Don Redfoot

Donald L. Redfoot, Ph.D., has been a strategic policy advisor with the AARP Public Policy Institute for 18 years, conducting and supervising policy research on: financing options for long-term services and supports; trends in disability, institutional care, and family caregiving; and international comparisons of long-term care systems.
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Life spans are increasing around the world, but countries differ enormously in how they deal with increasing demands for long-term services and supports (LTSS). AARP International recently sponsored a policy symposium on the LTSS systems in Germany, France and the United Kingdom to inform important discussions about how to reform the U.S. system.
Imagine that you have been named CEO of an underperforming major corporation. Your competitors outperform your company on some measures by ratios of 3 or 4 to 1. Consumers prefer the products of your competitors by similar lopsided margins. Your operating costs are lower than most, but your equipment and management processes are antiquated and result in unnecessary inefficiencies and poor quality products. What would you do?
Mature woman with dog.
How would you describe what "home" means to you? When do you feel most engaged in a "community"? If you struggle to answer those questions, imagine a federal agency trying to define what "home" and "community" mean for the purposes of important public benefits. That is essentially the task that the Centers for Medicare & Medicaid Services (CMS) set for itself several years ago as it began the long path to its recently released rule related to home- and community-based services (HCBS) funded under the Medicaid program.
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The AARP Public Policy Institute (PPI) had a Solutions Forum on Oct. 30 to discuss ways to ensure that Medicaid beneficiaries get the supportive services they need in settings that they choose (See Twitter conversation at #MedMod and event transcript). AARP Executive Vice President Debra Whitman remarked that "the need for long-term services and supports is not a partisan issue. It affects Democrats. It affects Republicans. It affects wealthy people. It affects poor people. It affects old and young, all races and creeds. And we also know that most people want to live in their homes and communities."
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Do the rich benefit from the welfare-based Medicaid program? Not according to much of the testimony presented at a recent hearing of the federal Commission on Long-Term Care. Here are key questions the hearing addressed:
Caregiving value
A welcome recognition of the value of family caregiving came in a recent report by the Congressional Budget Office (CBO), which estimated the economic value of caregiving for older persons in 2011 to be $234 billion. This estimate vastly exceeds the total amount of paid care from all sources (Medicaid, Medicare, private pay and others) for both institutional care ($134 billion) and home and community-based services ($58 billion).
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Dealing with disability in old age can cost a lot of money. As a result, Medicaid has been an important safety net program for those who exhaust their life savings. Some observers worry that projected growth in the older population could greatly increase Medicaid expenditures while others are concerned that too many well-off older people shirk their personal responsibility and rely on Medicaid to pay for long-term services and supports (LTSS).
Redfoot
Greater longevity is a measure of enormous progress for older Americans. But greater longevity has also created new challenges.  Particularly troubling is what happens to middle-class security for Americans who reach advanced old age.
Who Turns to Medicaid?
Most people don't think of themselves as potential welfare recipients. But seven out of ten people who reach the age of 65 will need long-term services and supports (LTSS) during their lives, and three in ten will eventually rely on Medicaid to pay a significant share of the costs of their care.
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