CMS Report Confirms Medicaid Cuts Would Jeopardize Critical Services and Long-Term Program Stability

CMS Report Confirms Medicaid Cuts Would Jeopardize Critical Services and Long-Term Program Stability

The proposed American Health Care Act (AHCA) would make significant changes to the Medicaid program, which serves as a critical safety net for millions of people who deplete their life savings and turn to Medicaid for assistance as their ability to care for themselves declines. The bill would repeal the Medicaid expansion and implement a capped financing model for states. According to the nonpartisan Congressional Budget Office (CBO), the AHCA would cut $834 billion from the Medicaid program through fiscal year (FY) 2026. CBO projects that 23 million people would lose coverage as a result of the AHCA, most of them — 14 million — because of the changes to Medicaid.

The Centers for Medicare & Medicaid Services (CMS), which administers the Medicaid program, has released a new report suggesting, based on different assumptions, that 8 million people would lose Medicaid under the AHCA through FY2026. While the numbers differ between the CMS and the CBO, one thing is clear: The AHCA would cut Medicaid financing to states and millions of people would lose coverage for critical services. In its report, CMS also makes clear the danger of the bill for Medicaid enrollees, particularly for older adults and people with disabilities that rely on Medicaid for home- and community-based services.

Medicaid Home and Community-Based Services in Jeopardy

Zeroing in on the CMS report, an initial read suggests minor implications of capped financing for Medicaid. According to CMS, “There is no estimated impact on Medicaid enrollment because of the presence of the per capita allotments.” Reading between the lines, however, tells a much different story.

To reach this conclusion, CMS assumes that states will “(i) lower provider reimbursement rates; (ii) manage utilization and program efficiency; and (iii) reduce optional services.” When CMS refers to “optional services” it means services that are not required by the federal government and offered at the discretion of states. Home- and community-based services (HCBS) are generally classified as optional, and states have the flexibility to offer this support or to take it away. Notably, while “optional,” HCBS is often a more cost-effective option than nursing home care — not to mention what people tend to prefer.

According to analysis from the Center on Budget and Policy Priorities, most (88 percent) Medicaid spending on optional services went toward older adults and people with disabilities, and of this spending, more than half went toward home- and community-based services.

If, as CMS suggests, states are going to reduce optional services to make up for gaps caused by capped Medicaid financing, HCBS will almost certainly become a target. This is a potential unintended consequence of the bill — that is, states limiting access to Medicaid HCBS to stay within the caps and thereby likely increasing the use of more expensive services like nursing home care, which is required by law.

While HCBS are more in line with consumer choice and has the potential to limit cost growth, they are optional in Medicaid and thus in jeopardy if the bill becomes law. The new CMS report makes this clear, and suggests additional, long-term danger for Medicaid under the AHCA.

Long-Term Implications of the AHCA for Medicaid

In addition to the impacts of the per capita caps on HCBS, the CMS report makes clear that the proposed per capita caps in the AHCA may have long-term impacts that threaten how states run their programs.

The report states, Over a longer time period, it may be more difficult for States to operate their Medicaid programs without making more significant changes to their programs,” although no further explanation is available.

Additional research, however, has given insight toward the long-term impacts of capped Medicaid financing. A recent AARP report, for example, shows that the growing and aging of the 65-plus population will have significant cost implications for Medicaid that the AHCA does not take into account.

If a per capita cap structure is implemented in Medicaid, the impact will be felt for years beyond 2026. The limited growth rates allowed by the caps would lead to shortfalls in how much money states have to serve older adults, people with disabilities and low-income children and adults. As a result, states will be forced to cut services, restrict eligibility, cut provider rates — or a combination of any number of those.

Looking Forward

Whether it’s research from CMS or CBO, it is clear that changes proposed to the Medicaid program under the AHCA pose significant near- and long-term risks to states and to consumers. Reducing access to home- and community-based services — and Medicaid in general — will harm older adults and people with disabilities. Going forward, discussion around health reform should focus not on where to cut Medicaid, but rather on how existing funds could be used more efficiently to meet people’s needs.


Brendan Flinn is a policy research senior analyst for the AARP Public Policy Institute. He works on Medicaid, long-term services and supports, and family caregiving issues.

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Celebrate Father’s Day: Acknowledge Our Male Family Caregivers

Celebrate Father’s Day: Acknowledge Our Male Family Caregivers

When Eric Epstein, 56, a lawyer from New York City, learned that his 83-year-old father, Bill, had fractured his right hip while vacationing in Utah, he was on the next plane. “I wanted to make sure he was getting quality care in an unfamiliar hospital,” Epstein recalls. When the doctors determined a few days later that Bill would need a second surgery, Eric was instrumental in booking the return flights to NYC, arranging for transportation, wheeling his 6’4”, 250-pound father onto the plane, and transferring him carefully from the wheelchair to his seat.

Now that Eric’s father is recovering at a nearby rehab facility, Eric visits at least four days a week (often after a long day at work) to check on his progress, and will help prepare his mother to prepare their apartment when Bill gets the green light to return home in a few weeks.

Eric is one of 16 million male family caregivers in the U.S. Like their female counterparts, male caregivers are often called upon to perform a range of tasks—from managing finances and grocery shopping to housework and meal prep as well as challenging medical and nursing tasks.

When I hear Eric’s story—and when the AARP Public Policy Institute releases research on this important topic—I’m struck by the fact that the male population traditionally isn’t recognized for performing caregiving tasks. Yet there are many of them, and they’re rising to the challenge.


Leading the Way on Male Caregiver Research

Until recently, not much research was available that examined the impact of caregiving on male family caregivers, whether they’re caring for a parent, spouse, other relative, or even a neighbor or friend (also included in the term family caregiver). It’s a topic I’ve long wanted the Public Policy Institute to explore, so that’s what we’ve done. In March we released a report by my colleague Jean Accius, PhD, “Breaking Stereotypes: Spotlight on Male Family Caregivers,” that provides current information about the experiences and challenges facing this important segment of our health care system. A major takeaway from the report is that, contrary to many people’s assumptions, men represent four in 10 family caregivers.

Since the report’s release, Jean, who serves as VP of livable communities and long-term services and supports for the AARP Public Policy Institute, has become a go-to source on the topic for media outlets including Forbes and ESPN’s The Undefeated. And, of course, he’s blogged on the topic for our website.

One statistic that jumped out at me from the research is that nearly two-thirds of male family caregivers indicated that their caregiving experience was stressful, both physically and mentally. Male caregivers also are less likely than women to seek external support to deal with this stress.


Support Is Available

To help alleviate the stress and get the word out that support is available, we produced a series of videos, specifically targeted at the male caregiving community. Two of the videos focus on support groups in various communities that help men realize they’re not alone in their day-to-day struggles to care for loved ones.

With Father’s Day coming this weekend, I hope you’ll take the time to acknowledge any male caregivers in your life, and perhaps offer to take a task or two off of their plates. Running an errand on a relative or friend’s behalf may not seem as significant as a necktie or a set of golf clubs. But chances are, he’ll appreciate the effort as much as any gift you could buy.

Are you a male caregiver, or do you live with one? If so, please share how you (or he) keep(s) stress at bay. I would love to share your tips in a later post.

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Good for Business: Making the Case to Fight Financial Exploitation

Good for Business: Making the Case to Fight Financial Exploitation

Financial exploitation is an issue that demands financial institutions’ attention. Banks lose an estimated $1 billion (and rising) annually in deposits. Thieves especially target older Americans (those over 50), with good reason — these customers own two-thirds of all bank deposits. An estimated 1 in 5 older Americans are victims of financial exploitation.

Despite these statistics, many financial institutions may not immediately see the business case for fighting exploitation. Executives and managers may believe that the additional training, manpower and corporate focus on this issue may not deliver the return on investment that other initiatives can provide. Some may even feel that customers are responsible for protecting themselves from scams and other forms of exploitation.

As we celebrate the 12th anniversary of World Elder Abuse Awareness Day we applaud the leadership of many financial institutions that have voluntarily developed simple yet effective solutions to fight exploitation. Financial institutions like First Financial of Texas, Suncoast Credit Union, Barclays UK, Lloyds of London and Bank of American Fork, to name a few, are making dedicated efforts to fight financial exploitation because it makes good business sense. Benefits from efforts to prevent exploitation include:

  • Reduced loss: Money stays in customers’ accounts when bank employees spot and prevent exploitation. One small community bank prevented an estimated $1 million in losses in just one year.
  • Community Reinvestment Act (CRA) credits: Several banks obtained CRA credits for their efforts to educate customers and the community on avoiding financial exploitation.
  • Enhanced employee morale: Contributing to a greater cause like preventing exploitation increases job satisfaction, boosts performance, and makes employees feel a greater sense of purpose, according to studies.
  • Increased brand distinction: Institutions working actively to fight exploitation report that brand distinction (the number of customers recommending the bank to someone else) increased as a direct result of these efforts. In addition, fighting exploitation often results in positive press coverage for financial institutions.
  • Stronger customer relationships and trust: Fighting financial exploitation builds trust among customers. Recent research shows four out of five customers age 50-plus prefer establishing their accounts with financial institutions that provide anti-exploitation services.


A new AARP report, “Join the Fight: Why Financial Institutions Should Fight Exploitation and Protect Savings,” presents the business case for anti-exploitation efforts. The report examines some of the barriers that prevent financial institutions from doing more to fight exploitation, and presents solutions that banks are successfully using to overcome or eliminate these barriers. It also offers several promising practices that financial institutions can adopt to ensure the effectiveness of their exploitation prevention programs. Using these principles banks can learn that fighting exploitation is good for business and for their older customers.

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Coming June 14: All-New State Scorecard on Long-Term Services & Supports

Coming June 14: All-New State Scorecard on Long-Term Services & Supports

This is an exciting month for AARP’s Public Policy Institute. We’re set to release our third Long-Term Services and Supports (LTSS) State Scorecard Report on June 14, and this powerful tool is far more interactive and comprehensive than the 2011 and 2014 installments.

A lot has changed since 2011 when we first partnered with the Commonwealth Fund and the SCAN Foundation to conceive of the idea for a scorecard that would measure long-term services and supports for older adults as well as people with physical disabilities and family caregivers on a state-by-state basis.

At the time, I concluded in an article that, based on the report’s findings, even the best performing states had a long way to go to create a high-performing system of long-term services and supports. Certainly many states have made progress since then, and no doubt the 2017 Scorecard will continue to highlight that progress. But there’s also little doubt that the Scorecard will uncover a list of shortcomings and areas for improvement. That’s what the Scorecard was all about in its 2011 and 2014 iterations, and that’s what the 2017 Scorecard promises to illuminate.

Of course, the actual Scorecard release is not the most exciting part. What’s truly exciting is the impact it can have after its release. We’re encouraged by how policymakers and advocates viewed the 2014 Scorecard for what it was: a call to action. Many used the information in the report as a tool to make positive change in their states. With Americans living longer and LTSS demand continually growing, our call to action must be louder and more pronounced than ever.

Thanks to the efforts of all involved in compiling and organizing data for the 2017 Scorecard, I’m proud to say that—no question—it tops the 2014 installment in value as a key tool in the field. So, what’s the same and what’s different this time around? Like the first two installments, the 2017 Scorecard examines state performance across five key categories, or dimensions:

  • Affordability and access
  • Choice of setting and provider
  • Quality of life and quality of care
  • Support for family caregivers
  • Effective transitions

But this year, we’ve placed an emphasis more than ever on how the results are presented. The information on our website will be truly interactive and engaging than in years past. (The new version of the site,, will appear June 14.)   Users can easily customize data to suit their needs, no matter what role they play in LTSS and where they’re located. While our accompanying report remains an invaluable source of information, the interactive website has become the true centerpiece of the offering.

Other new additions of which we’re extremely proud: Visitors to the site will have access to videos, called Impact Stories, that show how improving on the Scorecard can impact the lives of real people. Users can also download Promising Practices such as this one as well as Emerging Innovations that states can use as they work to improve the lives of older adults, those with physical disabilities, and family caregivers. Better still, new and groundbreaking content will not stop with the June 14 Scorecard release. We’ll continue to bring you more Promising Practices and Emerging Innovations, as well as releases in our Impact Story video series, throughout the year.

My colleague Jean Accius, vice president for Independent Living/Long-term Services and Supports, who was instrumental in spearheading these changes, summed up their value succinctly when he said, “These concrete tools and innovative practices will help states improve their performance and, ultimately, the lives and well-being of others.” As for the addition of the Impact Story videos this year, he added that they “literally complete the picture—putting a face to the diversity of individuals whom the Scorecard examines.”

Will this year’s Scorecard illuminate shortcomings and challenges in LTSS as it has in the past? Absolutely. (Here’s a teaser: we’ve got a long way to go.) But I’m extremely excited that we’ll also shine a light on a path forward for all caregiving stakeholders.

Susan Reinhard is a senior vice president at AARP, directing its Public Policy Institute, the focal point for AARP’s public policy research and analysis. She also serves as the chief strategist for the Center to Champion Nursing in America, a resource center to ensure the nation has the nurses it needs.


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No Wrong Door: Promising Practices for Accessing Long-Term Services and Supports

No Wrong Door: Promising Practices for Accessing Long-Term Services and Supports

Photo courtesy of Sullivan County New Hampshire ServiceLink

Most of us will need long-term services and supports (LTSS), either for ourselves or our family members. However, most of us do not know about our options and how to pay for these services. That is why the LTSS State Scorecard—created by the AARP Public Policy Institute and funded by The Scan Foundation and The Commonwealth Fund—ranks states on their Aging and Disability Resource Centers. These Centers are an important feature of a high performing LTSS system.

Aging and Disability Resource Centers can serve as the gateway for helping individuals and their families find and access LTSS, including light housekeeping, transportation, and respite care to give family caregivers a break, just to name a few. States have these “one-stop-shopping” models to help people receive public and private services regardless of which organization they contact. Therefore, they are sometimes called “no wrong door.” If people contact an organization within this system, they can be connected with information, referrals, and supports, resulting in “no wrong door” to services irrespective of their age, income, or disability. Area Agencies on Aging, Centers for Independent Living, and state agencies such as Medicaid agencies and state units on aging work together to make up this no wrong door system. While the states have these centers, the operations and functions of each center vary greatly, which is why the Scorecard ranks them.

Although the previous two Scorecards included an indicator on these Centers, the upcoming third edition contains an updated indicator to reflect published guidance on key elements of no wrong door systems from the federal government. AARP, in collaboration with the U.S. Administration for Community Living and The Lewin Group, collected information for this indicator from a survey of state administrators. Then, they followed up by interviewing administrators from states that had scored well or demonstrated innovation to produce a newly released promising practices and toolkit paper on person- and family-centered practices.

This first in a series of promising practices and toolkit papers provides concrete examples of how six states—Connecticut, Michigan, New Hampshire, Virginia, Washington, and Wisconsin—plus the District of Columbia promote person- and family-centered practices in their no wrong door systems. These Centers are using an interactive process directed by individuals and family members to support decision making. They also help to develop a plan of support that reflects an individual’s and family’s strengths, preferences, needs, and values. It affirms the core principle that each person is the expert in his or her own life rather than simply plugging people into programs based on their eligibility.

The promising practices are:


  • Ensuring leadership support for these practices (with examples from the District of Columbia’s mayor-led cross-population task force, Michigan’s broad support for change, and Virginia’s state legislation on this practice);
  • Creating standards for these practices (with examples from Washington’s statewide standards of practice, Virginia’s co-employment model between aging and disability organizations, the District of Columbia’s intake to better listen to people and families, and Wisconsin’s follow-up);
  • Training the “no wrong door” workforce (with examples from New Hampshire’s training and certification, the District of Columbia’s training for all, New Hampshire’s peer support model, Virginia’s person-centered advocates, and Connecticut’s essay exam); and
  • Helping people maximize use of private resources (with an example from Wisconsin that has been a leader in serving private pay clients).


This promising practices and toolkit paper includes resources and contacts for state and federal administrators, providers, and advocates to learn about—and even replicate—these practices. This paper also provides a checklist of what is needed to move toward more person- and family-centered practices.

NOTE: The third edition of the Scorecard will be released soon … on June 14th. Promising practices and toolkits are a new feature of the Scorecard project. More papers—such as promising practices in preventing long-term nursing home stays—will be forthcoming. For the new Scorecard, the promising practices and toolkit papers, and more, please go to the LTSS State Scorecard interactive website at


Wendy Fox-Grage is a Senior Strategic Policy Advisor for the AARP Public Policy Institute. She works on state long-term services and supports issues, including Medicaid and home- and community-based services.






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State-Facilitated Retirement Plans Can Save Taxpayers $33 Billion and Reduce Dependence on Government Programs

State-Facilitated Retirement Plans Can Save Taxpayers $33 Billion and Reduce Dependence on Government Programs

U.S. taxpayers could save almost $33 billion over the next 15 years if every state established a state-facilitated retirement savings plan for small-business employees, according to a new report from the University of Maine. While most of the savings would come from reduced costs paid by the federal government, state taxpayers would save almost $7.8 billion. The savings reflect the lower cost for basic government benefits new retirees would otherwise need if they continue to be unable to save for retirement.

Today, about half of all full- and part-time workers, about 55 million in total, don’t have access to a payroll deduction retirement savings plan. When employees don’t have access to payroll deduction, very few of them save for retirement on a regular basis. And without significant retirement savings, millions of those retiring between 2018 and 2032 will be forced to rely on basic taxpayer-financed government programs to supplement their Social Security benefits. Recognizing this, almost 30 states are considering a state-facilitated retirement savings program that would enable small-business employees to build their own economic security.

When considering the data, it’s easy to understand why states want to use this effective policy tool. Using public databases and widely accepted economic modeling tools, the University of Maine estimated the number of people who reach age 65 each year between 2018 and 2032, as well as their Social Security benefits and any additional income. The study then determined how many new retirees will have incomes so low that they will qualify for means-tested benefits (i.e., benefits available only to those below a certain income level) and the amount of benefits they would receive. The study considered both the total cost of those benefits as well as the share of that cost paid for by each of the 50 states.

Next, the study brings state-facilitated retirement savings plans into the equation. To do so, the study increases the retirement income of lower-earning workers by just $1,000 a year and estimates how many fewer retirees would need the taxpayer-paid services. Some of these people would permanently avoid needing these programs, and some would be able to delay starting those payments. In both cases, taxpayers would see reduced costs. In addition to the national study, which also includes Maine state numbers, the researchers developed individual state data showing how much taxpayers in each state could save.

As the study shows, state-facilitated retirement savings plans would reduce the costs for taxpayers — to the tune of $33 billion — and reduce dependence on government programs by allowing workers to rely on their own resources to build retirement security. Today, only 1 out of 7 small businesses offer their employees a payroll deduction retirement savings plan. State-facilitated retirement savings plans for small-business employees would be simple, low-cost and easy to understand for both employers and their workers. Enabling Americans to depend more on their own resources is a valid goal in itself. The fact that such a plan would also save taxpayers money is an added benefit.

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