In some states, home and community-based alternatives are replacing nursing homes as the primary form of long-term elder care. Despite widespread support for home care for the elderly as more desirable and less costly, there are problems with this picture, including problems of quality assurance.

Medicaid spending for long-term care grew to $75 billion in 2001. This is roughly one-third of the total Medicaid budget, with the majority spent on caring for the elderly. Efforts to increase home and community-based care while decreasing institutional care have been effective, with the share of the Medicaid budget spent on institutional care declining.

Although states that participate in the Medicaid program must provide nursing home and home health care to those who meet eligibility requirements, things get murkier when other services are considered. States can apply to the Centers for Medicare and Medicaid Services (CMS) for waivers of some federal Medicaid requirements in order to provide alternatives such as transportation, caregiver training for family members, nursing services, and respite care.

Waivers allow states to offer such services in geographically limited areas and/or to specific populations, to limit the number of persons served, and the like. Every state but Arizona has at least one waiver for elderly services. According to a General Accounting Office report released July 7, Medicaid spending on “waiver care” grew from 5 to 19 percent of long-term expenditures, from $1.6 to $14.4 billion, between 1991 and 2001, with 55 percent of beneficiaries being elderly. This is an incredible increase in elder care that need not meet the usual Medicaid requirements.

Even worse, the GAO found little, if any, quality control over this care. In fact, CMS hasn’t even provided quality assurance guidelines as part of the waiver approval process. Of the state annual reports reviewed by the GAO, more than a third had no information on quality assurance measures and more than 70 percent of reviewed waivers contained quality of care problems.

Perhaps not surprisingly, since waivers are about limiting services, the most frequent problem was failure to provide necessary services, followed by weaknesses in care plans and case management. More and more federal tax dollars are being spent on elder care that is less regulated, with fewer guidelines, resulting in clear lapses in the services provided for some of those in greatest need.

Most home-based care is provided by family members, a major source of the cost savings over institutional care. Many of these family members must limit or even give up paid employment in order to provide care, a serious financial blow to the family. Many caregivers themselves are older, suffer health problems of their own, and develop more health problems as a result of caregiving. Thus, even if the home and community-based care programs operated within all requirements and without quality shortcomings, they would still fall short of an optimal caregiving situation.

Frail and disabled elders and their family caregivers need all-inclusive, high quality care. Decisions regarding such care cannot be left to individual states, many in cahoots with a right-wing administration, with waivers from federal regulations. Despite the unquestioned value of Medicaid and Medicare, only a solid national health care program, providing universal, comprehensive services can assure elders of the most comfortable old age possible, whether that be in a nursing home or the family home.

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