By Tippy Irwin, Executive Director
I must start at the beginning to give a very brief explanation of the Supreme Court’s Olmstead decision. In 1999 the US Supreme Court, in a 6-3 ruling, rejected an appeal brought by the state of Georgia to enforce the institutionalization of a developmentally disabled adult . In doing so, the court thereby recognized the right of the individual to live in the community, in the least restrictive environment possible.
To give some more background on how California has handled paying for long term care I must explain that, in the past, MediCal has only paid for nursing home care, never for those that live in residential care facilities for the elderly (sometimes called assisted living). The burden of payment in those facilities has always fallen to the individuals to pay privately (or, if available, with long-term care insurance). If individuals living in assisted living facilities actually spent down their assets and ran out of money, the fall back position was to work with the physician and MediCal, to get the individual qualified for MediCal and to transfer them to a nursing home so that MediCal would pick up the costs (whether or not they actually needed nursing care). The result of this practice is that in California there are many individuals who are housed in nursing homes that actually do not need nursing care. A very expensive alternative for the state to be funding through MediCal!
In their efforts to comply with the Olmstead Decision, different states have dealt with this decision differently. California has implemented efforts to come into compliance with this ruling by moving individuals housed in nursing homes who are not in need of nursing care, into less restrictive environments at enormous expense, starting initially with the developmentally disabled who were housed in some of the state’s nursing homes. Linked somewhat to the Olmstead decision, but in an attempt to control the rising costs of providing nursing home care, the Center for Medicare and Medical Services (CMS) has driven a project to transition all those out of nursing homes that in fact do not need nursing home care but who could function well in a lesser level of care. A pilot program was implemented some years ago in California to do just that – transition people out of nursing homes back into the community or into assisted living facilities, costs for those that qualify for this program to be covered by MediCal. That pilot project has recently been enlarged to include San Mateo County. The pilot is led by Health Plan San Mateo, who have contracted with Institute on Aging to implement it. Some 200 folk have been identified in our nursing homes who , it has been determined, do not need nursing care and who are to be transferred to more appropriate living situations. We applaud these efforts.
However, there is an unforeseen impact that we are now experiencing. When our frail elders currently living in residential care facilities run out of money, they are not able to qualify for transfer to a nursing home unless they actually need nursing care. A case in point is “Mrs. Jones” who at 93 years old has outlived her life expectancy, outlived all her relatives, and has run out of money. In her words, “I did everything right. I sold my house to pay for the necessary long term care I needed in an assisted living facility, but I did not anticipate living this long.” Where does she go from here? With no money left to pay for her care and no prospect of qualifying for MediCal (she is a relatively healthy 93 year old and needs only assistance to meet her activities for daily living), what is she to do? The safety net that has been in place for years in this state has been taken away, without any apparent plans to fill the gap. She does not meet the criteria to be included in the county’s pilot program. Mrs. Jones is talking about suicide. And she is not alone. There are others who find themselves in similar circumstances and are talking in the same vein. This is the unforeseen impact I refer to in the title of the blog.