Information Bulletin #261 from Steve Gold, June 20, 2008
June 22, 1999 - The U.S. Supreme Court issued the Olmstead decision, holding that "unjustified institutional isolation of persons with disabilities is a form of discrimination." The Court rejected the State's argument that Medicaid statute reflected a congressional preference for "treatment in the institution over treatment in the community," pointing out that was not correct since 1981 when Medicaid provided for home and community-based services and the U.S. Department of Health and Human Services has had a "policy of encouraging" States to serve people with disabilities in the community.
The decision recognized that the ending of this discrimination would not occur immediately. In 1999, the Court permitted States to have "waiting lists" for community services as long as such lists "moved at a reasonable pace not controlled by the State's endeavors to keep its institutions fully populated."
For people with disabilities, this decision was a clarion call. No longer, the disability and elderly advocates believed, would people be institutionalized if they wanted to reside in the community. Obviously, where one resides should be one's own choice.
We all know, however, that the availability and allocation of funds frequently determines the "choice." Specifically, if you are on Supplemental Security Income, and/or your only source of income is either only Social Security Disability Income or Social Security Retirement, your "choice" may be limited to where your State spends its Medicaid funds - in nursing homes or in the community.
AARP surveys point out that more than 90% of older Americans do not want to reside in nursing homes, and according to the Minimum Data Set reports, the national percentages of people in nursing homes who want to live in the community continues to increase steadily year by year (2003 -18.7%,
2004 -19.9%, 2005 - 20.5%, 2006- 21.4%, 2007 - 22.0%, and 2008 22.8%)(check out your state http://www.cms.hhs.gov/MDSPubQIandResRep/
click on MDS Activity Report and then Q1a).
One might think that amount Medicaid expenditures going to nursing homes would reflect the implementation of the Olmstead decision, national surveys, and MDS data. How has your State done?
Using FY 1999/Olmstead as a benchmark, we have calculated, by state, what was the percentage of Medicaid's "Long-Term Care" expenditures that were allocated to services in the nursing institution versus in the community.
The Centers for Medicare and Medicaid define "Long Term Care" to include the total of expenditures, on the one hand, to institutions, i.e., nursing homes, and, on the other hand, to the community, i.e., home health, personal care option and Medicaid waivers (we've limited the waiver expenditures to aged, aged/disabled, and physical disabilities - which are the counterparts for nursing facilities).
We've followed the CMS dichotomy.
Obviously, the greater the percentage of these Medicaid funds expended in the nursing home institution, the lower the percentage in the community.
It's like a scale- as one side goes down, the other increases. While the following data is provided in percentages, it is critical to remember there are billions of dollars involved and the ratio of expenditures significantly impacts whether one has a meaningful choice. That is, the more your State spends on nursing facilities, the less it will have to spend on the community.
We receive numerous inquiries from people who do not want to be institutionalized in nursing homes or who are in them and want to live in the community. The only way to achieve real "choice" is to provide people with Medicaid services where they want them. "Waiting lists" for services are not services. Living in fear of being institutionalized or living with fear because one is institutionalized is not the type of a "choice"
either the ADA or the Olmstead decision intended.
Whether the promise of Olmstead will be achieved depends entirely on the elderly and disability advocates! Those states that have moved the percentages to greater equality between the community and the institution must have terrific, effective advocates and/or empathetic elected officials and/or compassionate administrators.
For some States it is "Olmstead, happy ninth anniversary!" For many others, it is not.
Below we provide two lists of States. The first is the FY 1999 benchmark.
In FY1999, nationally, 80.8 % of Medicaid's Long Term Care funds were spent on nursing homes and19.2 % in the community.
The second list provides percentages for FY 2006, the last year for which we have data. In FY 2006, nationally, 71.4% of Medicaid's Long Term Care funds were spent on nursing homes and 28.6 % in the community - a shift of 9.4%. (The FY 2007 data will be available later in the summer and we will update this information. Data is from Medstat to whom we are extremely
appreciative.)
Check out how much progress your State has made since the Olmstead decision. Compare the FY1999 benchmark with FY 2006. For example, Alabama in FY 1999 spent 87.6 % of its Medicaid Long Term Care funds in nursing homes and 12.4% in the community. Seven years later, in FY 2006, it spent 88.8% of its Medicaid LTC funds in nursing homes and 11.2% in the community.
Using the data for your State, disability and elderly advocates should ask whether the change between FY 1999 and FY 2006 is satisfactory, whether it reflects what the Supreme Court in the Olmstead decision intended, whether it provides elderly and disabled people in your State with a choice where they want to receive services, and what the advocates will do about the pace of change.
FY 1999: % of Medicaid Long Term Care Expenditures in Nursing Homes vs. % in the Community
National .....80.8% LTC expenditures in nursing homes.. 19.2% in the community.
Alabama ............87.6.% nursing homes............12.4 %community
Alaska .............74.2 % nursing homes............35.8% community
Arizona* .......... 25.5% nursing homes............74.5% community
Arkansas........... 66.0% ............ 34.0%
California......... 80.7% ............19.3%
Colorado............70.3% ............39.7%
Connecticut.........83.5 % ............16.5%
Delaware............90.9% ............ 9.1%
D. C................85.0% ............15.0%
Florida.............87.5 % ............12.5%
Georgia.............83.4% ............16.6%
Hawaii..............90.3% ............9.7%
Idah................71.8% ............ 28.2%
Illinois............92.0% ............8.0%
Indiana.............91.8% ............ 8.2%
Iowa................84.5% ............15.5%
Kansas..............68.8% ............ 31.2%
Kentucky............78.6% .............21.4%
Louisiana.......... 91.0% ............ 9.0%
Maine.............. 80.0% .............20.0%
Maryland............86.4% ............ 13.6%
Massachus...........84.3% ............ 15.7%
Michigan............85.9% .............14.1%
Minnesota...........79.9% .............20.1%
Mississippi.........94.0% ............ 6.0%
Missouri............81.2% ............ 18.8%
Montana.............75.1% ............24.9%
Nebraska............85.2% ............14.8%
Nevada..............80.1% ............19.9%
New Hampshire.......90.6% ............9.4%
New Jersey..........79.3% ............20.7%
New Mexico..........87.8% ............12.2%
New York ...........70.1% ............29.9%
North Carolina......67.2% ...........32.8%
North Dakota........95.0% ............5.0%
Ohio................88.1% ............11.9%
Oklahoma............85.7 % ............14.3%
Oregon............. 54.9% ............45.1%
Pennsylvania........96.5% ............3.5%
Rhode Island........92.3% ............7.7%
South Carolina......79.0% ...........11.0%
South Dakota........94.1 % ...........5.9%
Tennessee...........98.7 % ...........1.3%
Texas.............. 73.9 % ........... 26.1%
Utah................92.3 % ............7.7%
Vermont............ 81.9 % ............18.1%
Virginia............81.5% ...........19.5%
Washington .........62.1 % ............37.9%
West Virginia.......76.6 % .............23.4%
Wisconsin...........78.5 % ............ 11.5%
Wyoming ............83.0% ..............17%
*Arizona has had a statewide managed care Medicaid program, so the figures may not accurately reflect the distribution.
FY 2006:
% of Medicaid Long Term Care Expenditures in Nursing Homes vs. % in the Community
National...71.4% LTC expenditures in nursing homes..... 28.6% in the community.
Alabama .............88.8% nursing homes............11.2% community
Alaska ............. 48.4% nursing homes............51.6% community Arizona ............ 60.6%nursing homes.............39.4% community
Arkansas.............74.0% ............26.0%
California.......... 51.7% ............ 48.3%
Colorado............ 66.6% ............33.4%
Connecticut..........80.1% ............19.9%
Delaware.............86.9% ............13.1%
D. C.................72.9% ............ 27.1%
Florida..............87.3% ............12.7%
Georgia..............83.8% ............16.2%
Hawaii...............82.9% ............17.1%
Idaho................59.7% ............ 40.3%
Illinois.............79.5% ............20.5%
Indiana..............91.9% ............ 8.1%
Iowa.................75.3% ............24.7%
Kansas.............. 64.1% ............35.9%
Kentucky............ 80.7% .............19.3%
Louisiana........... 82.6% ............ 17.4%
Maine................75.0% .............25.0%
Maryland.............83.5% ............ 16.5%
Massachus............75.5% ............24.5%
Michigan.............84.0% ............16.0%
Minnesota............57.0% ............ 43.0%
Mississippi..........97.6% ............ 2.4%
Missouri.............70.2% ............ 29.8%
Montana..............71.2% ............ 28.8%
Nebraska.............79.7% ............ 20.3%
Nevada...............67.8% ............32.2%
New Hampshire........86.6% ............13.4%
New Jersey...........79.5% ............20.5%
New Mexico...........46.3% ............53.7%
New York ............63.9% ............36.1%
North Carolina.......56.9% ............43.1%
North Dakota........ 94.3% ............5.7%
Ohio.................78.9% ............21.1%
Oklahoma.............73.3% ............26.7%
Oregon.............. 45.1% ............54.9%
Pennsylvania.........88.0% ............12.0%
Rhode Island.........88.4% ............11.6%
South Carolina.......79.9% ...........20.1%
South Dakota.........89.5% ...........10.5%
Tennessee............98.9% ...........1.1%
Texas................54.4% ...........45.6%
Utah.................90.2% ............9.8%
Vermont..............72.8% ............27.2%
Virginia.............76.9% ...........23.1%
Washington ..........45.4% ............54.6%
West Virginia........77.8% .............22.2%
Wisconsin ...........69.7% ........... 30.3%
Wyoming .............80.1% ............19.9%
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.