LG I ‘+6 *:t3/:11 K "H" I’ "-‘\ '- .7 I I IIII!IHflflflflflFflmfliIfl]\ET@i[fliyfliflifllflmiiilml ; LONG TERM CARE: COMMUNITY-BASED ALTERNATIVES TO INSTITUTIONALIZATION ISSUE BRIEF NUMBER IB8l0l3 AUTHOR: o'snaugnnessy, Carol Education and Public Welfare Division Reiss, Kathleen Education and P'U.bliC Welfare DiViSiOI'1 THE LIBRARY OF CONGRESS CONGRESSIONAL RESEARCH SERVICE MAJOR ISSUES SYSTEM DATE ORIGINATED O1/30/81 DATE UPDATED 01/13/82 FOR ADDITIONAL INFORMATION CALL 287-5700 Oll8 CRS- 1 . IB8lOl3 UPDATE-O1/l3/82 ISSUE DEFINITION Long term care for the elderly and disabled involves services rendered both within and outside institutions. As the median age of the Nation's population rises and hence becomes more susceptible to the chronic illnesses of old age, more alternatives are being sought to costly institutional care. Public programs that assist persons needing long term care provide substantially more support for institutional care than for community-based ialternatives. Although somewhat similar, these programs were enacted at different times and for different purposes, and they were directed toward many disparate constituencies. Attempts have been made recently, in demonstration projects and elsewhere, to reduce fragmentation among public programs. Emphasis in particular is on the role of comprehensive ‘assessment for services. Studies have shown that many of the elderly and disabled can be treated effectively at home if appropriate services are made available through the community. on the one hand, community-based care can be effective in reducing rates of institutionalization and improving levels of patient satisfaction and well-being. On the other hand, the true overall costs associated with community-based care remain unknown, as do the numbers of persons who may be in need of such services. In some cases, the costs for such care may indeed equal or even exceed the amounts spent for the equivalent level of institutional care. ’ .Legislation to encourage the spread of community-based long term care was the subject of congressional hearings during the 96th Congress. There is continued interest in this issue in the 97th Congress including examination of methods to test new ways of organizing community-based long term care systems. Recent provisions included as part of the Omnibus Reconciliation Act of 1981 conference agreement would allow expansion of community-based long term care services under the Medicaid program. There may be additional emphasis on developing incentives for increased private sector and family support for persons in need of long term care services through tax incentives and other means in lieu of increased Federal subsidies. 5 I BACKGROUND AND POLICY ANALYSIS Increase of the Elderly Population In the early 20th century, shorter life spans made unnecessary many of today's specialized institutions for the care of the elderly and chronically ill. In 1900, only about one out of every 25 Americans reached the age of 65. Sick or disabled older Americans could usually depend on assistance from family, friends, or religious or charitable organizations. About ll% of the Nation's population is over age 65 today, as compared with only 4% of the total population in 1900. By the year 2030, the United States is projected to have about 55 million elderly, more than twice as many as today. Among the elderly, the proportion of the "old-old" (age 75 plus) will increase even faster than the "young-old" (ages 65-74). Today, 38% of those age 65 plus are also over age 75; more than 9% are age 85 plus. By the year 2000, the age 75 plus group will constitute 45% and those age 85 plus will represent l2% of those over age 65. CR8? 2 in lB810l3 upDATE—o1/is/82 These population shifts will have dramatic implications for future public policy- As the number of older Americans increases, so too will the cost for_ long term care for the elderly, particularly institutional care. Current Investment in Long Term Care The phrase "long term care" encompasses a wide array Of services offered ‘in a variety of settings ranging from nursing homes and other institutions to adult day care centers and other innovative non-institutional arrangements to the patient's own home. Community-based long term care typically refers to such noninstitutional services as home health care (including part-time skilled nursing care and certain other medically-related services); occupational, physical, and speech therapy; social services (including adult day care, counseling, financial advice, transportation, friendly visiting); nutritional and health education; homemaker, chore and personal services (including cooking, shopping, housekeeping, home maintenance, and feeding). Many observers feel that the present system of long‘ term care in the United States is biased toward institutional care. By and large, publicly financed health programs provide substantially more support for hospital and nursing home care, for example, than for home health . and other% community-based services. (See discussion below on Federal programs supporting long term care.) Private efforts to expand the continuum of community-based long term care have been uneven and tenuous in the absence of public funds. To some extent, the size of the current investment in institutional care -- the Nation's 7,000 hospitals and almost 19,000 nursing ‘ homes -- has tended to preempt spending for noninstitutional alternatives. The magnitude of spending for institutional care tends to dwarf the resources that can be devoted to any community-based alternatives. Roughly 5% of the total U.S. population over age 65 are residents of nursing homes. Twenty-two percent of those over 85 are in nursing homes. Estimates are that perhaps 25% of the elderly will "use" nursing home care at some point in their lives. Recent indications are that by the year 2003, given a declining mortality rate, the number of nursing home residents could be as high as 2.8 million (compared with 1.3 million today), more than half of whom will be 85 years of age or older. Assuming current utilization grates, certain estimates show that the number of nursing home residents will, increase by 54% over the next 20 years. Expenditures for nursing home care have experienced annual increases‘ averaging 16% since 1970. These expenditures are expected to reach $76’ billion by 1990 (compared to $17.8 billion in 1979). Among the factors cited as contributing to this growth are increases in life expectancy of the aged, increases in third-party payments for nursing home care, and increases in prices that nursing homes pay for resources, especially labor. In any discussion of long term care policy, enormous amounts of public dollars are at stake. For nursing homes alone, the public share of the bill in 1979 reached $10.1 billion (with an additional $7.7 billion financed through private sources). By far the largest portion of public expenditures for nursing home care was funneled through the Medicaid program for the poor and medically indigent -- more than $8.8 billion in 1979. This $8.8 billion represented 49% of all spending and 87% of public spending for nursing homes in 1979. The Medicare program for the aged, on the other hand, accounts for only a small portion of the billions spent on nursing homes -- about 2% of CRS- 3 IB8l0l3 UPDATE~Ol/l3/82» all nursing home expenditures in 1979 were covered by this program. A recent General Accounting Office (GAO) report entitled "Entering a Nursing Home -- Costly Implications for Medicaid and the Elderly" noted that the impact of Medicaid's nursing home coverage on its budget has been profound: While only a small percentage of all Medicaid recipients are in nursing homes, its high costs make it the service requiring the largest expenditures....In FY l978, 74 percent of the States (37) spent 40 percent or more of their total Medicaid expenditures (Federal and State) on nursing home care; in 19 States, at least half of their budgets went for these services. Whereas nursing home care accounted for 41% of total Medicaid expenditures for personal health care in l979, home health care and other community-based services accounted for only l.2% of total Medicaid expenditures in that year. In most States, home health benefits constitute only about 0.1% to 0.5% of total Medicaid expenditures. Even though its total share remains small, home health care has become one of the fastest growing components of the Medicare and Medicaid budget. In 1972, home health visits were provided to about 250,000 persons under Medicare and ll3,000 under Medicaid. By 1978, nearly 770,000 Medicare recipients and over 300,000 Medicaid recipients received home health care. Together, Medicare and Medicaid funded about 80% of the $845 million spent nationwide for home health services in 1978. A variety of home health care services, including homemaker, home health aide, chore, and home delivered meals are funded through Title XX of the Social Security Act and the Older Americans Act. For FY79, homemaker services alone represented the second largest service expenditure category under Title XX (after day care for children) with total expenditures estimated at $393 million out of a total expenditure amount of $3.5 billion, including Federal, State, local, and private funds. This amount for homemaker services represents a 21% increase over FY78 expenditures. For FY79 an estimated quarterly average of 143,800 Supplemental Security Income (SSI) recipients received homemaker services with an estimated expenditure of $247 million per quarter. Home care, including homemaker/home health aide services, is also one of the major service categories under Title III of the Older Americans Act, with the total number served in FY80 estimated at 700,023 older persons. The Older Americans Act also authorizes a home-delivered meals program with $55 million authorized in FY81. Current figures on aggregate spending for all institutional and noninstitutional long term care services provided under the complete array of public programs are not available at present. Expenditure data for long term care are extremely sensitive to definition due to inconsistent reporting across the multiple Federal programs which support such services. The most recent attempt to aggregate total public spending for long term care was contained in a 1977 Congressional Budget Office (CBO) report which revealed that Federal, State, and local governments spent $5.7 billion to $5.8 billion on long term care in l975. At that time, annual private expenditures for long term care were estimated at $5.9 to $7.7 billion. It was further estimated that, by 1980, Federal spending alone for long term care under existing programs would reach from $7.2 to $7.6 billion, compared to $3.1 billion in 1975. More recent CBO data (February 1981) estimate that total case 4 IB8l0l3 UPDATE-Ol/13/82“ Federal spending for only institutional care and home care 0 services considered as substitutes for institutional care was over $8.6 billion in FY80. This estimate included Medicare, Medicaid,“ Veterans’ Administration“ housing, Title XX and Older Americans Act programs, but excluded income‘ assistance, mental health services, and extended care services in acute facilities among others. The financial burden of long term care can reach catastrophic proportions for many elderly individuals and their families. Despite substantial public financing of long term care, particularly institutional care, CBO estimated that 38-44% of total national spending for all long term care services in FY76 was paid directly by consumers without assistance from private health insurance or philanthropy. Costs for institutional care can be particularly devastating. A recent survey revealed that the average bill for nursing home care runs around $8,700 per patient on an annual basis. . ' ~ Major Federal Programs and Activities in Community-Based Long Term Care At least 26 separately authorized Federal programs assist persons with long term care problems. These programs often respond in a manner that is problem—specific, categorical in nature, or targeted at specific client groups. For example, certain programs provide health services while excluding social ~services; others are oriented to the elderly to the exclusion of the younger disabled. some programs carry income eligibility requirements, others do not. Although long term care may include assisting clients with housing, income, nutrition, and transportation needs, two major program areas are related to health and social services programs. Various Federal health and social service programs -- Medicare, Medicaid, Title XX of the Social Security Act, and the Older Americans Act -- as , they relate to community-based long term care services are briefly described below. Although none of these programs may be described as a community-based long term care program, they each contain elements related to long term care service systems. Note: Although there are other, Federal programs which support components of community-based care, such as housing and transportation services, this discussion is limited to specified health and social service programs. In addition, while the Veterans‘ Administration supports certain institutional and community program care services, since the program is essentially a closed system in which eligibility for care is limited to one segment of the population it is not included in this discussion. Program Goals. Medicare iS a nationwide health insurance program fOI' the aged and disabled intended primarily to address acute medical care needs. To the extent that it provides coverage of certain long term care services, it ‘does so with the intent of reducing the need for acute care -- the program was not designed to respond specifically to chronic care needs over a sustained period of time. Medicaid is the major Federal program financing health care services for certain low income persons. While it provides some health care benefits to those with chronic care needs, it is not envisioned as a comprehensive long term care program. The Title XX program is designed to assist families and individuals in maintaining self-sufficiency and independence; however, the program is generally limited to the provision of community-based social services selected and defined by each State. The Older Americans Act carries a broad mandate to improve the lives of older persons. Title III of this Act is intended to foster the development of a CRS- 5 A lIB8l0l3 UPDATE-O1/13/82 broadly defined, comprehensive and coordinated aging service system. Administrative Authority and Financing Mechanisms. The Medicare programqi is administered and financed at the Federal level with uniform national standards. The Medicaid, Title XX, and Older Americans Act programs are shared Federal-State programs with States responsible for implementation of Federal legislation and regulations. Each of these latter three programs carries specific requirements for States to match Federal funds. Effective Oct. 1, I981, the Title XX program-will no longer carry a requirement for a non-Federal matching rate, according to provisions in the Omnibus Budget Reconciliation Act of 1981. The Medicaid and Title XX State programs receive Federal funds as payments for services, while the Older Americans Act program allots funds to States on a formula grant basis. Some feel that by virtue of their statutory obligations to beneficiaries, Medicare and Medicaid represent "uncontrollable" expenditures in the Federal budget. The total funding available for the Older Americans Act, however, is subject to an annual limit imposed through the appropriations process, and Title XX carries a statutorily-imposed Federal expenditure ceiling. Service Benefits, Definitions, and Standards. Medicare and Medicaid provide reimbursement for medical and health care services; however, in certain limited instances Medicaid reimbursement is available for social service components of health care services, e.g., under personal care or adult day care service options. The Title XX program provides reimbursement for social services only but will provide coverage for medical care when such care is "integral but subordinate" to the provision of a social service. Funding under Title III of the Older Americans Act is to be utilized for the development of a service delivery system for older persons focusing on social and nutritional services. Definitions for similar or complementary services vary among programs. Certain service definitions are established through Federal regulation and others are established at the State level, or at the local level by individual service providers. Similarly, standards for services may be established at the Federal, State or local level depending upon legislative specifications. Eligibility. Entitlementi for ,Medicare is generally based on Social Security status, or aged persons may voluntarily opt to enroll in the program by paying monthly premiums. Medicaid and Title XX eligibility is based upon income status and/or an individual's relationship to a categorical cash assistance program. Effective Oct. 1, 1981, the Title XX program will no longer require States to apply a means test to individuals who apply for services under the program, according to provisions in the Omnibus Budget Reconciliation Act of 1981. The Older Americans Act program prohibits means testing for services; however, funds under the program must be directed toward those with the greatest social or economic need. Below are descriptions of these programs as they relate to community-basedn long term care. - Medicaid--Title XIX of the Social Security Act. The Medicaid program is a Federal-State matching program providing medical assistance for certain low—income persons. Each State administers its own program and, subject to Federal guidelines, determines eligibility and scope of ‘benefits. In general, each State also determines the reimbursement rate for services provided to Medicaid recipients. The Federal Government's share of medical expenses is tied to a formula based upon the per capita income of the State. As a minimum, the Federal Government will pay 50% of the costs of medical CRS- 6 A IB8l0l3 UPDATE-Ol/l3/32) care; this amount may range up to 83% in the lower per capita income States. The Omnibus Reconciliation Act of 1981 provides, effective Oct. l, 1981, for reductions in Federal matching payments otherwise available» to the States¢ under certain circumstances, States may_ offset" some of the reductions otherwise applicable. Medicaid law requires that States cover under their programs the so-called "categorically needy" (all persons receiving assistance under the Aid to Families with Dependent Children AFDC program and most persons receiving assistance under the Supplemental Security Income SSI program). States may also cover individuals in medical or intermediate care faciltiies as "categorically needy," if these persons meet certain income standards. In addition to the "categorically needy," States may at their option cover the "medically needy" (persons whose income and resources are large enough to cover daily living expenses, according to income levels set by the State, within certain limits, but not large enough to pay for medical care). If the income and resources of the "medically needy" individual are above a State-prescribed level, the individual must first incur a certain amount of medical expense which lowers the income to the medically needy levels (the so-called "spend-down" requirement). The Omnibus Reconciliation Act of 1981 provides States considerable _leeway in establishing both eligibility requirements and scope of benefits to be provided under their medically needy programs. Major long term care services provided under Medicaid include skilled nursing facility (SNF) services, home health services, and intermediate care facility (ICF) services. Other Medicaid services sometimes associated with the needs of long term care patients include: private nursing services, clinic services, physical therapy and related services, inpatient care for patients 65 years of age or older in institutions for mental’ diseases or tuberculosis, inpatient psychiatric services for individuals under the age of 21, personal care services at home, and adult day health services. The States vary greatly with regard to Medicaid eligibility. (One State, Arizona, has no Medicaid program.) only 33 States, for example, cover the medically needy. As a result of State variations, persons with identical circumstances may be eligible to receive Medicaid benefits in one State but not in another; even individuals in the same state with similar incomes may not be equally eligible for benefits due to welfare rules. Medicaid benefits also vary from State to State. Most States have imposed limits on the amount, duration, and comprehensiveness of certain community-based services in order to contain program costs. For example, only nine States cover personal care services; only nine States reimburse for adult day health services. Frequently, an additional barrier is the low level of reimbursement for certain Medicaid services. Some States pay only half of what the Medicare program pays for home health sources. Consequently, many home health agencies refuse to accept Medicaid patients. GAO has noted that Medicaid's eligibility policies and restrictive benefits have actually created financial incentives to use nursing homes rather than community services. On the one hand, Medicaid support to the chronically impaired elderly living in the community is usually quite limited though this may change somewhat as a result of the provisions of the Omnibus Budget Reconciliation Act of 1981. On the other hand, States usually offer full or partial coverage for long term care provided in nursing homes. ’ In addition, certain elderly poor who are ineligible for Medicaid while living in the community may become eligible once they enter a nursing home because 'cRs— 7 IB8l0l3 the State has a different income standard for nursing home residents. become eligible for Medicaid once they deplete their resources after entering the nursing home as privately paying patients.. A l977 gcongressional Office report on long term care estimated 47.5% of nursing lhome whose costs were paid by Medicaid in 1974 were not initially poor by State definitions, but depleted their resources sufficiently to qualify as medically needy. 9 I Medicare--Title XVIII of the Social Security Act. Medicare is a Federal health insurance program with a uniform eligibility and benefit structure throughout the United States. The program covers most individuals age 65 or over, persons under 65 entitled to Federal disability benefits, and certain individuals with end-stage renal disease. Protection is available to insured persons without regard to their income or assets. Medicare is generally not regarded as a _program providing significant support for long term care. Its coverage is focused primarily on acute care, particularly hospital and surgical care and accompanying periods of recovery. For example, Medicare Part A covers up to loo days of skilled nursing facility services following a hospital stay of at least three consecutive days. The benefit is further limited in that the patient must be in need of skilled nursing care on a daily basis for treatment related to a condition for which he or she was hospitalized. The SNF benefit is subject to a daily patient copayment after the 20th day of care. The program pays for neither intermediate care facility services nor custodial care in a nursing home. Medicare does pay for some community-based long term care services, primarily home health services. fPrior to July 1, 1981, Part A of Medicare covered lod home health visits following a 3-day hospital stay_ or discharge from a skilled nursing facility and Part B of Medicare covered an additional 100 medically necessary home health visits a year without a requirement of iprevious hospitalization, but subject to payment of the $60 Part B deductible the 200-visit limit on home health services under Parts A and B no longer applies, in accordance with Medicare amendments contained in P.L. 96-499. These Medicare amendments also exempted home health services from both the prior hospitalization requirements and the Part B deductible. Benefits under both Parts A and B ’are available only to individuals who are "homebound," who need part-time or intermittent skilled nursing services and/or physical or speech theraPY. find who are under a physician's care. feature. Effective July 1, 1981, requirements cause of care major such as the "homebound" and. skilled services are recognized as a underutilization of these community-based services. Regulations and definitions associated with these home health requirements are also very complex, making them subject to a variety of interpretations. As a result, reimbursement is sometimes retroactively denied to providers who ‘have supplied services. Restrictions pertaining to home health Title XX of the Social Security Act (Social Services). Title XX of the Social Security Act authorizes reimbursement to States for the establishment of social services to low income individuals and families. The Title XX program is broadly structured-to include the following goals: achieving or maintaining economic self-support and self-sufficiency; preventing or abuse or exploitation of persons unable to protect preventing or reducing inappropriate institutional care and securing referral or admission for or providing remedying of neglect, their own interests; by providing for community-based care; institutional care when other forms of care are not appropriate, UPDATE-01/13/829% Othersi Budget, patients* CRS= 8 ' IB8lOl3 UPDATE-Ol/l3/82~ services to individuals in institutions (excluding room and board). Through FY81 persons ‘eligible. under Title XX include recipients. of, Supplemental Security Income (SSI) or State supplementary payments,. Aid to Families with Dependent Children (AFDC), Medicaid, and those who have incomes less than ll5% (or at State option, a lower percentage) of the State's median income adjusted for family size. Each State determines the range of social services it will provide to the eligible population and sets forth its service program in its Comprehensive Annual Services Plan (CASP). Each State must provide at least three services for SSI recipients, at least one of which must be directed at each of the program goals. States must charge reasonable income-related fees for services to persons whose incomes exceed 80% of the State's median income. - Effective Oct. l, 1981, the Omnibus Budget Reconciliation Act of 1981 will eliminate requirements that States expend a portion of funds for welfare recipients, that services be limited to families with incomes below ll5% of the State median income, and that fees be charged to persons with specified income levels. The Budget Reconciliation Act also provides that before expending funds under the new Title XX program for any fiscal year, States are required to develop and make public a report on how funds are to be used, including information on the types of activities to be funded and the characteristics of individuals to be served. I Title XX funds are allotted to States on the basis of State population within a Federal expenditure ceiling. In FY81 the program operates under a Federal funding ceiling of $2.9 billion; States are required to provide 25% non-Federal matching funds for services. The Omnibus Budget Reconciliation Act of I981 reduces the expenditure ceiling to $2.4 billion in FY82 and eliminates the requirement for a non-Federal matching rate. Many States provide a variety of community-based long term care services. Home care services, which may include homemaker, chore, and home management services, are provided by virtually all States (to adults and children); adult day care is provided by 40 States. Other long term care supportivei services include home-delivered meals, foster care, companionship-reassurance services, and transportation services. Since there are no Federal definitions for services, there may’ be great variability in the service components offered under State Title XX program plans. The Older Americans Act of 1965, as Amended " The Older Americans Act carries a broad mandate to improve the lives of older persons in the areas of income, emotional and physical well-being, housing, employment, social services, civic, cultural, and recreational opportunities. The Act also authorizes formula grants to States under Title III and discretionary grant programs for research, demonstration, and training activities under Title IV. The purpose of Title III is to foster the development of a comprehensive and coordinated service system for older persons in order to (a) secure and maintain maximum independence and dignity in a home environment for older persons capable of self-care; (b) remove individual and social barriers to economic and personal independence for older persons; and (c) provide a continuum of care for the vulnerable elderly. Under Title- III, formula grants are made to State agencies on aging for planning and coordination of, and advocacy for, programs for older persons. The State agency on aging divides the State iI'1tO planning and service areas and designates area agencies on aging t0 administer and plan aging programs within their CRS- 9 I IB8lOl3 UPDATE-oi/13/82 respective areas . Although Title III may support a wide range of social services, wcertain service components have been designated as priority services, including those associated with access to other services (transportation, outreach, and information and referral); in-home services (homemaker, home health aide, visiting and telephone reassurance, and chore maintenance); and legal services. An area agency must spend at least 50% of its social services allotment on priority services, demonstrating an expenditure of at least some funds in each category. A waiver of this requirement may be granted by the State if sufficient services are already available. Another major component of the Title III program is the congregate and home-delivered meals program. Under Title III, State agencies on aging must establish a statewide long term care ombudsman program responsible for the following activities: investigating and resolving complaints relating to the health, safety, welfare and rights of nursing home residents; monitoring Federal, State and local laws, jregulations and‘ policies with respect to long term care facilities; providing information to public agencies regarding problems of older persons in long term care facilities; and establishing procedures for access to facilities’ and patients‘ records, including protection of the confidentiality of such records. . Services under the Title III program are to be provided to older -persons without regard to income, although concentrated on those _with the greatest social or economic need. older persons are to be given the opportunity to contribute to the cost of the service, but failure to contribute will not be a basis for denial of service. I The Federal matching rate for social and nutrition. services under Title III is 85%. M other Federal Initiatives In addition to the Federal programs described above, the DHHS is supporting certain demonstration activities that focus on the development and management of community-based long term care systems. Factors encouraging development of these projects have included: (a) need to mitigate the current institutional bias of the long term care service system and its social consequences for individuals; (b) increasing costs of institutionally based long term care and the comparative paucity of community-based services in proportion to need; (c) prospects for future growth in the older~ population; and (d) need to develop a sound knowledge base for possible creation of expanded community-based programs through Federal and/or State legislation. Funding for the federally sponsored demonstrations has emanated primarily from the Health Care Financing Administration (HCFA) and the Administration of Aging (AoA). In some instances, HCFA has waived Medicare or Medicaid service or eligibility requirements so that a fuller range of services may be provided persons who would not ordinarily benefit under the existing programs. In certain cases, States have authorized support of the programs through special legislation and funding. Notable among the federally sponsored demonstration projects are: the Monroe County (New York) Long Term Care Project, Inc. called ACCESS (Assessment for Community Care Services); Triage, Inc. (Connecticut); Wisconsin Coordinated Care for the Elderly; Washington Community-Based Care cRS§lO IB8l0l3 UPDATE-01/13/82 for the Functionally Disabled; and Georgia Alternative Health Services. Projects range from those in which systemwide changes have. been made ‘to . those in which the existing system has been modified by the addition of new‘ services. In some cases, new organizations have been created to organize, manage, and direct the community long term care service program, while in others existing health and social service organizations have been modified to carry out new or additional functions. The organization, administration, auspices, funding source, and service packages may differ among the projects; however, certain commonalities exist. Many projects are geared toward the development of procedures to provide assessment, case management, and follow-up of clients with long term care needs in order to assure care in the least restrictive setting. A multidisciplinary team (generally composed of medical, health, and social service professionals) is established to accomplish this objective. Most projects aim to provide or access a range of health and health-related social services for specified client groups, including homemaker, home health, chore, home—delivered meals, adult day health, transportation, etc. , Noteworthy among the long term care activities of the DHHS is the National Long Term Care channeling Demonstration Program funded for the first time during FY80 at a level of $20.5 million. During FY80, 27 States received funds as part of a multi—year $150 million effort to test new systems for providing long term health and social services to the elderly and chronically disabled. The term "channeling" is used to refer to organization structures and operating systems to coordinate available long term care resources and manage them effectively on behalf of clients. The purposes of the channeling program are: l. To stimulate system level changes in the organization of the delivery system, the relationahip among service providers, and in the way existing long term care dollars are allocated; 2. To create at the community level the structures that are necessary to coordinate, manage, and arrange for the provision of appropriate and efficient long term care services on behalf of the clients who need such services; and 3. To collect comparable information across the demonstration projects that will assist HEW in the development of a comprehensive long term care policy including the legislative and administrative specifications required to implement policy objectives. DHHS has specified that in the implementation of the channeling program the State must establish a working group which must, at a minimum, include the State agencies responsible for the administration of Medicaid, Title XX, and Title III of the older Americans Act. other major Federal activities related t0 community-based long term care have included formation Of a task force under the direction Of the Undersecretary Of DHHS (under the Carter Administration) t0 develop coordinated long term care policies; development Of university-based long term care gerontology training and research centers funded through ADA; and POliCY and data needs considerations by the Federal council on Aging, in itS role as advisor t0 the President. Although much activity hast been sponsored through these Federal cns-11 IB8lOl3 UPDATE-Ol/13/82 demonstration activities, it is important to stress that certain parallel activities have been initiated by States without the benefit of Federal demonstration funds and without any change in Federal legislation. A number m of States have attempted to reduce the need for institutionally based care by‘ redirecting existing Federal program funds or by using existing Federal and complementary State funds in new ways. For example, the Virginia State Medicaid agency has established a nursing home preadmission screening program, operated through local public health departments, for persons likely to be admitted to a nursing home but whose needs could be addressed through community-based services. The Massachusetts State agency on aging has established community-based organizations to manage certain key home care services for older persons through creative use of Title XX and Title Ill funds. The Utah State agency on aging has established a program to identify kpersons who risk being institutionalized and develop alternative community-based service plans using personnel of the State's area agencies on aging. A ‘ Measuring the Need for Long Term Care The potential need for long term care services, particularly among persons "at risk" off institutionalization, raises a critical issue for public policymakers concerned about future program costs. while numerous studies have attempted to estimate such need, hard figures remain elusive. T It has been estimated that 70% of the elderly receive home care services from family or friends rather than at public expense. lIt becomes difficult to ‘assess both the residual unmet need for long term care and the extent, to which an expanded public program might displace the amount and kind of care privately provided. Data in the 1977 CEO report on long term care and other estimates placed the total number of persons needing such care somewhere between 5.5 and 9.9 million, with one-half to two-thirds being elderly. It was also estimated that 3.6 to 7.8 million physically disabled adults who need long term care do not receive it —- compared to a minimum of 1.9 to 2.7 million who are known to obtain some services. yAs noted earlier, only 5% of the elderly are in institutions. Yet 3.4 million of the noninstitutionalized elderly have functional disabilities that require long term assistance. Somewhere between 3% and 5% of the noninstitutionalized elderly are so severly disabled that they are either bedridden or incapable of performing the most basic daily functions by themselves. For some of these very dependent people, an apparent shortage of beds has prevented their being placed in nursing homes. There are no firm nationwide estimates of the potential needed supply of nursing home beds. However, there is some anecdotal evidence of the current short supply, as measured by numbers of long term care patients backlogged in acute care hospitals waiting for nursing home beds to empty so they can be discharged. In some areas, it appears that there is a "shortage" merely of Medicare and/or Medicaid nursing home beds since privately—paying patients reportedly have no trouble getting admitted. t Conservative estimates are that between 10%. and 40% of those in institutions are being served at inappropriate levels of care. Usually, they don't need the highly skilled level of care provided, e.g., in a hospital or skilled nursing facility as opposed to an intermediate care facility. Costs CRS-12 IB8lOl3 UPnATE—o1/13/82 associated with keeping a long term care patient occupying a high-cost hospital, rather than a lower-cost nursing home, bed can be very high. Two counties on Long Island, New York with, 500, patients a day backlogged in __' hospitals, figure‘ the annuals waste at- $25 million.- "Massachusetts has reportedly budgeted $58 million this year for "administratively necessary days" spent in hospitals by Medicaid patients waiting for nursing home beds. Despite the fact that many nursing home residents may" be inappropriately placed according to medical criteria, most observers feel it would be difficult to deinstitutionalize large numbers of current residents. About 50% of nursing home patients are diagnosed as senile; nearly 50% of those in institutions lack any family or friend to help them live in the community. It has also been observed that once an elderly person has been institutionalized for a significant period of time, a pattern of dependancy is built up making residence elsewhere difficult. And perhaps most significantly, institutionalization can virtually deplete the elderly person's life savings and other private resources, making independent living financially impossible. The issue therefore becomes one of preventing unnecessary institutionalization before it occurs. Studies consistently point to the preference of the impaired elderly to receive long term care services in their own homes rather than enter a nursing home. The previously mentioned GAO report noted that "in addition to fearing a loss of independence, many elderly resist nursing home placement because it often means they must give up their lifelong possessions and sever their community ties; others perceive institutionalization as a prelude to death." Cost-Effectiveness and Cost Control of Community-Based Services With nursing home care representing a substantial portion Of public and private resources coupled with evidence of client preference for community-based care, there has been increasing emphasis on examining ways to reduce the rate of institutionalization through substitution of community-based services. However, there has been uncertainty about the potential costs of expanded community-based care, the optimal manner in which to control such costs, and alternate methods of organizing communityébased care systems. i A number of studies have attempted to compare the costs of community-basedl or in-home services t0 the COStS Of institutional care. Such comparisons have usually been sparked by the belief that if greater emphasis were placed on providing community-based alternatives, significant cost savings could‘ accrue from lowered admissions, earlier discharges, and reduced capital construction costs for inpatient facilities. Furthermore, costs could be reduced if patients now inappropriately placed- in nursing homes could be returned to the community, thus freeing essential beds for chronic care patients backlogged in hospitals. a At present, however, the data to support this theory are inconclusive. A survey of various studies indicates that home health care, for example, may ‘indeed be less COStlY for certain patients With lower levels= Of impairment. But such cost savings tend to disappear when more severly impaired persons are cared for at home. The exact breakeven point is unclear. In addition, there is growing evidence that increased availability of home health care may ,actually increase total health COStS by increasing overall utilization throughout the system and by substituting care provided through a formal cRs~i3 IB8lOl3 UPDATE~Ol/l3/82 system for care presently provided informally by family, friends, and volunteer organizations. The consequent issue, therefore, may be whether such alternative forms of care are desirable in and of themselves for.aspects_ other than immediate cost—savings potential. Questions regarding the types of persons to be served through community-based services, as opposed to institutional services, and who ‘should be given priority fOI‘ community care, remain vexing PFODIEITIS fOI’ planners concerned about the cost-effectiveness of substituting one form of care for the other. The GAO study cited earlier has indicated that many of the community-based long term care demonstration programs have failed to show. that persons served through community care would have otherwise entered a nursing home. Unless these persons were truly "at risk of institutionalization," the community services costs might be viewed as "add—on" costs to the total system. One study by the National Center for Health Services Research (NCHSR) demonstrated the "add-on" factor, showing discouraging results about the cost-effectiveness of community—based care. The study was designed to examine the effects of adult day care and homemaker services on‘ a Medicare-eligible population and to assess the impact of those services on institutionalization, outcomes, and Medicare costs. The findings suggested that persons using day care did not substitute it for other Medicare-provided services but instead used it as an additional service. The number of experimental day care users who did finally enter a nursing home was not significantly lower than control group members who did not use day care. Net total Medicare costs (the new services plus existing Medicare services) were 7l% higher for the day care group and 60% higher for the homemaker experimental group. It should be noted that this study's conclusions regarding net total program costs were challenged during hearings in 1980 before the House Committee on Aging. For example, witnesses on behalf of the adult day care programs sponsored under the Massachusetts Medicaid program testified that their rates for adult day care services (about $24 per person per day) were significantly lower than nursing home rates (about $33 per day) would have been and that at least half of the people in the day care program would have otherwise gone into nursing homes. Other testimony showed day care rates similar to those of Massachusetts, e.g., Washington, New Jersey, and California have rates below $30 a day. Another factor to be considered is whether expanded or new ways of providing community care would act as a substitute for care now provided informally by family and friends. The potential substitution effect of publicly financed and organized care for informal support services will likely be a key issue in coming years. Some observers believe that the current trend of high labor force participation by women, who have traditionally provided much of the informal care for older relatives, is bound to continue. If so, the future elderly population may have fewer relatives with adequate time to provide informal care, consequently forcing families to seek out formal community services on behalf of their relatives- The recent growth of adult day care programs is an example of this phenomenon. Many feel that one of the key methods of controlling long term care costs is to control the demand for nursing home care by diverting persons who would ordinarily be referred and admitted to institutions to community-based services through various systems of client assessment and case management. CRS-l4 IB8lOl3 UPDATE-Ol/13/82 As pointed out above, community-based long term care demonstration projects supported by DHHS have incorporated the concept of assessment and case management, or "channeling," Of, clients t-O assure appropriate responses .tQ-’ long term care needs by providing care in the least restrictive setting; Impact of these demonstrations on costs of care has varied from project to project. However, some projects appear to indicate that home care costs are less than or at least comparable to the equivalent level of nursing home costs, that nursing home administration rates can be controlled and even lowered, and that numbers of hospital days can be lessened through ~use of community care. " In Monroe County, New York, implementation of ACCESS, in which control is exercised on Medicaid nursing home admissions through increased emphasis on a variety of home care services, has resulted in a reduced growth rate for Medicaid hospital expenditures. In addition, overall expenditures for skilled and intermediate nursing home care, home care, and inpatient care did Snot grow as compared to an average increase of 17% for six comparison counties. Medicaid costs for home care were only 52% of the comparable Medicaid institutional rate. The Wisconsin Community Care Organization, another demonstration designed to test the impact of client assessment and home care expansion, showed reduced hospital and nursing home utilization for persons in the experimental groups. However, when adding overall administrative and service coordination costs of the project, total Medicaid costs for control and experimental groups were roughly equivalent. I The Georgia State Medicaid agency's demonstration, the Alternate Health Service Project, has altered its Medicaid program by providing reimbursement for a variety of community services, including foster care, adult day rehabilitation, homemaker/chore, and home-delivered meals. Like the other projects mentioned above, assessment and case management are integral parts of the project. The project has shown that the mean direct cost of project services to the Medicaid program is about $300 less than an equivalent level of nursing home care. The success of this project has motivated the State to plan statewide implementation. In Connecticut, the Triage model has reportedly saved $1.7 million net dollars in terms of days of institutional care saved, based on preliminary findings of the first 3 years of the project. On the other hand, a Washington State project reports that the reduction in Medicaid nursing home population in demonstration sites was offset by a large increase in the number of patients receiving community services. Since this resulted in an estimated 5% to 10% increase in total program costs, the report suggests that strategies to control latent demand for community services would be required for cost containment to be effected. Although these projects have been in operation only a short time, or have operated as timeelimited demonstration projects, and findings are based on preliminary analysis of data collected on a limited number of clients, a number of key project elements could be considered for future policy formation. For example, GAO notes that ideally there should be intervention in the nursing home admission process to screen all applicants on the basis of a comprehensive needs assessment. Also desirable would be a packaging and financing of community services required to permit those who do not need or desire institutional care to remain in the community. In addition, GAO recommends some form of control over cost and utilization of community-based long term care until more information is available about the mix, amount, and I)?‘ CRS-15 IB8lOl3 costs of services which prevent institutionalization. .One final point with respect to pcost. control _issuesp is thee negd gfiors improved lmanagement of existing‘ community-based services. Methods'l of“ reimbursing providers of community-based services appear to vary widely, Improvements may be necessary in local authorities especially under social services programs. the contracting procedures used by many State and administering community-based services, such as development of more precise definitions of units of service and better methods of monitoring service delivery.’ ' Finally, any discussion of the cost-effectiveness of home or community-based care versus institutional care ideally should consider total societal costs -- both public and private. Yet there is very little evidence available at present ‘even as to total public costs associated with maintaining an elderly ill or disabled person in the home setting as opposed to the institution. Studies comparing costs for home care to costs for alternative treatment modes generally focus on Medicare and/or Medicaid program costs but fail to account for other public programs often fproviding assistance to the elderly living in the community, such as food stamps, subsidized housing, SSI payments, energy assistance, property tax relief, transportation assistance, etc. i Preliminary data from the Wisconsin project do show that overall public costs_ of community-based care and institutional care are generally equivalent, with public costs defined as all governmental programs, including social security income, food stamps, and subsidized housing. There is also some evidence that institutionalization itself hastens the transition to public support since. many -persons who enter an institution as private ~patients convert to Medicaid status after exhausting "their own resources., While outside the institution, they may be ineligible for Medicaid or most other public assistance programs. Perhaps even more difficult to gauge are the costs or values of home services provided privately by family or friends. In particular, for the greatly impaired person living at home the value of supportive services provided by families and friends often becomes so high that home care costs more than care provided by institutions. A 1977 GAO report noted that once the greatly impaired person reaches the breakeven point in terms of home care costs versus institutional costs, families and friends provide over 70% of the value of services received -- an average of Vabout $287 per month in services for every $120 being spent by public agencies. Future Prospects for Community-Based Long Term Care: The Range of Options In general, there appears to be a certain consensus among observers regarding the overall desirability of more extensive, better-organized community care as an alternative to institutionalization. While home or community care may not necessarily be less costly than institutional care to the system as a whole, such noninstitutional alternatives may be desirable for other aspects, such as the importance of family) the physical-emotional and mental health of the patient, and freedom of choice. Some observers have asserted that the community should not be viewed as an "alternative" -- the institution should be viewed as the alternative to the community. most people over age 65 community-based Despite the common occurrence of chronic ailments, are by and large in reasonably good health. An adequate UPDATE-O1/13/82'i CRS-16 1381013 -UPDATE-O1/13/92‘ avoid unnecessary enable many such elderly to As one observer has commented: support system may institutionalization. The underlying assumption in the movement toward alternatives in long term care is that most patients want to be self-sufficient and independent.... It is also assumed, and supported by substantial evidence, that the family of the potential long term care recipient would prefer to continue providing long term care services if family members were to receive some assistance which would make their continued efforts possible. (Weissert, p. 99) Yet as another author has aptly noted, "discussions concerning health care for the elderly usually begin with the subject of quality of care and end with the bleak topic of costs." The present economic climate in the Nation is certain to elevate the cost issue to the forefront of any discussion of future prospects for long term care. Directly related to the cost issue is the concern among policymakers as to whether the right course of action in the years ahead involves greater public subsidies or improved incentives for action by the private sector. To some observers, the built-in bias toward institutional care under public programs such as Medicaid is considered a major factor limiting the spread of community-based long term care. ~Such observers argue that additional Federal legislation is needed to expand the scope of covered services and/or to provide for preferential payment for noninstitutional care. In this regard, proposed 96th Congress legislation would have significantly expanded the Federal effort with regard to community-based long term care. These bills received a long list of .congressional sponsors and elicited endorsement by many special interest groups. However, concern was expressed over the cost implications of these proposals, particularly for the public sector, over and above current levels of spending. one of these measures has been reintroduced in an amended form (S. 861), in the 97th Congress. Another, the Medicaid Community Care Act of 1980, served as the basis for a community-based long term care provision contained in the Omnibus Budget Reconciliation Act of 1981 in the 97th Congress. This provision authorizes waivers of State Medicaid plans for home and community-based services (see "97th Congress Legislation" below). Interest has also been expressed in providing greater tax incentives to families to care for their elderly dependents in their own homes. options might include greater incentives for the private sector to develop more congregate housing arrangements to enable the elderly to live independently and yet have access to medical, social, and allied services. Legislative efforts might focus on local voluntary "self projects for the elderly residing in the community. help" legislation will add vast and “will inevitably Some observers fear that broad new Federal increases to the public budget for long term care substitute for private efforts of families and friends. Such observers look to more limited changes in the existing network of public and private programs as a means to accomplish improved long term care services, such as encouragement to States to make better and more creative use ,of existing Federal and State resources. States such as Utah and Massachusetts have initiated programs to channel long term care assistance without resorting to additional Federal assistance or mandate for encouragement. term care Various forms of assessment of individuals‘ need for long Otheri support’ CRS-17 dIB8lOl3 UPDATE-O1/13/82 services and pre-admission screening for nursing home care are viewed by some as ways t0 improve community-based care and t0 control potential demand for institutional care.. As pointed out abovep such efforts have been the subject, of research and demonstration over the’ past several years. The Medicaid community-based long term care provisions contained in the Omnibus Budget Reconciliation Act of 1981 may encourage additional Federal-State cooperative efforts in this regard. Concern has been expressed over the limited availability ‘of community-based services and the best combination of services to be offered the long term care population. How can States be encouraged to combine existing resources in more effective ways to impact more directly on those persons in danger of institutionalization? Considering the budget constraints faced by many State legislatures and Federal budget cutbacks, is it realistic to expect States to broaden existing long term care services? Should Federal efforts to combine elements of existing programs into one long term care program be pursued? LEGISLATION_ 97th Congress Legislation Polio HORO Omnibus Budget Reconciliation Act of 1981. Amends Title XIX of the Social Security Act (Medicaid). Authorizes the Secretary of the Department of Health and Human Services (HHS) to approve waivers of State Title XIX plans to include as medical assistance home or community—based services (other than room and board) to individuals who, without such services, would require the level of care provided in a skilled nursing facility or intermediate care facility. Community-based services. under the waiver may include case management, homemaker/home health aide services, personal care services, adult day health care services, habilitation services, respite care, and other services requested by the State and approved by the Secretary. Requires the State: to provide for an evaluation of the individual's need for institutional services; to inform individuals likely to require the level of care provided in a skilled nursing facility or intermediate care facility of the feasible community-based alternatives (if available under the waiver) to such institutional care; and to develop a written plan of care .for individuals provided waivered services. Requires that the average per capita expenditure in any fiscal year for medical assistance for such individuals pmay not exceed the average per capita expenditure that would have been made in any fiscal year under the State plan if the waiver had not been granted. Requires that the initial waiver of the State plan requirements be for 3 years with an extension of 3 years as approved by the Secretary.~ Requires the State to provide the Secretary of HHS annual information on the impact of the waiver on the type and amount of medical assistance and on the health and welfare of recipients. Reported by House Committee on the Budget (H.Rept. 97-158) June 19, 1981. Reported by Senate Committee on the Budget (S.Rept. 97-139) and passed the Senate, amended, June 25. House and Senate agreed to the. conference report (H.Rept. 97-208) July 31. Signed into law Aug. 13, 1981. S. 234 (Hatch et al.) Community Home Health Services Act of 1981. Amends the home health cRs418 I IB8lOl3 UPDATE-Ol/13/82 services grant program authorized under the Public Health Services Act. Authorizes grants to public and nonprofit private entities and loans to proprietary entities through FY84 for establishing and operating home .health~ programs. Provides that funds for these programs may be used to train ‘home health program personnel. Also provides that in making grants and loans priority shall be given to areas without home health services and special consideration shall be given to areas with inadequate means of transportation. Extends the training demonstration grants for one year. Requires the Secretary of Health and Human Services to report by Dec. 31, l98l on the impact of the training demonstration grants and the need to continue them, the extent to which uniform training standards have been established, and the extent to which training costs .are or could be reimbursable under Medicare and Medicaid. Amends the definition of home health services in title XVIII of the Social Security Act (Medicare). Adds nonprofit hospitals to entities authorized to provide home health services under Medicare, and expands covered services to include nursing services for chronic or acute care and services of ,a homemaker when medically necessary. Also amends the definition to include any professional health services which could be a service provided as part of inpatient hospital services, but which is provided in an individual's home by a nonprofit hospital or members of its staff, including its physicians, nurses, social workers, therapists, technicians, home health aides, homemakers, housekeepers, dieticians, and other personnel. Finally amends section title XIX of the Social Security Act (Medicaid) requiring the States include as a home health service under a State plan any item or service that is included as a home health service under Medicare. Introduced Jan. 22, 1981; referred to Committee on Labor and Human Resources. S. 861 (Packwood et al.) Noninstitutional Acute and Long Term Care Services for the Elderly and the Disabled Act. Adds a new Title XXI to the Social Security Act providing for a 6-year demonstration program of comprehensive community—based noninstitutional acute and long term care services for persons aged 65 and over and for persons with chronic disabilities. Provides for 10 statewide demonstration programs to test the implementation of an organized system of noninstitutional acute and long term care services. Provides that all noninstitutional acute and long term care services presently available to the aged and disabled under Medicare, Medicaid, and the Title XX Social Services program be combined under the new Title XXI. Makes a Preadmission Screening Assessment Team (PAT) responsible for conducting a health status and functional assessment of each person seeking Title XXI services and developing an appropriate plan of care for each person. Requires that a copayment system be tested for individuals participating in the program. Introduced Apr. 2, 1981; referred to Committee on Finance. 96th Congress Legislation H.R. 6194 (Waxman and Pepper) Medicaid Community Care Act of 1980. Amends title XIX of the Social Security Act to provide increased Federal contributions for community—based long term care services under Medicaid. Requires States to put in place a State community care plan, providing for comprehensive medical and social assessments of Medicaid-eligible persons who are at risk of needing CRS-19 IB8lOl3 UPDATEFO1/13/82 institutional long term care. For persons at risk’ of institutionalization for whom community-based care is a feasible alternative, requires States to provide a broad.range of services. -Provides that. certain persons, who, are currently " eligiblei for‘n a State'sRi Medicaid’ -program‘ only ‘when institutionalized, would be considered eligible for community-based services. Introduced Dec. 19, 1979; referred to Committee on ‘Interstate and Foreign ,Commerce. Hearings held June 10 and June 23, 1980. P.L. 96-499 -- the Omnibus Budget Reconciliation Act of 1980 (H.R. 7765) -- contained several amendments to Title XVIII of the Social Security Act which expand, effective July 1, 1981, certain long term care benefits for persons covered by Medicare. Specifically, the measure removes Medicare's current 200-visit limit on home health services and the program's present 3-day prior hospitalization requirement for home health care. For a more detailed description of the various provisions and legislative history of P.L. 96-499, see IB76028, Medicare and Medicaid. HEARINGS U.S. Congress. House. Committee on Interstate and Foreign Commerce. Subcommittee on Health and the Environment. Community-based long term care: obstacles and opportunities. Hearing,, 96th Congress, lst session. Dec. 11, 1979. Washington, U.S. Govt. Print. Off., 1980. 4 Committee print 96-80 ----- H.R. 6194, Medicaid Community Care Act of 1980. ‘Hearings, 96th Congress, 2d session. May 30, June 10, 23, 1980. Washington, U.S. Govt. Print. Off., 1980. "Serial no. 96-165" U.S. Congress. House. Select Committee on Aging. Adult day care. Hearing, 96th Congress, 2d session. Apr. 23, 1980. Washington, U.S. Govt. Print. Off., 1980. Committee Pub. no. 96-260 NU.S. Congress. House. Select Committee on Aging. Subcommittee on Health and Long Term Care. Long term care for the 80s: channeling demonstrations and other initiatives. Hearing, 96th Congress, 2d session. Feb. 27, 1980. Washington, U.S. Govt. Print. Off., 1980. Comm. Pub. no. 96-234 U.S. Congress. Senate. Committee on Finance. Comprehensive community-based noninstitutional long term care for the elderly and disabled. Hearing, 96th Congress, 2d session. Aug. 27, 1980. Washington, U.S. Govt. Print. Off., 1980. REPORTS AND CONGRESSIONAL DOCUMENTS Packwood, Bob. S. -- Submission of a bill to amend the Social Security Act to provide for a 6-year demonstration program of comprehensive community-based non-institutional acute and long term care services for the elderly and the disabled. Congressional record daily ed. Apr. 2, 1981: S3346-S3356. CRS-20 IB81013 UPDATE-O1/13/82‘ Waxman, Henry A. Medicaid Community Care Act of 1980. Congressional record tdaily ed+— Dec. 19, 1979:.H12345-H12346.. Floor statement by Representative Claude Pepper: H12346—Hl2348. CHRONOLOGY OF EVENTS 04/02/81 -- S. 861 introduced by Senator Packwood et al. and referred to the Committee on Finance. 12/19/79 -- H.R. 6194, the Medicaid Community Care Act of 1980, introduced by Representatives Waxman and Pepper and referred to the Committee on Interstate and Foreign Commerce. ‘ ADDITIONAL REFERENCE SOURCES U.S. Congress. Congressional Budget Office. Long term care for the elderly and disabled. Washington, U.S. Govt. Print. Off., Feb. 1977. 62 p. U.s. Congress. House. Committee on Energy and Commerce. Subcommittee on Health and the Environment. Report on experimental efforts in long-term health care for the elderly. Washington, U.S. Govt. Print. Off., June 1981. 47 p. U.S. Department of Health, Education and Welfare. Public Health Service. National Center for Health Services Research. Health 1978. Chapter V-Long-term care: an overview by William G.‘ weissert. December 1978. DHEW pub. no. 78-1232. U.S. Department of Health, Education, and Welfare. Public Health Service. Office of Research, Statistics, and Technology. National Center for Health Statistics. The national nursing home survey: 1977 summary for the United States. Washington, July 1979. DHEW pub. no. (PHS) 79-1794. Series 13, no. 43. 213 p. U.S. General Accounting Office. Entering a nursing home -- costly implications for Medicaid and the elderly. Nov. 26, 1979. PAD-80-12. 181 p. ----- Home health -- the need for a national policy to better provide for the elderly. Dec. 30, 1977. HRD-78-19. 67 p. U.S. Library of Congress. Congressional Research Service. Federal programs and assistance benefiting the elderly by Evelyn Tager. Washington 1978. 81 p. CRS report 78-122 EPW ----- Federal programs that finance home health care services by Kay Reiss.‘ Washington 1981. 24 p. CRS report 81-74 EPW ----- Medicare-Medicaid by Jennifer O'Sullivan. Washington CRS-21 UPDATE-01/13/82 IB8l0l3 1980. ll P. CRS report 80-48 EPW Medicare and Medicaid by Jennifer O'Su11ivan.’ Washington 1980. Regularly updated 15 p. (Issue brief 76028) as amended; The Older Americans ACt2 major provisions, _ by Evelyn development of major provisions; appropriations H. Tager. Washington 1979. 56 p. CRS report 79-166 EPW social services under the Social security Act (Title XX) by Rick Praeger. Washington 1979. 67 p. CRS report 79-129 EPW 1 program description, 1981. 47 p. Title xx of the Social Security Actzi current issues by Karen Spar Washington CRS report 81-58 EPW. 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