Long-Term Care

Women constitute the majority of long-term care (1) recipients- more than 70 percent of nursing home residents are women. (2) There are many barriers to quality long-term care services, including cost. Medicare does not cover most long-term care services, and there are serious limitations on the coverage available through private insurance or Medicaid. (3) The Report Card measures states' commitment to affordable, quality long-term care in two ways. First, states' long-term ombuds staffing levels are examined. The federal long-term care ombuds program, administered and partially funded by the states, provides ombuds who act as advocates to help residents and their families obtain a better quality of life in long-term care settings. (4) Second, the Report Card examines "spousal impoverishment" Medicaid eligibility rules. To prevent the high cost of long-term care from impoverishing the spouses of nursing home residents, federal law requires states to protect some assets and income of the non-institutionalized spouse ("community spouse") through a resource allowance and income allowance. (5)

Data Points for this Issue:

Ombuds Staffing Levels
Medicaid Spousal Impoverishment

Ombuds Staffing Levels

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	25
Limited Policy	0
Weak Policy	0
No/Harmful Policy	26
Better	4
Worse	0
Same	47

Does the state’s long-term care ombuds staffing level meet the Institute of Medicine’s (IOM) minimum acceptable standards?

States receive a "meets policy" if their ratio of paid ombuds per long-term care facility beds is one to 2,000 or fewer, the minimum determined by the 1994 landmark IOM report. States receive a "no policy" if their ratio is greater than one to 2,000.(6)

Data Source: Ombuds Staffing Levels, FY 2004.

U.S. Department of Health and Human Services, Administration on Aging, "Table A-1: Selected Information by State for FY 2004." Available at http://www.aoa.gov/prof/aoaprog/elder_rights/LTCombudsman/
National_and_State_Data/2004nors/2004nors_pf.asp.

Medicaid Spousal Impoverishment1

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	8
Limited Policy	9
Weak Policy	12
No/Harmful Policy	22
Better	0
Worse	0
Same	0

1. The way in which this indicator is evaluated has changed from the 2004 Report Card and therefore there is no comparison to 2004. In an effort to more fairly capture what states are doing to protect the income and assets of "community" spouses of nursing home residents, a weak category was added to the grading scale.

Has the state chosen the greatest allowable protection for income and assets of the “community” spouses of nursing home residents under the Medicaid program?

States that have the highest resource and income allowances permitted by the federal government receive a "meets policy." States receive a "limited policy" if they have chosen the highest level of either allowance, but not both. States receive a "weak policy" if they have chosen levels below the maximum but above the federal minimum. States that offer the lowest levels permitted receive a "no policy."

Data Source: Medicaid Spousal Impoverishment, 2006.

Eric M. Carlson, "Appendix A: 2006 State-Specific Medicaid Resource and Income Allowances; Average Monthly Private Pay Rates," in Long-Term Care Advocacy, section 7401 (Matthew Bender & Co., 2007).

1. "Long-term care" includes both nursing homes and services provided in the home or in the community. Such care can include various medical services and assistance with daily living activities (e.g., dressing, bathing, and eating) for people with chronic long-term conditions that reduce their ability to function independently. AARP, The Policy Book: AARP Public Policies 2007 (Washington: AARP, 2007), available at http://www.aarp.org/issues/policies/policy_book/.

2. Ari N Houser, "Women and Long-Term Care." AARP Public Policy Institute, April 2007, available at http://assets.aarp.org/rgcenter/il/fs77r_ltc.pdf.

3. AARP, The Policy Book: AARP Public Policies 2007 (Washington: AARP, 2007), available at http://www.aarp.org/issues/policies/policy_book/ (discussing limitations of Medicaid and private insurance coverage for long-term care). State-mandated nursing home staffing levels are also important to ensuring women's access to quality long-term care but it is still difficult to identify the most appropriate ways to evaluate state commitment to adequate staffing.

4. 42 U.S.C. § 3058g.

5. For the "community spouse resource allowance," states must allow the community spouse to retain the greater of: (1) a minimum of $19,908 and a maximum of $99,540 in assets or (2) half the couple's joint assets up to $99,540. For the "income allowance," the community spouse can retain his or her own income, but also has the right to retain some or all of the resident's income, according to the state-established Minimum Monthly Maintenance Needs Allowance (MMMNA) that, according to federal law, must be at least $1,603 and no more than $2,489. Hawaii and Alaska are set higher because of a higher poverty level.; Eric M. Carlson, "Appendix A: 2006 State-Specific Medicaid Resource and Income Allowances; Average Monthly Private Pay Rates," in Long-Term Care Advocacy, section 7401 (Matthew Bender & Co., 2007); 42 U.S.C. § 1396r-5(d).

6. Institute of Medicine, Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act (Washington: National Academy Press, 1994), 175, Table 5.5d. The ratio of paid ombuds program staff (funded by state, regional, and local governments, with some state responsibility for overseeing the regional and local programs) to the number of beds in all facilities is obtained by comparing the number of paid ombuds program staff to the number of beds in all facilities (licensed nursing facilities, and licensed board and care, and similar facilities). Although states may have an effective volunteer ombuds corps, the IOM report determined that the appropriate measure involved paid ombuds. The number used in the Report Card is for full-time equivalents (FTEs), i.e., not all of the ombuds serve this role in a full-time capacity.