Students in the Master of Public Policy program at Duke’s Sanford School of Public Policy spent part of their spring semester examining a policy issue for the N.C. Center for Public Policy Research.
The students investigated Alzheimer’s disease in North Carolina, looking at the rates of the disease, caregiving options for patients, and also looked to other states to learn about different options for comprehensive plans.
The students’ report, which includes recommendations for action in our state, is presented in this series of blog posts. Today’s post outlines how coverage for Alzheimer’s care continues to change, and touches on mental health reform in the state. Read previous posts here:
Part One in the series provides an introduction to Alzheimer’s disease and an overview of prevalence rates
Part Two discusses caregiving options
Part Three takes a look at programs and services supporting Alzheimer’s patients in N.C.
Note: The pictures used in this series are from the Alzheimer’s North Carolina organization, a nonprofit dedicated to education, support, and advocacy for Alzheimer’s patients and their families. Visit their website here: http://www.alznc.org/.Pictures also featured from The A.R.C. Community, long-term care facilities in North Carolina for residents with Alzheimer’s. www.thearccommunity.com
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Medicaid and Alzheimer’s disease
As the primary payer for nursing home care, state Medicaid policies directly affect Alzheimer’s patients and caregivers. Many Alzheimer’s patients and caregivers who do not initially qualify for Medicaid at the time of diagnosis will qualify for Medicaid eventually. They will either “spend down” their assets to become eligible, or simply lose enough wealth due to the extraordinary care costs of Alzheimer’s.
In 1999, the Supreme Court ruled that under the Americans with Disabilities Act of 1990 (ADA) reimbursement rates must be the same for all disabled Medicaid beneficiaries. For over a decade, North Carolina had paid a higher Medicaid reimbursement rate for beneficiaries living in group homes, including Alzheimer’s special care units and adult care homes, than to beneficiaries who opted to receive services in their own homes (Hoban, 2013). The state also set higher eligibility criteria for beneficiaries receiving assistance at home, creating an incentive to seek institutional care. North Carolina maintained dual reimbursement rates and eligibility criteria until a 2011 investigation by the Department of Justice found that North Carolina was violating the ADA. The state responded by cutting benefits for all group home residents rather than increasing Medicaid benefits for disabled beneficiaries living at home (Hoban, 2012b).
There is a three-year moratorium, from July 31, 2013 through July 1, 2016, on new licenses for Alzheimer’s special care units.
Alzheimer’s special care units and adult care homes saw dramatic funding cuts overnight (Hoban 2012b). Between 3,000 and 4,000 Alzheimer’s patients living in special care units were in danger of being forced out of their care facilities on January 1, 2013 (Leslie and Morgan, 2013). The legislature passed a stopgap bill in February of 2013 (“Group Homes/Special Care Units,” 2013). It established an emergency fund of $39.7 million for Alzheimer’s patients and other people living in group homes. When the stopgap measure expired in July of 2013, the legislature allocated an additional $4.6 million in bridge funding (Oakes, 2013).
The NC state budget for fiscal year 2013-2014 included a three-year moratorium, with exceptions, on issuing new licenses for Alzheimer’s special care units. The moratorium is set to end on July 1, 2016. The current NC state budget, passed in August of 2014, included further cuts to Medicaid, hospitals, and group homes, including Alzheimer’s special care units. Without additional funding, group homes are experiencing serious financial problems (Hoban, Singh and Namkoong, 2014). Rather than providing for group home funding in the state budget, the legislature decided that North Carolina’s Department of Health and Human Services (DHHS) would be responsible for devising a permanent budgetary solution to fund these facilities (Hoban, Singh and Namkoong, 2015).
In 2001, the NC legislature privatized the delivery of mental health services. As a result, many qualified public-sector mental health workers left the state. Additionally, quality of care decreased substantially, as private providers only offered the most profitable services, typically low-impact community services such as tutoring and running errands for clients provided by unlicensed, low-paid personnel. More costly intensive services that many clients needed, such as home care, were not offered (In the Public Interest, 2015). Many mentally ill individuals, including those with Alzheimer’s, ended up in jail or the ER, and they did not receive the support services or case work they needed. Alzheimer’s patients are already more likely to sustain injuries that require hospital visits. A weak mental health system exacerbates the issue. ER personnel are not trained in how to deal with Alzheimer’s patients, thus treatment times are longer, putting an extra burden on hospitals that are already running low in ER beds (In the Public Interest, 2015). More money is being funneled into providing mental health services in prison than in the community. Alzheimer’s patients and their caregivers benefit most from community programs. The longer that patients stay in the community, the less costly they are to the state. Mental health reform that focuses on community-based supports would be an integral part of a state Alzheimer’s strategy (In the Public Interest, 2015). |
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Note: Here is information about this student project, provided by the Duke Sanford School of Public Policy. This student presentation was prepared during the spring of 2015 in partial completion of the requirements for PUBPOL 804, a course in the Master of Public Policy Program at the Sanford School of Public Policy at Duke University. The research, analysis, policy alternatives, and recommendations contained in this report are the work of the student team that authored the report, and do not represent the official or unofficial views of the Sanford School of Public Policy or of Duke University. Without the specific permission of its authors, this report may not be used or cited for any purpose other than to inform the client organization about the subject matter. The authors relied in many instances on data provided to them by the client and related organizations and make no independent representations as to the accuracy of the data. |
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