Commission on Long-Term Care

REPORT

to the Congress

September 30, 2013
ii Commission on Long-Term Care
U.S. SENATE

COMMISSION ON LONG-TERM CARE

Report to the Congress iii
Washington, DC 20401

iv Commission on Long-Term Care
Report to the Congress v

COMMISSIONERS

Bruce Chernof, Chair

Mark Warshawsky, Vice Chair

Javaid Anwar

Judith Brachman

Laphonza Butler

Henry Claypool

Judith Feder

Stephen Guillard

Chris Jacobs

Neil Pruitt

Carol Raphael

Lynnae Ruttledge

Judith Stein

Grace-Marie Turner

George Vradenburg

STAFF

G. Lawrence Atkins, Staff Director

Christine Bishop 

Pamela Mazerski

Elizabeth Blair

Dennis Kodner
vi Commission on Long-Term Care
Report to the Congress vii

CONTENTS

Introduction.............................................................................................1

Chapter I: A Call to Action ....................................................................3

Chapter II: Specific Challenges to Providing LTSS.............................7

Chapter III: Recommendations

Part One: Service Delivery ...............................................................35

Part Two: Workforce .........................................................................49

Part Three: Financing .......................................................................60

Chapter IV: Advancing an Agenda on 

Long-Term Services and Supports......................................................75

Appendix A: Commissioner Ideas......................................................79

Appendix B: Public Comments.........................................................123

Appendix C: Hearings and Meetings................................................127
viii Commission on Long-Term Care Report to the Congress
Introduction 1

INTRODUCTION

The Commission on Long-Term Care was established under Section 643 of American Taxpayer Relief Act of 2012 (P.L. 112–240), signed into law January 2, 2013. 

The Commission was established with 15 members. Three members each were 

appointed by the President of the United States, the majority leader of the Senate, 

the minority leader of the Senate, the Speaker of the House of Representatives, and 

the minority leader of the House of Representatives. The Commission elected Dr. 

Bruce Chernof as its Chair and Dr. Mark Warshawsky as its Vice-Chair.

The statute directed the Commission to: “...develop a plan for the establishment, 

implementation, and financing of a comprehensive, coordinated, and high-quality 

system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who 

require assistance to perform activities of daily living, and individuals desiring to 

plan for future long-term care needs.”

The statute further directed the Commission within 6 months of the appointment of Commissioners (by September 12, 2013) to: “...vote on a comprehensive 

and detailed report based on the long-term care plan... [described above]... that 

contains any recommendations or proposals for legislative or administrative action as the Commission deems appropriate, including proposed legislative language to carry out the recommendations or proposals.”

The Commission convened its first meeting on June 27, 2013. It held four public hearings with testimony for 34 witnesses. It solicited extensive comments from 

the general public. It met in 9 executive sessions. The Commission met on September 12, 2013 and voted, by a vote of 9 to 6, in favor of putting this Final Report 

forward as the broad agreement of the Commission.

On the question: “Should the report be put forward as the broad agreement of 

the Commission?” the vote was:

■ Yeas: Chernof, Warshawsky, Anwar, Brachman, Guillard, Pruitt, Raphael, 

Turner, and Vradenburg

■ Nays: Butler, Claypool, Feder, Jacobs, Ruttledge, and Stein
2 Commission on Long-Term Care Report to the Congress
Institutional Total

Community—High Need

(multiple self-care/ADL)

Community—Medium Need

(some self-care/ADL)

Community—Low Need

(no self-care/ADL) 5.4

6.7

0.6

Children Working Age Elderly

Population Needing LTSS, by Age Group and Level of Need (Millions)

0

1

2

3

4

5

6

7

8

Source: S. Kaye, data from 2012 NHIS, 2010 Census, Nursing Home Data Compendium 2010

Chapter I A Call to Action 3

CHAPTER I

A CALL TO ACTION

Over 12 million Americans of all ages with functional impairments today rely 

on personal assistance and other long-term services and supports (LTSS) in their 

home and community or in an institution to perform daily activities to maintain 

their quality of living and, when possible, their independence. Most of them receive services and supports from dedicated caregivers that enable them to cope 

with their cognitive or physical limitations with dignity. The services and supports 

they receive are provided by family or friends who provide unpaid assistance out 

of love and commitment and by paid caregivers who have chosen to earn their 

living in an intensely personal caring profession. 
Out-of-pocket

$45.5 billion

21.6%

Other Public

$9.7 billion

4.6%

Medicaid

$131.4 billion

62.3%

Other Private

$24.4 billion

11.6%

LTSS Expenditures by Source, 2011

Source: National Health Policy Forum, based on data 

from 2011 National Health Expenditure Accounts

4 Commission on Long-Term Care Report to the Congress

LTSS are essential but costly for individuals with cognitive and functional 

limitations and their families. Family caregivers sacrifice other family and work 

responsibilities and bear a financial and emotional burden that can be overwhelming. Paid services and supports are expensive, and when received over an extended 

period of time, can be financially catastrophic. Individuals and families rarely have 

sufficient resources (either savings or private insurance) to pay for an extended period of LTSS. Medicaid provides a critical safety net for those with few resources or 

who have exhausted nearly all of their resources paying for care. Nearly two-thirds 

of the cost of LTSS today is financed by the federal and state governments through 

the Medicaid program. 

LTSS have improved substantially in recent decades. Yet problems remain for 

individuals and families who need care, notwithstanding the commitment and 

dedication of thousands of paid and family caregivers providing loving and quality 

services. Paid services and supports are highly fragmented and difficult for individuals and family caregivers to access, lacking the focus and coordination across 

agencies and providers necessary to ensure the best outcomes for the person and 
The Number of Americans 

Needing Long-Term Care 

Will More than Double by 2050

2010 2050

12

Million

27

Million

Source: S. Kaye, C. Harrington, and M. Laplante (2010). Analysis of 2005 SIPP, 

2007 NHIS, 2007 ACS, 2004 NHHS, and the 2005–2006 Medical Expenditure Survey 

Chapter I A Call to Action 5

family, and are provided in ways that can be expensive and inefficient. The need for 

LTSS and the costs of paid LTSS must be addressed in the context of the financial 

pressures for many American families and the fiscal challenges, including population aging and high health care costs, which face our Nation. 

A dramatic projected increase in the need for LTSS in coming decades will 

confront significant constraints in the resources available to provide LTSS. Aging 

Baby Boomers will grow the numbers of older Americans with physical and cognitive limitations. At the same time, fewer family caregivers combined with more 

limited personal financial resources to pay for caregiving due to declines in savings 

rates, retirement asset accumulation, and private insurance purchase, will place increasing pressure on the Medicaid program and the federal and state budgets that 

fund it. Governments will have to balance growing LTSS needs with education, 

public health and safety, and other priorities. 

New approaches are needed to bring LTSS care integration, technology, and 

innovative workforce strategies together to reduce the overall cost of achieving 

better health and well-being outcomes for individuals and their families. Many 

persons living with disabilities are able and want to participate in the workforce. 

Changes are needed to support them so they can receive the LTSS they need for 
6 Commission on Long-Term Care Report to the Congress

full workforce participation. Creative financing efforts are needed to affordably 

insure the risk of needing LTSS and encourage higher levels of savings. Finally, a 

more accessible and sustainable Medicaid is needed to assure its continued role in 

guaranteeing the availability of LTSS for individuals and families with few resources to provide for themselves.

Now is the time to put these new approaches and efforts in place if the coming generations of Americans are to have access to the array of LTSS needed 

to remain independent themselves or to assure the safety and well-being of a 

loved one with substantial physical or cognitive limitations. The need is great. 

The time to act is now. 
Chapter II Specific Challenges to Providing LTSS 7

CHAPTER II

SPECIFIC CHALLENGES TO PROVIDING LTSS

Over 12 million Americans and their families are confronted with long-term functional and cognitive limitations and face the challenge of arranging and financing 

or providing the necessary assistance with performing daily activities. This chapter 

defines long-term services and supports (LTSS) and describes specific structure 

and process challenges experienced by American families in three key domains – 

service delivery, workforce, and financing. 

What are Long-Term Services and Supports?

■ Long-term services and supports (LTSS) are defined as assistance with activities of daily living (ADLs, including bathing, dressing, eating, transferring, 

walking 1) and instrumental activities of daily living (IADLs, including meal 

preparation, money management, house cleaning, medication management, 

transportation2) to people who cannot perform these activities on their own 

due to a physical, cognitive, developmental, or chronic health condition that is 

expected to continue for an extended period of time, typically 90 days or more. 

■ LTSS include such things as human assistance, supervision, cueing and standby assistance, assistive technologies, workplace supports, and care and service 

coordination for people who live in their own homes, community residential 

settings, or institutional settings. 

■ LTSS are a distinct set of services from health care services, although they may 

include health-related services. LTSS are a critical element of support and 

service for persons who are receiving health care services for severe chronic 

health conditions or disabilities that contribute to their functional limitations. 

1 The index of ADLs was developed by Katz, see S. Katz, et al. Progress in the development of the 

index of ADL. The Gerontologist, 10:20-30, 1970. 

2 The index of IADLs was developed by Lawton and Brody, see M. Lawton and E. Brody. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 

9:179–186, 1969.
8 Commission on Long-Term Care Report to the Congress

■ LTSS include both paid assistance and assistance provided by family members 

and other unpaid caregivers.3 

Who Has Functional Limitations?

■ The 12 million Americans who rely on LTSS are a diverse group in terms of 

age, the condition causing functional incapacity, and place of residence. People who rely on LTSS are almost equally split between adults who are age 65 

and older (56 percent) and adults under 65 (44 percent). Adults are 96 percent 

of the total population who rely on LTSS.4 

■ Responding to LTSS needs is often contingent on an individual’s stage of life 

and circumstances.

Children under the age of 18 are a small percentage of the total population 

requiring LTSS, but can have substantial needs that will last a lifetime. For 

the most part, their care is provided by their families. Their functional 

limitations primarily result from impairments that occur at birth or infancy. Their impairments are equally split between physical and intellectual/

developmental disabilities (I/DD) with a significant number experiencing 

mental health disorders.5

The top ranking conditions for working-age adults with functional limitations between the ages of 18 and 44 who need LTSS include intellectual 

disabilities, paralysis and nervous system disorders, back problems and 

mental health disorders. 

The majority of those needing LTSS in the 45 to 64 age group have adult 

onset disabilities, primarily consisting of physical disabilities with a significant number of those also suffering from mental health disabilities.

About half of the physical functional impairments associated with LTSS 

needs of older adults have onset after age 65 (90 percent after age 18) and 

are caused primarily by arthritis, heart condition and diabetes. Dementia 

3 Adapted from Reinhard S, Kassner E, Houser A, Mollica R. Raising Expectations: A State 

Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, 

and Family Caregivers. 2011; http://www.longtermscorecard.org/~/media/Microsite/Files/AARP_Reinhard_Realizing_Exp_LTSS_Scorecard_REPORT_WEB_v3.pdf. Accessed August 26, 2013.

4 H. Stephen Kaye. Non-Elderly People Needing Long-Term Services & Supports: Who are they? 

What services do they get? What services do they need? Testimony to the Commission on Long-Term 

Care. July 17, 2013.

5 S. Kaye. Testimony to the Commission on Long-Term Care. July 17, 2013 (The data presented 

is based on Kaye’s analysis of data from the 2012 National Health Interview Survey & 2010 Census 

and represents those who use LTSS in community settings).
Institutional Total

Community—High Need

(multiple self-care/ADL)

Community—Medium Need

(some self-care/ADL)

Community—Low Need

(no self-care/ADL) 5.4

6.7

0.6

Children Working Age Elderly

Population Needing LTSS, by Age Group and Level of Need (Millions)

0

1

2

3

4

5

6

7

8

Source: S. Kaye, data from 2012 NHIS, 2010 Census, Nursing Home Data Compendium 2010

Chapter II Specific Challenges to Providing LTSS 9

and stroke, however, are both major causes of impairment, especially for 

the 22 percent of older adults needing LTSS who do not have physical impairments. Cognitive impairment is a complicating comorbidity for many 

other LTSS users.6 Alzheimer’s disease, the most common form of dementia, accounting for 60–80 percent of dementia cases, almost always results 

in a need for LTSS.7 One in 8 Americans over the age of 65 has Alzheimer’s, and the disease affects 42.5 percent of Americans over the age 85.8

■ These different populations have different needs that can be met with similar 

services and supports, but are often provided in different settings or care systems. For the older population, ability to work is not a factor in eligibility for 

assistance. For working-age persons with functional limitations, eligibility for 

income support and related health benefits is typically based on the inability 

to work.9 The need for LTSS, however, is related to functional impairment, 

6 S. Kaye. Testimony to the Commission on Long-Term Care. July 17, 2013.

7 Alzheimer’s Association (2013). 2013 Facts and Figures. Alzheimer’s Association. Retrieved 

from http://www.alz.org/downloads/facts_figures_2013.pdf. 

8 Alzheimer’s Study Group (2009). A National Alzheimer’s Strategic Plan.

9 While age 65 is typically the dividing line between work-related disability and aging since eligi-
Adults Under 65

Percent

Lives With Family

Lives Alone or With Roommates

Adults Over 65

Use of Paid Help Among Community-Resident Adults Needing LTSS 

5%

36% 24%

16%

Source: S. Kaye, analysis of 2010 SIPP data

0

10

20

30

40

50

60

70

100

80

90

10 Commission on Long-Term Care Report to the Congress

which may exist in a context in which the individual is unable to work or in 

which assistance is needed to maintain employment. Many adults with functional limitations are able to work with personal assistance, workplace supports, and other LTSS.

■ The shift of the population receiving paid LTSS from institutional to home 

and community-based care (“de-institutionalization”) has had the greatest 

impact on care for the under 65 population in need of LTSS. Among Medicaid beneficiaries, nearly 80 percent of the under-65 LTSS population is using 

community-based services, compared to less than half of the older adult LTSS 

population.10 Non-elderly adult LTSS users are also likely to depend entirely 

on their families for care—less than a third use paid help compared to over 

half of the older adult LTSS users.11 

bility for income security benefits and related Medicare and Medicaid is typically based on inability to 

work before age 65 and retirement after age 65, the division at age 65 is not a bright line—functional 

impairment that impedes work can be a factor for workers and potential workers at any age. 

10 D. Rowland. Testimony to the Commission on Long-Term Care. August 1, 2013.

11 S. Kaye. Testimony to the Commission on Long-Term Care. July 17, 2013.
Chapter II Specific Challenges to Providing LTSS 11

■ The population with intellectual and developmental disabilities (I/DD) has been 

particularly affected by policy decisions to close large public and private institutions and shift to community-based care, in part in response to litigation.12 

■ There are racial and ethnic disparities in the need for and the use of LTSS. 

Older black and Hispanic individuals have higher rates of functional impairment than whites.13 Nursing home use has declined markedly among older 

whites, but has increased over time among older blacks and now exceeds the 

usage rate among whites.14 Growth in nursing home use has been especially 

rapid among older Hispanics and Asians in recent years, albeit from a very 

low rate.15 Researchers have found many reasons for racial and ethnic disparities, including stronger reliance on or preference for family-provided informal care, disparities in area resources, and differences in economic status.16

Black residents remain more likely to live in nursing homes that have deficiencies in care.17

■ The number of people needing LTSS is expected to grow in the next few decades as the Baby-Boom generation ages, although trends in age-adjusted 

rates of disability now appear to be holding steady after a period of improvement for older populations.18 The number of individuals with Alzheimer’s and 

other dementias will increase as the number of elderly people increases. By 

2050, the annual number of new cases of Alzheimer’s is projected to more 

than double.19

12 D. Braddock. Testimony to the Commission on Long-Term Care. July 17, 2013.

13 Congressional Budget Office. (2013). Rising Demand for Long-Term Services and Supports for 

Elderly People. Washington, DC: Congressional Budget Office. 

14 Ness, J., Ahmed, A., Aronow, W.S. (2004). Demographics and payment characteristics of nursing 

home residents in the United States: A 23 year trend. Journals of Gerontology, 59A (11):1213–1217.

National Center for Health Statistics. (2009). National Nursing Home Survey: 2004 Overview. Washington, DC.

15 Z. Feng, M. Fennell, D. Tyler, M. Clark, V. Mor. (2011). Growth of racial and ethnic minorities 

in U.S. nursing homes driven by demographics and possible disparities in options. Health Affairs, 30, 

1358-1365.

16 Murtaugh, C.M., Kemper, P., & Spillman, B.C. (1990). The risk of nursing home use in later life. 

Medical Care, 28, 952-962.

17 Smith, D.B., Feng, Z., Fennel, M.L., Zinn, J.S., & Mor, V. (2007). Separate and unequal: Racial 

segregation and disparities in quality across U.S. nursing homes. Health Affairs. 

18 Kaye, H.S. (2013). Disability rates for working-age adults and for the elderly have stabilized, but 

trends for each mean different results for costs. Health Aff (Millwood), 32, 127–134; Freedman, V. 

A., B. C. Spillman, P. M. Andreski, J. C. Cornman, E. M. Crimmins, et al. (2013). “Trends in late-life 

activity limitations in the United States: an update from five national surveys.” Demography 50(2): 

661-671. 

19 Alzheimer’s Association, “Alzheimer’s disease facts and figures”(2013).
12 Commission on Long-Term Care Report to the Congress

The Critical Role of Family Caregiving

■ Most people who receive LTSS in the home rely on family caregiving. A 

“family caregiver” may be a relative, partner, friend, or neighbor who has a 

significant relationship with, and provides assistance for, a person who has 

functional limitations. 

■ Family caregivers are a major part of the care delivery system, providing the 

majority of LTSS and often coordinating paid LTSS and health care. Many 

caregivers also contribute direct financial support to individuals with daily 

functional needs to remain in their homes and remain as independent as possible. On a typical day in 2009, 42 million family caregivers nationwide were 

providing care to an adult with LTSS needs, with women being the vast majority of unpaid caregivers.20

■ The value of family caregiving exceeds the total value of all paid LTSS. Family caregiving was estimated to be worth $450 billion in 2009 21 as compared 

to $211 billion in spending on all paid caregiving in 2011.22 In addition, the 

cost to U.S. businesses from lost productivity from family caregiver employees (from reduced hours, replacement of employees, absenteeism, and other 

factors) was estimated at $34 billion dollars in 2004.23

■ Families typically expect to and prefer to care for a loved one with a chronic 

illness or disability. In surveys, most Americans say they would feel obligated 

to care for a parent who needed assistance.24 However, many family caregivers 

have no alternative to providing care themselves due to the expense of paid 

care. Families with children in need of LTSS typically prefer to care for their 

children, but are likely to need support with complex care needs. Adults under age 65 with functional impairments are more likely to rely exclusively on 

family caregiving than older adults.25 

20 An estimated 62 million family caregivers provided care at some time during the year in 2009. 

L. Feinberg. Populations in Need of LTSS and Service Delivery Issues. Testimony to the Commission 

on Long-Term Care. July 17, 2013.

21 L. Feinberg, S. Reinhard, A. Houser, R. Choula. Valuing the Invaluable: 2011 Update: The 

Growing Contributions and Costs of Family Caregiving. 2011; http://assets.aarp.org/rgcenter/ppi/ltc/

i51-caregiving.pdf. 

22 National Health Policy Forum. National Spending for Long-Term Services and Supports 

(LTSS), 2011. February 1, 2013. 

23 L. Feinberg, S. Reinhard, A. Houser, R. Choula. Valuing the Invaluable: 2011 Update: The 

Growing Contributions and Costs of Family Caregiving. 2011; http://assets.aarp.org/rgcenter/ppi/ltc/

i51-caregiving.pdf.

24 Pew Research Center. Social and Demographic Trends: The Decline of Marriage and the Rise 

of New Families. November 18, 2010.

25 Two thirds of older adults with disabilities who receive care at home are cared for only by 
Chapter II Specific Challenges to Providing LTSS 13

■ Caregiving often places financial, physical, and emotional hardship on the 

caregivers. Frequently caregivers have little advance knowledge or training 

in the activities they have to perform, have little access to information and 

support they need to help navigate the fragmented health and LTSS systems, 

and have no opportunity to arrange other support when they are unable to 

provide care.26

■ Caring for an individual with cognitive limitations can pose a particular challenge. Approximately 15.4 million people provide care to individuals with 

Alzheimer’s and other dementias. Caregivers of individuals with Alzheimer’s 

and other dementias spend more years caregiving on average than family 

caregivers providing care to individuals without dementia, and are also more 

likely to report assisting their loved ones with at least one ADL, compared 

with caregivers of older adults in general. Moreover, caregivers of individuals 

with Alzheimer’s report high levels of physical and emotional stress due to 

caregiving, and are more likely to suffer from depression than caregivers of 

older adults in general.27

■ The nature of family caregiving is changing as more individuals are discharged 

early from acute settings with increasingly complex medical care needs to be 

met in the home. The increasing complexity of post-acute care is making care 

more challenging for family caregivers who are capably providing LTSS for a 

loved one, but often do not have training in the medical/nursing tasks they 

need to perform in the wake of an acute care episode.28 

■ While families will likely continue to be the primary support for individuals 

with LTSS needs, declining birth rates over the last 50 years mean there will be 

fewer family members available in the near future to provide hands-on support compared to the number of Baby Boomers who are providing care for an 

aging relative today. A recent AARP study projected a dramatic decline over 

the next 20 years in the caregiver support ratio: from 7 potential caregivers for 

family members, while 26% receive both care from family members and paid help. Only 9% use paid 

help alone. [P. Doty. 2010]. Non-elderly adults with disabilities rely even more heavily on family 

caregiving—only 24% of the non-elderly population who lived alone used paid help in 2010. [S. Kaye. 

2013].

26 Feinberg op. cit.

27 Alzheimer’s Association (2013). 2013 Alzheimer’s Disease Facts and Figures. Chicago, IL: 

Alzheimer’s Association. 

28 S. Reinhard, C. Levine and S. Samis (2012). Home Alone: Family Caregivers Providing Complex Chronic Care. AARP Public Policy Institute and United Hospital Fund. http://www.aarp.org/

content/dam/aarp/research/public_policy_institute/health/

home-alone-family-caregivers-providing-complex-chronic-care-rev-AARP-ppi-health.pdf.
14 Commission on Long-Term Care Report to the Congress

every person in the high-risk years of 80-plus in 2010 to 4 for every person 

80-plus in 2030.29

■ The challenges family caregivers face, in the context of a likely decline in the 

future in the availability of family caregivers, threaten to increase the use of 

paid care, the burden on private financial resources, and the stress on publicly 

financed programs. 

How Paid LTSS is Provided—Delivery System Challenges

■ Individuals with substantial functional and cognitive needs struggle to participate in everyday activities of living, live safely and well at home or in their 

residence of choice, and to enjoy many aspects of daily life. Various services, 

ranging from personal care assistance, adaptive technologies, environmental 

modifications, and residential communities exist to address these difficulties.30

■ However, the network of providers to deliver this support is complex, multifaceted, specialized, isolated from other service providers, and confusing to 

the average consumer. Few providers in this network evaluate a person’s overall situation in order to arrange for the right combination of services based on 

one’s actual needs. Instead, access to services is often organized in relationship 

to their funding streams, governed by a mix of federal, state, and local rules 

and procedures. Separate agencies may have unique eligibility rules, intake 

and assessment processes.

■ When the need for LTSS arises in the wake of a medical event—a hospitalization for an accident or illness, or a transition from a post-acute stay to longterm care—the planning and organization of LTSS for an individual is often 

handled separately from the health care planning, and there are few incentives for health care providers to integrate LTSS with medical care planning or 

service delivery. Patients may be discharged to a nursing home or their own 

home for post-acute care. When individuals need LTSS, frequently they and 

their families must find and arrange for LTSS on their own, sometimes on 

29 D. Redfoot, L. Feinberg, and A. Houser. The Aging of the Baby Boom and the Growing Care 

Gap: A Look at Future Declines in the Availability of Family Caregivers. AARP Public Policy Institute. August 2013. http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2013/

baby-boom-and-the-growing-care-gap-insight-AARP-ppi-ltc.pdf.

30 Gitlin, L.N., Szanton, S.L., & DuGoff, E.H. (2011). The SCAN Foundation CLASS Technical 

Assistance Brief No. 1: Supporting Individuals with Disability Across the Lifespan at Home: Social 

Services, Technologies, and the Built Environment. Retrieved from http://www.thescanfoundation.

org/sites/default/files/TSF_CLASS_TA_No1_Supporting_ Individuals_At_Home_FINAL.pdf.
Chapter II Specific Challenges to Providing LTSS 15

short notice when the need arises from a medical event or a change in the individual’s functional capacity. Families responding on short notice rarely have 

the opportunity to make solid LTSS arrangements that will enable a safe living 

environment. When a fragile care system fails, individuals may experience a 

longer-than-needed hospital stay, an interim discharge to a nursing facility, 

and/or an unwarranted re-hospitalization.

■ When people have to arrange paid LTSS, the fragmented system is difficult for 

the individual and family caregiver to access and negotiate. Currently, there 

is no comprehensive approach to care coordination for these individuals and 

caregivers. As a result, services and supports may not be provided in the most 

appropriate setting by the most appropriate provider, the individual’s needs 

and preferences may not be met, and their caregivers may experience substantial stress trying to arrange for or provide care. This fragmented, provider- and 

setting-centered approach (as opposed to a person-centered approach) results 

in service and supports needs that go unmet, putting individuals at risk for 

injuries and/or adverse health consequences requiring medical attention. 

■ Persons with functional limitations do not always have a choice of the LTSS 

they need in the least restrictive environment appropriate for their level of 

functioning.31 The 1999 Supreme Court decision in Olmstead32 required states 

to make reasonable accommodation to enable persons with disabilities to receive services in the most integrated setting appropriate to their needs. Since 

then, federal and state spending has shifted from primarily supporting institutional care to a more balanced mix of institutional and non-institutional 

care. Several initiatives have been funded aimed at increasing access for individuals with functional limitations to a choice of LTSS that can provide assistance with daily living toward the goal of maintaining their independence, 

self-determination, and dignity. 

■ The Olmstead decision resulted in substantial Medicaid funding and state 

waiver authority to increase access to home and community-based services 

(HCBS). Medicaid spending for HCBS has increased substantially both in 

amount and as a proportion of all Medicaid LTSS spending since 1997. The 

Bush Administration’s New Freedom Initiative in 2001 and the Obama Administration’s Community Living Initiative in 2009 included implementation 

of Aging and Disability Resource Centers (ADRCs) as a way to meet the in31 S. Kaye. Testimony to the Commission on Long-Term Care, July 17, 2013.

32 Olmstead v. L.C. 527 U.S. 581 (1999).
Medicaid Spending on Long-Term Care Has Been 

Shifting Toward Community-Based Care

Home and Community-Based Care Institution-Based Care

$54

$75

$104

$121 $123 billion

20%

30%

39% 45% 45%

80% 70% 61% 55% 55%

1995 2000 2005 2010 2011

Source: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of CMS-64 data

16 Commission on Long-Term Care Report to the Congress

tent of Olmstead. The ADRCs are intended to serve as single points of entry 

into the LTSS system for older adults, people with disabilities, families and 

others, to make efficient use of care options and maximize available services. 

■ However, results are inconsistent across the country, with state-by-state variations in eligibility and services provided through public sources and severe 

constraints on the availability of services in some states. There are significant 

access limits on many LTSS. Many states cap enrollment in HCBS, and some 

maintain waiting lists. An estimated 500,000 people are currently on state 

HCBS waiting lists of one kind or another.33 Publicly-funded programs do not 

cover many services that are needed to remain independent (e.g., technology, 

home modifications, family supports). In addition, public funding is available 

to provide services and supports for people with disabilities who are not able 

to work but is not generally available to support persons with functional limitations who can and will work with assistance.

■ There are a number of promising initiatives aimed at integrating LTSS with 

acute and post-acute care to develop a continuum of care that is person- and 

family-centered rather than centered on the setting or funding source. New 

organization and payment initiatives have the potential to align financial in33 S. Kaye. Testimony to the Commission on Long-Term Care, July 17, 2013.
Chapter II Specific Challenges to Providing LTSS 17

centives of health care organizations to focus on and take accountability for 

health outcomes. Several states are pioneering comprehensive LTSS initiatives 

to combine assessment, information, counseling, care management, and other services to empower persons with functional limitations to choose settings 

and services that best meet their needs. Most of these initiatives are pilot and 

small scale projects, reaching only a small part of the range of services and 

supports, consumers, and geographic areas in the U.S.

The Program of All-inclusive Care for the Elderly (PACE), a well-known 

forerunner of many of today’s community-based models of integrated 

care for dual beneficiaries, is an excellent case in point with respect to the 

challenges involved in bringing successful programs to scale. Initiated in 

1990, PACE now serves over 25,000 enrollees nationally. A single model of financing and organizing care cannot serve the entire population in 

need. As of 1999, there were approximately 3 million elderly in the United 

States who met the eligibility criteria for PACE: community-based, nursing home-certifiable, and dually eligible, who could benefit from PACE or 

other integrated service options.34 

The Centers for Medicare and Medicaid Services (CMS) Medicare-Medicaid Coordination Office Financial Alignment Demonstration will test 

capitated and managed fee-for-service models on a large-scale basis for 

dually-eligible beneficiaries in which primary, acute and behavioral health 

services are covered in addition to LTSS. Eight states (Massachusetts, 

Washington, Ohio, Illinois, California, New York, Virginia, and Minnesota (through an alternative model)) were recently selected to begin full 

implementation of their demonstrations.35

Several States, including Minnesota and Washington, are pioneering the 

development of innovative, ‘high-functioning’ LTSS systems which bring 

together easy-to-access information, assessment, counseling, care management, nursing home pre-admission and transition services and a wide 

array of home and community-based and managed care options.36

34 Bodenheimer T. Long-Term Care for Frail Elderly People—The On Lok Model. New England 

Journal of Medicine. 1999; 341(17):1324–8.

35 M. Bella. What Would Strengthen Medicaid LTSS? Testimony to the Commission on LongTerm Care. August 1, 2013; CMS MMCO Financial Alignment Initiative. Retrieved from http://www.

cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html. 

36 L. Colman. Statement on Service Delivery and Provider Innovation and Issues. Testimony to 

the Commission on Long-Term Care. August 20, 2013.
18 Commission on Long-Term Care Report to the Congress

Participant-directed or consumer-directed services are increasingly being 

offered under Medicaid home care waivers.37 Under these programs, older 

adults and persons with a disability are approved for a certain number of 

hours according to their needs. They are then able to recruit, hire, and 

train their own personal care attendants to provide services; programs 

may also offer an agency option; and, in many states, family members may 

take these jobs. Personal direction has proved very popular with care recipients, who feel more in control of their care.38 To facilitate the individual employment of direct care workers, Medicaid programs set up fiscal 

intermediaries to process paychecks and file payroll taxes.39 

Who Provides Paid LTSS?: Workforce Challenges

■ The workforce providing paid LTSS is a critical link in the availability and 

quality of services. It is a mix of professionals and direct care workers who 

are found in a number of settings, such as nursing homes, institutions for 

individuals with intellectual and developmental disabilities, and in home and 

community-based settings. 

■ The professional workforce includes physicians, nursing home and assisted 

living administrators, registered nurses (RNs), licensed practical and vocational nurses (LVN/LPNs),40 physical and occupational therapists, and social 

workers.41 However, nurses provide the majority of professional long-term 

care. RNs tend to hold supervisory roles in nursing homes and home health 

37 O’Keeffe, J., P. Saucier, B. Jackson, R. Cooper, E. McKenney, S. Crisp, et al. (2010). Understanding Medicaid Home and Community Services: A Primer. Assistant Secretary for Planning and 

Evaluation, U. S. Health and Human Services. http://aspe.hhs.gov/daltcp/reports/2010/primer10.pdf.

Newcomer, R., T. Kang and J. Faucett (2011). “Consumer-directed personal care: comparing aged and 

non-aged adult recipient health-related outcomes among those with paid family versus non-relative 

providers.” Home Health Care Serv Q 30(4): 178–197.

Caldwell, J. and T. Heller (2007). “Longitudinal outcomes of a consumer-directed program supporting adults with developmental disabilities and their families.” Intellect Dev Disabil 45(3): 161–173.

38 Wiener, J. M., W. L. Anderson and G. Khatutsky (2007). “Are consumer-directed home care 

beneficiaries satisfied? Evidence from Washington state.” Gerontologist 47(6): 763–774.

39 Scherzer, T., A. Wong and R. Newcomer (2007). “Financial management services in consumer-directed programs.” Home Health Care Serv Q 26(1): 29–42.

40 Institute for the Future of Aging Services (2007). The Long-term Care Workforce: Can the Crisis Be Fixed? Retrieved from http://www.leadingage.org/uploadedFiles/Content/About/Center_for_

Applied_Research/Center_for_Applied_Research_Initiatives/LTC_Workforce_Commission_Report.

pdf.

41 Eldercare Workforce Alliance. Geriatrics Workforce Shortage: A Looming Crisis for Our Families. Washington, DC: Eldercare Workforce Alliance. 
Chapter II Specific Challenges to Providing LTSS 19

agencies, while LPNs provide direct patient care, including tasks such as medication administration and taking vital signs.42

■ Direct care workers include nursing aides and orderlies, home health aides, 

and personal care and home care aides. Nursing aides and orderlies work 

primarily in nursing homes and assisted living facilities, and perform both 

paramedical tasks and assistance with ADLs. Home health aides perform 

tasks similar to those of nursing aides, but in the home and community. 

Personal care attendants, also called personal care aides and home care 

workers, generally provide social supports and assistance with ADLS to individuals in their homes.43

■ The professional workforce specifically trained to meet the LTSS needs of 

the older adult population will not be adequate to meet the future needs for 

LTSS. There were only 7,356 board-certified geriatricians in the United States 

in 2012,44 and there is only about one geriatric psychiatrist for every 23,000 

older adults. By 2030, this will fall to one for every 43,000 older adults.45 In 

addition, less than 4 percent of social workers specialize in aging, despite the 

fact that 75 percent report working with older adults.46 Nurses, who provide 

a significant amount of care for older adults, have high rates of turnover in 

nursing homes.47

■ The direct care workforce provides between 70 and 80 percent of paid longterm personal assistance.48 Due to the aging of the population and the rebalancing towards home and community-based services, demand for direct 

care workers is set to increase by 48 percent over the next decade, adding 1.6 

million positions.49 The anticipated increase in the demand for workers could 

lead to a shortage of experienced workers.50 Retention is also an issue. While 

some workers have stable job tenure, others have low job and industry attachment. Studies of turnover have found rates of 44–46 percent for home care 

workers, 49 percent for certified nurse assistants (CNAs) in nursing homes, 

42 Institute for the Future of Aging Services. 

43 PHI (2011). Facts 3: Who Are Direct Care Workers? Bronx, NY: PHI. 

44 The American Geriatrics Society. (2012). Projected Future Need for Geriatricians. 

45 ADGAP Status of Geriatrics Workforce Study, American Geriatrics Society (2008). http://www.

americangeriatrics.org/files/documents/gwps/Table%201_29.pdf

46 T Lustig. Testimony to the Commission on Long-Term Care. August 20, 2013.

47 American Health Care Association (2011). 2011 Staffing Survey Report. Washington, DC: 

American Health Care Association. 

48 PHI (2012). Facts 3: America’s Direct Care Workforce. Bronx, NY: PHI.

49 National Center for Health Workforce Analysis, 2004.

50 Institute of Medicine (2008). Retooling for an Aging America. 
Direct Care Workforce, 2012

Nursing Assistants

37%

Independent Providers

20%

Personal Care Aides

20%

Home Health Aides

23%

Source: PHI analysis of BLS 2012 data 

20 Commission on Long-Term Care Report to the Congress

and 26 percent among CNAs in assisted living facilities.51 CNAs have a 49 percent retention rate in nursing homes, and a 78 percent retention rate in assisted living facilities. Agencies have reported difficulty attracting and retaining 

qualified workers,52 which may affect the quality of care that individuals with 

LTSS needs receive. 

■ Factors that contribute to the difficulty in attracting and retaining experienced direct care workers are the low levels of compensation, lack of benefits, 

and limited opportunities for advancement that are associated with the skill 

51 Seavey, D. & A. Marquand (2011); American Health Care Association (2011). 2010 AHCA 

Survey: Nursing Facility Staffing Survey 2010. American Health Care Association; Hewitt, A. and C. 

Larson. (2007). The Direct Support Workforce in Community Supports to Individuals with Developmental Disabilities: Issues, Implications, and Promising Practices. Mental Retardation and Developmental Disability Research Reviews 13 (7):178–187. National Center for Assisted Living (2012). 

Findings from the NCAL 2011 Assisted Living Staff Vacancy, Retention, and Turnover Survey. 

Institute of Medicine (2008). Retooling for an Aging America.

52 American Health Care Association (2011). Nursing Facility Staffing Survey 2010; National 

Center for Assisted Living (2012). Findings from the NCAL 2011 Assisted Living Staff Vacancy, 

Retention, and Turnover Survey. 
Chapter II Specific Challenges to Providing LTSS 21

levels required for the job.53 In addition, compensation has not increased for 

these jobs over the last decade.54 Compensation is generally higher for direct 

care workers in nursing homes than in home and community-based settings. 

However, nursing home positions also exhibit high turnover, due not only 

to low compensation, but also to high caseloads and supervisory style. For 

example, nursing aides are more likely to stay with their positions if they feel 

valued and respected.55 Demographic changes will also affect the supply of direct care workers. The growth of the labor pool of women aged 25 to 54, from 

which direct care workers are primarily drawn, is not expected to keep pace 

with the demand for workers.56

■ With the increase in HCBS, it is likely that workers will tend to serve consumers with more complex needs with less supervision. At the same time, 

nursing home residents are projected to become increasingly elderly and 

frail.57 Experts are concerned that direct care workers serving consumers 

with increasingly complex care needs do not receive adequate training.58

At the federal level, there is currently no minimum training requirement 

for personal care attendants. Home Health Aides and CNAs who work at 

Medicare-certified agencies are both required to have 75 hours of training, 

of which 16 must be clinically supervised. In 2008, the Institute of Medicine 

recommended raising this requirement to at least 120 hours of training, but 

most states have not adopted this standard.59 The training requirements for 

consumer-directed personal care aides are even more minimal.60 In addition 

to leaving workers unprepared for the tasks they might face at work, lack of 

training or career pathways also makes it difficult for workers to advance.61

53 Seavey, D., & A. Marquand (2011). 

54 PHI. (2011). State Chart Book on Wages for Personal Care Aides 2000–2010. Retrieved from 

http://www.pascenter.org/documents/PCA_Wage_Chart_Book_2000_2010.pdf.

55 Seavey & Marquand, 2011; Mickus, M., C.C. Luz, and A. Hogan. (2004). Voices from the Front: 

Recruitment and Retention of Direct Care Workers in Long-Term Care across Michigan. Michigan 

State University. 

56 Seavey, D. and A. Marquand, 2011

57 Dawson, 2007. Recruitment and Retention of Paraprofessionals. PHI. 

58 Institute of Medicine (2008). Retooling for an Aging America. Institute of Medicine. 

59 IOM, 2008; A. Marquand (2013). Personal Care Aide Training Requirements. PHI. Retrieved 

from http://www.phinational.org/research-reports/personal-care-aide-training-requirements-summary-state-findings. 

60 Seavey & Marquand, 2011.

61 Testimony of Carol Regan. Hearing on Population in Need of LTSS and Service Delivery Issues. 

July 17th, 2013.
22 Commission on Long-Term Care Report to the Congress

Training has also been shown to reduce turnover and increase job satisfaction among direct care workers.62

■ High turnover and workforce shortages have an impact on care quality. 

Though there is little data about the effect of worker turnover in home and 

community-based settings, studies in nursing homes have shown that higher 

turnover is associated with poor quality of care as measured by use of restraints, pressure ulcers, psychoactive drug use, and certification survey quality of care deficiencies.63

Paying for LTSS: Financing Challenges

■ Paid LTSS are labor-intensive and can be costly due to the duration of care.64

Traditionally, LTSS has been the responsibility of family caregivers. But when 

paid services are needed, most Americans are not effectively prepared to 

shoulder the cost, whether services are needed due to a disability with onset 

at birth, during working years, or in old age. 

■ Individual needs for LTSS for those under the age of 65 vary widely due to 

the diverse nature of the conditions being addressed. Individuals with a permanent condition may face LTSS costs that have a long duration that can be 

costly. Children and pre-65 adults and their families are unlikely to have access to long-term care insurance, due to their condition and the limitations 

62 Dawson, 2007. Recruitment and Retention of Paraprofessionals. Paraprofessional Health Institute.

63 Seavey & Marquand, 2011; Castle, N.G., Engberg, E., Anderson, R.A., & Meng, A. (2007). Job 

satisfaction of nursing aides in nursing homes: Intent to leave and turnover. Gerontologist, 47:193–

204. 

64 For persons that need LTSS and their families, the cost of paid assistance can be substantial. 

According to the Genworth’s 2013 Cost of Long-Term Care Survey, the median private pay daily 

rate in a nursing home is $207 for a shared room and $280 for a private room, though prices vary 

widely depending upon location and provider. According to the 2012 Eljay Survey of State Nursing 

Home payment rates across the United States, Medicaid programs pay an average rate of $178 per 

day ($7.42/hr) for 24-hour nursing services in a nursing home. For assisted living facilities, the average daily rate is approximately $117/day or less than $5.00/hour. Meanwhile, the median hourly 

prices of homemaker and home health services were $18 and $19 an hour, respectively—although 

individuals accessing home care use services on a limited number of hours per day compared to facility-based care. [From Genworth (2013). 2013 Cost of Care Survey: Home Care Providers, Adult 

Day Health Care Facilities, Assisted Living Facilities and Nursing Homes. Retrieved from https://

www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/130568_032213_Cost%20

of%20Care_Final_nonsecure.pdf and Eljay, LLC (2012). A Report on Shortfalls in Medicaid 

Funding for Nursing Center Care. Retrieved from http://www.ahcancal.org/research_data/funding/

Documents/2012%20Report%20on%20Shortfalls%20in%20Medicaid%20Funding%20for%20Nursing%20Home%20Care.pdf]. 
Chapter II Specific Challenges to Providing LTSS 23

of insurance that would cover these expenses, and are unlikely to have accumulated substantial assets. A high percentage of them will rely on Medicaid 

to finance care when they need paid care. The population with functional impairments due to intellectual and developmental disabilities are most dependent on Medicaid funding—77 percent of the funding for I/DD services and 

supports comes from the Medicaid program,65 compared to 61 percent of the 

LTSS funding for the total non-elderly adult population and 22 percent of the 

LTSS funding for the elderly population.66

■ Working-age adults with disabilities who continue to work have extra expenses associated with disability such as personal assistance, mobility devices, and 

assistive technology, among others. These supports are necessary for employment but require more resources to achieve the same outcomes as their nondisabled counterparts. Medicaid is the only program that provides LTSS for 

individuals with disabilities. But Medicaid is a means-tested program and is 

available only to those with very limited income and assets. Those receiving 

Medicaid benefits face a dilemma in considering work: if they work successfully, their income would likely disqualify them from receiving Medicaid coverage of the LTSS they need to work, yet they may not earn enough to pay for 

the services on their own. The implicit tax on working overwhelms earned 

income, even from high-paying jobs. Insurance can only work for this population if risks are broadly pooled and this is difficult in today’s private markets. 

■ Older adults who need paid services may need them for varying lengths of 

time, depending on nature and onset of the condition and their life expectancy. Functional impairment is not an inevitable consequence of aging, and 

many older adults reach the end of their lives without experiencing a long 

spell of disability. A person turning 65 has a 20 percent chance of experiencing more than 5 years of ADL and IADL impairment requiring help from 

family or paid care in his or her remaining lifetime, but also has a 31 percent 

chance of dying without any serious long-term care need, and faces a 17 percent chance that needs will last less than a year.67

■ Under current spending patterns, the expected value of all paid LTSS for a 

persone turning 65 in 2005 was $47,000, but the distribution of expenditures is highly skewed. Sixteen percent of the cohort could expect to use paid 

65 D. Braddock. 2013.

66 S. Kaye. 2013.

67 Kemper, P., Komisar, H.L., & Alecxih, L. (2005/2006). Long-term care over an uncertain future: 

What can current retirees expect? Inquiry, 42, 335–350.] 
Duration of Expected Future LTSS Need for Persons Turning 65

Source: Kemper, Komisar and Alecxih, 2005. Outputs 

of model using March 1993 and March 1994 CPS data

No LTSS Need

31%

5+ years

20%

<1 year

17%

1–2 years

12%

2–5 years

20%

24 Commission on Long-Term Care Report to the Congress

care valued at $100,000 or more over the course of their remaining years, 

and 12 percent could be expected to incur expenditures between $25,000 and 

$100,000. Forty-two percent of that cohort could expect no LTSS expenditures at all, either due to lack of need or exclusive reliance on informal care.68

■ These varying amounts of paid LTSS are funded through a mix of sources 

with individuals and their families relying first on personal resources, including savings and private long-term care insurance when available, and then on 

multiple, uncoordinated public sources all with unique requirements, most 

notably Medicaid, a means-tested federal-state program. Each source of funding has constraints, and their interaction leads to further problems. The issues 

for each funding resource are different for younger persons with disabilities 

and older adults. 

68 Kemper, P., Komisar, H.L., & Alecxih, L. (2005/2006). Long-term care over an uncertain future: 

What can current retirees expect? Inquiry, 42, 335–350. Costs are in 2005 dollars. 
$100,000 or more

6%

$25,000–

$100,000

12%

$10,000–

$25,000

7%

Distribution of Future LTSS Expenditures for Persons Turning 65, All Sources

Source: Kemper, Komisar and Alecxih, 2005. Outputs of model using March 1993 and March 1994 CPS data

$0

50%

Less than 

$10,000

25%

Chapter II Specific Challenges to Providing LTSS 25

Personal Savings

■ Individual income and assets are the first source for paid LTSS. However, 

many older adult households lack sufficient financial assets to provide for 

their LTSS. The inadequacy of many Americans’ retirement wealth is well 

known: working-age individuals and families, facing competing and more 

immediate demands for spending or with few resources to save, do not save 

enough for retirement, let alone LTSS needs. Later, need for paid LTSS adds 

a further burden on retirement assets that are already strained. In 2005, only 

one in three older adults had non-housing financial assets equal to the yearly cost of nursing home care ($70,000).69 The proportion was even lower for 

the subgroup that were more likely to require nursing home care due to age, 

family status or disability: only 16 percent held enough wealth to cover a year 

of care.70 About 46 percent of older adult households have less than $10,000 

69, 70 Feder J, Komisar H. The Importance of Federal Financing to the Nation’s Long-Term Care 

Safety Net. (2012) p. 3.
26 Commission on Long-Term Care Report to the Congress

in non-housing assets.71 Given the unpredictability and catastrophic nature of 

extensive LTSS needs, relying on savings to finance these services is unlikely 

to be effective.

■ Americans do not generally plan for future LTSS needs as they approach retirement. Sixty-five percent of Americans age 40 and up say they have done 

little or no planning even for ongoing living expenses in their older years—

barely more than half know where to go for information on long-term care. 

Three in 10 Americans age 40 and older say growing older is something they 

“just don’t want to think about,” a sentiment especially expressed by those 

who worry about burdening their families, worry about being alone in their 

later years, lack confidence that they know where to turn to find information 

on the issue, and feel they lack the financial resources to pay for long-term 

care costs. Those who do not want to think about aging are less likely to 

plan for it. However, people who feel they know where to get information on 

aging issues are more apt than others to have prepared for these needs. Experience also matters: planning is significantly higher among the 53 percent of 

Americans age 40 and older who have themselves provided LTSS assistance 

to another person.72

■ Experience to date suggests that, for generations retiring in the next few decades, there will be large numbers of older adults who will not have sufficient 

income and assets built up over working years to enable them to pay for a 

lengthy period of LTSS on their own. 

Insurance

■ Given the skewed incidence of functional impairments for older adults, with 

some people needing large amounts of services for a long duration and some 

needing none, it would seem that LTSS should be an appropriate area for insurance solutions. 

71 James M. Poterba, Steven F. Venti, David A. Wise, “Were They Prepared for Retirement? Financial Status at Advanced Ages in the HRS and AHEAD Cohorts, NBER Working Paper No. 17824 

(February 2012).

72 Associated Press-NORC Center for Public Affairs Research (April 2013). Long-Term Care Poll: 

Perceptions, and Attitudes among Americans 40 or Older. http://www.thescanfoundation.org/associated-press-norc-center-public-affairs-research-long-term-care-poll-perceptions-and-attitudes; Langer 

Research Associates (August 2013). Pathways to Progress in Planning for Long-Term Care. http://

www.thescanfoundation.org/sites/thescanfoundation.org/files/langer-ltcpoll-analysis-8-15-13.pdf.
Chapter II Specific Challenges to Providing LTSS 27

■ Private health insurance typically does not cover non-medical expenses beyond short-term, rehabilitation-oriented care. Likewise, Medicare, which 

provides universal coverage for people receiving Social Security Disability Insurance benefits (after a two-year waiting period) and for persons over age 65, 

does not cover long-term services and supports. 

■ While private long-term care insurance products have been sold for more 

than 30 years, any potential for them to serve a large percentage of the population has not been realized. Private long-term care insurance policies currently 

play a minor role in financing LTSS—only 10 percent of the potential market 

of Americans age 50 and above is currently insured.73 New issuance of policies 

has declined in recent years, and a significant number of insurers have left the 

private LTCI market and closed blocks of policies due to low interest rates 

that have affected the products’ financial performance, and unexpectedly low 

forfeiture rates, among other reasons.74 Many policies that are in force have 

recently experienced substantial premium increases.75 

■ Issues on the demand and supply sides of the long-term care insurance (LTCI) 

market are responsible for the low penetration of private LTCI. The potential 

to benefit from Medicaid coverage deters (“crowds out”) some people from 

purchasing LTCI, although analysts disagree on the significance of this effect.76 Features of the products, the insurance market, and some regulatory 

requirements limit the value and attractiveness of private LTCI, including: 

73 Brown, J.R. and A. Finkelstein (2004). Supply or Demand: Why is the Market for Long-Term 

Care Insurance So Small? National Bureau of Economic Research. Retrieved from http://www.nber.

org/papers/w10782.

74 M. Cohen. Testimony to the Commission on Long-Term Care. June 27, 2013.

75 CalPers LTCI (a California State Employee group insurance) raised premiums 22 percent in 

2009 and recently announced another 85 percent increase in premiums. R. G. Frank, M. Cohen & N. 

Mahoney (2013). Making Progress: Expanding Risk Protection for Long-Term Services and Supports 

through Private Long-Term Care Insurance. SCAN Foundation. http://www.thescanfoundation.org/

sites/thescanfoundation.org/files/tsf_ltc-financing_private-options_frank_3-20-13.pdf

76 In the Commission’s August 20 public hearing, J. Brown testified that given crowd-out, all but 

the highest 10 to 35 percent of the wealth distribution would be rational not to buy private LTCI. [J. 

Brown. Testimony to the Commission on Long-Term Care. August 20, 2013]. Brown also noted that a 

separate study comparing showed that states with more generous Medicaid eligibility had lower rates 

of private LTCI coverage. (Brown, J.R., Coe, N.E., & Finkelstein, A. (2007). Medicaid Crowd-Out of 

Private Long-Term Care Insurance Demand: Evidence from the Health and Retirement Survey. In 

J.M. Poterba (ed.), Tax Policy and the Economy (1–31). Cambridge, MA: MIT Press.) 

D. Grabowski testified that crowd-out is rational and likely at low asset levels (bottom tercile), but 

not at middle and upper asset levels—citing buyer/non-buyer data that shows a big uptake in private 

insurance between $50,000 and $100,000 in assets. Grabowski also noted that even with Brown and 

Finkelstein estimates of crowd-out, 40 percent of the population would still be candidates for private 

LTCI. (D. Grabowski. Testimony to the Commission on Long-Term Care. August 20, 2013).
28 Commission on Long-Term Care Report to the Congress

underwriting standards that prevent many individuals from qualifying, high 

monthly premiums, policy forfeiture rules, limits on benefits, and a lack of 

public understanding and confidence in the private LTCI products.77 

■ Innovation with LTCI product designs has shown some promise of attracting 

more consumers. One approach—the Partnership for Long-Term Care—is 

an arrangement between states and private insurers that enables purchasers 

of LTCI to retain larger amounts of assets and still qualify for Medicaid after 

they have used their long-term care policy. The Partnership expanded after 

the Deficit Reduction Act of 2005 extended eligibility to all states and enabled 

policyholders to change states and retain the policy. Forty-five states now offer Partnership plans. The number of policies, though still only 10 percent of 

LTCI policies, grew in recent years.78 Surveys have shown that almost half of 

those surveyed would purchase LTCI if their state had a Partnership program, 

although most knew little about the program and were unaware that their 

state offered those plans.79 

■ Another promising approach is combination products that combine life insurance or annuities with long-term care insurance. Products like the Life 

Care Annuity can combine risks in ways that can make premiums more affordable and deliver more value to the consumer. The combination of the life 

annuity with long-term care insurance enables the insurers to issue the product with less underwriting.80

■ The potential for savings and private insurance purchase to meet financing 

needs for LTSS has been limited by the proportion of the population with 

sufficient lifetime earnings and asset accumulation to pay for LTSS or to af77 Assistant Secretary for Planning and Evaluation (2012). Long-Term Care Insurance: ASPE Research Brief. Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human 

Services. Retrieved from http://aspe.hhs.gov/daltcp/reports/2012/ltcinsRB.shtml#note26.

78 CBO, 2013. Exhibit 20.

79 America’s Health Insurance Plans (2012). Who Buys Long-Term Care Insurance in 2010–2011? 

America’s Health Insurance Plans. Retrieved from http://www.ahip.org/Issues/Long-Term-Care-Insurance.aspx.

80 M. Warshawsky. The Life Care Annuity: A proposal for an insurance product innovation to 

simultaneously improve financing and benefit provision for long-term care and to insure the risk 

of outliving assets in retirement. Working Paper No. 2. Long-Term Care Financing Project, Health 

Policy Institute, Georgetown University. June 2007. 

Murtaugh, C.M., Spillman, B.C., & Warshawsky, M. (2001). In sickness and in health: An annuity 

approach to financing long-term care and retirement income. The Journal of Risk and Insurance, 68

(2), 225–254. 

Brown, J., & Warshawsky, M. (2013). The life care annuity: A new empirical examination of an 

insurance innovation that addresses problems in the markets for life annuities and long-term care 

insurance. Journal of Risk and Insurance, 80 (3), 677–704.
Chapter II Specific Challenges to Providing LTSS 29

ford insurance purchase. New options and incentives making it practical for 

people to save or purchase insurance at lower levels of income could expand 

this market, enabling more people to prepare for their own LTSS needs.

Medicaid

■ When individuals and families have exhausted their personal resources and 

can no longer shoulder LTSS costs on their own, they have to depend upon 

Medicaid for help. Individuals become eligible for Medicaid if they are eligible for Supplemental Security Income due to low incomes and assets, or 

as a result of spending down their incomes and assets on medical and LTSS 

expenses. Eligibility for Medicaid and the array of benefits provided vary substantially by state. 

■ Working-age adults with sufficient work histories may qualify for Social Security Disability Insurance (and Medicare after a two-year waiting period) 

and may be dually eligible for Medicare and Medicaid by virtue of having 

low incomes.81 About 15 percent of Medicaid enrollees are dually eligible and 

about a third of these are under age 65 adults with disabilities. Two-thirds of 

Medicaid enrollees using LTSS are dual beneficiaries.82

■ State Medicaid programs pay for the specific LTSS services specified by each 

state plan for people who meet the income and assets tests particular to their 

state. Nursing home services must be offered, but other LTSS services are optional. Depending on state thresholds, older adults with low income and assets are likely to have been eligible for Medicaid before they experience LTSS 

needs. But some people become eligible for Medicaid due to their spending 

on paid LTSS: they “spend down” to Medicaid eligibility by spending nearly 

all their income and assets on services. Because nearly all income must be 

spent before Medicaid begins to pay, rules protect some income and assets 

for community-resident spouses. In addition, there are asset exclusions that 

enable a Medicaid recipient to retain working assets of substantial value. For 

example, the value of the family home is protected during the lifetime of the 

Medicaid recipient and spouse.83 

81 Dual Eligibles: Medicaid’s Role for Low-Income Medicare Beneficiaries. Kaiser Commission on 

Medicaid and the Uninsured. Fact Sheet May 2011.

82 Kaiser Family Foundation. Medicaid’s Long-Term Care Users: Spending Patterns Across 

Institutional and Community-based Settings. October 2011. http://kaiserfamilyfoundation.files.

wordpress.com/2013/01/7576-02.pdf. page 3.

83 Medicaid eligibility is complicated and varies substantially from state to state. For states that 
30 Commission on Long-Term Care Report to the Congress

■ Some have suggested that individuals with high lifetime incomes may transfer assets to become Medicaid-eligible instead of planning for LTSS risk, and 

thus subvert Medicaid’s purpose of serving the poor. However, a Government 

Accountability Office (GAO) study examining the impact of tightened asset 

transfer provisions enacted in the Deficit Reduction Act of 2005 found that 

most older adults gaining Medicaid eligibility have very limited incomes, and 

that asset transfers were both rare and generally modest in size, both before 

and after the new provisions.84 There are competing views concerning the extent to which individuals can plan within current Medicaid rules to retain 

assets while achieving Medicaid eligibility.85

■ Medicaid is the single largest payer for paid long-term services and supports. 

Today, Medicaid pays for 62 percent of paid LTSS while more than 22 percent 

is paid out-of-pocket, and other private payers pay for only 12 percent. In 

2011, total spending for LTSS expenditures from all sources was $211 bilbase eligibility on the federal SSI coverage requirements, in 2013 recipients must have monthly 

income below $710 for an individual ($1,066 for a couple), about 75 percent of the federal poverty 

level (FPL). States may extend Medicaid coverage to individuals in a nursing home or other institution with incomes up to 300 percent of FPL. Under SSI program rules, Medicaid recipients may also 

have countable assets of no more than $2,000 for an individual (no more than $3,000 for a couple). 

Medicaid allows the recipient to exclude the value of the primary residence (up to $536,000 in 2013, 

although states can allow up to $802,000 in 2013) as well as a car and personal and household items 

and burial funds and term life insurance, and, in many states, qualified retirement assets in distribution status, from countable assets. States may use more restrictive income and asset rules, and there 

are some states with less restrictive rules. (K. Colello, Congressional Research Service, Testimony 

before the Commission on Long-Term Care, June 27, 2013). The Medicaid estate recovery program 

allows states to recoup private assets when a beneficiary dies in order to recover Medicaid expenditures on that person’s behalf. The amount of recovery through this program has been relatively small, 

but varies among states. (Julie Stone, CRS Report for Congress, Medicaid Coverage for Long-Term 

Care: Eligibility, Assets Transfers, and Estate Recovery, January 2008).

84 U.S. Government Accountability Office, Medicaid Transfers of Assets by Elderly Individuals to 

Obtain Long-Term Care Coverage. GAO–05–968 (Washington, DC: U.S. Government Accountability 

Office, September 2005). 

85 K. Colello, Congressional Research Service, Testimony before the Commission on LongTerm Care, June 27, 2013. The CRS testimony provided an extensive discussion of asset transfer and 

estate recovery rules and state variation in rules and compliance. E. O’Brien. (2013). Interaction of 

Insurance, Private Resources, and Medicaid: Assessing the Evidence. Testimony before Commission 

on Long Term Care. August 1. http://www.ltccommission.senate.gov/Ellen%20O%27Brien%20PP.

pdf; Stone, J. (2008). Medicaid Coverage for Long-Term Care: Eligibility, Asset Transfers, and Estate 

Recovery. RL33593. January 31. http://www.aging.senate.gov/crs/medicaid18.pdf; Stone, J. (2011). 

Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities: 2009 State Profiles. Congressional Research Service. Report,R41899. June 28. http://www.pascenter.org/documents/medicaid_eligibility.pdf. 
Out-of-pocket

$45.5 billion

21.6%

Other Public

$9.7 billion

4.6%

Medicaid

$131.4 billion

62.3%

Other Private

$24.4 billion

11.6%

LTSS Expenditures by Source, 2011

Source: National Health Policy Forum, based on data 

from 2011 National Health Expenditure Accounts

Chapter II Specific Challenges to Providing LTSS 31

lion of which Medicaid expenditures account for $131 billion.86 About half 

of Medicaid LTSS spending pays for services for persons under the age of 65. 

■ State Medicaid spending overall is putting pressure on state budgets now and 

is likely to overwhelm both state and federal budgets in the coming decades. 

However, only 30 percent of Medicaid spending is for LTSS; about half of this 

pays for nursing home services and the remainder pays for services provided 

in home and community settings.87 A small percentage of Medicaid enrollees 

(6.4 percent) use LTSS, although this group (half aged and half disabled) account for nearly half (45.4 percent) of total Medicaid spending (counting both 

medical and LTSS expenses). 

86 National Health Policy Forum. National Spending for Long-Term Services and Supports 

(LTSS), 2011. February, 2013. Available data underestimates the amount of out-of-pocket (OOP) 

spending for LTSS because existing surveys do not capture all OOP spending on LTSS (for example, 

OOP spending for assisted living is not reported, although it may be substantial).

87 In addition, 4 percent pays for mental health services and intermediate care facilities for 

persons with intellectual disabilities. Kaiser Family Foundation. Medicaid and its Role in State/

Federal Budgets & Health Reform. April 2013. http://kaiserfamilyfoundation.files.wordpress.

com/2013/04/8162-03.pdf. Figure 18.
32 Commission on Long-Term Care Report to the Congress

■ Medicaid LTSS spending has grown, but no faster than Medicaid’s growth 

overall—about 5 percent a year since 2005. As a result, LTSS has remained 

a fairly constant share of total Medicaid spending.88 On a per enrollee basis, 

Medicaid LTSS spending has grown only 0.1 percent a year since 2007.89 Within total LTSS spending, however, spending on non-institutional services has 

grown substantially (from a third in 2005 to nearly half of total LTSS spending 

today) while spending on institutional services has remained fairly flat. 

■ Growing Medicaid spending competes with education and other state spending priorities. Moreover, the contraction of state tax revenues during the recent recession has put even more pressure on states to manage these costs. 

State spending on Medicaid accounted for 16.7 percent of all state general 

fund expenditures on average in 2011, roughly half the share that went to elementary and secondary education, consistent with its share over the preceding half decade. However, recently Medicaid’s share of state budgets has been 

growing—from 14.8 percent in 2010 to a predicted 19.6 percent in 2012.90

■ Total Medicaid spending is predicted to grow substantially over the next decade and put increasing pressure on federal and state budgets. The Congressional Budget Office (CBO) projects Federal Medicaid spending growth of 8 

percent per year, rising from 1.7 of GNP today to 3.6 percent in 2037.91 Much 

of this spending growth is expected to come from the addition of a population 

of previously uninsured adults and not from growing LTSS costs. CBO projects a 5.5 percent annual growth for LTSS spending in Medicaid, lower than 

the 8 percent annual growth rate CBO projects for Medicaid overall.92 

■ In response to growing budget constraints, almost every state has initiated 

Medicaid cost containment efforts. Over the last two years, almost all of Medicaid changes have focused on reductions in provider payments, with relatively few states initiating changes directly affecting LTSS users. Nevertheless, 

state budget pressures have influenced state decisions to seek Medicaid waiv88 S. Eiken, et al. Medicaid Expenditures for Long-Term Services and Supports: 2011 Update. 

Thomson Reuters. October 2011.

89 Kaiser Family Foundation. How Much Will Medicaid Cost in the Future and Why: A Look at 

Federal Projections. August 2013. Figure 8.

90 Kaiser Family Foundation. Medicaid and its Role in State/Federal Budgets & Health Reform. 

April 2013. http://kaiserfamilyfoundation.files.wordpress.com/2013/04/8162-03.pdf. Figure 32.

91 Congressional Budget Office. The 2012 Long-Term Budget Outlook. June 2012. P. 58. The 

projections as a share of GNP are for the combination of federal spending for Medicaid, CHIP, and 

tax credits for health insurance purchase under the ACA.

92 Congressional Budget Office. Rising Demand for Long-Term Services and Supports for Elderly 

People. June 2013. Exhibit 16.
0

50

100

150

200

2012

7 7 8 7 8 8 9 10 10 11 12 12

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

Source: Kaiser Commission on Medicaid and the Uninsured, 2013, based on CBO baseline projections 

Fee-for-service

Managed care

Long-term care

Medicare Premiums

In Billions of Dollars

CBO Federal Medicaid Spending Projections for Benets 2012–2013

79

71

66

72 77 81

87 92

98 103 108

115

121

127

73

88

100

118

128

136

144

151 159

169 178

84

97

110

126

136

154

162

172

181

192

145

Chapter II Specific Challenges to Providing LTSS 33

ers to gain greater flexibility in eligibility and benefits to ensure appropriate 

targeting and to limit overall spending. In LTSS, Medicaid waivers have enabled states to implement HCBS for recipients who would otherwise qualify 

for institutional care, and to limit eligibility or cap slots for these services. 

■ States are increasingly turning to contracts for LTSS with Medicaid managed 

care organizations as a means of containing LTSS costs and increasing coordination of services. In 2012, sixteen states were pursuing this strategy for at 

least a portion of their LTSS recipients, and a survey found that 11 additional 

states were planning to introduce this approach.93 The programs are starting 

modestly, with only 389,000 enrolled by the end of 2012.94 A number of the 

duals demonstration projects also use a contracted managed approach.

93 Saucier, P., B. Burwell, A. Halperin and H. Butera (2013). Consumer Choices and Continuity 

of Care in Managed Long-Term Services and Supports: Emerging Practices and Lessons. AARP. 

2013–07. July.

Cheek, M., M. Roherty, L. Finnan, E. G. Cho, J. Walls, K. Gifford, et al. (2012). On the Verge: The 

Transformation of Long-Term Services and Supports. AARP Public Policy Institute. http://www.aarp.

org/content/dam/aarp/research/public_policy_institute/ltc/2012/On-the-Verge-The-Transformationof-Long-Term-Services-and-Supports-Report-AARP-ppi-ltc.pdf.

94 Saucier, P., J. Kasten, B. Burwell and L. Gold (2012). The Growth of Managed Long-Term 

Services and Supports (MLTSS) Programs: A 2012 Update. Prepared for the Centers for Medicare & 

Medicaid Services (CMS), Disabled and Elderly Health Programs Group under Contract #: HHSM500-2005-00025I, Task Order No. 0002. July. <http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/MLTSSP_White_paper_combined.pdf>.
34 Commission on Long-Term Care Report to the Congress
Chapter III Recommendations 35

CHAPTER III

COMMISSION RECOMMENDATIONS

PART ONE – SERVICE DELIVERY

Vision: A more responsive, integrated, person-centered, and fiscally sustainable 

LTSS delivery system that ensures people can access quality services in settings 

they choose. 

Issue: Over 12 million Americans of all ages with functional impairments today 

receive long-term services and supports (LTSS) in their home and community 

or in an institution to assist them in performing daily activities of living. Family caregivers are the primary providers of these services and supports, but many 

individuals and their families rely on paid services for all or a part of their care. 

Many individuals and families pay for LTSS themselves or rely in part on coverage 

under private long-term care insurance they have purchased. Nearly a third of 

those receiving LTSS, however, rely on coverage under Medicaid. Medicaid, and 

the systems and providers it funds along with Medicare, are essential components 

of the network of services and supports for Americans with functional limitations. 

LTSS have improved substantially in recent decades and today most people with 

cognitive or functional limitations receive services and supports from dedicated 

caregivers and assistive technologies. 

The process of accessing and navigating services, however, can be a tremendous 

challenge. People with cognitive and functional limitations today receive LTSS using a patchwork of family caregiving and publicly- and privately-funded assistance. 

The organization and delivery of services and supports is typically defined in terms 

of providers, settings, and funding streams rather than the needs of the person receiving assistance. Individuals and families in need of LTSS often lack a choice of 

services and supports that can meet their needs in the least restrictive setting. 

The fragmentation and lack of coordination of the LTSS delivery system is due 

in part to the misalignment of benefit structures, conflicting rules, and separate 

funding streams of Medicare, Medicaid and other public and private programs. 
36 Commission on Long-Term Care Report to the Congress

The lack of coordination is further compounded by an array of agencies, professionals and paraprofessionals that do not work together in an integrated, personand family-centered way. In addition to access problems and the lack of consumer 

choice in the current system, individuals with cognitive and functional limitations 

and their family caregivers also experience disjointed care often disconnected 

from health care, housing, transportation and social services needed to support 

person- and family-centered LTSS. 

LTSS are essential but costly for individuals with cognitive and functional limitations and their families. The array of confusing and poorly coordinated health 

care and LTSS creates a greater cost for individuals with cognitive or functional 

limitations, their families, and taxpayers than it should. Paying for needed LTSS is 

challenging for families facing severe financial pressures and for federal and state 

governments facing fiscal constraints and a growing need in the future for LTSS as 

the population ages and overall health care expenditures rise. 

The current system of LTSS cannot meet the needs of a growing population in a 

time of severe fiscal constraints. Improvements in LTSS need to be developed with 

an appreciation for the economic challenges today and in the future and should 

include changes in the organization and payment for services. The application of 

new technologies can help improve health outcomes and lower the overall costs of 

LTSS and health-related services in the future.

Principles: The Commission believes that the LTSS delivery system should be organized to provide:

■ A comprehensive array of person- and family-centered, high-quality, financially-sustainable medical and social services and supports that meets the heterogeneous needs, preferences and values of individuals with cognitive and 

functional limitations.

■ Easy-to-access information and assistance for persons with cognitive and 

functional limitations and their caregivers to navigate the delivery system.

■ Choice of settings and providers, the active involvement of individuals and 

family caregivers in making care decisions, and the delivery of services and 

supports that meet individuals’ needs in the least restrictive setting consistent 

with their preferences.

■ Integration of LTSS with medical and health-related care, including effective 

management of transitions between one type or level of care and another.

■ Affordable, more efficient, coordinated health care and LTSS that aligns payment to reward providers for outcomes, quality of care and quality of life.
Chapter III Recommendations 37

RECOMMENDATIONS

REBALANCING – A BALANCED ARRAY OF LTSS

Recommendation: Promote services for persons with functional limitations in the 

least restrictive setting appropriate to their needs—building a system, including 

Medicaid, with options for people who would prefer to live in the community. 

Problem:

■ While states are mandated to cover nursing home and other institutional 

care, home and community-based services (HCBS) are an option funded only 

through a hodgepodge of waivers and state plan amendments.

■ States primarily use Medicaid waivers to provide home and community-based services (HCBS) to recipients who would otherwise require institutional care. State variation in eligibility, services, limitations and caps results 

in very different levels of access to HCBS in different states. There are over 

300 waivers providing for HCBS today. States have used waivers to limit access to the Medicaid services or impose enrollment caps and waive some 

income and asset rules and still retain the federal match. Many individuals 

who would otherwise qualify for HCBS are currently on state waiting lists 

for services or do not have access to services. The amount of service available 

to an individual once eligible for HCBS is also capped in terms of hours and 

state expenditures. 

Detailed Recommendation:

■ The Commission recommends that Congress incentivize state provision of 

care and services to enable individuals to live in the most integrated setting 

based on a person-centered process that is informed by an objective assessment of need. 

CMS should ensure that evolving systems of care prioritize access to 

HCBS, based on individuals’ needs, values, and preferences.

Ensure individuals and their family caregivers have access to information 

on choices of LTSS services to enable them to make informed choices between institutional and HCBS services. 

Reduce Medicaid waiver complexity by streamlining the HCBS provisions 

of the Medicaid statute and having CMS provide technical assistance to 

the states in order to encourage rebalancing efforts. 
38 Commission on Long-Term Care Report to the Congress

Commission a study of the potential for savings across acute care and 

LTSS resulting from expanded access to HCBS for targeted populations 

due to more successful transitions from acute and post-acute care to 

community- and home-based care, and fewer unnecessary institutional 

admissions and readmissions.
Chapter III Recommendations 39

CARE INTEGRATION

Recommendation 1: Establish a single point of contact for LTSS on the care team.

Problem:

■ Persons with cognitive and functional limitations and their families faced 

with a care transition—from an episode of acute care to an institutional 

stay or services in their home or in a home- or community-based setting—

often find it difficult to identify and obtain access to the right services in 

the right settings and to navigate the confusing maze of requirements, 

agencies, and providers. 

■ Arrangements made for post-transition care may not be well coordinated 

with the medical care plan or sufficient to reduce the need for follow-on medical care or hospital readmission. 

■ A single point of contact—a personal navigator, case manager or care coordinator—for the individual with cognitive and functional limitations and primary caregiver can address issues that arise with their LTSS needs. A medical 

professional who serves as the single point of contact with the medical care 

team alone is not sufficient for LTSS needs that are typically met through a 

separate care system not coordinated with the activities of the medical team. 

Detailed Recommendation:

■ The Commission recommends that certification and accreditation bodies 

adopt a standard for incorporating a LTSS single point of contact for persons with LTSS needs that is coordinated with or an integral part of the 

medical care team. 

Recommendation 2: Align incentives to improve the integration of LTSS with 

health care services in a person- and family-centered approach.

Problem:

■ LTSS has traditionally been provided in a fragmented, uncoordinated system 

of care provided by disparate agencies, each with its own funding, rules and 

processes, and which are separate from the health care system. 

■ Particularly for the two-thirds of persons receiving Medicaid LTSS benefits 

who are also Medicare beneficiaries (“dual eligibles”), the separate funding 

and provider silos have interfered with the coordinated care for an individual 

across the continuum of care.
40 Commission on Long-Term Care Report to the Congress

■ Successful integrated models that provide comprehensive, person-centered 

services across an array of settings (e.g., Program of All-inclusive Care of the 

Elderly (PACE)) have been small scale and have not been widely adopted.

■ Demonstrations to test models to integrate care across the settings (e.g., CMS’s 

Duals Demonstrations) and pioneering state efforts to develop innovative, 

high-functioning statewide LTSS systems (e.g., Minnesota and Washington), 

including projects to improve transitions from the hospital to home and community-based services, will only serve a small population in the short term. 

Detailed Recommendations:

■ The Commission recommends that CMS, the states, consumers, and the provider community work together to devise creative strategies to encourage a 

more rapid and widespread adoption of successful evidence-based personand family-centered integrated care pilots. 

■ The Commission recommends that CMS’s Accountable Care Organization 

(ACO) initiative and physician payment reforms focus on the whole range of 

LTSS needs of individuals and explore ways in the next round of experiments 

to expand the scope of the ACO’s and new physician payment models to include coordination with LTSS providers. 

Recommendation 3: Use technology more effectively to mobilize and integrate 

community resources and to share information among providers, individuals and 

family caregivers across settings of care.

Problem:

■ Activity underway now to develop the platform for electronic health records 

(EHRs) does not currently incorporate the LTSS components of care in a way 

that would enable all care providers to have access to a unified care plan. LTSS 

are not included in “meaningful use” requirements and incentive programs 

that are shaping the contents of EHRs. Some states have begun to incorporate 

LTSS in state-level Health Information Exchanges (HIE) that enable providers 

to exchange health records for purposes of providing coordinated services. 

■ A variety of tele-health applications are already in use in LTSS and the related 

health care system. Others are under development. Emerging evidence shows 

that technology enabled-LTSS has the potential to increase team efficiency 

and effectiveness, enhance care coordination, promote quality of life, and 

improve outcomes such as reducing hospital admissions/readmissions and 
Chapter III Recommendations 41

preventable injuries, such as falls. The biggest challenge has been to finance 

technology solutions in the context of relatively low-cost LTSS.

Detailed Recommendations:

■ The Commission supports development by CMS and the Office of the National Coordinator for Health Information Technology (ONC) of an integrated 

HIT platform that would include LTSS (including incorporation of LTSS in 

Health Information Exchanges (HIEs), and recommends providing public resources necessary to support and accelerate the pace of this work. 

■ The Commission supports efforts to incorporate LTSS care plans in Electronic Health Records (EHRs) to enable providers to utilize a standardized 

care plan document as consumers with LTSS needs move among settings of 

acute care and LTSS. 

■ Family caregivers should be identified in the individual’s EHR, especially 

when they are a part of the care plan. With the individual’s permission, family 

caregivers should have access to such records as key members of care teams.  

■ The Commission supports efforts to innovate, test, and develop viable economic strategies for applying tele-health technologies to the LTSS system. 

Recommendation 4: Create livable communities building on models that can improve access to services and health care-LTSS coordination.

Problem:

■ Persons with LTSS needs require demand-responsive modes of transportation, accessible housing options, access to participate in employment, social 

and civic activities, as well as access to homecare services, clinics, and wellness programs.

■ Few persons with LTSS needs today have access to livable communities (communities or neighborhoods that facilitate aging-in-place, personal independence, meaningful social engagement, and optimum health and well-being 

through approaches that share or arrange LTSS for people of all ages with 

functional limitations). 

■ The growing movement across America to create livable communities by 

mobilizing local residents, government, business and health care providers 

from the “ground up” to design and develop better places to grow old is still 

small scale. Successful models exist that are not replicated widely, including 

grassroots programs like the Village model, programs sponsored by charitable organizations or a combination of government and private-sector support 
42 Commission on Long-Term Care Report to the Congress

like NORC-Supportive Services Program, Age-Friendly Communities, and 

commercial ventures by non-profit or religious organizations, like Continuing Care at Home.

Detailed Recommendation:

■ The Commission recommends efforts to stimulate voluntary community efforts 

to create and sustain livable communities and aging-in-place support programs 

by establishing a national clearinghouse on successful practices, encouraging 

new model incubators that would provide small start-up funds and technical 

assistance, and undertaking further research and evaluation activities. 
Chapter III Recommendations 43

UNIFORM ASSESSMENT

Recommendation: Completion of a simpler and more usable standard assessment 

mechanism across care settings (acute, post-acute, and LTSS).

Problem:

■ A tool to assess cognitive and functional capacity and LTSS needs is an essential component of effective care planning that ensures that services provided 

align well with an individual’s needs, values, and preferences. A common or 

standard assessment tool across programs and services enables better alignment and coordination of care provided to the same individual from multiple programs and funding sources, and helps ensure consistent evaluation of 

need and provide data for evaluation of program performance and quality of 

care. However, the use of uniform assessment tools is rare within and across 

LTSS and health care providers.

■ There is a wide array of tools for evaluating cognitive and functional capacity 

and LTSS needs (e.g., MDS, OASIS, MDS-Home Care). Yet, a CMS demonstration project to develop a single tool for Medicare post-acute patients did 

not result in implementation of the unified instrument across settings. 

■ Several assessment tools have been developed and used by various states 

for LTSS to determine eligibility, plan services and supports, and/or monitor quality. More than half of all states use a standard assessment tool for at 

least some portion of their LTSS populations, but these have not been adopted 

broadly for assessing HCBS need. Minnesota is creating a uniform, web-based 

assessment tool, to be implemented in June 2014, which is a comprehensive, 

person-centered, planning support tool that will be used for individuals of all 

ages, and with all types of disabilities (physical, cognitive, intellectual or other 

mental impairments) or other LTSS needs. The Minnesota uniform assessment tool also assesses the needs of family caregivers through direct questions 

directed at the caregivers themselves.

■ There is currently no single national assessment tool that applies across settings, services, and the full range of LTSS populations.

Detailed Recommendation: 

■ The Commission recommends the development and implementation of a 

standardized assessment tool that can produce a single care plan across care 

settings for an individual with cognitive or functional limitations. The standardized tool would inform consumers of LTSS choices and be responsive to 
44 Commission on Long-Term Care Report to the Congress

the needs of older adults and all categories of individuals with disabilities in 

need of LTSS. The tool should:

Be used to inform LTSS choices by presenting service options based on 

individual’s needs, goals, values, and preferences (not to close off LTSS 

options).

Be responsive to the needs of different populations (e.g., cognitive, intellectual, behavioral health, etc.).

Include the role of all providers and the needs of the family or other caregiver identified by the individual. Identify the caregiver in the uniform 

assessment and assess the caregiver’s needs for training in the full care 

demands they are expected to perform.
Chapter III Recommendations 45

CONSUMER ACCESS/ASSISTANCE

Recommendation 1: Expand the “No Wrong Door” approach to provide enhanced options counseling for individuals to navigate LTSS, and provide the support needed to make this approach effective nationally.

Problem:

■ Consumers have difficulty navigating the complex and confusing array of 

LTSS administered by multiple private and public agencies with complex and 

sometimes conflicting rules and regulations. 

■ “No Wrong Door” is a proven approach that assists consumers in identifying 

and qualifying for the appropriate services no matter where they enter the 

system—typically involving the cooperation of multiple agencies and organizations. It includes options counseling to assist families in making decisions 

about appropriate long-term care choices. There is considerable variation 

across the country in the quality and level of services provided by ADRCs, 

and a lack of funding needed to improve their performance. CMS and the 

Administration for Community Living (ACL) developed extensive criteria 

and outcome measures for “fully functioning” ADRCs, and report that 80% of 

ADRCs have achieved more than half of the outcome measures. This indicates 

that many consumers are not served by fully functioning ADRCs, and are 

limited in services they receive. 

Detailed Recommendation: 

■ The Commission recommends the expansion of the ongoing Enhanced 

ADRC Options Counseling Program, using states that are being funded now 

as national models, and relying on ACL and CMS to ensure best practices are 

disseminated to other states, and that other states receive support to expand 

their Options Counseling programs. 

Recommendation 2: Provide information and assistance to consumers and family 

caregivers in advance of transition from one setting to the next (for example, acute 

care patients at admission not just at discharge).

Problem:

■ Care transitions, such as a discharge from hospital or nursing facility, are often difficult and confusing for individuals with LTSS needs and their families. 

Individuals need access to information and assistance in exploring choices 

of possible support options in advance of discharge and at all hours. Inade-
46 Commission on Long-Term Care Report to the Congress

quately prepared and supported transitions can result in unnecessary hospital 

admissions, readmissions, or institutionalization.

Detailed Recommendation: 

■ The Commission recommends the appropriate accrediting bodies review 

hospital policy on discharge planning and care transitions to ensure that 

discharge planning and risk assessment of the receiving setting occur at the 

beginning of an initial hospitalization or other precipitating event. Sources 

of information need to be developed that can provide timely (including after-hours) independent information in advance of discharge. 

Recommendation 3: Improve access to information technology that can improve 

consumer and caregiver access to information.

Problem: 

■ Technological innovations can improve access to information and resources 

for older adults and individuals with disabilities.

■ An example of the application of information technology is Minnesota’s Senior LinkAge Line which provides information on Medicare, medications, 

LTSS, home care services, meal delivery, caregiver planning, and a host of 

other resources. 

Detailed Recommendation: 

■ The Commission recommends that the ACL should establish a clearinghouse 

on information technology, and should support efforts to improve awareness 

and availability of such technologies for consumers and family caregivers. 
Chapter III Recommendations 47

QUALITY

Recommendation: Improve focus on quality across settings of LTSS—with particular attention to home and community-based services.

Problem:

■ Nursing homes have been the primary focus of multi-faceted efforts to measure and improve quality for decades. Quality assessment and improvement 

efforts in nursing homes have not been translated to LTSS provided in home 

and community-based and other settings. Measurement of quality and appropriateness of services is important where recipients are dispersed and 

professional oversight is intermittent. 

■ Quality measurement is challenging for home and community-based services. 

Risk adjustment is a necessary component if measures are to be accepted and 

used as the basis for improvement efforts. HCBS measures should focus on 

outcomes, processes, utilization, and consumer and family experience.

■ Efforts are currently underway to develop quality measures for home and 

community-based services. CMS has developed a set of quality domains and 

specified desired outcomes. The Measure Applications Partnership, convened 

by the National Quality Forum, is working to certify measures for the state 

duals demonstrations. Of special interest are measures focusing on consumer 

experience as an outcome.

Detailed Recommendations:

■ The Commission recommends increasing resources and accelerating the time 

frame for activities currently underway to:

develop quality measurement tools for use in home and community-based 

settings; 

develop appropriate procedures and mechanisms for applying quality 

measures to ensure quality and appropriateness of services in these settings; and

develop measures on family experience of care, especially when caring for 

people with Alzheimer’s disease or other cognitive or intellectual disabilities.

■ The Commission recommends working with states to establish a system to 

publish quality measures that will be understandable to consumers, develop 

payment incentives and value-based purchasing of services based on quality 

after testing in pilot projects, and develop provider accreditation and certification based on quality.
48 Commission on Long-Term Care Report to the Congress

PAYMENT REFORM

Recommendation: Advocate for new models of public payment that pay for 

post-acute and long-term services and supports on the basis of the service rather 

than the setting.

Problem:

■ Historically, Medicare has paid for post-acute care based on phases of a beneficiary’s illness as defined by a specific site of service, rather than on the characteristics or care needs of the beneficiary. Payments for the same consumer 

and services vary considerably across post-acute care settings.

■ Providing “site-neutral” Medicare payment on the basis of the service provided across post-acute and LTSS settings would reduce incentives for serving 

individuals in more costly settings and could reduce Medicare (and possibly 

Medicaid) overall spending, realizing savings that could support HCBS and 

other LTSS. 

Detailed Recommendation: 

■ The Commission recommends that necessary regulatory or legislative changes be made to adjust Medicare payment rates for post-acute services; and to 

test person- and family-centered payment models to include LTSS that would:

Pay providers based on the service provided to the consumer rather than 

site of care (while allowing for separation of the room and board components and capital adjustment for facility-based care).

Ensure beneficiaries are served where necessary care is available and provided. Settings that provide for highly specialized rehabilitation needs 

should be exempted and paid in a way that recognizes their special value. 

Enable persons with cognitive or functional limitations to be served in 

the most cost-effective setting that can adequately deliver the most appropriate care. 
Chapter III Recommendations 49

PART TWO – WORKFORCE

Vision: An LTSS system that is able to support family caregivers and attract 

and retain a competent, adequately-sized workforce capable of providing high 

quality, person- and family-centered services and supports to individuals across 

all LTSS settings. 

Issue: Family caregivers today provide the majority of LTSS. Those who take on 

this unpaid role risk the stress, physical strain, competing demands, and financial hardship of caregiving, and thus are vulnerable themselves. Due to declining 

birthrates that will result in fewer family caregivers than in years past, there could 

be greater reliance on fewer family caregivers and the availability and quality of 

paid caregivers will become increasingly important. 

Direct care workers, whether working in residential settings or in a person’s 

home, are often most familiar with the individual and his or her service needs, and 

are best able to provide services and supports in a person-centered way. Individuals with high levels of disability and complex health conditions increasingly receive LTSS in home and community-based settings, increasing the skill demands 

both for family caregivers and paid workers. 

Many home care workers are employed by home care agencies, and many 

others are employed directly by individuals and their families, as personal care 

attendants under a Medicaid consumer-directed services program or as private 

household employees. Rarely do any of these workers receive adequate training 

to meet the demands of providing LTSS in a home setting, resulting in high rates 

of injury and high rates of turnover, reducing continuity of service. Low wages 

and few, if any, benefits with little opportunity for advancement compound to 

make it more difficult to retain a trained workforce. Growth of the older adult 

population and increasing integration of medical services with LTSS for all populations with cognitive or functional limitations will require more professional 

and direct care workers in LTSS settings, care planning, and participation in 

teams providing direct care.

Efforts to improve the availability and quality of paid and unpaid caregivers 

need to be framed in the context of the fiscal and economic pressures facing this 

country and the challenge of ensuring access to quality health care and LTSS for 

an aging population. 
50 Commission on Long-Term Care Report to the Congress

Principles: The Commission believes that workforce policy should follow the 

following principles:

■ Family caregivers should be identified and assessed for their needs, especially 

when care plans are dependent on them, and they should receive the support 

they need to continue providing care to their loved ones. 

■ Paid direct care positions should hold the possibility of advancement and job 

satisfaction through career ladders and lattices.

■ Competency evaluation should ensure that front-line care workers have the 

knowledge and skills they need to meet the assigned needs of the individuals 

in their care. 

■ The LTSS system should utilize both paid and family caregivers to their fullest 

potential by including them as integral members of care teams. 

■ Workforce policies should be designed to increase quality of care and retention of direct care workers.

■ Sufficient numbers of health and social service professionals should be available to provide services connected with LTSS.

■ Teams coordinating care for individuals with LTSS needs should include professionals who can address LTSS needs of individuals with functional limitations, 

and are able to incorporate LTSS into the care planning for the individual.
Chapter III Recommendations 51

COMMISSION RECOMMENDATIONS

FAMILY CAREGIVING

Recommendation 1: Maintain and strengthen a person- and family-centered 

LTSS system with both the person with cognitive or functional limitations and the 

family caregiver (spouse or partner, child or grandchild, parent, sibling, or other 

unpaid assistant) as a focus for services and supports. Include family caregivers 

and their needs in assessment and care planning processes. 

Problem:

■ Person- and family-centered care includes the individual with LTSS needs and 

his or her family at the center of the care team, and takes into consideration the 

individual’s needs, preferences, cultural traditions, family situation, and values. 

■ Because family caregivers currently provide the majority of LTSS for individuals 

with disabilities, it is important that they be included in care planning and on 

the care team. Providers and professional caregivers can help ensure that family 

caregivers have the supports they need to continue caring for their loved one. 

■ Family caregivers are expected to perform complex medical/nursing tasks 

with little to no training and support from professionals.

■ While there is a growing awareness that family caregivers need to be central in 

the care planning process, person- and family-centered care is practiced only 

to a limited degree. 

■ CMS, the Veterans Administration (VA), and ACL have identified a number 

of evidence-based transition interventions, many of which specifically include family caregivers in the intervention.

Detailed Recommendations:

■ The Commission recommends that Congress require the Department of 

Health and Human Services (HHS) to develop a national strategy to support 

family caregivers, similar in scope to the national strategy developed to address Alzheimer’s disease.

■ The Commission recommends that CMS require assessment of family caregivers’ needs and inclusion of family caregiver needs in a care plan or discharge plan that is dependent on them.

■ The Commission recommends that CMS work with the VA and states to 

scale-up successful, evidence-based, person- and family-centered care and 

transition programs that effectively support individual’s decision making 

and family caregivers.
52 Commission on Long-Term Care Report to the Congress

Recommendation 2: Include family caregivers in patients’ records and as a member of the care team.

Problem: 

■ Family caregivers already play an important role in the LTSS and medical care 

of their loved ones, serving as “de facto” care coordinators, and frequently 

performing nursing-level tasks such as medication management and wound 

care with little training. 

■ Many family caregivers of individuals with chronic conditions who play this 

role report feeling anxiety that they will make a mistake with medications, 

and that interacting with so many professionals and medical suppliers adds 

to their stress.

■ Family caregivers providing wound care and managing medications for their 

care recipients reported that clearer instruction and training would make 

performing these tasks easier. These responses indicate that family caregivers 

should be offered appropriate training, be more integrated into care teams, 

and that communication between LTSS and medical professionals and family 

caregivers needs to be clearer. 

■ There is little information currently about the degree to which family caregivers are included as members of the care team, though advising bodies such as 

the Institute of Medicine have advocated for caregiver inclusion in care teams 

for some time, and the Office of the National Coordinator recently recommended that care team members, including family caregivers, should be listed 

on patients’ medical records. 

Detailed Recommendation:

■ The Commission recommends that HHS and national accrediting bodies 

identify mechanisms that will encourage providers to integrate family caregivers into care teams and decision making. 

Recommendation 3: Ensure family caregivers have access to relevant information 

through technology.

Problem:

■ It is important that caregivers have access to all the information that they need 

to provide care, in addition to being listed on medical records. 

■ Development of caregiving technology has increased rapidly. Applications 

now allow users to track physiological conditions and symptoms/chronic 
Chapter III Recommendations 53

disease management (blood glucose, blood pressure) and if individuals are 

pursuing their regular daily activities or if they may have fallen. New tools 

facilitate communication with health care and LTSS providers. Smart phone 

apps assist in a variety of caregiving functions. Assistive technologies increase 

mobility, the ability of individuals to accomplish daily tasks, and can improve 

communication.

■ Research indicates that barriers remain for caregivers attempting to use health 

information technology to assist in caregiving. Mobile health applications do 

not yet support cognitive symptoms or brain health detection. Caregivers 

perceive cost of technology as a barrier to use, including the cost of assistive 

technologies. The general lack of awareness of these technologies is another 

barrier to more widespread use. 

Detailed Recommendation:

■ The Commission recommends that HHS create a resource to disseminate information regarding new caregiving technologies and best practices for family caregivers, and provide local information about what is available to address 

their specific needs. 

Recommendation 4: Encourage caregiver interventions, including respite options, and integration with volunteer efforts. 

Problem:

■ Respite care is the most commonly requested form of caregiver assistance; but 

respite must be addressed in the context of other forms of assistance provided 

by states, including information/assistance, education, and training and other 

caregiver support services.

■ A number of federally-funded programs provide a limited amount of funding to states to provide caregiver support—including respite care. These include the National Family Caregiver Support Program, the Lifespan Respite 

Care Act, and the Alzheimer’s Disease Supportive Services Program. The VA 

provides caregiver training systems for family caregivers of veterans. The resources provided by these programs are inadequate to meet the needs of all 

of these populations.

■ Although researchers speculate that investing in respite care can result in cost 

savings by preventing caregiver burnout and the institutionalization of individuals who could have continued to receive care at home, most research to 
54 Commission on Long-Term Care Report to the Congress

date shows mixed results in terms of impact on caregivers, delay of institutionalization, and cost effectiveness. 

Detailed Recommendations:

■ The Commission recommends further efforts to study caregiver interventions 

including respite care as part of a comprehensive approach to caregiver support, for their effectiveness in sustaining family caregiving and limiting the 

costs of most expensive institutional care.

■ The Commission encourages an expansion of caregiver interventions based 

on evidence of their benefit, including volunteer efforts through a “caregiver 

corps” or modification of senior corps. 
Chapter III Recommendations 55

PAID WORKFORCE

Recommendation 1: Revise scope of practice to broaden opportunities for professional and direct care workers with demonstrated competency.

Problem: 

■ Studies have documented the shortage of both professional and direct care 

workers for the care needs of older adults and persons with disabilities today 

and in the future.

Experts believe that expanding the roles of trained direct care workers 

may help compensate for the shortage in the professional workforce by 

allowing care to be provided more efficiently. This would permit taking 

full advantage of the capabilities of available workers, and would give 

professional workers more time to perform tasks for which only they are 

qualified. 

For example, allowing nurses to delegate to appropriately-trained direct 

care workers under their supervision tasks typically performed by nurses, such as administration of oral medications or injections, may result in 

more positive experiences for consumers.

■ In addition, allowing direct care workers greater flexibility, respect, and responsibility has been shown to increase job satisfaction, which could have 

positive effects on retention of the workforce.

■ One recent study of a pilot delegation demonstration in nursing homes found 

that all stakeholders, but particularly consumers, reported positive experiences with delegation. 

Detailed Recommendation:

■ The Commission recommends that states permit nurses to delegate and 

supervise certain tasks to direct care workers with sufficient training and 

demonstrated competency to perform them, particularly in home and community-based settings that do not have regularly scheduled registered nurses, 

subject to sufficient consumer protections.

Recommendation 2: Recommend that the federal government work with states to 

enable national criminal background checks for all members of the LTSS workforce.

Problem:

■ No Medicaid program mandates criminal background check screening 

for all workers, although CMS does require states to report on their back-
56 Commission on Long-Term Care Report to the Congress

ground check activities, if they choose to perform them. In addition, most 

states require criminal background checks on some LTSS workers, but there 

is significant variation in which workers are covered and which convictions 

preclude employment. 

■ Six states exclude family caregivers in consumer-directed programs from 

criminal background check requirements for workers providing services in 

the home. 

■ States can access multiple databases for background checks, including National FBI checks, state and county criminal records, state adult protective and 

child protective service registries, and sex offender registries, among others.

■ However, the data systems available have many limitations, and states’ ability 

to access data from other states is limited. In addition, a number of databases 

exist within each state, and they are often not integrated.

Detailed Recommendation:

■ The Commission recommends that Congress direct the Department of Justice 

to examine barriers to sharing inter-state criminal background data for health 

care workers and accelerate efforts to develop solutions. 
Chapter III Recommendations 57

DIRECT CARE WORKFORCE

Recommendation 1: Create meaningful career ladders and lattices for direct 

care workers that result in access to career advancement opportunities and improved compensation.

Problem: 

■ Direct care worker positions are often viewed as low-wage, entry-level jobs with 

little to no opportunity for advancement. Establishing career ladders and lattices 

can increase the desirability of these positions, and improve job retention. [A lattice refers to a structure that allows workers to move laterally along a career path 

by developing specialized skill sets. A ladder, in contrast, allows workers to move 

upward by earning new credentials that build on prior experience.] 

■ A number of efforts have been made at the state and federal level to develop 

career ladders and lattices for direct care workers.

Extended Care Career Ladder Initiative (ECCLI) in Massachusetts: a competitive multi-round grant program available to nursing homes and home 

health agencies to develop career ladders and other training programs for 

nursing aides and home health aides that reported increased retention. 

The Personal and Home Care Aide State Training (PHCAST) demonstrations administered by the Heath Resources and Services Administration 

—focused on the development of new training programs and curriculum 

centered on core competencies. Some states that have participated have 

incorporated career ladders and lattices into their training programs. 

CMS has also made efforts to identify core competencies among direct 

care workers across LTSS settings. These core competencies can be used to 

develop training programs, as well as career lattices and ladders. 

Detailed Recommendation:

■ The Commission recommends that, based upon the upcoming PHCAST 

evaluation, efforts should be made to identify best practices, and expand this 

program into other states, including successful career lattices and ladders.

Recommendation 2: Integrate direct care workers into care teams. 

Problem:

■ Direct care workers have a significant role in consumers’ day-to-day lives and 

are often involved in health care activities (e.g., medication management, 

monitoring health status). Not giving direct care workers a significant role in 
58 Commission on Long-Term Care Report to the Congress

interdisciplinary care teams limits the information available to the team on 

day-to-day care delivery and adherence and reduces the ability to coordinate 

with in-home assistance. 

■ Giving direct care workers integral roles in care teams has positive effects on 

consumer outcomes.

■ A number of prominent care models, such as PACE or the Green House model, include personal care workers in their interdisciplinary teams. 

Detailed Recommendation:

■ The Commission recommends that CMS identify mechanisms to encourage 

providers to integrate direct care workers into care teams. 

Recommendation 3: Recommend that the appropriate federal agency collect detailed data on the LTSS workforce.

Problem: 

■ Currently, there is a dearth of data on the direct care workforce. Although 

a number of states report worker shortages and high rates of turnover, they 

have little data available to assess the magnitude of the problem, and therefore 

find it difficult to address. 

■ A number of states are collecting data already, but none collect data across 

all settings in which workers work, and there is significant variation in which 

data they collect. 

■ Because states may use different terminology and use different means for classifying workers, data across states is not comparable. 

■ All states are required by OBRA 1987 to have CNA registries, but these datasets are designed to track certification processes and do not include adequate 

data about hours worked, wages, turnover rates, and workforce shortages. 

■ A recent CMS report on the subject suggested that states begin to collect data 

on the number of full and part time workers, turnover rates, vacancy rates, 

average hourly wages, and status of benefits for workers. 

■ Another challenge is that turnover is difficult to measure, and studies frequently use different methods to measure it, limiting the comparability of 

turnover data across studies. 

Detailed Recommendation: 

■ The Commission recommends that the appropriate agency (e.g., CMS, Health 

Resources and Services Administration, Bureau of Labor Statistics) initiate a 
Chapter III Recommendations 59

process to collect detailed data on the direct care workforce and launch comprehensive data collection efforts. 

Recommendation 4: Encourage states to improve standards and establish a certification process for home-care workers.

Problem: 

■ Minimum training standards have been established by Federal regulation 

for nursing home certified nursing assistants (CNAs) and home health aides 

(HHAs). To meet Conditions for Participation in Medicare or Medicaid, 

workers holding these positions in skilled nursing homes or home health 

agencies respectively must meet these standards. Some states have established 

higher training standards. No Federal standards for training apply to home 

care workers providing Medicaid services. 

■ Currently, about a quarter of states either have state-sponsored curriculum 

for personal care attendants or require certification, but certification appears 

to be much more widespread for workers in institutional settings.

■ The PHCAST demonstration requires that states develop certifications for 

trained and newly credentialed workers. The states involved in the demonstration differ in their approach to certification. While some have allowed the 

training organization to issue the certification directly, others plan to integrate the certification process into a state-wide process establishing a formal 

registry of direct care workers. 

■ The National Direct Service Resource Center within CMS has been developing core competency standards that apply to direct care workers across the 

care spectrum. 

Recommendation:

■ The Commission recommends that CMS explore the development of national training standards for direct care workers based on the outcome of the 

PHCAST demonstration in conjunction with CMS’s effort to develop core 

competency standards or other model standards and certifications being developed by states. Following the approach taken with CNAs and HHAs in 

Medicare, CMS should explore ways for Medicaid to encourage states to apply 

training standards that at least meet minimum national standards. 
60 Commission on Long-Term Care Report to the Congress

PART THREE – FINANCE

Vision: A sustainable balance of public and private financing for long-term services and supports (LTSS) that enables individuals with functional limitations 

to remain in the workforce or in appropriate care settings of their choice. One 

that (1) provides the tools and protections to enable Americans to comprehend 

and better prepare for the financial risk of needing LTSS; and (2) ensures that 

individuals with limited financial resources or for whom the cost of their care 

exceeds their financial resources have access to needed high-quality services and 

supports. 

Issue: Americans are not adequately prepared for the magnitude of LTSS costs 

they could face as a result of their own aging or an extended period of physical 

or cognitive impairment. Nor are Americans, as taxpayers, ready to support the 

public cost of LTSS that will be exacerbated in coming decades by a growing aging 

and disability population, increased costs of care, and other factors. 

Medicaid today finances 62 percent of all paid LTSS. Private savings and private long-term care insurance covers roughly a third of these costs. The looming 

retirement of tens of millions of baby boomers who have not acquired long-term 

care insurance or accumulated sufficient assets for potential long-term care needs, 

coupled with a decline in the availability of family caregivers, threatens to increase 

the reliance on Medicaid, to be financed by future taxpayers. 

Expanded market penetration of private LTC insurance has been limited by the 

cost of coverage and medical underwriting, and is further hampered today by insurers reassessing the market due to unforeseen demographic and investment conditions. In addition, most people are unaware of the risks they bear for future LTSS 

needs, often falsely believing that Medicare or private health insurance will cover 

those costs. Finally, many workers today are not saving enough to maintain their 

standard of living in retirement, independent of any LTSS needs they may face. This 

lack of saving for future LTSS needs reflects not only more immediate competing 

concerns for today’s workers but also a general difficulty in retirement saving.

To achieve a balance of public and private financing for LTSS and to assure 

that public resources continue to be available for those with the greatest need, 

more private resources must be accumulated to finance LTSS for a growing future 

population of individuals with cognitive and functional limitations. Without robust financial capacity from private LTC insurance and personal savings, Medicaid 

becomes the payer of last resort for the catastrophic LTSS costs of people who 

exhaust their resources paying for care. 
Chapter III Recommendations 61

Medicaid is a critical safety net program, but it is not designed to meet the LTSS 

needs of a diverse population. Its eligibility rules enable people who have earnings 

or other resources to qualify for LTSS, but only after spending down nearly all of 

their income and assets they need to remain independent. Younger workers with 

disabilities who need LTSS to enable them to work, often fall in the gap between 

making too much to qualify for Medicaid and too little to pay their LTSS costs. The 

tremendous state-by-state variability of Medicaid eligibility and benefits makes 

qualifying for benefits an uncertain exercise with uneven results across the country. Lack of clarity about public, private-sector, and individual responsibilities in 

financing LTSS adds to the uncertainty about the responsibilities of individuals 

and their families for supporting their LTSS resource needs.

Principles: Public policy toward the financing of LTSS must reflect a comprehensive and balanced approach to public and private responsibility. It must encourage 

and enable individuals to prepare adequately to finance their own needs while 

providing a strong safety net for those whose simply cannot do so. 

An effective, publicly-funded safety net is essential for those with limited lifetime resources, including those whose physical, intellectual, or cognitive disabilities originate early in life. Medicaid must be improved to better provide needed 

LTSS to enable people to have more choice of person- and family-centered services 

that meet their needs, and promote opportunities for persons with disabilities to 

engage in meaningful work.

Although for most people the risk of needing a protracted period of LTSS is an 

insurable risk, this risk is not widely insured today. People who exhaust their resources end up using public support for costs that could have been insured either 

publicly or privately. Insuring these most devastating costs through catastrophic insurance would make clearer to individuals what they have to cover through 

savings and insurance. Policy interventions that provide or enable catastrophic 

insurance might well encourage Americans with modest financial resources to 

strengthen preparation for their LTSS needs through a more robust private insurance and personal savings. In turn, public policy changes to make long-term 

care insurance (LTCI) products more affordable and attractive, including allowing 

more variety in the structure of policies, would encourage private LTCI purchase. 

The Commission considered very different approaches regarding the mechanisms needed to make this vision possible. The Commission did not agree on a 

financing approach, and, therefore, makes no recommendation. The Commission 

is instead offering two different approaches presented by members of the Commis-
62 Commission on Long-Term Care Report to the Congress

sion (below) to illustrate ways the Congress could achieve a restructuring of LTSS 

financing. In doing so, we seek to achieve a better balance of public and private 

resources, improve financial protection from the risk of LTSS expenses in coming 

decades, and better prepare those in future generations who can prepare for the 

potential expenses of LTSS. 

Regardless of the policy approach adopted, the Commission believes Americans are more likely to adequately prepare if they have a clearer understanding 

of the risk of needing LTSS, the interrelated public and private mechanisms for 

financing that risk, and access to reliable and affordable tools they need to do so.
Chapter III Recommendations 63

ALTERNATIVE APPROACHES

Approach A: Strengthen LTSS financing through private options for 

financial protection.

Problem:

■ Governments are facing serious budget constraints that threaten funding for 

existing health care, disability, and retirement programs. We cannot assure 

the safety net will hold for the most vulnerable who must rely on public programs if we also publicly finance care for millions of Americans who could 

prepare now for their needs in future years. 

■ Private long-term care insurance (LTCI) could play a more substantial role in 

LTSS financing, but changes are needed to boost participation, including new 

incentives, more flexibility so insurers can offer greater variety in the structure 

of policies and make coverage more affordable, and educational campaigns to 

explain future risks and options for financial planning. 

■ Creative solutions are needed to bring together new partnerships, new incentives, and innovative programs for those who can prepare now for their own 

long-term care needs to make sure the public safety net is there for those most 

in need. Private savings and a diverse choice of products are critical components of the LTSS financing solution.

Proposal:

■ Provide new market incentives: Fewer people are purchasing long-term care 

insurance policies today, and fewer companies are offering the policies. The 

high cost of policies is a primary deterrent. A lack of understanding about the 

risks of not having financial protection and the lack of incentives to purchase 

coverage also contribute to limited uptake of LTCI. 

Provide a tax preference for long-term care policies through retirement 

and health accounts: Allowing withdrawals from existing 401k, IRA, or 

Section 125 accounts to pay LTCI premiums or distributions would have 

minimal tax implications. The tax costs of incentivizing broader participation would be more than offset over time as those with private coverage 

draw on private rather than public resources to finance their care.

Support new forms of combination policies such as a “life care annuity,” 

which combines a life annuity insurance policy with long-term care insurance: A change in tax law to allow investment and distribution in the 

LTCI portion through tax-advantaged retirement accounts would encourage creation and uptake of these policies. The combination policy reduces 
64 Commission on Long-Term Care Report to the Congress

adverse selection in the immediate life annuity portion, resulting in lower 

premiums, and allows for considerable relaxation in underwriting standards for the long-term care portion of the policy. 

Support Long-Term Care Partnership Programs that currently operate in 

most states: These public-private partnerships allow residents to purchase 

long-term care insurance and still qualify for Medicaid if and when their 

insurance is exhausted without depleting all of their assets. The program 

combines the benefits of private insurance with the backing and safety net 

of the government. 

Allow a Medicaid Carve Out: individuals would have the option (when 

claiming Social Security retirement) of receiving a portion of the expected 

actuarial present value of Medicaid benefits, adjusted down by income, 

as a subsidy to purchase permanent long-term care insurance, including 

through combination policies. In exchange, they would give up the right 

to future Medicaid LTC services. 

Provide protection for catastrophic LTC costs: Create a financing mechanism for the catastrophic “tail” of costs (the small number of long-durational, high-cost LTSS) not now covered by private LTCI. This would 

combine a safety net for truly catastrophic costs, through private or 

public reinsurance, with private responsibility (savings, family care, and 

private LTCI). 

Remove regulatory burdens and barriers: regulatory inflexibility has hampered the ability of carriers to respond to rapid and large changes in the 

economy and to provide affordable and attractive products to consumers. 

Allow flexibility in pricing and product design: rapid and sustained drops 

in interest rates induced by unusual Federal Reserve monetary policies 

have challenged LTCI carriers expecting a more traditional return on investment. Private LTCI carriers need greater flexibility in structuring policies, including policies with varied benefit structures (e.g., longer elimination periods) and benefit time periods, to continue to meet consumer 

needs for affordable policies.

Allow LTCI policy portability: allow policy portability through such 

mechanisms as multi-state compacts, possibly developed in consultation 

with the National Association of Insurance Commissioners. 

Minimize Medicaid Crowd-Out: The structure of federal health care programs, particularly Medicaid, discourages individuals from taking responsibility for their future long-term care needs. Medicaid resources need to 
Chapter III Recommendations 65

be more carefully targeted to those individuals the program was intended 

to serve—the needy and the poor.

Strengthen Medicaid eligibility requirements for middle-income Americans: Consider retirement assets and a larger portion of home values for 

those applying for Medicaid. 

Strengthen asset recovery: Ensure states meet their responsibility to oversee and enforce asset recovery to prevent middle- and upper-middle income seniors from hiding assets to gain eligibility for Medicaid.

Use reverse mortgages: Use reverse mortgages to enable seniors to use 

the value of their home equity to fund long-term care services, including 

while remaining in their homes. Enable retirees to pre-qualify so funds 

would be available when needed. 

■ Education:

Establish an ongoing awareness campaign: Educate the public about the 

limitations of Medicare and Medicaid in funding LTSS and the options 

and incentives for private financial protection.
66 Commission on Long-Term Care Report to the Congress

Approach B: Strengthen LTSS Financing Through Social Insurance.

Problem:

■ The LTSS crisis is a societal problem that requires a societal solution. The need 

for LTSS is an unpredictable, catastrophic risk for people under and over age 

65. Responsible individuals and families cannot plan for exigencies such as 

illness, accident, or advanced age that create LTSS needs or pay for services 

when those needs arise. 

■ America does not have a LTSS financing system that provides a comprehensive, coordinated, reliable structure for people in need of long-term care; it 

has an area of disparate public and private payment mechanisms. 

■ Currently, the only way to finance care over the long term is to either qualify 

for Medicaid or have enough resources to purchase long-term care insurance 

and/or self-insure. Neither Medicaid nor private insurance is certain to meet 

an individual’s LTSS financing needs. Medicare is a social insurance program, 

but it only covers post-acute care and does not cover children and individuals 

who have not worked sufficiently to qualify.

■ A social insurance approach provides a public financing mechanism that 

spreads risk broadly, sharing the costs between the government, participants, 

and /or employers and employees. Since everyone is at risk, everyone contributes in order to benefit should a long-term functional need arise. Mandatory 

participation makes the risk pool viable.

■ Insuring a portion of the risk for everyone through social insurance allows 

those who have resources to assume responsibility for the uninsured portion 

through personal savings, private insurance, or other mechanisms. 

Proposals—Two Possible Social Insurance Models

1. Create a Comprehensive Medicare Benefit for LTSS

■ Include a comprehensive LTSS benefit in Medicare Part A that would be triggered, like the hospice benefit, when an individual is certified to meet certain 

qualifying criteria. 

■ Qualification for the LTSS benefit would be based on a physician certification 

that the individual requires assistance with at least two activities of daily living, has needed such assistance for 90 days, and is likely to continue to need 

the services. Individuals could qualify equally based on certified ongoing and 

continued cognitive or mental health issues such that independence is impossible or contraindicated. 
Chapter III Recommendations 67

■ The LTSS benefit would be financed through a combination of an increase to 

the current Medicare payroll tax and the creation of a Part A premium.

■ Qualifying individuals would be eligible for reasonable and necessary LTSS 

services that would include: Skilled nursing facility care or daily skilled care; 

home health care without the need for a skilled service; personal care attendant services; care management and coordination; adult day center services; 

respite care options to support family or other volunteer caregiver; outpatient 

therapies; other reasonable and necessary services.

■ Since not all people with LTSS needs are eligible for Medicare, consideration 

should be given to including those who meet the agreed-upon benefit criteria but would otherwise not be part of the Medicare program. In the alternative, other social insurance funding should be developed to meet these 

individuals’ needs.

2. Create a Basic LTSS Benefit Within Medicare or a New Public Program 

■ This approach would create a more limited benefit, either within Medicare or 

as a new public program, to insure only catastrophic risk and making clear 

the “hole” that people able to prepare in advance should plan to fill through 

private resources.

■ People assessed as meeting a specified threshold of functional impairment 

would qualify for benefits after a waiting period. The length of the waiting 

period (shorter for people with lower incomes and becoming longer at higher incomes) would be established at or near retirement age and tied to Social 

Security-reported income, averaged over a number of years. For younger 

people who become impaired, the formula relating waiting periods to income would be appropriately adjusted to reflect the lesser accumulation of 

resources at younger ages. 

■ To make the benefit available to people currently in need of assistance, an 

alternative to the proposed waiting period would be necessary, since private 

insurance to fill it may be unavailable or prohibitively expensive and people 

may lack the means to otherwise protect themselves. A broadly inclusive benefit would therefore replace the waiting period with an income/asset-related 

deductible for people who, at the time the new benefit is established, have 

significant disabilities or are age 75 or older.

■ Benefits under this arrangement would be specified as a dollar amount per 

day, vary with level of impairment and be applicable to the full range of LTSS 

services. Individuals could opt for a service rather than a cash benefit.
68 Commission on Long-Term Care Report to the Congress

■ Benefits could be financed through a combination of Medicaid savings (federal only or federal and state) and a surcharge on the income tax (higher for 

people currently near or at retirement age).

Neither of these social insurance models eliminates the private part of the public-private LTSS partnership. On the contrary, they mitigate risks and create a clear 

and manageable role for private insurance. To support supplementary or gap filling, new regulations are needed for the private long-term care insurance market 

to, at a minimum:

■ Standardize and limit the types of policies insurers can offer, as in the Medigap market, in order to facilitate comparison and competition.

■ Create an electronic market and provide information and direct assistance to 

consumers in order to facilitate comparison shopping and educated choices. 

■ Create effective consumer protections to ensure people receive fair value and 

promised benefits.

■ Create easily accessible, meaningful appeals to those who are denied coverage 

or other rights afforded by their social or private insurance.

Social insurance would not cover all service needs or eliminate the need for 

personal financial contributions of family care or eliminate the need for an adequate public safety net—whether within it or through a continued (albeit much 

smaller) Medicaid program.
Chapter III Recommendations 69

RECOMMENDATIONS

MEDICAID IMPROVEMENT

Recommendation 1: Create a demonstration project to provide workers with disability coverage for the LTSS they need to remain employed.

Problem:

■ Individuals with disabilities often need personal assistance, mobility devices, 

assistive technology, or other LTSS in order to work and live independently. 

The cost of these supports greatly reduces the net benefits of paid employment 

and can be a barrier to a person with disabilities entering or remaining in the 

labor force. 

■ Workers with disabilities may or may not have access to health insurance 

through their employment. For those that do, employer-provided health insurance rarely covers the cost of LTSS. 

■ Medicaid provides LTSS to individuals with disabilities based on eligibility for 

the Supplemental Security Income (SSI) disability program. The SSI income 

limits prevent a worker with a substantial disability from qualifying for Medicaid if they earning more than roughly 250 percent of the federal poverty 

level. 

■ Consequently, those receiving SSI benefits face a dilemma in trying to work: 

If they work successfully, their income would likely disqualify them from receiving Medicaid LTSS, yet they may not be earning enough to pay for the 

services entirely on their own.

Detailed Recommendation: 

■ The Commission recommends that Congress authorize a demonstration 

project (under section 1115 of the Social Security Act) to test the feasibility of 

providing LTSS to those who work despite having a significant disability. The 

project would:

Target workers with a severe disability (that meets or equals Social Security’s medical listings) but whose income from work precludes SSI or SSDI 

eligibility

Provide LTSS that can wrap around employer-provided health benefits

Include worker cost sharing that would be graded with amount of income
70 Commission on Long-Term Care Report to the Congress

Recommendation 2: Assist the states to achieve greater uniformity of eligibility 

and benefits in State Medicaid Buy-In programs for LTSS for workers with significant disabilities.

Problem: 

■ Working-age adults with disabilities who need LTSS, such as personal assistance, mobility devices, or assistive technology, to enter or remain in the 

workforce do not have health insurance that will cover the LTSS.

■ The Medicaid Buy-In program was created to enable working adults with 

disabilities whose income and assets would otherwise make them ineligible 

for Medicaid coverage to pay premiums to “buy into” Medicaid for its LTSS 

coverage. 

■ The two federal laws creating the Medicaid Buy-In (the Balanced Budget Act 

and the Ticket to Work and Work Incentives Improvement Act) impose different rules around issues such as income limits, premiums, and the treatment 

of employment interruptions; and State programs vary in how they apply 

these rules.

■ Disabled workers are limited in their mobility to pursue job opportunities 

by the risk of losing their Medicaid coverage for their LTSS expenses if they 

move to another state.

Detailed Recommendation: 

■ CMS should assist states in developing a more uniform Medicaid Buy-In 

program that would allow individuals with significant disabilities to remain 

attached to the labor market and optimize employment opportunities, including those that may require moving to another state.
Chapter III Recommendations 71

MEDICARE IMPROVEMENT

Recommendation 1: Eliminate the three-day hospital stay requirement for SNF 

coverage.

Problem:

■ Medicare covers acute hospital and limited post-acute care. It does not cover 

long-term services and supports. Medicare will pay for skilled nursing facility 

care only after a prior hospitalization lasting at least three days. Medicare then 

pays the full cost of the nursing home stay for the first 20 days and a portion 

of the cost after for up to 100 days total. 

■ The three-day prior hospitalization requirement was implemented shortly after Medicare’s enactment. The three-day requirement, along with the cap on 

nursing home days, is intended to limit the use of Medicare in funding skilled 

nursing care. Congress eliminated the three-day rule in 1989 in a law that was 

later rescinded, leaving the rule intact. 

■ With declining hospital lengths of stay, many inpatient stays that require 

post-acute skilled nursing may not qualify for coverage. Also, in recent 

years, hospitals have been holding increasing numbers of patients in “observation status,” rather than admitting them as inpatients. Recently, CMS 

has been allowing hospitals to retroactively recode inpatient stays as “observation status.”

■ Without the three-day inpatient stay, patients who should be transferred for 

a short post-acute stay in a skilled nursing facility cannot get coverage for 

the stay unless they are also eligible for Medicaid. Failure to transfer patients 

who need rehabilitation in a skilled nursing facility may increase unnecessary 

hospital readmissions.

Detailed Recommendation:

■ The Commission recommends enactment of legislation to eliminate the requirement of a prior three-day inpatient stay in a skilled nursing facility.

■ The Commission recommends that CMS count stays in observation status 

toward the meeting the prior three-day hospitalization requirement for SNF 

coverage until such time as the statute is changed to remove the requirement.
72 Commission on Long-Term Care Report to the Congress

Recommendation 2: Reconsider the requirement for receiving home health services under Medicare that the individual be “homebound.”

Problem:

■ Medicare requires that an individual be “homebound,” need intermittent 

skilled nursing care, and be under a physician’s plan of care to qualify for 

home health and therapy services.

■ An individual is considered “homebound” if he or she cannot leave home 

without “considerable and taxing effort,” which includes requiring the aid of 

supportive devices, the use of special transportation, the assistance of another 

person, or has a medical condition for which leaving the home is contraindicated.

■ An individual can leave the home without assistance without being disqualified for services if the absence is for:

medical or therapeutic and psychosocial treatment, or

a non-medical purpose that is “infrequent or short in duration,” such as 

attending a religious service, trip to a hairdresser, special family event, or 

walk around the block. 

■ For Medicare beneficiaries who could use the Medicare home health benefit 

to meet their long-term needs, the limitation to certain short and infrequent 

trips imposes a difficult lifestyle burden. Beneficiaries who could leave their 

home if they obtain home care are either trapped in their homes or have to 

find an alternative way to meet their care needs.

Detailed Recommendation:

■ The Commission recommends that CMS revise the homebound requirement 

to ensure it does not create inappropriate barriers to care and to assess the cost 

implications of doing so.
Chapter III Recommendations 73

SAVINGS

Recommendation: Allow individuals and families with significant disabilities to 

access the educational savings program to assist in saving for a current or future 

LTSS need. 

Problem:

■ Section 529 of the Internal Revenue Code allows families to set aside funds 

for future college expenses in an education savings account operated by a state 

or educational institution, allowing the principal to grow tax deferred and 

exempting distributions for college costs from tax. 

■ Parents of children with disabilities want their children to have access to higher education, have a pathway to a meaningful career, and save for the future so 

that they can live independently. Adults with disabilities also want to accumulate assets so that they too can live independently.

■ An expansion of IRC section 529 would allow individuals with disabilities 

or their families to set funds aside in a tax-advantaged savings account, up 

to $100,000, so that funds could be withdrawn to cover costs of health care, 

employment support, housing, transportation, the purchase of technology, 

and education. 

Detailed Recommendation: 

■ The Commission recommends that Congress amend Section 529 of the IRS 

code to allow individuals and families with significant disabilities living 

with LTSS needs who are not receiving assistance from the Medicaid program to have access to an established program designed to assist individuals 

and families to save for an educational need and to also save for a current 

or future LTSS need.
74 Commission on Long-Term Care
Chapter IV Advancing an Agenda 75

C H A P T E R I V 

ADVANCING AN AGENDA ON LONG-TERM SERVICES 

AND SUPPORTS

Recommendation 1: Create a subsequent national advisory committee to continue 

this work and consider the Commission’s recommendations and potential financing frameworks as a starting point for its own assessments and recommendations.

Problem:

■ The breadth and depth of issues encompassing long-term services and supports, the magnitude of its impact on American families now and in the future, as well as its cost implications on private and public resources all dictate 

the need for a sustained national dialogue on the subject. 

■ While the constitution of this dialogue could take several forms, several reasons listed below necessitate, in our view, the creation of a longer-tenured national committee that includes both governmental and private-sector stakeholders along with consumer and family caregiver representatives and LTSS 

service recipients.

The need for designing, executing and financing LTSS is of major continuing importance to the health and quality of life of millions of Americans 

today and tens of millions of Americans in the future. An effort to find 

substantial consensus on these elements will require sustained focus, conversation, and additional analysis.

There is dynamic change in our country’s health care payment and delivery systems, technology, health and supportive service structures, behaviors and performance, and demographics requiring ongoing evaluation of 

the models being tested at the local, state, and federal levels for those that 

can be taken to scale.

The costs to and burdens on Americans—both as individuals and taxpayers—for LTSS for the large and growing population of those with functional and cognitive impairments needing such services will place increasing stress on American families and the nation’s fiscal health.
76 Commission on Long-Term Care Report to the Congress

Increasing the availability and quality of paid caregivers is critical to meeting the needs of this growing population as is the strengthening of mechanisms to support family caregivers, who will remain a mainstay support 

for many, if not most, of those with LTSS needs. Ongoing evaluation and 

promotion of new technologies and best practices in the monitoring of 

LTSS service needs and delivery as well as training of unpaid and paid 

caregivers, will be necessary.

The ability to integrate LTSS into our rapidly changing health and supportive services environment in light of the capacities for both human and 

technological capital requires persistent and consistent engagement by Executive and Legislative branch officials as well as leaders in the health and 

supportive service sectors and representatives of consumers, caregivers, 

and those with LTSS needs.

■ The current Commission on Long-Term Care, working within its budget, 

operational structure, and statutorily defined timelines, deliberated on many 

of these items in its less-than-100-day working period. Chapter Three includes a series of recommendations and potential financing frameworks that 

begins to address these issues. Having said that, this Commission recognizes 

that its work is not the end of the road for the consideration of all of the issues implicated by the needs and demands for a more responsive and better 

financed LTSS system. 

Detailed Recommendation:

■ The Commission recommends that a subsequent national advisory committee be created to continue this work and consider the Commission’s recommendations and potential financing frameworks as a starting point for its 

own assessments and recommendations. This advisory committee should be 

positioned and composed so it can effectively engage with and appropriately 

leverage the existing federal knowledge and resources that exist on this topic, which operate within and across several departments (i.e., HHS [including the Social Security Administration], Education, Labor, Veterans Affairs, 

Transportation, Justice, and Treasury). The advisory committee should also 

receive analytic support from and coordinate with the congressional advisory 

bodies on Medicare and Medicaid (i.e., Medicare Payment Advisory Commission and Medicaid and CHIP Payment and Access Commission) as well as 

the key congressional and Administration budgetary and accounting bodies 

(i.e., CBO, Office of Management and Budget, and GAO).
Chapter IV Advancing an Agenda 77

■ The charge of this new committee should be to assess, report on an ongoing basis and, where appropriate, recommend actions to achieve the following results: 

Service Delivery: Create a more responsive, integrated, person-centered, 

and fiscally sustainable LTSS delivery system that ensures people can access quality services based on their needs, values, and preferences.

Finance: Ensure provision of a sustainable and integrated range of public 

and private financing mechanisms to meet the needs of people with functional and cognitive impairments.

Workforce: Attract and retain a competent, adequately sized, and sustainable workforce capable of providing high-quality, person-centered support to people across a variety of settings.

Caregiving: Provide information and services needed to maintain the 

physical and emotional health, safety, and financial stability of American 

families seeking to provide LTSS to their family members and friends.

Education: Develop an effective educational program about the availability of public and private financing of long-term care.

Recommendation 2: Convene the White House Conference on Aging to include LTSS.

■ The Commission recommends convening the White House Conference on 

Aging in 2015 in coordination with the National Council on Disability to 

allow for the participation of states and other constituents in the continued 

focus on LTSS improvements.
78 Commission on Long-Term Care
APPENDIX A: Commissioner Ideas 79

APPENDIX A

COMMISSIONER IDEAS

A. FINANCING IDEAS

Multi-Faceted

1. Reconfiguring LTSS financing to share responsibility and enhance protection

Goal: To build a financing framework that (a) provides meaningful protection 

against the risk of costly long-term care; (b) is, to the extent possible, pre-funded by future users; and (c) includes significant personal responsibility, an effective insurance market, and a strong safety net. 

Premises:

■ The need for expensive, extensive LTSS is an unpredictable, catastrophic risk that, like similar risks, can be most efficiently and effectively met 

through insurance.

■ Private insurers face enormous difficulties in addressing this risk and, even 

with supportive public policy interventions and possible expansions (short 

of required purchase), can reach only a modest share of the population.

■ A limited public insurance program can establish a financing framework 

that encourages the purchase of private insurance. 

■ Given responsible limits to public as well as private insurance, a public safety net will always be essential to assure access to adequate care for people 

with inadequate resources.

Proposal:

A. Establish a basic public LTSS benefit available to people assessed as meeting 

a specified threshold of functional impairment after a waiting period of up 

to x years. The length of the waiting period (shorter for people with lower 

incomes and becoming longer at higher incomes) would be established at 

or near retirement age and tied to Social Security-reported income, averaged over a number of years. For younger people who become impaired, 

the formula relating waiting periods to income would be appropriately adjusted to reflect the lesser accumulation of resources at younger ages. Benefits would be specified as a dollar amount per day, vary with level of im-
80 Commission on Long-Term Care Report to the Congress

pairment, and be applicable to the full range of LTSS services. Individuals 

could opt for a service rather than a cash benefit. With this type of benefit, 

people would know throughout their working years the risk or “hole” they 

should plan to fill (or the protection they might want to supplement) from 

personal resources or private insurance should they become impaired.

The benefit could be financed through a combination of Medicaid savings 

(federal only or federal and state) and a surcharge on the income tax (higher for people currently near or at retirement age). 

B. To supplement public coverage, create an effective private insurance market 

(for background and rationale, see Richard Frank, Mark Cohen and Neale 

Mahoney; http://www.thescanfoundation.org/sites/thescanfoundation.org/

files/tsf_ltc-financing_private-options_frank_3-20-13.pdf.) 

1. Standardize and limit the types of policies insurers can offer, as in the 

Medigap market, in order to facilitate comparison and competition.

2. Create an electronic market and provide information and direct assistance to consumers, in order to facilitate comparison shopping and educated choices. 

3. Require that alongside current level premium products, insurers offer 

people under age 65 products that index premiums and benefits in time 

blocks and apply “term pricing” (i.e., charge an annual premium covering the expected claim costs for a specified “term,” say of 1–5 years, 

rather than for a lifetime—in order to engage younger people in the purchase of long-term care insurance and provide them lower premiums 

that reflect their own disability risks.

4. Established reinsurance arrangements, financed by private insurers, 

that establish parameters for risk management and mitigate risks to 

individual companies.

C. To address current LTSS inadequacies and inequities across states as well 

as the unequal burdens of aging, strengthen the Medicaid safety net with 

enhanced federal financing (for background and rationale, see Judy Feder 

and Harriet Komisar, http://www.thescanfoundation.org/sites/thescanfoundation.org/files/Georgetown_Importance_Federal_Financing_LTC_2.pdf.)

1. Gradually increase federal financing for Medicaid long-term care benefits from existing match percentages to 100 percent. 

2. Define a nationally uniform benefit (imbedded in a mandatory personal 

care benefit and including an increase in the personal needs allowance)

to vary with an individual’s level of impairment, as determined by a 
APPENDIX A: Commissioner Ideas 81

standardized assessment process. Provide federal match at current rates 

to states choosing to supplement the federal benefit.

3. Set federal payment rates to providers, adjusted for geographic variation 

in input costs.

4. Finance the new benefit in part with state contributions (as in Medicare Part D)—set initially to reflect their current long-term care spending (up to a maximum) and indexed to reflect inflation and economic 

growth; the index would hold states “harmless” for increased demand 

associated with the aging of the population.

Moving forward:

The framework presented here is by no means a substitute for a variety of other 

policy changes we have discussed—including policies affecting younger people 

with disabilities, informal caregivers and the direct care workforce, care delivery, prevention, community initiatives, and existing Medicare and Medicaid 

payment, quality, assessment or other policies. Rather, it offers an over-arching 

financing strategy that can accommodate those improvements—the “comprehensive” part of the strategy in our mandate. 

Furthermore, as a framework it is an outline, not a full proposal. Clearly it 

requires more detail, refinement, and analysis to move forward. Some of that 

can occur with the help of commission members and staff, but its full development will require post-commission work—as is likely also true for other proposals. As we’ve discussed, a call for that work should be part of this and other 

recommendations.

Finally—although I’ve written this proposal in a way that, I hope, facilitates 

understanding of its intent and architecture, my recommendation is that the 

timing of its implementation (and likely its legislation), start with step 3. 

■ The highest priority should go to preservation and enhancement of the 

safety net for people who are most disadvantaged, which is currently at risk.

■ Adoption of a long-term strategy for long-term care financing will be a 

long-term struggle to which we should not hold this population hostage.
82 Commission on Long-Term Care Report to the Congress

2. Create a voluntary Medicaid carve-out program using adequate and permanent private LTCI policies.

Motivation: Theoretical and empirical evidence point to a significant crowdout effect from Medicaid significantly reducing the role of private LTCI in 

financing LTSS. This effect increases government expenditures now and increasingly in the future, providing public insurance to many households in the 

middle class and upper middle class income strata who could otherwise afford 

and would be interested in private insurance coverage. Moreover, because it is 

the inevitable nature of government entitlement programs to have more static and restrictive designs (owing to bureaucratic and legislative rigidities and 

budget constraints), the crowd-out effect causes a limit to the utilization of 

existing and future innovative and flexible designs found in private LTCI (for 

example, equal access to home care as to institutional care). Finally, there does 

seem to be some public resentment to the spend-down rules in Medicaid as 

well as some public confusion about what Medicare and Medicaid cover in the 

LTSS area (leading to a lack of long-range personal financial planning), all of 

which would be obviated by more widespread use of private LTCI. 

Proposal: A fraction (initially 75 percent, declining gradually over time) of the 

expected actuarial present value of Medicaid benefits by income level would 

be provided as a subsidy from the government (federal and state equally) to 

individuals at the point in time of claiming Social Security retirement benefits 

to purchase adequate permanent private long-term care insurance, including 

through combination policies. The standards for adequacy would include benefit levels sufficient to pay for average costs of home and institutional care in the 

current region of residence, lifetime benefits, and exclusion periods no greater 

than a year. “Permanent” means that the LTCI would have to be structured so 

that no lapses were allowed, such as through single-premium LTCI, the life 

care annuity, or similar products. Consistent with current law, the subsidy 

would decline as individual income (measured by the Social Security AIME) 

increased so that it would be large at the lowest income levels and would be 

eliminated at the very top of the income bands. It is anticipated that financial 

planning software packages and financial planner advice would quickly recognize this major change in public policy and lead to the incremental expected 

lump-sum cost of LTCI at retirement to be included in household retirement 

planning and the setting of savings goals, likely causing a boost in lifetime savings rates. Finally, the resulting increase in total (public and private) resources 
APPENDIX A: Commissioner Ideas 83

from this proposal would put upward pressure on LTSS worker compensation 

and demand for enhanced qualifications. 

3. Financing—Create a comprehensive, understandable, and affordable LTSS 

financing system with both public and private components that work together effectively to enable individuals to plan for their LTSS needs.

Such a system would include the following components:

■ A public insurance program to broadly spread risk and help individuals 

pay for LTSS;

■ Expansion of private savings incentives and access to workplace savings 

options;

■ Reforms and improvements in the private long-term care insurance market including: 

Providing greater standardization of private long-term care insurance 

policies while promoting innovations that benefit consumers; 

Strengthening and updating consumer protections for tax-qualified 

policies;

Improving consumer information about these products; and 

Examining opportunities to make the selection of long-term care insurance available when consumers make decisions about insurance or 

other benefits.

■ Information, educational resources, and/or tools for individuals to help 

them understand different financing options and make the choices that are 

best for them and their families.

Private Savings

4. Increase substantially the amount of long-term care insurance/private savings/personal investments available to fund LTSS. The populations needing 

LTSS are now using, and will in the future require, increasingly large amounts 

of federal and state funds at a time when the budgets of those governmental 

entities need to constrain rather than escalate their expenditures (see William 

Hoagland testimony 6–27–13). The projected expenditures are unsustainable 

and can only be counteracted by immediate and prolonged efforts to change 

the LTSS funding system. On an individual level, it is vital that the public anticipate its potential future need for LTSS by purchasing long-term care insurance 

or by employing other financial savings vehicles. On a macro level, it is crucial 
84 Commission on Long-Term Care Report to the Congress

to safeguard public budgets by ensuring that non-public dollars are available 

for injection into the LTSS funding stream. 

Reasonable people can disagree as to whether the sources of personal 

funds should be long-term care insurance, annuities, pensions, personal savings, HSAs, retirement accounts, or some combination thereof, but federal 

regulations restricting the use of all these resources for funding LTSS should 

be relaxed or eliminated (see Lane Kent 8–1–13 testimony). Subsidies for the 

purchase of LTCI, if retained, should be redirected to middle-income and middle-age population, as agents selling LTCI indicate that persons with income in 

the $40,000–$50,000 range are good starter prospects. Educational campaigns 

should be introduced to create public awareness of the need to plan ahead for 

personal or family disability needs. As witnesses have testified, products and 

their marketing should be improved, including encouraging employers to offer 

family LTCI. AARP data show that U.S. businesses lose up to $33.6 billion per 

year in productivity from full-time caregiving employees and were found to be 

paying about 8 percent more for the health care of employees with elder care 

responsibilities.

5. Amend Section 529 of the IRS code as called for in the Achieving a Better Life 

Experience Act of 2013 (ABLE Act; S. 313, H.R. 647) to address the unique 

needs of families with individuals with disabilities, particularly those waiting for Medicaid home and community-based services: Across the country, an 

estimated 400,000 individuals are on waiting lists to receive long-term services 

and supports (LTSS); many of whom are children who will require these supports over their lifetime.95 The ABLE Act will allow families of these children an 

opportunity to save for their needs.  Currently, families are providing the bulk of 

their LTSS needs that in many cases comes at a significant cost to their ability to 

maintain and improve their economic circumstances, especially for the middle 

class.96 AARP estimates that the economic impact of family caregiving for members with significant disabilities at $350 to $450 million per year. The ABLE Act 

95 Of 3.5 million families with a member with a severe and chronic disability expected to last 

a lifetime, only 13% are supported by the states’ public agency services (Braddock, Presentation to 

AIDD, February 2013)

96 In a national survey conducted by the Arc of the United States, 82% of families reported that 

their overall economic security is challenged. 73% reported not having adequate savings for retirement, which puts aging parents in particularly vulnerable situations. (Still in the Shadows with Their 

Futures Uncertain, Arc of the US, June 2011). According to Braddock (2013, above) there are 853,000 

persons with developmental disabilities/intellectual disabilities (DD/ID) living at home with caregivers over the age of 65 years.
APPENDIX A: Commissioner Ideas 85

encourages work, savings, and asset development for families and individuals 

with disabilities that reduces dependence on scarce public benefits.

The ABLE Act allows families to set funds aside in a tax-advantaged savings 

account (ABLE accounts) that allows the funds to be withdrawn to cover qualified disability expenses such as health care, employment support, housing, 

transportation, assistive technology, and education. ABLE Accounts would 

amend and follow the existing Section 529 of the Internal Revenue Code for 

Qualified Tuition Programs so that they would be consistent with all the requirements and regulations of a traditional 529 qualified tuition program; they 

are easy to open and available in any state, and families can make the same 

annual contributions and enjoy the same tax-free treatment as under 529 accounts.97 In this respect, ABLE accounts mirror a familiar and popular financial mechanism for many families.

The ABLE Act has broad bicameral and bipartisan support: S.313 was introduced by Sen. Robert Casey (D–PA) with 36 bipartisan cosponsors with 

27 Democrats and 9 Republicans, and H.R. 647, introduced by Rep. Ander 

Crenshaw (R–FL–4), has 223 bipartisan cosponsors with 113 Democrats and 

110 Republicans. 

6. Perform a well-designed analysis of private sources of funding for long-term 

care supports and services and encourage implementation to provide private 

capital support for long-term care.

a. Insurance products

i. Encourage the development of simplified hybrid-type products (Life 

Care Annuity type approach).

ii. Assess and expand if possible the conversion of life insurance policies to 

long-term care benefit plans.

iii. Support/standardize LTC programs as components or options of Medicare Advantage.

b. Alternative Funding Sources/Incentives

i. Allow tax-exempt and penalty-free distributions from qualified retirement plans to fund costs, programs, or premiums designed to provide 

long-term care.

ii. Lift or remove Health Savings Account contribution cap.

97 Income earned grows tax free; withdrawals for qualified disability expenses are tax free; there 

are rollover provisions to traditional 529 accounts or other family members, ABLE or 529 Accounts; 

and the same reporting requirements apply as to a traditional 529. 
86 Commission on Long-Term Care Report to the Congress

iii. Provide 529-type programs for long-term care.

1. Possible support from payroll deductions.

iv. Develop insurance programs that insure for a limited front-end part of 

service delivery in order to enable more efficient and controlled use of 

public dollars.

Private LTC Insurance

7. Education—Educational campaigns are needed to increase take-up of private long-term care insurance. Surveys show that few people know they are 

at risk; they don’t know that Medicare does not cover long-term care expenses 

and that people must be poor or divest themselves of their assets to qualify for 

Medicaid. Medicare, Medicaid, and Social Security are projected to consume 

half of all federal spending a decade from now. There is simply no money for 

new public programs to fill the gap between the millions of people needing care 

and the few prepared today to finance that care. Educating the public about 

these realities is crucial, as is providing options and incentives for them to purchase affordable, portable, reliable insurance.

8. Education and other initiatives.

■ Education campaign to clarify guidance on what the public programs 

(Medicare/Medicaid) provide and encourage early planning for retirement 

and LTSS needs.

■ Clarify FDA regulations to encourage the development of assistive care 

technology. 

■ Encourage small business investment through SBIR, STTR, and SBA to develop assistive technology.

■ Recommend to Office of the National Coordinator for Health Information 

Technology to provide, as part of implementing “meaningful use” Stage 

3 standards, an optional place for recording care plans in the electronic 

health record.

9. There is a strong need to encourage the development of personal and family 

capacity—through private insurance, savings, and otherwise—for their retirement and LTSS expenses.

A. Long-Term Care Insurance 

■ As is the case with Medigap insurance, establish federal standards to 

standardize and simplify the types of policies insurers can offer in order 

to facilitate comparison and competition.
APPENDIX A: Commissioner Ideas 87

■ HHS, in cooperation with the states, creates an electronic market and 

provides information and direct assistance to consumers in order to 

facilitate comparison shopping and educated choices. 

■ Relieve state regulations on high-deductible, long-term care insurance 

products, thereby providing for catastrophic insurance coverage and 

for clarity to families about the amount they need to save for LTSS 

deductibles or provide for in their Medigap policies.

■ Working with the states, HHS calls for the establishment of reinsurance arrangements, financed by private insurers that establish parameters for risk management and mitigate risks to individual companies.

■ Allow above-the-line tax deductions for long-term care insurance premiums. 

■ Exclude value of long-term insurance policies or payments from Medicaid eligibility requirements.

B. Private Savings

■ Allow tax-exempt, penalty-free withdrawal from qualified retirement 

funds to fund LTC insurance or LTSS expenses. 

401K

402B

IRA

Roth IRA

■ Amend Section 125 plans (cafeteria) to include LTC insurance. 

■ Lift or remove Health Savings Account (HSA) contribution cap. 

■ Amend IRC to establish tax-exempt ABLE accounts to assist an individual and families with an actual or anticipated disability in building 

an account to pay for qualified disability expenses, including long-term 

care insurance premiums (see, e.g., Introduced as S. 313, H.R. 647).

10.Create new federal regulations allowing the private insurance sector (i.e., 

health, long-term care, disability, and/or life) to create a new generation of 

simple, easy-to-understand, affordable, and standardized insurance products targeted for purchase by working individuals. These products should be 

marketed through employers and could be offered as a supplemental benefit 

at the employer’s discretion. These products should also be backed by state/

regional reinsurance pools to ensure greater affordability.

11. Protect consumers from inappropriate denials of coverage from any public 

or private LTSS financing system.
88 Commission on Long-Term Care Report to the Congress

a. Develop enforceable national consumer protections for all private longterm care insurance models.

b. Provide consumer-friendly, meaningful appeals in all public and private 

financing systems.

12. Allow the life care annuity to be used as an investment in tax-advantaged retirement accounts. Motivation: The life care annuity is a combination insurance product innovation that reduces adverse selection in its immediate life annuity portion, resulting in lower premiums, and would allow for a considerable 

relaxation of underwriting standards for its long-term care insurance portion. 

Common purchase of this product would accommodate the delayed purchase 

of LTCI until closer to retirement, reducing various pricing risks on the insurer, 

while at same time providing permanent coverage (that is, not subject to the risk 

of lapses) to the insured. Under current law, it is not allowed to be used as an 

investment or distribution mechanism in employer-sponsored retirement plans 

or in retirement accounts such as IRAs, unless taken as a taxable distribution. 

Proposal: Allowing the life care annuity to be used as an investment in 

tax-advantaged retirement accounts would essentially give the LTCI portion 

tax-favored status equivalent to the tax deductibility of premiums. But in the 

form of the life care annuity, it would be tied to other desirable public policy 

goals—permanent LTCI coverage, and improvement in the efficiency of life 

annuity markets. Technical tax requirements governing retirement assets such 

as minimum distribution requirements and incidental benefit rules would be 

waived for the LTCI portion of the life care annuity. 

13. Lighten regulatory burdens on private LTCI. Motivation: A significant part 

of the current difficulties for writers of LTCI lies in the regulatory inflexibilities of the product to respond to rapid and large changes in the macroeconomic environment, especially with regard to interest and inflation rates. In 

particular, the recent rapid and sustained drops in interest rates induced by 

unusual Federal Reserve monetary policies, as well as the drop in inflation 

rates caused by the Great Recession, have made LTCI unprofitable to writers (because it was priced assuming much higher investment returns) and 

expensive to consumers (because the requirement for automatic annual 5% 

increases in benefits in tax-qualified LTCI implicitly assumes a more inflationary environment). 

Proposal: For sufficiently large changes in the macroeconomic environment, allow (in the upward direction) and require (in the downward direction) 
APPENDIX A: Commissioner Ideas 89

writers of LTCI to change automatically the pricing of existing outstanding 

LTCI policies on an actuarially fair basis; the same would apply to the requirement for inflation adjustment in benefits. The “sufficiently large” nature of the 

macroeconomic changes would be determined by the National Association of 

Insurance Commissioners on a uniform national basis. All other desired pricing and product changes arising from other sources of actuarial experience, 

such as claims and lapses, and so on, which are generally more specific to the 

business judgment and actuarial skill of the insurer, would continue to be governed by current state laws requiring specific state commissioner approvals of 

pricing and product changes. 

14. Regulatory Reform for LTCI. Currently, long-term care insurance products 

often suffer from a lack of portability. For instance, an individual who purchases an LTC insurance policy while living and working in New York and subsequently moves to Florida upon retirement may find difficulty accessing benefits after moving to a new state. This lack of portability discourages take-up of 

private LTC policies, increasing the burden on public programs in the process.

One possible solution to this problem could involve the formation of multistate compacts to ensure portability of LTC policies for all states participating in the compact. The National Association of Insurance Commissioners 

(NAIC) could help to develop such a system, which would allow states themselves to suggest the best possible solutions, rather than having a top-down 

model imposed by Washington. To the extent that federal policymakers wish 

to support the NAIC endeavor, a gain-sharing demonstration—in which any 

potential reductions in public expenditures arising from the compact are 

shared with the states participating in it—would both encourage states to participate and promote a new regulatory framework designed to alleviate the 

burdens on the public purse.

15. Tax Incentives. As was noted in testimony at the most recent commission hearing, the federal government provides significant tax incentives to encourage 

participation in both health care and retirement programs. Incentives for employer-provided health insurance and for contributions to pension and 401(k) 

plans represent some of the largest incentives in the tax code. Yet the incentives 

to purchase private long-term care insurance are small by comparison, particularly given that private insurance can alleviate the financial burdens placed on 

Medicare and Medicaid as the Baby Boomers retire.
90 Commission on Long-Term Care Report to the Congress

The obvious solution to this problem would involve equalizing the tax treatment of health insurance and long-term care insurance by allowing LTC insurance premiums to be paid through a Section 125 cafeteria plan. Other similar 

solutions would allow for tax- and penalty-free distributions from retirement 

savings accounts like IRAs and 401(k)s, and the use of LTC policies in life care 

annuities without triggering taxable distributions.

Equalizing the tax treatment between health and long-term care insurance 

would effectively provide a 30–40% discount on current LTC premiums. Moreover, by encouraging broader take-up of private policies, such incentives could 

reduce both adverse selection and administrative loading—thereby lowering 

premiums further.

Secondarily, equalizing the tax treatment of health insurance and longterm care insurance could encourage the introduction of hybrid health/longterm care insurance products—a solution presented by one of our panelists last 

week. In the absence of equal treatment for both products, the tax complexities 

presented by hybrid policies could serve as a major disincentive to their widespread adoption.

16. Tax incentives. All levels of government are facing serious budget constraints 

that threaten funding for existing health care, disability, and retirement programs. To assure that the safety net is secure for the most vulnerable in our society, we need to provide new incentives for those who can prepare now to take 

responsibility for their own long-term care needs. However, sales of individual 

long-term care insurance policies have been declining for a decade, and fewer 

and fewer companies are selling the policies. The share of the market represented by people aged 40–69 in middle- and lower-income categories is declining. 

We need new incentives, new partnerships, and innovative programs to address these challenges.

Recommendation: Equalize the tax treatment of health insurance and longterm care insurance. As a first step, this could include allowing employees to 

use pre-tax dollars through Section 125 “cafeteria” plans and/or through Flexible Spending Accounts to purchase long-term care insurance. States could also 

provide tax credits, as Minnesota has done with its $100-a-year credit for those 

who enroll in long-term care insurance. 

Changing the tax treatment of long-term care insurance would incentivize creation of a more robust market for these products. Witness Jason 

Brown described an integrated insurance product consisting of a life annu-
APPENDIX A: Commissioner Ideas 91

ity policy combined with long-term care insurance, offering evidence that 

this could be a stable market even if the product were purchased at or near 

retirement. Our Vice Chair, Mark Warshawsky, has produced a detailed plan 

describing this innovative solution, “The Life Care Annuity: A Proposal for 

an Insurance Product Innovation to Simultaneously Improve Financing and 

Benefit Provision for Long-Term Care and to Insure the Risk of Outliving 

Assets in Retirement.” 

This is not a solution for everyone but is for those who can afford to begin planning for their own future needs. Adding new incentives for people to 

purchase private insurance protection and reduce the disincentives for people 

to begin preparing for their own needs will mean the public safety net will be 

stronger for the most vulnerable who have no other alternatives and must rely 

on public support to finance their care. We received public testimony from 

Rebecca Underwood, parent/guardian/advocate for Aaron Underwood, to explain so very clearly how important it is to make sure the resources are available for those with the most critical needs.

17. Site-Neutral Payments should produce notable savings; a portion of the 

savings would be tax rebates for LTSS, and a portion would be used as subsidies for low-income individuals. As discussed above, many believe that 

a site-neutral payment system would produce savings and achieve better 

outcomes for patients. In an effort to improve quality of care and generate 

cost-saving concepts, a new patient-focused payment model would be developed that would reduce spending on post-acute care while facilitating 

movement toward a more rational system for PAC payment and delivery. 

This model would focus on the needs of the patients rather than the setting 

of care, with the potential to reduce federal spending approximately $15–20 

billion over the 10-year budget window. 

The savings from such an initiative could be used to create tax rebates for 

LTSS use or purchase of an LTSS private financing option, such as Private LTSS 

Insurance. Additionally, a portion of such savings could be used to create a 

subsidy program for those with low income to purchase private LTSS options. 

Medicare Eligibility and Benefits

18.Create new regulations and accountability standards for a new generation 

of Medicare Advantage/Special Needs Plans and/or Medigap coverage that 

would cover specified long-term care services as an optional supplemental 
92 Commission on Long-Term Care Report to the Congress

benefit. To ensure proper evaluation of the financing models needed to sustain these new models, updating the CMS Hierarchical Condition Categories 

to better reflect the clinical and functional profile of high-risk, high-utilizing 

beneficiaries should be required.

19. Make the most of Medicare—the one national program we have now by removing current barriers to Medicare coverage for people with long-term and 

chronic conditions.

1. Redefine the homebound requirement for Medicare home health coverage 

so that people who cannot obtain the services they need outside the home 

can obtain them at home. 

a. Currently the homebound definition restricts some people from getting 

care at home although they cannot consistently leave home to obtain the 

services they need.

b. Do NOT add a cap or co-insurance to the Medicare home health benefit.

i. Proposals are being considered to limit home care, which would further exacerbate the already limited ability of people to obtain home 

and community-based services. 

ii. The savings estimate, at $730 million/10years for the co-pay, does 

not warrant this further limitation on home care.

2. Remove the three-day hospital stay requirement for skilled nursing facility 

(SNF) coverage so people without the need for an acute inpatient hospital 

stay can at least get some Medicare nursing facility coverage.

i. Absent removing the three-day requirement, eliminate hospital “observation status,” or count all days spent in the hospital as “inpatient” 

for purposes of qualifying for subsequent SNF stays.

3. Eliminate the 24-month Medicare eligibility waiting period for people who 

qualify for Social Security Disability Insurance (SSDI).

4. Ensure the Jimmo v. Sebelius settlement is effectively implemented to eliminate the “improvement standard” requirement for determining Medicare 

coverage and ensure coverage is also available for skilled services to maintain an individual’s condition or slow deterioration.

20. Add a new Long-Term Services and Support (LTSS) benefit to Medicare.

The LTSS benefit would be triggered when an individual is certified to be dependent in two or more activities of daily living and/or has cognitive or mental 

health issues such that independence is contraindicated. In such cases the individual would be eligible for:
APPENDIX A: Commissioner Ideas 93

a. Skilled nursing facility coverage for up to 150 days per calendar year;

i. Without the need for a three-day hospital stay;

ii. Without the need for daily skilled care (custodial care alone would 

be covered).

b. Home health coverage, including coverage for home health aide services, without the need for a skilled service;

c. Personal care attendant;

d. Care management and coordination;

e. Adult day center; 

f. Respite care to support family or other volunteer caregiver;

g. Outpatient therapy without an annual cap;

h. Other reasonable and necessary services.

Note: The CLASS Act experience demonstrates that any such LTSS benefit 

must be mandatory in order to be financially viable. 

■ Various options are possible, but a new Medicare LTSS benefit should not 

add to the complexity of Medicare and should not diminish the stability of 

the current program. 

■ Consider adding the LTSS benefit to Medicare Part A, with a defined % 

increase to current Part A payroll tax to pay for it. This additional may even 

strengthen Medicare Part A, which is mandatory for those with Medicare. 

Medicaid Eligibility and Benefits

21.Create a national Medicaid Buy-In (MBI) program for workers with significant disabilities up to 250% of FPL. Medicaid is the only affordable option to 

access long-term services and supports for millions of people with significant 

disabilities.  Standard health insurance policies do not offer coverage for the 

long-term services and supports (LTSS) required for individuals with disabilities to live in the community. And although private long-term care insurance 

coverage does exist, it is not a realistic option for working-age individuals 

with disabilities. To help provide access to affordable LTSS to working people with disabilities, Congress gave states an option to let working individuals 

with disabilities continue to receive LTSS through the Medicaid program when 

their income or resources exceed Medicaid’s normal limits through an option 

known as the Medicaid Buy-In, or MBI, programs. States can implement MBI 

programs under two different authorities: the Balanced Budget Act of 1997 or 

the Ticket to Work & Work Incentives Improvement Act of 1999. Forty-six 

states currently have MBI programs, and more than 200,000 workers with dis-
94 Commission on Long-Term Care Report to the Congress

abilities are currently working and receiving needed LTSS as result of this option. The different authorities impose different requirements states must follow 

in creating MBI programs: 

Balanced Budget Act Ticket to Work 

Age limits None 16-64

Income Limits Up to 250% of FPL None 

Resource Limits Up to state Up to state 

Premiums Based on sliding scale – no upper limit Premiums and cost sharing 

based on income 

Definition of work States cannot define work States cannot define work 

Grace period for employment Limited Not allowed 

Although MBI programs offer opportunities for people with disabilities 

who work to continue to receive LTSS, the variation in state programs and 

some design flaws limit the effectiveness of these programs to support working 

individuals with disabilities—forcing people not to take promotions to remain 

within income or resource limits; making it difficult, if not impossible to relocate for a better position; and making people less likely to work because of not 

being able to get back onto regular Medicaid if their work attempt fails. 

The program would have no upper age limit, with a standard definition of 

work, grace periods for unemployment that recognize the episodic nature of 

many disabilities, allow people to save for current and future needs and retirement, and disregard resources accumulated during MBI participation for 

access to Medicaid if a person can no longer work. Here are some specifics: 

■ Income limits vary from a low of 80% of FPL to unlimited income;

■ Resource limits vary from a low of regular Medicaid limits ($2000 for an 

individual) up to unlimited resources; 

■ No grace period for participation; 

■ No pathway back to regular Medicaid if a person accumulated resources 

while participating in MBI; and

■ Uncertainty regarding eligibility for Medicaid at age 65.

22. Pilot a program for workers with significant disabilities whose earnings exceed 250% FPL and need LTSS to remain employed without support from the 

Social Security income assistance programs. U.S. Disability Support Systems 
APPENDIX A: Commissioner Ideas 95

Fail People With Disabilities: The United States has made significant strides in 

changing the expectations of and attitudes toward people with disabilities. The 

passage of landmark civil rights legislation in the Americans with Disabilities 

Act (ADA) in 1990 contributed to this evolution of attitudes and creation of 

opportunities. Court decisions, such as the Supreme Court decision in the historic Olmstead case, have also called for the full integration of individuals with 

disabilities in society. And while many doors have been opened, the lack of 

pathways to access needed services and supports that allow people with significant disabilities to live and work independently while achieving even a modest 

level of economic security has hindered the progress that might otherwise have 

been made. 

Individuals with Disabilities Face Unique Challenges: People with significant 

disabilities who require supports and services to work often face a catch–22. 

Currently, Medicaid is the only option available that provides access to the 

services and supports needed to get and keep a job. Private long-term care insurance is not an option for a variety of reasons, including: denial of coverage 

outright; cost-prohibitive premiums if one is able to get coverage; services and 

supports not available in a work setting; and/or a short timeframe of authorized benefits. Self-financing the services and supports is out of the question 

for all but the highest earners and makes people with disabilities less economically competitive than their non-disabled peers. And although many working 

people have access to private health insurance, and more will gain it through 

the Affordable Care Act, private health insurance does not cover at all or inadequately covers many needed services and supports. 

Medicaid, While Vital, Doesn’t Work for Many Working People with Disabilities: Although Medicaid is the only game in town, it is also an imperfect solution. Medicaid is intended to provide health care and related long-term services 

and supports to individuals with limited income (both earned and unearned) 

and resources. Medicaid work incentives allow working people with disabilities to continue their participation in the Medicaid program while allowing 

them to increase their earnings up to a set limit (usually 250% of FPL) and, in 

some very limited cases, save for emergency expenses or life goals. These work 

incentives include, but are not limited to, the Medicaid Buy-In programs and 

the 1619(b) program.98 However, as Medicaid was designed to provide health 

98 MBI programs allow people to work and save and maintain access to Medicaid while paying 

co-pays based on income. Most states have MBI programs, but income and resource limits vary 
96 Commission on Long-Term Care Report to the Congress

care to low-income individuals with no other access to insurance coverage, 

its structure and eligibility rules make it difficult to impossible for working 

individuals with significant disabilities to achieve the things associated with a 

middle-class lifestyle for a number of reasons. 

■ Upper limits on income and resources for program eligibility are often the 

drivers of career decisions rather than opportunities. 

■ Variations in state Medicaid programs (e.g., income and resource limits for 

MBI participation, income limits for eligibility, types of waivers and whether slots are available, and the package of services and supports available) 

make relocating for a better opportunity difficult, if not impossible. 

■ SSI/Medicaid’s resource limits (e.g., a person can have no more than $2,000 

in assets for an individual or $3,000 for a couple to be Medicaid eligible) 

are often problematic, making it impossible for people with disabilities who 

work to save for emergencies and retirement, let alone save to purchase a 

home or start a business. 

■ People with significant disabilities often have extraordinary support needs 

that make it difficult, if not impossible, to get those needs met outside of 

public programs. 

■ People with disabilities often find themselves in the unenviable position 

of turning down jobs or promotions to maintain access to these vital services and supports. The U.S. must provide people with disabilities a pathway to access service and supports that allows them to earn to their potential, save for their futures, achieve a middle-class lifestyle, and achieve 

the vision of the ADA. 

Proposal: A pilot program that provides access to the services and supports 

needed by employed individuals with significant disabilities (meet SSA definition of disability absent the inability to work assessment) combined with a 

waiver of rules that prevent people with disabilities to earn income and accumulate assets without jeopardizing access to services and supports. This 

program is designed to wrap around health insurance products (offered by 

employer or through the state marketplaces) and modeled on the 1619(b) program; specific program design elements include: 

significantly. 1619(b) programs allow people to maintain Medicaid access while working but do not 

change resource limits. Every state participates in 1619(b), but income limits vary significantly. 
APPENDIX A: Commissioner Ideas 97

■ Eligibility: To be eligible to receive wrap-around services and supports 

through this program, a person would have to be a working individual with 

a disability defined as: 

Meeting or equaling the Social Security disability listings or qualifying 

for quick disability determination/compassionate allowances for eligibility for the Social Security disability programs. 

Be working, defined as earnings at or above 250% FPL.

■ Pay applicable cost sharing based on income, employment-related disability expenses, as well as level of services needed.

■ Wrap-around package: The program would offer access to services and 

supports that people with disabilities need to become and stay employed 

and fill coverage gaps between what is offered by health care insurance 

products and the unique health care needs of individuals with significant 

disabilities. The services and supports package available through the program would include: personal attendant care, assistive technology, and 

other services and supports. 

23. Tighten Medicaid eligibility for people age 62 and older by considering assets currently excluded from eligibility tests as countable and by removing 

opportunities for gaming program rules. Motivation: Given severe state and 

federal government budget constraints and the concomitant tendency for the 

government to cut Medicaid reimbursements to providers, thereby harming 

quality, public resources need to be focused on providing care to the needy and 

poor, not the upper middle class and the well-to-do households to enable them 

to leave large bequests. 

Proposals: Limit the home equity exemption to $50,000 (this would redirect many households to use reverse mortgages to fund LTSS and discourage 

the game of investing otherwise countable assets in exempt homes). Extend the 

look-back period for real estate to 10 years, as it is administratively easy to accomplish. Outlaw Medicaid-friendly, fixed-period annuities and Miller trusts, 

currently used as eligibility gaming devices. Include retirement assets (401(k) 

accounts, IRAs, etc.) in countable assets unless they are being distributed as 

an immediate straight life (not fixed-period) annuity, whereby they would be 

included as countable income. Include premiums being paid for life insurance 

as countable income. Any assets that are exempted and not divested should be 

available for estate recovery by the states, which activity needs to be aggressively overseen and enforced by the federal government.
98 Commission on Long-Term Care Report to the Congress

B. SERVICE DELIVERY IDEAS

Strengthen Medicaid

1. Medicaid—Strengthen and maintain Medicaid as a safety net that effectively 

targets and utilizes resources, leverages technology, encourages innovation, 

rewards quality, and honors consumers’ choice of and access to the services 

and supports they need in the setting of their preference by: 

■ Requiring coverage of HCBS for eligible individuals, just as for institutional care; 

In the short term, providing financial incentives to build state and local 

capacity to make the transition to HCBS as the primary LTSS system; 

■ Enabling consumers and their spouses to stay in their homes and communities by increasing the Medicaid asset test and indexing it to inflation and 

by making permanent spousal impoverishment protections for HCBS, consistent with such protections for the spouses of nursing home residents;

■ Urging states that choose to implement Medicaid-managed LTSS to use 

these programs to balance resources so more beneficiaries and their families can receive HCBS;

■ Requiring states that use Medicaid-managed LTSS to provide important 

consumer protections including: promoting consumer choices, creating adequate networks to assure access to services, administering strong 

oversight to assure quality, and measuring outcomes such as consumer 

experience;

■ Offering consumers the option of self-direction, including allowing for the 

payment of family caregivers to provide services, as in the successful Cash 

and Counseling Demonstration; and

■ Provide incentives for innovative, high-quality residential settings, including those licensed as nursing homes, like Green Houses, and those licensed 

as assisted living or other models of housing and services.

Rebalance LTSS

2. Eliminate the institutional bias in Medicaid LTSS. Barrier- and regulation-free selection and choice of location to receive LTSS would allow substantial numbers of Medicaid-eligible clients to remain at or to return home 

at lower cost than living in institutional facilities. In her 8–1–13 testimony, 

Patti Killingsworth goes further by recommending that HCBS be the default 

selection. Killingsworth also suggests mandating individual cost neutrality as 
APPENDIX A: Commissioner Ideas 99

another mechanism for creating economies in the program. While critics express concern about the “woodwork effect,” a number of studies would indicate 

otherwise. More evidence-based programming is also important. Insufficient 

effort has been devoted to research that would demonstrate the most care- and 

cost-effective LTSS needed to allow someone to remain safely at home. 

In relation to person-centered care, the rigidity of Medicaid regulations often hinders or obstructs the selection and delivery of the most appropriate care 

for individual clients and their informal caregivers. Consideration should be 

given to review of regulations and statutes that thwart the goal of providing 

proper care. The Older Americans Act (OAA) offers the type of flexibility that 

should be used as a model for providing services. It is attuned with individual 

and local needs, brings community resources into the system, and administratively is far less costly than Medicaid. 

3. Rebalance Medicaid Long-Term Services and Supports (LTSS). The vast majority of Medicaid beneficiaries of any age who require LTSS prefer to receive 

those services in their own home or in a community-based setting instead 

of living in an institution—known as home and community-based services 

(HCBS). As a whole, the United States still over relies on the institutional side 

of LTSS. Despite the increase from 2.1 to 3.2 million HCBS users since 2000, 

states still only spend 36.8% of their LTSS budgets on HCBS for aging and 

physical disability populations. The range varies widely with the highest performing state spending 62% on HCBS and the lowest 10%. Only seven states 

spend more than 50% on HCBS (AARP 2011 Scorecard).

Nursing home utilization also varies widely across the states, with 838 persons per 100,000 of state population occupying NF beds in the highest state to 

84 in the lowest.

On the Developmental Disability side, only Mississippi spends less than 50% 

on HCBS. But of 4.9 million persons with developmental disabilities nationwide, 4.1 million live with their families, of which it is estimated that 25% of the 

caregivers or parents are over age 60. And many persons with developmental 

disabilities languish on long waiting lists (two-thirds of 511,174 individuals that 

38 states report on HCBS waiting lists) (from the Kaiser 2012 data update).

Currently many state Medicaid programs are consumed by exploring ways 

to expand health care to low-income populations or to more efficiently serve 

already covered populations. The capacity of these agencies to simultaneously 

overhaul and maximize the efficiency of their LTSS systems is under consid-
100 Commission on Long-Term Care Report to the Congress

erable strain. Partly for this reason, many states are looking to managed care 

organizations to administer their Medicaid LTSS systems.

Proposal: This proposal would create a single HCBS state plan authority 

that unifies and bundles the best features of the options described above and 

would make permanent the enhanced match incentives in the Money Follows 

the Person (MFP) program and the Balancing Incentive Program (BIP). The 

key features would include:

■ States can set needs-based functional eligibility less stringent than the institutional level of care (LOC).

■ Allows states to include any or all Medicaid eligibility groups with income 

standards up to 300% of SSI, with strategies incorporated to ensure the lowest-income individuals receive coverage first.

■ Allows states to craft multiple programs or consolidate multiple programs 

across disability or other target groups in a manner that adheres to applicable laws (ADA, etc.).

■ Payments for HCBS services are 6% higher than the regular match rate, 

subject to Secretarial approval, using criteria reflective of autonomy, choice, 

and applicable rules related to HCBS characteristics. The Secretary will determine the specific HCBS services, settings, and attributes that will be eligible for the enhanced FFP, including time periods for review of enhanced 

FMAP eligibility. 

■ Institutional services are held at the regular match rate.

■ Makes permanent the MFP feature of full FFP for HCBS costs for one year 

after relocation from a nursing home, hospital, ICF/DD, or PRTF where 

a person has resided for more than 90 days and includes features of both 

MFP and the “K” to pay for certain start-up costs.

■ Adds Partial Residential Treatment facilities (PRTF) as an allowable alternative for LOC determinations.

■ As a state plan option, states must serve all eligible individuals; however, a 

state may negotiate enrollment growth targets tied to specific rebalancing 

benchmarks that permanently decrease the state’s institutional footprint. 

■ Allows a time-limited differential match for buy down of vacant institutional beds taken offline. 

■ Allows a state under this authority to create health homes to coordinate 

care for a subset of eligible individuals who are receiving HCBS services 

and have two or more chronic conditions, and the state can receive 90% 

FMAP for up to eight quarters as defined in the Affordable Care Act.
APPENDIX A: Commissioner Ideas 101

■ Includes opportunities for easy linkage to tools for integration, such as 

health homes and managed care authorities, setting forth uniform expectations yet streamlined authority linkage quality and reporting structures.

■ Will create the possibility for a medically needy income level for community-based services.

The single-state HCBS authority would also have uniform requirements 

including:

■ Meets HCBS settings requirements;

■ Needs assessments include core elements for all populations but also address 

specific populations using valid and reliable population-specific assessments;

■ Person-centered planning requirements for all participants;

■ No Wrong Door for all intake and eligibility;

■ Requires a mitigation plan for potential conflicts of interests in the delivery 

of case management; and

■ Participant direction, including hiring and firing authority over personal 

care staff and access to an individual budget must be an available option.

Specified quality measures

The provision will also “clean up” the statute to remove the various provisions (driftwood) to definitively provide a sleek option. However, states may 

still elect to utilize the 1915(c) authority to fund HCBS services tied to an institutional level of care, subject to the periodic review by the Secretary to ensure 

that the services offered therein comport with established standards for HCBS.

4. Removing the Institutional Bias. Medicaid’s bias towards institutional, as 

opposed to home and community-based care, stems in part from its original 

design, and in part from budgetary strictures that have impeded the road to 

reform in the years since. Traditionally, the Congressional Budget Office has 

stated that expanding HCBS could cost more money than it saves—largely due 

to a potential “woodwork effect” caused when family caregivers utilize expanded access to Medicaid’s HCBS services.

However, testimony last week provided several potential ways to alleviate 

the budgetary impact of any “woodwork effect” as a result of a transition from 

institutional care to HCBS. Specifically, Tennessee’s recommendations to make 

institutional care an optional benefit, mandate cost-neutrality for HCBS, require 

beneficiaries to “opt-in” to institutional care, and require enrollment in HCBS first 

prior to placement in an institution all would tilt the bias away from institutional 
102 Commission on Long-Term Care Report to the Congress

and towards community-based care. These reforms could also provide “scoreable” 

budgetary savings that would reduce any increased spending from a potential 

“woodwork effect”—a critical consideration, given the current fiscal climate.

As one panel noted last week, removing the institutional bias in Medicaid 

cannot be achieved overnight. However, the recommendations provided could 

represent important ways to provide better care to more beneficiaries, at the 

same or lower cost—a true “win-win” solution.

5. Rebalance Medicaid so that institutional bias is removed, and people who 

qualify for Medicaid can obtain necessary LTSS in the least restrictive setting 

that meets their needs.

6. Remove “institutional bias”. Payment policies in current programs for LTSS 

make it more difficult for people to get care in alternative settings, including 

receiving care at home or other residential settings. We have heard testimony 

from witnesses describing the possibilities of new technologies and delivery 

systems that can improve care and save unnecessary spending. Allowing greater access to HCBC is the obvious solution, but it must be structured in such a 

way that it doesn’t create a woodwork effect. Marilyn Moon in her testimony 

suggested replacing the three-day hospitalization requirement for eligibility for 

skilled nursing care with “a more needs-based approach . . . Specific criteria 

concerning the need for SNF care should be the determining factor, not an 

arbitrary rule.” Witness Patti Killingsworth suggested an “opt-in” approach to 

institutional care and that enrollment in HCBC be required before placement 

in an institution—a kind of “step therapy” for nursing care.

7. Rebalance the current national health care system, oriented toward acute 

care and safety net programs, to increase Home and Community-Based 

Care. Doing so will require three changes: (1) Alter the design of Medicaid to 

focus on home and community-based and eliminate its “institutional bias” and 

at the same time achieve greater consistency across the states in their approach 

to HCBS, (2) provide greater flexibility to the States in the administration of 

their Medicaid programs subject to clear federal performance and quality standards, supporting states with the technical and administrative support needed 

to reorient their programs to include more home and community-based elements, and (3) introducing into Medicare a care-coordinated, caregiver-centric 

support program to strengthen the capacity of American families to support 

home and community-based care.
APPENDIX A: Commissioner Ideas 103

A. Medicaid

■ Require states to offer community- and home-based care option with 

determination to be made on basis of functional impairment.

■ Provide consistent information on availability of services, both institutional as well as home and community based, regardless of your point 

of entry into care and require the use of a universal assessment tool to 

evaluate need and placement. 

■ Decouple eligibility for HCBS from a determination of nursing home 

eligibility.

■ Consolidate and simplify waivers to states with performance-based requirements and gain-sharing.

■ Provide states with technical and administrative support to encourage 

move to HCBS and to build the needed community infrastructure to 

support HCBS.

■ Develop standard quality measures for both home as well as institutional LTC facilities. 

B. Medicare

■ Provide a new caregiver support benefit for Medicare eligibles with 

functional impairments in order to support more HCBS. (Need to determine basis of eligibility and cost.)

■ Replace three-day prior hospitalization requirement with a need assessment-based approach designed to encourage post-acute HCBS. 

■ Require and reimburse physicians as part of annual wellness visit to prepare a care plan for each beneficiary (researching recent regulation to 

determine if necessary).

■ Direct the ONC to work with the Agency for Health Research and Quality and Centers for Medicare and Medicaid Services in plan standardizing some elements of the care planning process, the care plan documentation, the continuity of care plans across settings of care, and the 

evaluation of the performance of care plans.

Care Integration/Care Management—Duals

8. System Transformation and Care Coordination—Create a more responsive, 

efficient, and integrated LTSS delivery system that ensures that people can access quality services in settings that they choose by: 

■ Establishing a more effective system to measure and reward quality, including:
104 Commission on Long-Term Care Report to the Congress

Developing and implementing better measures of quality of life and care 

that are tested and validated across settings (especially in HCBS) by a 

consensus body; 

Rewarding quality care based on validated measures that have been tested by pilot projects in various settings; and

Establishing systems to publicly report quality and cost that will be understandable to consumers as they compare providers and plans and 

make decisions about services. 

■ Using technology more effectively to mobilize and integrate community resources and to share information among providers, individuals, and family 

caregivers across settings, in order to:

Promote more effective integration with health care services, including 

extension of “meaningful use” incentives to LTSS providers as that becomes feasible;

Improve person-centered data collection to support the delivery of person- and family-centered care across settings and through transitions;

Permit real-time monitoring and timely interventions to address quality 

problems; and

Support greater independence by mobilizing and coordinating local 

community services such as transportation, shopping, and home maintenance services.

■ Align the incentives to improve the integration of health care and LTSS 

services in a person-centered approach rather than one tied to specific settings by:

Broadening the Center for Medicare and Medicaid Innovation’s work to 

include more focus on the integration of LTSS with health care services;

Reforming payment systems to promote systems transformation; 

Including better data sharing between Medicare and Medicaid; and

Supporting partnerships among health care, post-acute, and LTSS 

providers.

■ Creating livable communities that build on housing and services models to 

improve health care and LTSS coordination, and expand local initiatives, 

such as Villages, that coordinate community services to enable people with 

disabilities to live more independently.

■ Establishing a clear point of contact so that individuals and their family 

caregivers know who they can turn to when they need assistance, especially 

in transitions across settings.
APPENDIX A: Commissioner Ideas 105

■ Incentivizing states to test and develop models that could potentially inform federal policy.

9. Medicare payment/delivery reform innovation to target people needing 

long-term services and support. 

Premise: 

The 15% of Medicare beneficiaries with chronic conditions and functional impairments account for about a third of Medicare spending.

Fewer than half of these beneficiaries are Medicaid beneficiaries (dual 

eligibles).

The federal government finances 80 percent of Medicare and Medicaid 

spending on dual eligibles, predominantly through Medicare.

The federal government has a responsibility to promote better integrated care through Medicare, rather than shift responsibility to Medicaid.

Proposal:

The Centers for Medicare and Medicaid Services should use their authority 

to launch a Medicare payment and delivery reform pilot to promote provider 

initiatives that: (1) focus on people who need long-term services and supports, 

(2) coordinate services across the continuum to address long-term services 

and supports needs along with medical needs, and (3) work, in general, for 

all Medicare beneficiaries with long-term care needs, regardless of income or 

Medicaid eligibility. Such pilots would include: Monthly payments per enrolled 

patient to participating providers sufficient to support coordinators and other 

currently uncovered care management services; shared savings with providers 

who satisfy quality standards; provider accountability for savings sufficient to 

offset care coordination expenses; and shared savings with states that participate and invest in delivery improvement for dual eligibles.

10. Further national and state efforts to fully integrate Medicare and Medicaid 

financing and service delivery for those who are dually eligible in order to 

improve person-centered outcomes while lowering costs. In particular, CMS 

should continue to focus on two goals: (a) development and implementation 

of quality measures and service monitoring across the entire continuum of care 

including HCBS, and (b) upholding strong consumer protections such as transparent three-way contracts, state and health plan readiness reviews, ombudsman programs, and mechanisms for seamless transitions and continuity of care.
106 Commission on Long-Term Care Report to the Congress

11.Improvement in the quality of care for dual eligibles. A number of witnesses 

spoke to the need for better management and integration of care among providers, payers and patients. Among other problems, they noted the difficulties 

in maneuvering the publicly funded system, the fragmented relationship of 

dual eligibles to their health and LTSS funders, the difficulties in transitions 

between care settings, the complications in establishing provider relationships, 

and the struggles in determining appropriate patient care. Clearly the system 

needs major work to develop better client supports, improve care coordination, 

remove redundancies and gaps in the system, prevent unnecessary hospitalization and nursing home placement, and preserve funds. States are adopting 

a variety of models for dual-eligible clients. While bringing about both economies and improved quality of care, these programs allow for differences in 

state environments. Additionally, innovations that provide greater fungibility 

of resources, such as in Tennessee and Rhode Island, should be reviewed for 

replicability, quality of care, and overall cost. A much-needed overhaul in service can result in a far more efficient cost-effective system. 

Please note, as stated above, additions to publicly funded LTSS need to be 

expenditure neutral.

12.Care Coordination: The recent expansion of Medicaid-managed care for 

dual-eligible populations needing LTSS reflects the belief of many states that 

managed-care options can provide better coordination than the traditional 

state-run Medicaid model. Unfortunately, however, states looking to innovate 

in this sphere often face additional burdens imposed by Washington.

Freeing states from these federal requirements could expand the utilization of Medicaid managed-care options, particularly for dual-eligible beneficiaries. Solutions in this vein would include allowing states to utilize one 

Medicaid managed-care organization in a given region if that region’s population is too limited to support two organizations. Another possible reform 

could give states the option to incentivize beneficiaries who participate in 

healthy behaviors and disease prevention activities, or to offer additional 

services for those beneficiaries choosing high-value or managed care plans. 

These types of reforms would increase participation in coordinated care 

models, encouraging activities that lead to improved quality of care and thus 

reduced health expenditures.

13.Coordinated care: A recent study in the Medicare and Medicaid Research Review found that a “bundled hospital payment system that covers both acute 
APPENDIX A: Commissioner Ideas 107

and post-acute care can create financial incentives in the Medicare fee-forservice system to foster care coordination, improving the current disorganized system of post-acute care.” Witness Barbara Gage stressed the need for 

eliminating care silos and suggested that ACOs establish programs to target 

high-risk populations and to then provide follow-up care through community-based organizations.

The silo- and rule-driven approach to care delivery interferes with quality 

patient care and is a terrible waste of resources. We received public comment from, Carol Marshall, a health care consultant in Fort Worth, Texas, 

explaining the extraordinarily rigid rules involving payment policy for physical, occupational, and speech therapy that create stress for both medical 

professionals and patients, blocking the ability of practitioners to provide patient-centered care. Witness Patti Killingsworth also recommending realigning “incentives in the Medicare program to support delivery of Medicare and 

Medicaid LTSS in the most integrated setting possible,” and she offered specific solutions to achieve that goal.

14. Develop a national care-management system based on the Georgia Source 

Program: Georgia maintains a program called Service Options Using Resources in a Community Environment, or SOURCE.  The SOURCE program 

is unique to Georgia.  It is a State Plan enhanced primary care case management program that serves frail elderly and disabled beneficiaries to improve 

the health outcomes of persons with chronic health conditions by linking primary medical care with home and community-based services.  

SOURCE links primary medical care and case management with approved 

long-term health services in a person’s home or community to prevent hospital 

and nursing home care.  All SOURCE clients must be eligible for Medicaid 

and meet nursing home level of care.  SOURCE serves aged, blind and disabled Georgians who are eligible for Supplemental Security Income/Medicaid 

(SSI).  An assessment helps to determine how much care a participant needs. 

An individual care path is designed based on the need for medical monitoring 

and assistance with functional tasks. Family members and other informal caregivers as well as staff from support agencies participate in care paths. In addition to core services, SOURCE offers personal support services, assisted living 

services, extended home health, home-delivered meals, adult day health care, 

emergency response services, and 24-hour medical access to a case manager 

and primary care physician.
108 Commission on Long-Term Care Report to the Congress

The proposal would take the original SOURCE model one step further and 

create a SOURCE Patient Centered Health Home Model (PCHH). The PCHH 

model would include the following additions:

Expand SOURCE covered services to include some or all of the following: 

a. Skilled Nursing Facility (SNF)

b. Home Health

c. Hospice

d. Physician

e. Pharmacy

The PCHH model also includes six innovative elements to achieve the goals 

outlined above. These are:

Care management which includes those receiving Skilled Nursing Facility care;

Varying levels of care management based upon Resource Utilization 

Groups (RUGS) and case mix indices (CMI’s) to reduce care gaps that 

can occur between levels of acuity and different service settings;

A no wrong door access;

An information technology solution to permit the support of data sharing in real time across the network and more closely link a comprehensive post-acute spectrum of care and services;

Acute care partners in data sharing agreements;

The utilization of CMSs—or some other—Continuity Assessment 

Record and Evaluation (CARE) unified patient assessment tool vs. 

site-specific assessment tools.

All provider services across the spectrum would also be required to use the 

assessment tool and be compatible with the others. Care would be coordinated 

by a Care Manager who is paid on per member per month basis to manage 

care. Requirements include 24-hour telephonic availability, monthly telephonic care conferences, in-person quarterly care conferences with the patient in 

the care setting, and in-person care conferences with the patient and the physician. Attached please find a more detailed paper on the concept.

Improve Care in Residential Settings

15.Better provision of care in residential settings. Long-term care is a residence 

issue as much as it is a service delivery issue. Just as care for dual eligibles 

is complex and inefficient, the historic separation of the streams of funding 

for housing and care delivery has impeded the most effective use of public 
APPENDIX A: Commissioner Ideas 109

moneys. Traditionally publicly financed housing and disability care providers worked separately, with little acknowledgment that they were serving the 

same clients, often in the same places. More recently some efforts at recognition of common clients have been instituted in public housing. A more 

current initiative is the provision of services, including employment initiatives, within HUD Section 811 supportive housing for younger persons with 

disabilities. By law, Sec. 811 projects must establish a relationship with the 

state Medicaid agency to utilize appropriated funds. Consideration should 

be given to a similar requirement for Section 202 supportive housing for the 

elderly. For residents receiving Medicaid LTSS, this mandate would ensure 

closer coordination between the care providers and the not-for-profits who 

are the primary sponsors of this type of housing. With both 811 and 202 rent 

subsidized programs, comprehensive management of service delivery within 

a single housing structure can create efficiencies and produce better quality, 

less costly care. Studies of model programs in these housing projects will be 

important in demonstrating their value.

De-institutionalization of low income persons from nursing homes to less 

costly community settings and prevention of their entrance into nursing facilities are vital to providing greater personal independence simultaneously with 

lower outlays. To the extent that Sec. 811, Sec. 202, and public housing have 

vacancies, they are a good resource, along with the use of Money Follows the 

Person dollars. Use of Assisted Living Waiver slots can also be helpful where 

obtainable. However, many communities lack sufficient availability of rent-subsidized units that can also provide coordinated care. Killingsworth, along with 

other state Medicaid policy directors, proposes utilizing FFP for limited room 

and board supplement as a cost neutral or cost savings use of Medicaid dollars. 

Consideration of a waiver to permit its use, along with research of its value, 

would be useful. A question also arises about premature nursing home placement based on housing finances. Richard Johnson’s 8–1–13 testimony indicates 

that those using nursing homes under Medicaid have housing wealth of $69,000 

and other finances of $34,000. Those in nursing homes without Medicaid support own homes worth $155,000, and other finances totaling $289,000. It would 

be worthwhile to research the extent to which the Medicaid recipients go into 

nursing homes because of their inability to maintain their residences safely, 

while those at higher incomes but with the same care needs remain at home.

Creative collaborative use of public and private dollars may also assist provision of housing and care. Currently in Ohio, a not-for-profit entity is working 
110 Commission on Long-Term Care Report to the Congress

with the state to use Medicaid savings to help finance the capital costs of converting 75 units in an affordable independent living building to assisted living. 

This organization also has co-located primary care practitioners at many of 

its sites to supply preventive care and avoid hospitalization and nursing home 

placement, and has placed an adult day care program within a new tax credit 

affordable project. In Portland a not-for-profit has purchased four rent subsidy 

buildings, with plans to incorporate care, to the residents, including mental 

health and addiction services. 

Public entities working with not-for-profits make sense. In addition to 

sponsoring affordable housing projects, not-for-profits often offer units to rent 

subsidy vouchers holders within their market rate housing. The philanthropic 

contributions of those affiliated with the eleemosynary institutions frequently 

help finance supports of low income residents. 

In addition to improving living and care arrangements for low income persons with disabilities in subsidized housing, localities should be planning for 

the likelihood that greater numbers of elderly and other persons with disabilities at all income levels will remain in their own homes and communities. 

One initiative, identification of Naturally Occurring Retirement Communities (NORCs), allows for more efficient provision of services within a neighborhood or apartment building. NORCs can be either publicly or personally 

funded. Many other initiatives require no public funds. Cities should encourage planned unit developments and master planned communities at higher 

densities, with shops, medical facilities and amenities within easy access of 

those with physical disabilities or lacking personal transportation. Zoning laws 

should allow free standing “mother-in-law” units to be constructed in conjunction with single family homes. Other initiatives include Urban Villages, 

a grass-roots aging-in-place movement of neighbors and volunteers, who pay 

a fee to receive coordination of supportive and other services. The nexus of 

housing and supportive service has largely been overlooked. While this outlook appears to be changing, much needs to be done to promote care quality 

within defined residential settings for all income levels.

Encourage State Innovation

16. State Innovation Recommendation. The Commission Report should recognize that states have an important role to play as laboratories of democracy in 

creating LTSS solutions and programs that move beyond the public safety net 

of Medicaid or public subsidies for private insurance products. States already 
APPENDIX A: Commissioner Ideas 111

administer much of the LTSS in this country through Medicaid. Those with advanced systems are in a position to innovate and build off of existing strengths, 

and those innovations can then serve as models for future federal solutions. 

To this end, the Commission should not only encourage state and local 

experimentation in LTSS, but should also recommend that HHS set aside 

grant funding for state and local agencies to develop and implement LTSS 

innovations, perhaps through the CMS Innovation Center, that will ultimately 

remove some of the financial strain from the Medicaid system. States could 

open up registries and infrastructure on a FFS basis to connect workers and 

those in need, advise on the array of community-based options through case 

management, the AAAs and ADRCs to expanded populations, and develop state-based funding and delivery models outside of Medicaid in order to 

provide an affordable and accountable means of access to services especially 

for the middle- and lower-income populations, similar to what has been proposed and is currently being explored in Hawaii.

17. Expand CMMI demonstration authority and funding to test models of care 

that fully connect home and community-based services and their associated 

workforce with medical care for people with chronic health conditions and 

functional limitations. An example could include incorporating the following 

four key components into Accountable Care Organizations: (a) comprehensive 

health and functional assessment; (b) creation and execution of a personalized 

plan of care that includes a flexible range of benefits including long-term services and supports; (c) a multidisciplinary care team tailored to the individual’s 

needs; and (d) active involvement of family caregivers including assessing their 

needs and competencies.

18. Flexibility for the states. The diversity of the states is a challenge when trying 

to develop a top-down solution, but it can be an asset that can be harnessed to 

deliver better, more affordable patient-centered care. 

States have demonstrated their ability to develop creative solutions. Witness 

Gary Alexander said that the requirement in Medicaid for multiple waiver requests creates inefficiencies and poorer outcomes. He described his experience 

with the demonstration global waiver in Rhode Island that allows the state to 

rebalance Medicaid long-term care and increase access to home and community-based services, ensure access to medical homes providing coordinated 

care, promote accountability, and improve quality. The best recommendation 
112 Commission on Long-Term Care Report to the Congress

he offered: “Have the federal government set broad parameters but encourage 

bottom-up solutions.” 

Witness Patti Killingsworth recommended payment for limited room and 

board supplements in a community-based residential alternative setting, particularly for lower-income recipients. These kinds of innovations are best managed by states that can develop programs more quickly and that have a unique 

understanding of the resources available and the needs of their citizens. 

Other states, such as Pennsylvania, have had demonstrated success with an 

approach that integrates the medical home concept into a residential Continuing Care Retirement Community setting. This comprehensive approach allows 

physicians, advance practice nurses, and other professionals to coordinate each 

resident’s care needs. Today’s program silos and regulatory structures make this 

sought-after comprehensive system of care the exception rather than the norm.

19. Expand Medicaid Waiver Programs.

a. Similar to the Rhode Island experience;

b. Mandate that providers produce demonstrable outcomes.

20. Financial Flexibility in Medicaid. Testimony on the Rhode Island global 

compact waiver last week demonstrated the impact that providing greater 

flexibility to states can achieve in reducing Medicaid expenses. The Lewin 

Group’s December 2011 study of the state’s program found that the waiver resulted in at least $50 million in Medicaid savings—this in a small state—while 

increasing the access and quality of care provided to beneficiaries. And as the 

testimony noted, savings to the Medicaid program have continued in fiscal 

years 2012 and 2013.

The Rhode Island success story should pave the way for further reforms 

that provide states additional flexibility in exchange for demonstrated reductions in spending. Whether in the form of a block grant, or per capita caps on 

beneficiary expenditures, states could use new flexibility from Washington to 

introduce reforms that will improve care while reducing costs—thus improving the fiscal outlook for state and federal governments alike.

Critics of this approach express concern that any caps on expenditures will 

result in loss of coverage, access, or both for vulnerable beneficiaries. However, 

Rhode Island’s waiver has resulted in three straight years of expenditure growth 

below CPI inflation, GDP growth, and national Medicaid spending—this even 

as the state’s Medicaid caseload increased. These results strongly suggest that if 

given the proper flexibility, states can implement policies that slow the growth 
APPENDIX A: Commissioner Ideas 113

of spending—or reduce it outright on a per capita basis—not by harming the 

quality of care, but by improving it.

Improve Consumer Access and Assistance

21. Options for Helping Americans Meet Their LTSS Needs. Provide enhanced 

options counseling to help individuals better navigate LTSS in a “One-StopShop/No Wrong Door (NWD)” way to avoid unnecessary institutionalization, 

promoting access to home and community-based services (HCBS) and prevent 

Medicaid spend-down. This should be modeled after the “Enhanced Aging and 

Disability Resource Centers (ADRCs) Options Counseling Program” initiative 

released by HHS in 2012. States should be able to access enhanced administrative Medicaid match to build this necessary infrastructure. 

Nearly 10 million Americans of all ages need some form of long-term 

services and supports (LTSS), and about 70% of the people now turning 65 

will need LTSS at some point during their life. Yet, when consumers experience a need for LTSS—or want to plan ahead for their LTSS—they are often 

confronted with a complex and bewildering maze of public and private programs administered by a wide variety of agencies and organizations operating under different, sometimes conflicting, sometimes duplicative, rules, 

regulations, and administrative procedures. Compounding this situation, 

people often confront the need for long-term support amidst a crisis, such as 

an unexpected injury, a hospital admission, or the collapse of a fragile unpaid 

caregiver support network. Under these circumstances, individuals and their 

families have little time to explore the many options that might be available, 

which may result in the unnecessary use of nursing facility and other expensive forms of LTSS. The fragmentation in our LTSS makes it difficult not only 

for our citizens to make informed decisions, but it also makes it challenging 

to ensure that our public expenditures on LTSS are deployed in the most 

cost-effective manner possible.

States develop Aging and Disability Resource Centers (ADRCs) programs—

also known as One-Stop-Shop/No Wrong Door programs—to make it easier 

for consumers to learn about and access their LTSS options. The ADRCs program was based on best practices some states had developed to create “visible 

and trusted” sources of information, one-on-one counseling, and streamlined 

access to available LTSS options.

The importance of having an access program serve people of all income 

levels, not just those who qualify for Medicaid, since the vast majority of people 
114 Commission on Long-Term Care Report to the Congress

who need LTSS are not Medicaid eligible but can be at high risk of “spending 

down” to Medicaid.

Improve Program Efficiency

22. Require Medicare to audit and penalize hospitals who are abusing observer 

status. Motivation: There has been a rapid increase in the use by hospitals of 

observer status instead of admitting patients. This change is quite likely caused 

by a desire by hospitals to avoid the many cost control and quality enhancing 

mechanisms employed by Medicare. The result for many patients, however, is 

the loss of eligibility to Medicare coverage of skilled nursing care, which only 

arises after three consecutive days of admitted hospital care. 

Proposal: Medicare should embark on a program to rigorously audit and 

penalize hospitals who are abusing observer status, which could be indicated, 

for example, by a significant percentage increase in patients who stay longer 

than 18 hours, or receive significant surgical and other procedures, and so 

on, but are not admitted. The structure of incentives facing hospitals, such as 

third-party shared payment audits, should also be reviewed. 

Reform Payment 

23. Site-Neutral Payments. Currently, the Medicare system reimburses each type 

of post-acute care (PAC) provider according to different payment methodologies. Existing payment policies focus on phases of a patient’s illness defined 

by a specific service site, rather than on the characteristics or care needs of 

the patient. As a result, patients with similar clinical profiles may be treated 

in different settings at different costs to Medicare. This payment system fails 

to encourage collaboration and coordination across multiple sites of care and 

provides few incentives that reward efficient care delivery. Such misalignment 

has been understood and acknowledged for some time. 

The U.S. Department of Health and Human Services, Congressional legislation (e.g., the Deficit Reduction Act), and the Medicare Payment Advisory 

Commission (MedPAC) have all examined such an approach. Most recently, 

MedPAC established criteria for selecting potential services related to the 

mix of sites used, patient severity, similarity of service definitions, and frequency of an associated emergency department visit (which raises the service costs). This year MedPAC began an examination of how Medicare could 

equalize payments for similar patients treated in long-term care hospitals 

(LTCHs) and acute-care hospitals. In his remarks to Congress in 2013, the 
APPENDIX A: Commissioner Ideas 115

MedPAC Executive Director indicated that equal payments for similar PAC 

services would build on MedPAC’s work examining Medicare’s payments for 

select ambulatory services. 

MedPAC has recommended and discussed many changes to PAC that 

would increase the value of Medicare’s purchases and improve the coordination of care patients receive. These include site-neutral payments which would 

create more equity across providers in different sectors. MedPAC believes that 

such a change could be implemented in the near term and would serve as 

building blocks for broader payment reforms such as bundled payments and 

Accountable Care Organizations (ACOs). 

24. Move current programs to value care and accountability versus fee-for-service or procedure-driven systems.

a. Improve the quality of care through the development of standards based 

on patient outcomes;

b. Provide incentives for quality-driven outcomes and coordination of care.

25.Improve efficiency in current entitlement programs.

c. Rationalize payment systems and base them on objective uniform patient assessment versus site of care;

i. Reduce barriers to access that foster duplicative and unnecessary 

care, such as the three-day stay requirement;

d. Control access to Medicaid to ensure that the program is a definitive 

needs-based system;

i. Tighten rules for eligibility for Medicaid and for SSI and SSDI.

Develop Uniform Assessment

26. Develop a common uniform assessment under the guise of an independent 

cross-disciplinary team that’s separate from CMS. In order for a provider to 

deliver the best possible care across settings and maximize continuity of care, 

not only do the LTSS and PAC providers need to use the same assessment tools 

but they must also be used in hospitals. When hospitals use different assessment tools, not only is it difficult to track a patient’s condition as he or she 

moves in and out of the hospital but communication between settings to understand the patient’s needs and assess their condition is also compromised. As 

a result, the patient is less likely to receive appropriate care than when standard 

common clinical metrics are used. 
116 Commission on Long-Term Care Report to the Congress

Neither the assessment tools currently in use nor the Continuity and Record Evaluation (CARE) tool are perfect; however, the use of standard clinical 

metrics across settings is extremely important both to patient care and to evaluation of quality across settings. Therefore, it is preferable to have a standard 

metric in place that is not quite perfect rather than to have multiple “near-perfect” different clinical metrics that do not allow for effective integration of care 

delivery across settings.

In order to develop comparable measures across different providers, information needs to be collected in identical ways (e.g., use the same assessment tool); otherwise it is not possible to develop quality measures that can 

accurately compare different providers. For example, if one provider uses 

five questions to assess ADLs on a five point scale and another uses four 

questions to assess ADLs on a four point scale, it is extremely difficult if not 

impossible to develop one quality measure to comparably assess both providers. Similarly, even if both providers used the same number of questions 

and same rating scale, if one provider collected the information at admission and again every four weeks, and another collected it at admission and 

discharge only, developing a quality measure to assess improvement over 

time between the two providers is impossible. Therefore, collecting data using the same tool and following the same information collection methodology is essential to continuity of care. 

27. Allocate current research funding to support innovation in long-term care.

a. HIT Standards;

b. Telehealth;

c. Expansion of Uniform Patient Assessment.

Improve Quality

28. All fines collected from regulatory issues would be utilized to reward the top 

10% of providers that have the highest discharge rate of dual-eligible patients 

back into the community following a post-acute stay. Federal Civil Monetary 

Penalties (CMPs) and State CMPs/fines are imposed by the regulatory agencies 

that license skilled nursing facilities if a facility does not comply with regulatory standards. States are limited under federal law in how they may use federal 

CMPs. They can use federal CMPs to:

■ Maintain the operations of a facility, pending correction of deficiencies 

or closure;
APPENDIX A: Commissioner Ideas 117

■ Assist in receiverships and relocation of residents;

■ Reimburse residents for personal funds lost; and

■ Fund other projects that benefit facility residents.

State CMPs/fines are not subject to these restrictions; their use is dictated 

by each state’s laws. Under this concept, a fifth option would be created. States 

or the federal government would create a Quality Fund targeted to providers 

with the highest discharge rate to the community. Quality Fund could be aimed 

at people who utilize post-acute care and do not require a rehospitalization. 

29. Provide quality long-term services and supports for older people and people 

with disabilities in all settings.

i. Develop publically defined standards of care throughout all long-term care 

settings that are enforced through a public regulatory structure (in addition 

to market-based quality measures).

j. Develop enforceable quality measures through an objective regulatory system. 

k. Ensure sufficient numbers of properly trained staff are present at all times 

in institutional settings.

i. There is a high cost of poor care—improving the quality of care provided will improve health outcomes and overall savings when avoidable 

conditions and injuries are prevented. 

C. WORKFORCE IDEAS

Family Caregivers

1. Informal Caregiver support. An AARP study estimated that at any one given 

point in time in 2009, about 42.1 million family caregivers in the United States 

provided care with ADLs and/or IADLs to adults with disabilities, and about 

61.6 million were providing care at some time during that year. Yet these informal caregivers are themselves at risk from stress, physical strain, competing 

demands, and the financial effect of caregiving on their jobs and out-of-pocket 

expenses. Without their willingness to support family members, the dependency on public payment options would increase markedly. 

We can ill afford the loss or diminution of this voluntary help force. Rather, 

we should buttress it through assistance that will support informal caregivers: 

(1) Professional assessment of family caregivers to identify the information 

they need during transitions, and the skills and techniques they require at 

home to perform complex medical procedures and tasks such as lifting and 
118 Commission on Long-Term Care Report to the Congress

bathing. (2) Provision of locally adapted phone aps to provide portable guides 

to community resources, Web-based technical instructions for nursing and 

medical care in the home, and caregiver support sites. (3) Reduction in caregiver isolation through institution of a trained Caregiver Corps (see Dr. Joanne Lynn’s 7–17–13 testimony), which could be integrated into the Corporation for National and Community Service. For all supports, it is important 

to use evidence-based practices to ensure the most effective use of resources.

Please note: My recommendations for any changes to Medicaid LTSS assume expenditure neutrality within public sector spending. The degree of 

expansion of any LTSS would depend on the amount of savings that could 

be produced in another area, in this instance through savings associated with 

broader access to HCBS and through the work of informal caregivers preventing hospitalization and delaying entrance into a nursing home. Because the 

Commission will not have time to do fiscal analyses, any new or expanded 

services will require further study to verify costs and savings. 

2. Family Caregiving. Family caregivers, including relatives, friends, partners 

and neighbors, are the backbone of long-term services and supports in this 

country—they provided an estimated $450 billion in unpaid contributions in 

2009—more than total Medicaid spending that year. We must take the following steps to help support family caregivers caring for loved ones of all ages.

Develop and implement a national strategy to recognize and bolster families in their caregiving roles. The strategy should identify specific actions that 

government, communities, providers, employers, and others can take. The 

strategy should address the following areas: 

■ The unit of service in all health and LTSS settings should be redefined to 

include both individuals with disabilities and their family caregivers, with 

the person and the family caregiver (as appropriate) treated as integral parts 

of interdisciplinary services teams. 

■ The assessment and care planning process (including care transitions and 

coordination) must be person- and family-centered, not only identifying 

functional disabilities but also focusing on meeting personal goals for living 

as independently as possible.

■ All family caregivers should have access to relevant information, educational 

resources, referral services, training opportunities, and professionals supports;

■ When family caregivers agree to provide care and the care plan or discharge 

plan is dependent on them: 
APPENDIX A: Commissioner Ideas 119

Their needs should be assessed along with the person receiving services;

They should be included in health information systems that list family 

caregivers, their contact information, and their involvement in implementing care plans; and 

They should receive training (including on medical/nursing tasks), 

equipment, and support needed to carry out their roles. 

■ Respite options should be available to family caregivers, and employers 

should amend workplace policies to support caregiving by employees; and

■ The financial security of family caregivers should be addressed so that they 

are not required to make enormous financial sacrifices to provide support 

to loved ones.

3. Develop and implement a national strategy to recognize and bolster families 

in their care-giving roles. As was the case with NAPA, the strategy should 

identify the specific actions that each agency of the federal government can 

take to promote great adoption. 

Promote greater adoption of person- and family-centered care in all 

health and LTSS settings, with the person and the family caregiver 

(as appropriate) at the center of care teams.

Assessment and service planning (including care transitions and coordination), involving care recipients and family caregivers.

Training (including on medical/nursing tasks) and other supports.

Information, education, referral.

Respite options.

Financial security.

Workplace policies and supports.

Building supportive communities including offering Social Impact 

Bonds that integrate services for transportation, housing, etc. 

Increase appropriations for Geriatric Education Centers to enhance the dementia care capabilities of primary and secondary health care workforce.

Professional Workforce

4. All federally funded LTSS programs should be required to have a detailed 

plan for workforce recruitment, retention, and development as a requirement to continue to receive public funds. Federal agencies should be directed 

to fund programs that improve working conditions and build career ladders. 

This includes directing CMS to fund and collect best practices on expanded 
120 Commission on Long-Term Care Report to the Congress

home care worker role pilots, and to evaluate and expand Value-Based Purchasing Demonstrations that reward nursing home staffing, and implement an 

RN and nursing home staffing mix that meets patient needs and prevents poor 

outcomes and avoidable hospitalizations.

5. HHS should undertake a number of initiatives to ensure a more stable direct 

care workforce.

a. Institute systematic methods for, setting, rebasing, or updating payment 

rates for Medicaid home and community-based services create greater parity of wages and benefits across long-term care settings.

b. Continue the development of national training standards for home care 

workers not covered by current federal requirements and have this serve as 

the minimum standard for training.

c. Align government payment policies to create parity for reimbursing training costs across all direct-care occupations and provider types. 

d. Require states to collect workforce data including data on wages, benefits, 

hours, job vacancies and turnover rates.

6. Creation of a national program to attract individuals to direct care jobs. We 

propose that the Corporation for National and Community Service develop a 

program called Direct Care Corp, modeled on its SeniorCorp Companion program, to provide direct care services to individuals in need of LTSS. SeniorCorp 

currently runs a companion program that matches senior companions for 15 

to 40 hours per week with two to four adult clients that live independently in 

their own homes. Under the Direct Care Corp model, individuals of all ages who 

enroll to become direct care workers would receive pre-service orientation, free 

training and certification, health insurance, and an hourly wage. As an incentive 

to participate in the program, if individuals agree to serve for a specified amount 

of time (2–4 years) in that direct care position they would be eligible for a Health 

Professions Opportunity Grant (HPOG) to receive fully subsidized training for 

the health care profession of their choice. HPOG provides education and training to TANF recipients and other low-income individuals for occupations in the 

health care field that pay well and are expected to either experience labor shortages or be in high demand. HPOG Funds may be used for participant supportive 

services, including financial aid, child care, and case management.

7. Workforce—Recruit, train, and retain a stable, well-prepared, and high-quality workforce invested in LTSS by:
APPENDIX A: Commissioner Ideas 121

■ Revising scope of practice standards to permit services to be provided by 

workers commensurate with a demonstration of competency:

Advanced practice registered nurses should be permitted to expand 

their practices commensurate with their training and competence.

Laws should permit the delegation of more services by direct care workers under the supervision of appropriate licensed personnel in home 

and community-based settings.

■ Requiring training in developing effective relationships as well as core competencies for direct-care workers to meet the full needs of the LTSS population, including diverse populations and those with dementia and behavioral health issues.

■ Ensuring that direct-care workers are integrated into interdisciplinary teams 

and encouraging worker participation in decisions related to resident care.

■ Promoting career development for direct workers through effective mentoring and providing career ladder opportunities in specialty areas, such as 

rehabilitation, dementia care, end-of-life care, and behavioral health.

■ Requiring nationwide criminal background checks prior to LTSS employment, except for certain individuals hired through self-directed programs. 

8. Ensure adequate numbers of quality LTSS caregivers are available and retained for community-based and facility care.

a. Pay living wages to caregivers in all settings;

b. Establish a national Caregivers Work Force Advisory Panel to develop innovative and effective means of recruiting and maintaining a 

quality direct-care workforce;

c. Establish minimum federal training standards for personal care 

aides based on current state efforts.

D. FOLLOW-ON

1. Recommendation for mechanisms to move forward at the national level. 

This Commission is severely limited by the timeframe and resources allotted 

to it by Congress. While there is broad consensus among the Commissioners 

that LTSS in this country as it currently operates is not sufficient for current 

or future needs in this country, it is beyond the realistic scope of this body to 

propose a meaningful and comprehensive solution within the Commission’s existing framework. Perhaps one of the most meaningful recommendations we 
122 Commission on Long-Term Care Report to the Congress

can make is to propose a means for this work to continue in a meaningful and 

ongoing manner once the Commission has concluded. We recommend that 

Congress create a bipartisan LTSS reform task force, with appointed members 

from the Senate, House of Representatives, and the Secretary of Health and 

Human Services. The task force’s charge should be similar to that of this Commission, and should use the Commission’s work as a jumping-off point for its 

own. Ultimately the Task Force will draft a full report, make recommendations, 

and propose legislation to be voted on by Congress. Additionally, the Office of 

Disability, Aging and Long-Term Care at the Office of the Assistant Secretary 

for Planning and Evaluation (ASPE), should be charged with researching best 

practices and innovations at the state and local levels in LTSS around workforce, 

housing, access to services, LTSS education and public awareness, family caregiver support, and service delivery models to both inform the work of the Task 

force, and develop policy recommendations that can be pursued within HHS. 

Additionally, the Commission should recommend that legislation be passed 

authorizing the White House Conference on Aging in 2015, and to have a focus 

on long-term services and supports. Decennial White House Conferences on 

Aging are now embedded in our national history. Past White House Conferences on Aging, first held in 1961 and again in 1971, 1981, 1995, and 2005 

have been catalysts for aging policies and significant national programs such 

as Medicare, Medicaid, and the Older Americans Act. The conference has traditionally been a source of innovative solutions, and an opportunity delegates 

across the country, political backgrounds and professional experiences, and 

would be extremely valuable in the further development of policy work on 

long-term services and supports. 

2. Develop a new standing Commission or similar national-level governmental 

body to address issues of the financing and delivery of long-term care services. 

This Commission should be housed within the Department of Health and Human Services and work in concert with existing governmental bodies that relate to long-term care financing and delivery including the Governmental Accountability Office, MedPAC, MACPAC, the Advisory Council on Alzheimer’s 

Research, Care, and Services, and others.

3. The need for persistent and sustained attention to the design, development, 

and execution of a national LTSS plan requires the creation and support of a 

Long-Term Support and Services Commission with Executive and Legislative Branch and Private Sector Members.
APPENDIX B: Public Comments 123

APPENDIX B

PUBLIC COMMENTS

■ Karen Agron Flattery

■ Darby Anderson, Addus HealthCare, Inc., Senior Vice President

■ Mark Athon, Kansas Neurological Institute Parent and Guardian Group, 

President

■ Alex Bardakh, MPP, AMDA, Senior Manager, Public Policy

■ Libby Baxley, Sheridan, Arkansas

■ Alexandra Bennewith, MPA, United Spinal Association, Vice President, 

Government Relations

■ Katherine Berland, ANCOR

■ Rachel Brainard, Broydrick & Associates, Research Associate 

■ Sarah Burger, RN, MPH, FAAN, The Coalition of Geriatric Nursing 

Organizations, Coalition Coordinator

■ Doug Burr, Health Care Navigator, LLC, SVP of Finance Reimbursement & 

Gov’t Relations

■ Joe Caldwell, PhD, National Council on Aging, Director of Long-Term 

Services and Supports Policy

■ Harris T. Capps, Major, USAF, Retired, Advocate for Intellectually Disabled 

Persons

■ Roberta Carlin, MS, JD, American Association on Health and Disability, 

Executive Director

■ Kyra Clements, Golden Age Technology

■ Robb Cohen, Consultant to MHPA

■ Caitlin Connolly, Eldercare Workforce Alliance

■ Amy Cotton, GNP-BC, FNGNA, FAA, National Gerontological Nursing 

Association, President

■ Bruce Cowan, Sacramento, CA

■ Edward F. Coyle and Katy Beh Neas, Leadership Council of Aging 

Organizations and Consortium for Citizens with Disabilities

■ Mary Kay Cowen, Marrero, LA 
124 Commission on Long-Term Care Report to the Congress

■ John Cutler

■ Jennifer Dexter, Easter Seals, Assistant Vice President, Government Relations

■ Kim Dion, Westminster, CO

■ Sherrie Dornberger, RN, CDP, GDCN, FACDONA, NADONA Executive 

Director

■ Rep. Craig Eiland, Texas, District 23

■ Leni and David Engels, Hollywood, FL

■ Gail Fanjoy, KFI, Executive Director

■ Cheryl Felak, RN, BSN, Because We Care, Beyond Inclusion

■ Maureen Fitzgerald, The Arc Sarah Meeks, MSW, Lutheran Services in 

America Disability Network, Director of Public Policy and Advocacy 

■ Paul E. Forte, Long-Term Care Partners, LLC, Chief Executive Officer

■ Loren M. Freeman, Provider of LTC Services, Guardian, Consumer

■ Lex Frieden, National Advisory Board on Improving Health Care Services for 

Seniors and People with Disabilities, Convener

■ David Gallagher 

■ Mary Gann, Little Rock, AR 

■ Laura Gargano, MPA, RN

■ Dan Gaylin, NORC at the University of Chicago, Acting President

■ Susan Goodman, National Down Syndrome Congress, Director, 

Governmental Affairs

■ Fay Gordon, National Senior Citizens Law Center

■ Stuart Yael Gordon, JD, Wellpoint

■ David A. Gould, United Hospital Fund, Senior Vice President for Program

■ Richard Grimes, Assisted Living Federation of America, President & CEO

■ Carrie Hobbs Guiden, The Arc Tennessee 

■ David Hansell, KPMG LLP, Global Head, Human & Social Service Center for 

Excellence 

■ Mary M. Harroun, MS, LNHA, Geriatric Psychologist

■ Dr. Linda Heard, Hot Springs, AR

■ Jeff Hill

■ Tamie Hopp, VOR, Director of Government Relations & Advocacy

■ Julie M. Huso, VOR, Executive Director

■ Terry Johnson, Little Rock, AR

■ Paula Jorisch

■ Kate Josephson, Advance CLASS

■ Bob Kafka, Institute for Disability Access, Co-Director
APPENDIX B: Public Comments 125

■ Joan Kelley, KNI Parent Guardian Group, Vice President

■ Lois Sheaffer Kramer, CTRS; LNHA, Marklund, Director of Government 

Relations and Community Support

■ Rob Kramer, MPA, Alzheimer’s Association, Associate Director, Federal 

Affairs

■ Dale Krause, Krause Financial Services 

■ Gary Langer, Langer Research Associates

■ Sheryl A. Larson, ICI at University of MN, Senior Research Associate

■ Sharon Levine, The Arc of New Jersey, Director of Governmental Affairs

■ Bethany Lilly, The Bazelon Center for Mental Health Law, Policy Attorney 

■ James A. Lomastro, Ph.D., Larchmeadow Associates 

■ Joanne Lynn, Altarum

■ Jerry and Eleanor March, Conway, Arkansas

■ Andrea Maresca, National Association of Medicaid Directors, Director of 

Federal Policy and Strategy 

■ Carol Marshall, Healthcare Consultant; Fort Worth Texas

■ Stephanie Mensh, Caregiver of Stroke Survivor, Paul Berger, Falls Church, VA

■ Suzanne Mintz, Family Caregiver Advocacy, Founder

■ Anne Montgomery, Altarum, Senior Policy Analyst 

■ Tracey Moorhead, Visiting Nurse Associations of America, President & CEO

■ Sam Morgante, Genworth Financial, Government Relations

■ John O’Leary, O’Leary Marketing Associates, President

■ Chris Orestis, Life Care Funding

■ Paraquad, INC., St. Louis, MO

■ Rachel Patterson, MPA, Association of University Centers on Disabilities 

(AUCD), Policy Analyst

■ Susan Payne, Parent Association for the Retarded of Texas, President

■ Donald Putnam, Lexington, KY

■ Romeo Raabe LUTCF, LTCP, The Long-Term Care Guy

■ Max Richtman, National Committee to Preserve Social Security and Medicare

■ Lyle T. Romer, Ph.D., Total Living Concept, Executive Director

■ Jeff Rosen, National Council on Disability (NCD), Chairman

■ E. Clarke Ross, DPA, American Association on Health and Disability, Public 

Policy Director

■ Leo V. Sarkissian, The Arc of Massachusetts, Executive Director

■ Marva Serotkin, The Boston Home, President and CEO

■ Robin Shaffert, Caring Across Generations, Policy Director
126 Commission on Long-Term Care Report to the Congress

■ Phyllis Shelton, LTC Consultants, President

■ Carole Sherman, Little Rock, AK

■ Mary R. Sive, Montclair, NJ

■ Congresswoman Louise Slaughter, United States House of Representatives 

■ Eric Sokol, Alzheimer’s Foundation of America, VP, Public Policy

■ Jeffrey L. Strully, Jay Nolan Community Services, CEO

■ William Tapp, Elsevier, VP 

■ Morris J. Tenenbaum, Kings Harbor Multicare Center, Principal

■ Libby Terry, Omnicare Inc., Director of Gov’t Policy 

■ Debbie Toth, Rehabilitation Services of Northern California, Chief Executive 

Officer

■ Barbara Trader, TASH, Executive Director

■ Rebecca Underwood, Parent/guardian/advocate for Aaron Underwood 

■ Peter G. Wacht, CAE, National Academy of Elder Law Attorneys, Executive 

Director

■ Laura E. Weidner, National MS Society, Director Federal Government 

Relations

■ Kimberly Williams, LMSW, National Coalition on Mental Health and Aging, 

Chair

■ Marybeth Williams, Consumer Voice

■ Sue and Mike Yacovissi, Shreveport, LA

■ Bob Yee, FSA, MAAA, Towers Watson, Senior Consultant
APPENDIX C: Hearings And Meetings 127

APPENDIX C

HEARINGS AND MEETINGS

PUBLIC HEARINGS

Thursday, June 27th at 2:00 p.m. EDT 

Rayburn House Office Building, Room 2322

“The Current System for Providing Long-Term Services and Supports.”

Witnesses:

Anne Tumlinson, Senior Vice President, Avalere Health

Kirsten Colello, Specialist in Health and Aging Policy, 

Congressional Research Service

G. William Hoagland, Senior Vice President, Bipartisan Policy Center

Marc Cohen, Chief Research and Development Officer, LifePlans, Inc.

Wednesday, July 17, 2013 at 1:30 p.m. EDT

Dirksen Senate Office Building Room 50

“Populations in Need of LTSS and Service Delivery Issues.” 

Panel 1: Diversity of LTSS Demand: Subpopulations and Their LTSS Needs

David Braddock, Executive Director, Coleman Institute 

for Cognitive Disabilities

H. Stephen Kaye, Assoc. Professor, University of California 

at San Francisco

Kevin Martone, Executive Director, Technology Assistance 

Collaborative

Robyn Stone, Executive Director, LeadingAge Center 

for Applied Research

Panel 2: Meeting LTSS Needs: Coordination of Care and Workforce Issues

Randall S. Brown, Vice President and Director Health Research, 

Mathematica
128 Commission on Long-Term Care Report to the Congress

Josephina Carbonell, Senior Vice President, Independent Living 

Systems, LLC

Lynn Feinberg, Senior Strategic Policy Advisor, AARP Public Policy 

Institute

Joanne Lynn, Director, Altarum Center for Elder Care and Advanced 

Illness

Carol Regan, Government Affairs Director, Paraprofessional Healthcare Institute

Thursday, August 1, 2013 at 8:30 a.m. EDT

Dirksen Senate Office Building Room 562

“Strengthening Publicly and Privately Funded Long-Term Services and Supports.” 

Panel 1: Strengthening Medicaid LTSS

Diane Rowland, MACPAC

Patti Killingsworth, TennCare

Gary Alexander, formerly Rhode Island Office of Health and Human 

Services

Melanie Bella, CMS, Medicare-Medicaid Coordination Office

Panel 2: Strengthening Medicare for LTSS

Joseph Antos, American Enterprise Institute

Barbara Gage, Brookings Institution

Marilyn Moon, American Institute for Research

Panel 3: Strengthening Private Long-Term Care Insurance

David Grabowski, Harvard Medical School

Lane Kent, formerly Univita

Jason Brown, U.S. Treasury

Bonnie Burns, California Health Advocates

Panel 4: Interaction of Insurance, Private Resources, and Medicaid

Eric French, Federal Reserve Bank of Chicago

Jeffrey Brown, University of Illinois

Rich Johnson, Urban Institute

Ellen O’Brien, formerly MACPAC

Tuesday, August 20, 2013 at 1:00 p.m. EDT 

Dirksen Senate Office Building Room 562

“Addressing LTSS Service Delivery and Workforce Issues.” 
APPENDIX C: Hearings And Meetings 129

Panel 1: Service Delivery and Provider Innovation and Issues 1:00 to 3:00 p.m.

Eric Berger, CEO, Partnership for Quality Home Healthcare 

Lisa Alecxih, SVP and Director, Lewin Center for Aging & Disability 

Policy 

Loren Colman, Assistant Commissioner, MN Department of Human 

Services, Continuing Care Administration

Laura Taylor, Director of the Caregiver Support Program, Department of Veterans Affairs 

Panel 2: Workforce Innovation and Issues 3:00 to 5:00 p.m.

Tracy Lustig, Sr. Program Officer, Institute 

of Medicine

Suzanne Mintz, Founder, Family Caregiver Advocacy

Charissa Raynor, Executive Director, SEIU Healthcare NW., 

Training Partnership and Health Benefits Trust

Charlene Harrington, Professor Emeritus of Sociology and Nursing, 

University of California at San Francisco

Wednesday, September 18, 2013 at 2:00 p.m. to 4:00 p.m.

Dirksen Senate Office Building Room 106

Public Meeting to Release the Final Report
130 Commission on Long-Term Care Report to the Congress

EXECUTIVE SESSIONS

Thursday, June 27th at 8:30 a.m. to 12:45 p.m. 

Social Security Advisory Board, 400 Virginia Avenue SW., Suite 625

Monday, July 8, 2013 at 4 p.m. to 6 p.m. 

Teleconference 

Wednesday, July 17, 2013 at 8:30 a.m. to 12:30 p.m. 

SVC 202/203 (Capitol Visitors Center) 

Thursday, August 1, 2013 at 8:30 a.m. to 5:30 p.m.

Dirksen Senate Office Building Room 562

Monday, August 19, 2013 at 8:30 a.m. to 5:00 p.m.

Dirksen Senate Office Building Room 562

Tuesday, August 20, 2013 at 8:30 a.m. to 5:00 p.m.

Dirksen Senate Office Building Room 562

Thursday, August 29, 2013 at 8:30 a.m. to 5:00 p.m.

Russell Senate Office Building Room 485

Monday, September 09, 2013 at 4:00 p.m. to 6:00 p.m.

Teleconference

Thursday, September 12, 2013 at 8:30 a.m. to 5:00 p.m.

Russell Senate Office Building Room 485