Employer-sponsored long-term care insurance: best practices for increasing sponsorship

Behind the enthusiasm of policymakers for long-term care (LTC) insurance is the belief that increased ownership of private LTC insurance will reduce the government's future liability for financing the nation's LTC needs, currently projected by the Congressional Budget Office to increase by 2.6 percent annually between 2000 and 2040. Some observers say that sustained economic growth could keep these increased expenditures at the same share of total GDP; others argue that current federal expenditure trends will become unsustainable without large tax increases. The potential of the employer-sponsored group LTC market to stave off a national LTC financing crisis has recently started to receive popular notice in the news media. However, for the potential of the group LTC market to be realized, there must be widespread employer sponsorship of group LTC plans and significant participation levels among eligible employees in these plans. The present analysis of industry data estimates the LTC plan sponsorship rate for all U.S. employers with 10 or more employees at 0.2 percent. The sponsorship rate among large employers is significantly higher (8.7 percent). The greatest growth opportunities are projected to lie in the smaller employer market, because it is enormous and virtually untapped. Nonsponsors cite a variety of barriers to employer sponsorship of LTC plans. For many nonsponsors, the most important obstacles are the intrinsic characteristics of their work forces: employees are too young, transient, part-time, and/or low-income to be suitable for LTC insurance. For many others, lack of awareness and low priority are the primary obstacles. Because group LTC insurance has been widely available for only 10 years, many benefits managers view it as "too new and untested." Prior to the passage of the Health Insurance Portability and Accountability Act (HIPAA), in August 1996, the tax treatment of long-term care insurance premiums was unclear because Congress had not addressed the issue and the Internal Revenue Service had not issued clear guidance. In essence, HIPAA served to clarify the tax status of LTC insurance and establish product criteria for tax qualification. The interventions contained in HIPAA appear to have been insufficient to stimulate coverage growth rates that will meaningfully reduced the future burden on government financing of LTC. Although employment-based LTC insurance appears to be the best mechanism for mass expansion of coverage at affordable rates, the data suggest that employer sponsorship of LTC plans is relatively rare, especially among smaller employers, and that sponsorship rates may not dramatically increase without significant investments in employer education and new incentives.     

Financing reform for long-term care: strategies for public and private long-term care insurance

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and public long-term care insurance. This article uses the Brookings-ICF Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain severely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of long-term care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment.     

Group long-term care insurance: decision-making factors and implications for financing long-term care

This study proposes and tests a systemic family decision-making framework to understand group long-term care insurance (LTCI) enrollment decisions. A random sample of public employees who were offered group LTCI as a workplace benefit were examined. Findings reveal very good predictive efficacy for the overall conceptual framework with a pseudo R2 value of .687, and reinforced the contributions of factors within the family system. Enrollees were more likely to have discussed the decision with others, used information sources, and had prior experience when compared to non-enrollees. Perceived health status, financial knowledge, attitudes regarding the role of private insurance, risk taking, and coverage features were additional factors related to enrollment decisions. The findings help to inform policymakers about the potential of LTCI as one strategy for financing long-term care.     

Partnership long-term care insurance: lessons for CLASS program development

The Community Living Assistance Services and Supports (CLASS) Act was a voluntary public insurance strategy intended to help people pay for long-term care. CLASS was passed as part of health reform to overcome aspects of private long-term care insurance market failure but came under close scrutiny from both its supporters and its detractors. Experience with the long-term care insurance market and State Partnership Programs provide insights about how to make CLASS fiscally viable. A CLASS program that offered one set of options to cover front-end risk (e.g., 1 to 3 years) and another set to cover catastrophic risk (after a high deductible) could have been offered as an alternative to the basic CLASS "long and lean" benefit model with all enrollees joined into a single risk pool. This would have broadened the risk pool and lowered premium costs under the program.     

Assuring the quality of long-term care insurance benefits through care management: the California partnership for long-term care

Despite recent improvements in long-term care insurance (LTCI) policies, concerns have been raised regarding just how well LTCI benefits actually meet elderly consumers' health and financial needs. In this case study, we examined the quality assurance (QA) provisions in a state-sponsored LTCI program, the California Partnership for Long-Term Care (CPLTC). CPLTC invests the primary responsibility for QA with care management networks, which assure quality services through care monitoring, quarterly service record reviews, and annual documentation of care manager clinical competence. Study findings suggest a number of limitations in existing QA policies and procedures, which can undermine the ability of care managers and other third parties to identify and rectify potential unmet needs among LTCI policyholders. These findings, while based on an intensive analysis of QA provisions in a particular, state-sponsored LTCI program, are likely to have implications for other LTCI programs and policies, most of which have less well-developed QA provisions.     

Aged care service delivery in Japan: preparing for the long-term care insurance scheme

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term.     

The long-term care insurance law in Israel: present and future

Aging in place is a core component of the policy on aging in Israel. This was well expressed in the Long-Term Care Insurance law enacted in 1986 and implemented in 1988. Under the law, disabled persons can receive in-kind home- and community-based services to enable frail older adults to age in place and to complement or supplement the care provided primarily by family caregivers who are legally responsible for caregiving of their elderly family members. This article presents the main principles of the law and reviews the amendments that this law has undergone during the past 22 years. Finally, some core issues and dilemmas are discussed.     

The transition from state care to adulthood: international examples of best practices

Around the world, the transition from adulthood is a difficult time for many youth. It is even more difficult for those who are transitioning to adulthood without the benefit of a support network full of family and friends. Youth leaving state care face a transition to independence and adulthood without many of the skills and supports most others take for granted. Preparedness is key to a successful transition, and youth leaving state care tend to be lacking it. In order for youth to truly be prepared for the transition process, they must have support in key areas of their lives: relationships, education, housing, life skills, identity, youth engagement, emotional healing, and adequate financial support. Without these supports, the dismal outcomes for youth transitioning to adulthood will remain unchanged. The United States, England, and Australia have successful programs targeting youth as they transition out of state care. These initiatives bring together and address the variety of needs of this unique population and aim to improve outcomes. While many of these programs and policies are in their infancy, they show promising results, and each contributes valuable experience to successfully working with youth through this tough transition.     

Israel's long-term care insurance law after a decade of implementation

Israel's Long-Term Care Insurance (LTCI) law has been in effect for a decade. It is timely to review the effects of this legislation with a view to identifying possible directions for reform and lessons for other countries considering the introduction of a similar social insurance scheme. The paper considers the law's effects in terms of the size and characteristics of the beneficiary population, the coverage of the scheme, its financial standing, the rate of institutionalization of the elderly, the caregiving burden, the service delivery system, and the overall scope of long-term care services for the aged. Israel's experience has lessons for financing arrangements, target efficiency, service delivery arrangements, and the construction of the burden of care.     

The role of life experience in long-term care insurance decisions

This study uses data from a unique survey of the retirement planning behaviors of late middle-aged individuals living in New York State, to test hypotheses regarding the role of earlier life experiences on the demand for long-term care insurance. Our primary focus is on previous provision of informal long-term care, which some studies have found to be correlated with demand for long-term care insurance. We add to the literature by providing a test for causal relationships between previous care-giving and insurance demand, and by exploring the more generally the mechanisms through which previous life experiences are linked to insurance demand. Results are robust to a variety of empirical specifications and estimation methods, including consideration of current care-giving roles and endogenous selection into previous care-giving, and strongly support a causal relationship between previous long-term care-giving and demand for insurance. Our estimates also provide evidence that lifetime health trajectories and family relationships are associated with long-term care insurance demand, and suggest that both emotional and informational forces influence demand.     

Voluntary work in the Norwegian long-term care sector: complementing or substituting formal services?

ABSTRACT

Across Europe, governments call for increased involvement of volunteers to shoulder some of the welfare burden. Nevertheless, there is little research into what kind of work and how much volunteers currently contribute in the long-term care services and whether this has the potential to substitute formal services. Drawing on findings from a survey of employees in Norwegian nursing homes and home care districts, we examine the nature and volume of voluntary, unpaid work in the long-term care services in Norway. Our data suggest that volunteers to a very limited degree carry out work that has traditionally been considered the formal system’s domain: personal care and practical help. Nearly all the voluntary, unpaid contributions in our data takes place within cultural, social and other activities aimed at promoting mental stimulation and well-being, indicating a classic specialisation of tasks between volunteers and professionals. However, there has been an expansion of the formal care system to include activities aimed at promoting well-being in recent decades. This may indicate that there is a certain level of task sharing between voluntary and formal care. Thus, social workers need to consider voluntary service provision when assessing the needs of clients.     

The importance of employer sponsorship in the long-term care insurance market

Medicare and Medicaid are major sources of long-term care payments and thus will bear much of the burden from the growth in long-term care service use. The large future demand for long-term care services is of great concern among policymakers due to its expense and the use of public program dollars. It is argued that the individual purchase of long-term care insurance can help alleviate the increasing financial pressure on public programs responsible for the majority of longterm care financing. However, consumers have shown little interest in insuring against the high costs of long-term care. This analysis examines the effect of several factors on the decision to purchase a long-term care insurance policy: knowledge and attitudes of long-term care insurance and the long-term care financing system, the perceived risk for longterm care, financial planning behavior, and the availability of long-term care insurance. The interim results indicate the factor most likely to affect the decision to purchase long-term care insurance is access to employer-sponsored long-term care insurance. This suggests tht the availability of affordable and high quality coverage is more important than demand-side factors such as awareness of long-term care insurance and a perceived greater risk for long-term care.     

Enabling informed consumer choice in the long-term care insurance market.

Provisions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may increase private long-term care insurance sales without imposing substantially more stringent consumer-protection features. The ability of consumers to make informed choices when purchasing this complex product is examined in light of these changes. Data were collected through detailed examinations of policies and interviews with industry experts, insurance companies, agents, consumer groups, and regulators. Because of the complexity of this product, the goals of expanding, consumer choice and ensuring that consumers are able to make informed decisions often work against each other. Mechanisms are discussed through which the government can facilitate informed choice and improve consumer protection. The authors contend that, because the government is providing tax incentives that encourage consumers to purchase the product, it has the responsibility to ensure that consumers understand the long-term care insurance they purchase.     

Polyvictimization in later life: Trauma-informed best practices

ABSTRACT

This article provides a summary of salient trauma findings and conveys the dearth of research pertaining specifically to the trauma of elder abuse. This material, in conjunction with information contained in other articles composing this special issue, lays the foundation for advancing a trauma-informed approach to assisting older adults who have experienced polyvictimization. Informed by the findings presented and their extensive clinical experience with victims of violence, the authors suggest steps for providing a trauma-informed and victim-centered response to older adults who have suffered polyvictimization. These steps are then illustrated with an in-depth late-life polyvictimization case analysis.     

Health insurance for all long-term care workers: estimated costs and coverage impacts in Minnesota and recommendations for States

A major barrier to building a strong workforce to meet the growing need for long-care is lack of affordable health benefits. This study projects impacts of funding health coverage for all long-term care workers in Minnesota. Under the most cost effective model plan design, enrollment in employer-sponsored coverage would increase 73% to 100% for individual coverage and 26% to 42% for family coverage. Total monthly costs would be $698/worker in the commercial market or $634/worker through a new dedicated risk pool. Based on our findings and past research, the authors present recommendations for structuring and implementing a long-term care worker health insurance initiative.     

Differences in facilities' acceptance of patients under long-term care insurance in Japan

OBJECTIVES: In April 2000, Japan launched a public, long-term care insurance (LTCI) plan for elderly people who need support. This study describes how medical support for the elderly is delivered at LTCI care facilities in Japan now and gaps between system goals and current activity. Recommendations are made for enhancing the implementation of LTCI. METHODS: We mailed questionnaires to all health service facilities for the elderly (HSF) and special nursing homes for the elderly (SNH) located in the Kyushu area of Japan, asking whether they would accept patients with nine specific conditions. RESULTS: We found that HSFs, which are required to employ a full-time doctor and are reimbursed at a higher rate, accept significantly fewer patients with four conditions that need medical support than are accepted by SNHs, which are not required to employ a full-time doctor. DISCUSSION: In this study, we find discrepancies between system goals and current activities at LTCI care facilities. For the Japanese LTCI system to work well in the limitation of medical resources, we must understand how it really works and to reform the system continuously.     

Better Futures: A validated model for increasing postsecondary preparation and participation of youth in foster care with mental health challenges

Higher education participation rates of young people in foster care are dramatically lower than their level of postsecondary education aspiration. Increasing attention to this disparity has stimulated policy and practice enhancements, however rigorously validated models for promoting postsecondary preparation and participation have not existed for young people in foster care, including those with mental health conditions. This article describes Better Futures, which is the first such model to be experimentally validated as effective for increasing the higher education participation and other related outcomes of young people in foster care with mental health challenges. Better Futures features a four day on-campus Summer Institute, coaching provided to youth by older peers who are in college and have shared experiences around foster care and/or mental health, and workshops that bring together youth, coaches and guest speakers for information sharing and mutual support. This article includes the theoretical and component features of the Better Futures model, findings related to intervention fidelity, participants' evaluation of the program, and discussion of implications for future model refinement and research.     

Standardization of surgical procedures for identifying best practices and training

A taxonomy was developed a) to describe surgical procedures with sufficient detail to review differences among surgeons, b) to examine the relationship between individual technique and outcomes, c) to enable surgeons to standardize technique around best practices and d) to identify clinical-evidence-based key points of teaching and assessment for surgical training. Sixty-seven microvascular anastomoses were recorded through video cameras mounted in the dissecting microscope. A hierarchical task analysis was used to decompose the observed procedures into successive levels of detail. The results were then presented to individual and small groups of microvascular surgeons to help define steps and step attributes necessary to describe a procedure so that other surgeons can perform the procedure exactly the same way. Coincidently, it was found that because the surgeons' attention is confined to a very small field of view in which they can see only the veins and arteries and the ends of their instruments, they often have difficulty communicating with others in the operating room. Analyses of selected cases using the proposed taxonomy shows how subtle details are revealed that may affect outcomes, and indicate specific training needs. By comparing different methods and outcomes, it should be possible to identify best practices for given conditions.