Date of Publication:

June 20, 2016

The rapid aging of the U.S. presents future Administrations and Congress with multiple challenges and opportunities for improving access to long-term services and supports (LTSS).  As noted in a brief published in conjunction with the Sixth White House Conference on Aging, the baseline factors are complex: “Most Americans underestimate the risk of developing a disability and needing long-term services and supports…[W]e estimate that about half (52%) of Americans turning 65 today will develop a disability serious enough to require LTSS, although most will need assistance for less than two years. About one in seven adults, however, will have a disability for more than five years. On average, an American turning 65 today will incur $138,000 in future LTSS costs, which could be financed by setting aside $70,000 today. Families will pay about half of the costs themselves out-of-pocket, with the rest covered by public programs and private insurance. While most people with LTSS needs will spend relatively little on their care, about one in six (17%) will spend at least $100,000 out-of-pocket for future LTSS.” (Long-Term Services and Supports for Older Adults: Risks and Financing Research Brief, Urban Institute and ASPE, July 2015).

These statistics and analysis demonstrate that the U.S. lacks a coherently designed system to protect families from the catastrophic costs of traumatic illnesses and disabilities that too often accompany a need for LTSS. Medicaid acts as a critical backstop, but is means-tested and will continue to face strains, particularly as state budgets face pressures to cut services. In addition, despite progress, the U.S. delivery system is still biased towards provision of costly institutional care and lacks a robust home and community-based sector that can be readily expanded to address the demands of the “age wave.”

The chart and timeline below is an attempt to capture, advance and seed ideas for phased-in solutions that are politically feasible, national in scale, and which could potentially help to make LTSS more efficient through a better balancing of incentives and resources. Following repeal of the Community Living Assistance Services and Supports Act (CLASS) in 2013, stakeholders began to discuss and develop possible additional policy solutions to expanding and financing LTSS. This group of proposed solutions may offer a way to take lessons learned forward and to expand access to LTSS coverage using both the private and public sectors.  In the short term, economic and actuarial modeling, which is already underway, can be employed to develop details and estimate potential budgetary impacts. With this information, subsequent initiatives can be developed, implemented and scaled up, along with appropriate adjustments made over time.

Many more initiatives than are listed here are possible! Please feel free to add your ideas into this framework, highlight them, and email back to us ADD EMAIL. We’ll update the framework and keep it “live,” which can be found at ADD LINK.

Overview of LTSS Policy Solutions

Financing LTSS - Expanding on What Works

  • Model possible changes to Medicaid FMAP with addition of age and disability factors to ensure resources are there to help states with large and growing populations of beneficiaries needing LTSS.
  • Standardize consumer protections for all long-term care insurance (LTCI) policies.
  • Develop a front-end LTSS coverage initiative building off lessons learned from OPM’s Federal Long-Term Care Insurance Program that would offer time-limited front-end LTSS coverage through a variety of venues, including online, through exchanges and other venues.
  • Examine and model allowing those who participate at a certain level of coverage in the front-end LTSS program access to Medicaid LTSS without an asset spend-down after the policy term expires.
  • Examine and model options for development of a national LTSS reinsurance program that is linked to the front-end LTSS coverage initiative.

Reforming the Delivery System - Creating  Integrated, Community-Anchored Care

  • Within the constraints of current funding and current programs, accelerate the move toward programs that can offer medical+LTSS (e.g., more aid for family caregivers, greater availability of personal care, housing assistance and transportation) through programs that would harvest savings from overutilized medical care and repurpose them to buttress provision of critically important community-based LTSS.
  • For persons with disabilities who can work, develop Medicaid buy-in option to ensure they can receive LTSS.

Building an LTSS Workforce - Improving Training, Setting Standards, and Energizing Volunteers

  • Develop national training models and standards for “advanced-care aides;” also establish national standards for personal and home care aides based on results of six-state national demonstration (PHCAST).
  • Create a national blueprint for local “Caregiver Corps” programs that organize and train volunteers of all ages to provide companionship and non-medical assistance to older adults and individuals with disabilities.

Enhancing Quality and Protecting Consumers - Creating Measures for Performance

  • Develop and implement a core set of LTSS quality measures across all settings and programs, a standardized assessment process for family caregivers, and a universal care planning process that incorporates treatment preference sand quality of life goals for individuals receiving LTSS.


Financing LTSS - Expanding on What Works


Short Term Actions

Intermediate Term Actions

Longer Term Actions

--Develop legislation to create uniform standards for long-term care insurance to improve the private delivery system; specifically, all of the standards that have been developed by NAIC to date (adapted/updated from Confidence in Long-Term Care Insurance Act, 112th Congress). Building on the “federal floor” precedent established by HIPAA, national standards would be periodically updated as NAIC developed new standards, which would be reviewed by the Depts. of HHS and Treasury and promulgated via regulation. New reporting and transparency requirements to aid consumers and regulators would be established as well.

--Commission actuarial analysis of the design and impact of building out a new program that draws lessons from OPM’s Federal Long-Term Care Insurance Program to create a nationally-organized front-end LTSS coverage program for non-federal workers. Objective would be for consumers to be able to purchase a variety of time-limited, affordably priced LTSS products online, through exchanges and via other venues. Carriers would submit proposals/bids to be included in the program, including a cash option.


--Commission analysis of options for design of possible LTSS national reinsurance program tied to front-end LTSS coverage program.


--Commission cost analysis to examine allowing participants in front-end LTSS coverage program to modify asset requirements for Medicaid LTSS eligibility after product term has expired.

--Commission analysis of the possible structure and cost of a Medicaid buy-in program option for working individuals with significant disabilities and incomes are below 250% of FPL; a separate analysis would be done for those with incomes above 250% of FPL (Federal LTC Commission).

--Analyze options for strengthening Medicaid’s ability to finance LTSS services through examination of the impact of adding adjustments for age and disability to population and services data governing the program’s FMAP formula (GAO).

--Develop legislation for Medicaid age and disability FMAP adjustments; front-end LTSS coverage program for non-federal workers; LTSS national reinsurance framework; Medicaid buy-in option(s); and Medicaid modification of asset test as described in col. 1, depending on results of initial analyses..


--If and as enacted, implementation of programs for Medicaid age and disability FMAP adjustments, LTSS front-end coverage program, LTSS national reinsurance program, Medicaid buy-in option(s) and asset test modification.




Reforming the Delivery System - Creating Integrated Community Care

Short Term Actions

Intermediate Term Actions

Longer Term Actions

--Implement initiative for communities and states wishing to establish programs of medical+LTSS for Medicare beneficiaries (i.e., those with 2 or more ADLs, cognitive impairment requiring constant supervision, or age 85 and older) through appropriate modifications to existing models of care, e.g., the PACE program or Accountable Care Organization, or through development of new models, e.g., Alternative Payment Models. These programs would offer services to an enrolled population within a defined geographic coverage area. Programs would be required to repurpose a significant portion of savings harvested from reducing low-value, overutilized services (e.g., inappropriate hospitalizations and premature placement of beneficiaries in long-stay nursing facilities) for HCBS. Programs would also help launch a community-wide quality dashboard on performance metrics for local providers providing services to elders.


--Analysis of the impact of using HIPAA benefit eligibility triggers for accessing IRAs and 401K plans with no tax penalty in cases of permanent disability.

--HHS expands medical+LTSS programs for Medicare beneficiaries needing LTSS services (see col. 1) and other promising initiatives that provide medical+LTSS services in a cost-effective manner.







--Upon enrollment to Medicare, HHS would provide information to beneficiaries about available coverage options that offer both medical and LTSS services that they may wish to consider enrolling in, including community-anchored medical+LTSS programs, Independence at Home and other initiatives, including PACE, ACOs, D-SNPs, etc.



Building an LTSS Workforce - Improving Training, Setting Standards, and Energizing Volunteers

Short Term Actions

Intermediate Term Actions

Longer Term Actions

--Establishment of interagency LTSS workforce commission, which could, among other initiatives, examine training of the LTSS workforce across various settings, e.g., nursing homes implementing culture change, assisted living residences, various housing-with-services providers, home health and personal care agencies, and other types of providers/initiatives/programs/plans offering LTSS. Commission could also head development of core competencies and training criteria for “advanced care aides.”


--Development of national training standards for personal and home care aides that draw from and are informed by the Personal and Home Care Aide State Training Program (PHCAST) evaluation findings.



--Implementation of national standards for personal and home care aides based on PHCAST evaluation.


--Fund national demonstration to develop, test and evaluate advanced care aide training programs based on core competencies (see col. 1).


--Development of a national “Caregiver Corps” blueprint designed for adaptation by interested communities/public and private sector entities to expand the capacity of localities to serve frail elders and individuals with disabilities needing assistance with IADLs.  Applicants (young college grads through older adults) would undergo a screening process (including a background check) and training to prepare them for assisting frail elders and individuals with disabilities. Local Caregiver Corps programs sponsoring volunteers could provide them with a small stipend; a place to live for a period of time; loan forgiveness; a way to “bank” their volunteer hours for later use, or another form of recognition.

--Development of training recommendations for the LTSS workforce across various settings offering LTSS, e.g., nursing homes implementing culture change, assisted living residences, various housing-with-services providers, home health and personal care agencies and other types of providers/initiatives/programs/plans offering LTSS.

--Development and dissemination of recommendations for geriatric and LTSS competency standards that could serve as a baseline for informing training in medical schools and health professions educational institutions and continuing education programs. Competency standards could be developed by expert parties, e.g., GECs, AAMC, ANA, AMA, AMDA, AGS, NASW, PHI, etc.


--Implementation of advanced care aide national training standards (see col. 1,2).




Enhancing Quality and Measuring What Matters

Short Term Actions

Intermediate Term Actions

Longer Term Actions

--Development of standardized core assessment instrument for family caregivers, for possible adoption by OAA programs, Medicaid programs, LTSS and post-acute care providers.


--Development of a universal care planning template that could be used by providers offering post-acute and LTSS services, and which allows for incorporation of individual treatment preferences and quality of life goals.



--Dissemination of standardized core assessment instrument for family caregivers.


--Identification of a set of core LTSS quality of life measures.


--Implementation by HHS of a universal care planning template that incorporates individual treatment preferences and quality of life goals, for use in post-acute care and LTSS settings.


--Dissemination of a set of LTSS core quality of life measures. Construction of an LTSS Quality of Life Compare System across various providers.


Project Leaders

Project Leader

Anne Montgomery Portrait

Anne Montgomery

Deputy Director, Center for Elder Care and Advanced Illness


Subject Matter Experts

Areas of Expertise