H. Stephen Kaye

Long-Term Care: Who Gets It, Who Provides It, Who Pays, And How Much?

Long-term care in the United States is needed by 10.9 million community residents, half of them nonelderly, and 1.8 million nursing home residents, predominantly elderly. Ninety-two percent of community residents receive unpaid help, while 13 percent receive paid help. Paid community-based long-term care services are primarily funded by Medicaid or Medicare, while nursing home stays are primarily paid for by Medicaid plus out-of-pocket copayments. Per person expenditures are five times as high, and national expenditures three times as high, for nursing home residents compared to community residents. This suggests that a redistribution of spending across care settings might produce substantial savings or permit service expansions.

Why Don’t Employers Hire and Retain Workers with Disabilities?

Introduction Despite persistently low employment rates among working-age adults with disabilities, prior research on employer practices and attitudes toward workers with disabilities paints a generally rosy picture of successfully accommodated workers in a welcoming environment. Findings from previous studies might have been biased because of either employer self-selection or social desirability, yielding non-representative or artificially positive conclusions. Methods In this study, a novel approach was used to survey human resource professionals and supervisors working for employers known or reputed to be resistant to complying with the ADA’s employment provisions. Attendees of employer-requested ADA training sessions were asked to assess various possible reasons that employers in general might not hire, retain, or accommodate workers with disabilities and to rate strategies and policy changes that might make it more likely for employers to do so. Results As cited by respondents, the principal barriers to employing workers with disabilities are lack of awareness of disability and accommodation issues, concern over costs, and fear of legal liability. With regard to strategies employers might use to increase hiring and retention, respondents identified increased training and centralized disability and accommodation expertise and mechanisms. Public policy approaches preferred by respondents include no-cost external problem-solving, subsidized accommodations, tax breaks, and mediation in lieu of formal complaints or lawsuits. Conclusions Findings suggest straightforward approaches that employers might use to facilitate hiring and retention of workers with disabilities, as well as new public programs or policy changes that could increase labor force participation among working-age adults who have disabilities.

Do Noninstitutional Long-Term Care Services Reduce Medicaid Spending?

Medicaid spending on home and community-based services (HCBS) has grown dramatically in recent years, but little is known about what effect these alternatives to institutional services have on overall long-term care costs. An analysis of state spending data from 1995 to 2005 shows that for two distinct population groups receiving long-term care services, spending growth was greater for states offering limited noninstitutional services than for states with large, well-established noninstitutional programs. Expansion of HCBS appears to entail a short-term increase in spending, followed by a reduction in institutional spending and long-term cost savings.

Demographics and Trends in Wheeled Mobility Equipment Use and Accessibility in the Community

ABSTRACT This article presents a profile of household-resident U.S. adults using wheeled mobility equipment (WME) in 2005, trends in WME use from 1990 to 2005, and data on accessibility features and problems from 1994–97. Data were obtained from the Survey of Income and Program Participation (SIPP) and the National Health Interview Survey on Disability (NHIS-D). Compared to the general population, WME users are more likely to be older, female, and in poor health. Forty-four percent are working-aged, with twice the rate of poverty of the general population, and only 17% are employed. Mobility difficulty is the most significant predictor of WME use, but gender, race, poverty, and educational attainment are also significant predictors. From 1990–2005, WME use grew 5% per year, while mobility difficulty declined among the elderly and remained steady among working-age persons. This contrast suggests a reduction in unmet need for WME. In 1994–97, more than half of WME users had difficulty entering or exiting their homes, and one-third had accessibility problems outside their homes. Usage of home modification was low, with substantial unmet need. Regular national data collection on the use of WME and other mobility aids, their financing, and accessibility issues is warranted.

Stuck at the bottom rung: occupational characteristics of workers with disabilities.

Introduction The proportion of workers reporting disabilities varies tremendously across occupations. Although differences in the occupational distributions may partly explain the large disparities in earnings and job security between workers with and without disabilities, little is known about the reasons that workers with disabilities are underrepresented in certain occupations and overrepresented in others. Methods Using a large, national survey of the US population combined with official data on the skill and experience requirements and occupational risks of 269 occupations, a multilevel regression analysis was performed to identify occupational and individual factors that influence the representation of workers with disabilities across occupations. Models of overall, sensory, mobility, and cognitive disability were constructed for working-age labor force participants, as were models of overall disability for younger, in-between, and older workers. Results At the occupational level, reported disability is negatively associated with occupational requirements for information and communication skills and with the amount of prior work experience that is required, after controlling for individual factors such as age and educational attainment. Little relationship is found between disability status and a set of occupational risk factors. These findings generally hold true across disability types and age groups. Conclusions Even after taking into account their lower average educational attainment, workers with disabilities appear to be disproportionately relegated to entry-level occupations that do not emphasize the better-remunerated job skills. Underemployment results in lower wages and less job security and stability. Possible reasons include employer discrimination, low expectations, deficits in relevant skills or experience, and work disincentives.

Disparities in Usage of Assistive Technology Among People With Disabilities

Assistive technology is essential to the lives of many people with disabilities, but disparities in usage put certain segments of the disability population at a particular disadvantage. This article uses survey data and statistical modeling to explore differences in technology usage across disability subpopulations. Responses to a 2005 survey of nearly 2,000 adult consumers of California Independent Living Centers reveal large differences in technology usage by age, race, ethnicity, education, income, and type and severity of disability. Statistical modeling of overall device usage, number of devices used, and usage of high-, medium-, and low-tech devices reveals several factors that appear to put people with disabilities at a disadvantage in accessing and using assistive devices. These factors include lower educational attainment, racial or ethnic minority status, lower household income, later disability onset, and disability related to mental as opposed to physical or sensory functioning. Findings highlight approaches needed to expand usage of and to promote equal access to technologies that enable greater social and economic participation for people with disabilities.

Medicaid Home- and Community-Based Services: Impact of the Affordable Care Act

The Affordable care Act (ACA) legislation of 2010 has three important voluntary provisions for the expansion of home- and community-based services (HCBS) under Medicaid: A state can choose to (1) offer a community first choice option to provide attendant care services and supports; (2) amend its state plan to provide an optional HCBS benefit; and (3) rebalance its spending on long term services and supports to increase the proportion that is community-based. The first and third provisions offer states enhanced federal matching rates as an incentive. Although the new provisions are valuable, the law does not set minimum standards for access to HCBS, and the new financial incentives are limited especially for the many states facing serious budget problems. Wide variations in access to HCBS can be expected to continue, while HCBS will continue to compete for funding with mandated institutional services.

Disability Rates For Working-Age Adults And For The Elderly Have Stabilized, But Trends For Each Mean Different Results For Costs

The aging of the baby-boom generation, as well as predicted growth in the number of people with disabilities, is expected to increase the demand for long-term services and supports dramatically. This study analyzed data from the Survey of Income and Program Participation from 1984 to 2010 to discern trends among noninstitutionalized working-age adults and the elderly who had some level of disability or need for help with activities of daily living. Some impairments among the elderly, such as in mobility and mental health, decreased. Meanwhile, some impairments among working-age adults, such as in cognitive ability, increased substantially. Of particular importance, the overall prevalence of disability for both age groups has largely stabilized since 2000. Among working-age adults, that stabilization is good news because it eases concern, fueled by prior research, that this population was becoming increasingly disabled and costly to public benefit programs such as Social Security Disability Insurance. However, the flattening of disability trends among the elderly is not good news, since it suggests that the number of elderly people with disabilities will continue to increase in direct proportion to the growing size of the elderly population. Among other implications, the need for both paid workers and unpaid caregivers to assist elderly people, especially those ages seventy-five and older, will continue to increase sharply.

Gradual Rebalancing Of Medicaid Long-Term Services And Supports Saves Money And Serves More People, Statistical Model Shows

States are shifting Medicaid spending on long-term services and supports from institutional to home and community-based services, a process known as rebalancing. Using fifteen years of state expenditure data, a statistical model was developed to assess the effect of rebalancing on overall spending for long-term services and supports. The model indicates that spending is affected by the way rebalancing is implemented: Gradual rebalancing, by roughly two percentage points annually, can reduce spending by about 15 percent over ten years. More rapid rebalancing can save money, break even, or increase spending, depending on the pace and program specifics. Cuts to home and community-based services that hinder rebalancing are likely to increase, not decrease, overall spending on long-term services and supports as people who were receiving these services shift into nursing homes. Because many states continue to experience budget crises, policy makers must think carefully before altering spending patterns for long-term services and supports and adopt strategies that particular states have used to successfully reduce overall spending, such as gradually shifting expenditures toward home and community-based waiver programs.

Long-term services and supports in the community: Toward a research agenda

Researchers, policy experts, and advocates participating in an invitational conference discussed research needed to address pressing policy issues in long-term services and supports (LTSS). Future research on need for LTSS should focus on projections of need, geographic variations, equity, and unmet needs of consumers and caregivers. Research on access to home- and community-based services (HCBS) should address progress in rebalancing LTSS in favor of HCBS, cost-containment strategies, the shift to managed LTSS, and the performance of managed care organizations. Major gaps in research on LTSS costs and quality center on both comparative costs and cost-effectiveness of HCBS versus institutional programs, cost savings of managed LTSS versus fee-for-service, performance incentives in managed LTSS, and LTSS quality and outcome measurement. Research on workers and caregivers could focus on worker availability, improving job quality, worker training standards, the impact of paying family members to provide LTSS, and the private-pay LTSS workforce.