting staff travel and expenses, streamlining
administrative procedures, cutting state-only funding, and implementing staff freezes
                                            Programs with Increased Service Demands FY10
                                 Home-Delivered Meals
                                Information and Referral
                                                 Respite
                                      Case Management
                               Family Caregiver Support
                               Personal Care/Assistance
                                          Transportation
                                            Homemaker
Types of Services




                           Long-Term Care Ombudsman
                                Adult Protective Services
                    Disease Prevention/Health Promotion
                                                   Chore
                                 Elder Abuse Prevention
                                      Congregate Meals
                                          Adult Day Care
                                     Food Stamps/SNAP
                           Legal Assistance Development
                                          Assisted Living
                                                 LIHEAP
                                  Community Transition
                                                  SCSEP

                                                            0   5   10     15       20      25   30   35
                                                                         Number of States
                    End of ARRA Senior Nutrition Funding
                         Will Have Significant Impact

                  No impact


Programs will be eliminated


  Waiting lists will increase


 Services will be eliminated


  Programs will be reduced


   Services will be reduced


            Too soon to tell

                                0   5   10          15          20   25   30
                                             Number of States
                                                         Types of Increased APS Calls
                                         30


                                                                                             Despite an increase in the
                                         25                                                  number of APS calls , only two
                                                                                             states increased funding for
            Number of states reporting




                                                                                             APS while the rest either flat-
                                         20                                                  lined or decreased state
                                                                                             appropriations.
                                         15



                                         10



                                          5



                                          0
                                               Financial     Physical Abuse       Neglect     Emotional Abuse    Sexual Abuse
                                              Exploitation

                                                                              Categories of Abuse


1/18/2012                                                                                                                       15
   Impact of the Recession on Medicaid funded LTSS

   MEDICAID


1/18/2012                                            16
            Medicaid LTSS Policy Trends
 States “holding steady” with Medicaid LTSS
  • Implemented/plan few policy changes
  • Provider reimbursement is the exception: by far the primary
    LTSS policy change
  • HCBS a distant second but with slightly more enhancements
    for HCBS than restrictions

 ARRA - and its extension - were critical
  • Future remains uncertain with June 2011 expiration

1/18/2012                                                         17
 States appear to be committed to holding
     steady or increasing HCBS benefits
                                                HCBS Benefit Changes                       Slightly more states
                                            Implemented in 2010 or Planned for 2011        have or plan to increase
                                                                                           HCBS benefits than
                                                                                           have or plan to
            Decrease            6
                                                                                           decrease benefits
            Increase                    8
 2010




            No Change                                                                                         26


            Decrease            6
 2011




            Increase                    8
            No Change
                                                                                                   23


        0       2       4   6       8          10      12      14       16      18    20      22    24   26        28
                                                       Number of States



1/18/2012                                                                                                          18
            Standard
            FMAP
            +6.2%

                        January 1, 2011

                                          Standard
                                          FMAP



                                                     April 1, 2011




                                                                                July 1, 2011
                                          +3.2%
                                                                     Standard
                                                                                               Standard
                                                                     FMAP
                                                                                               FMAP
                                                                     +1.2%

             Extended ARRA Enhanced FMAP Phase-Down
                  Some states budgeted for an extension of ARRA with a 6.2%
                 enhancement to their standard FMAP through June 30, 2011.
                    Congress enacted a phase-down of the enhancement.
1/18/2012                                                                                                 19
U.S. Medicaid Enrollment Increases in
       Economic Downturns
Aged and Disabled enrollment largely unaffected
  by economic fluctuations, but….
                              may prompt states
    Enrollment increase        to curtail LTSS
      in other groups         optional services
    creates fiscal stress




                Enrollment increases likely
            contribute to LTSS policy decisions
1/18/2012                                         20
            ARRA and ACA MOE Requirements
              Protected Eligibility Standards
              MOE effectively restricted eligibility changes
                     HCBS waiver slot reductions

     31 states reported they made no eligibility changes in 2010
                  or have planned changes for 2011

                   3 states expanded standards in 2010
                     2 states plan expansions in 2011

                        1 state plans 2011 restriction
              - but will not follow through if MOE is violated
1/18/2012                                                          21
                  State Medicaid LTSS Policy Actions

                            FY 2010         Planned FY 2011
Provider                 States with Expansions / Enhancements
reimbursement is the
major policy area in
which states made or
plan changes




     Provider Payments     Eligibility          HCBS Benefits    State Plan Benefits




                             States with Program Restrictions
   Many states reported plans to develop or
  expand managed long term care initiatives
                           Medicaid Managed Long Term Care: State Actions

                                                           Number of States
                                           0           5               10     15        20

         Managed Care in Development                                               18
  Implemented or Expanded MC in 2010               1
Plan to Implement or expand MC in 2011                     5
                MC area expanded 2010              1
              Will expand MC area 2011         0
Changed to mandatory enrollment 2010           0
  Change to mandatory enrollment 2011          0
             Expand # of PACE sites 2010                   5
             Expand # of PACE sites 2011                        7
                    Other Program 2010         0
                    Other Program 2011             1

 1/18/2012                                                                                   23
Emerging Trend of Broad Medicaid
       Reform Proposals*




                                Broad Medicaid Reform
                                Proposal

                                Governor’s State of the
                                State Notes Changes but
                                Endorses or Stipulates
*Not part of Economic Survey.   Preserving LTSS and/or
                                HCBS Expansion
 Source: NASUAD Tracking
                                Both

                                                  24
   Impact of the Recession on States Ability to Use HCBS Opportunities in

   AFFORDABLE CARE ACT


1/18/2012                                                                   25
                           States Likely to Pursue HCBS Options in
                                     Affordable Care Act
                       State Balancing Incentive Payments Program


                                   Community First Choice Option
     HCBS Options




                        Money Follow the Person -Existing Grantee


                           Money Follows the Person-New Grantee


                             Medical/Health Home-Planning Grant


                                       Medical/Health Home-SPA


                    Medical/Health Home-Community Health Teams

                                                                    0   5       10        15   20   25        30
                                                                            Number of States




1/18/2012                                                                                                26
   What to expect in 2011 and 2012

   STATE OUTLOOK


1/18/2012                            27
1/18/2012   28
   Frequently Noted Medicaid Priorities

Balance/Expand HCBS


        Integrate acute/long-term care &
        services for duals


            Focus on quality and/or access


                Maintain level of services

1/18/2012                                    29
            State Outlook




1/18/2012                   30
 For More Information

        www.nasuad.org
           Mike Cheek
Senior Director for State Services
     mcheek@nasuad.org
                                     31
Further Survey Information

APPENDIX A


                             32
                       U.S. Medicaid Enrollment Increases
                   in Economic Downturns: FY 1998 – FY 2011
          Annual growth rate:
                                              9.3%
                                                                                                                    8.5%
                                     7.5%

                                                                                                                             6.1%
                                                      5.6%                                                 5.4%
                                                               4.3%
                            3.2%                                        3.2%                       3.0%



                   0.4%                                                          0.2%


                                                                                         -0.6%

          -1.8%

          1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: “Hoping for Economic Recovery, Preparing for Health Reform: A Look at Medicaid Spending, Coverage and Policy Trends. Results
from a 50-State Medicaid Budget Survey for State Fiscal Years 2010 and 2011;” Vernon K. Smith, Kathleen Gifford, Eileen Ellis, et.al.; Kaiser
Commission on Medicaid and the Uninsured; September 2010. Note: Enrollment percentage changes from June to June of each year.
        While Total Medicaid Funds Grew During the Recession,
        State Funding Experienced Negative Growth due to ARRA
                                                  FY 2000 – FY 2011
                                                                                                 ARRA Enhanced FMAP
                                          Total           State General Fund                     (2009-2011)

                     12.7% 12.9%                                                                                           13.1%

        10.4%9.9%                                           10.1%
8.7% 8.4%                         8.5%                                                                      8.8%
                                             7.7%                                                7.6%                7.4%
                                                     6.4%
                                        5.5%                                         5.8% 5.7%
                                                  4.9%
                                                                           3.8% 4.0%
                                                                   3.0%
                                                                1.3%


                                   Enhanced FMAP / Federal
                                   Fiscal Relief (2003-2005)


                                                                                                                   -7.1%


                                                                                                       -10.9%           2011
    2000       2001      2002       2003       2004     2005        2006     2007       2008      2009       2010      Adopted

Source: “Hoping for Economic Recovery, Preparing for Health Reform: A Look at Medicaid Spending, Coverage and Policy Trends.
Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2010 and 2011;” Vernon K. Smith, Kathleen Gifford, Eileen
Ellis, et.al.; Kaiser Commission on Medicaid and the Uninsured; September 2010. NOTE: State Fiscal Years.
     Most Home and Community Based waivers
    experienced upward trend in number served




 Based on states reporting average daily census for at least two years in FYs 09, 10 & 11.
 35 states reported census data for 88 waivers.
1/18/2012                                                                                    35
Medicaid nursing facility census is expected
to decrease or remain static in most states
                        States Reporting Nursing Facility Census Change:
                                       FY 2010 to FY 2011
                                                   (N=38)
                                 Increase        Decrease      Stay the Same



                    4



                                                                                              22



                                                          12



0           2   4         6      8          10       12        14      16      18   20   22        24


                                            Number of States
1/18/2012                                                                                          36
Few states reported changes to State Plan benefits
    25 states reported they have no plans to change benefits in FY 2010 or FY 2011
                                             N = 34 States

                                  FY 2010          Planned FY 2011

                                   States with Benefit Increases

PCS was most
frequent service
cut among states
that trimmed


Personal Care Services   Home Health HCBS State Plan Option Adult Day Health   Other




                                    States with Benefit Decreases
                   State LTSS Provider Rate Changes
                                    FY 2010 N = 39 states
                                    FY 2011 N = 36 states

                            FY 2010           Planned FY 2011

                                 States with Rate Increases
States were most
likely to change
NF rates
      17
           11                                                 9
                                         7                        5
                       3   2                   3                         1    2
 Nursing Home      Home Health        Personal Care           HCBS       Other Services

                           4                   5                     5    4    3
       9   7                             8                    8
                      10




                                 States with Rate Decreases
                               Reductions in Non-Medicaid Expenditures
                    20


                    18


                    16


                    14
 Number of States




                    12


                    10                                                                                  SFY 09
                                                                                                        SFY 10
                    8
                                                                                                        SFY 11
                    6


                    4


                    2


                    0
                         <5%     6-10%    11-15%         16-20%         21-25%        Over 25%
                                            Percent of Cuts

Source: AARP, HMA, NASUAD Economic Survey, FY 10, FY11. FY09 data is from NASUA Economic Survey, December 2009.

				
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