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Like the rest of the United States, the District of Columbia spends a substantial portion—nearly a fifth—of its Medicaid budget on long-term care for the elderly. Compared with the 50 states, however, the District faces special challenges in meeting the needs of the disabled elderly. The District's older population has a higher proportion of low-income people and African Americans than the older population of the 50 states. The District is not quite a state—it lacks the size, geographic diversity, and broad fiscal base characteristic of most states—and it is also distinct from other cities in the governmental responsibilities that it assumes. In addition, decisionmaking in the District, as the nation's capital, has always been complicated, in part because of the involvement of Congress and the federal executive branch. The transfer of most government functions in 1995 from the mayor and the city council to a federally appointed control board has made policy development and implementation even more complex.
Although the context of long-term care policy in the District of Columbia is unique, local policymakers must address the same issues of cost containment and delivery system reform that shape reform efforts in the states. This paper presents an overview of long-term care for the elderly in the District and the major issues that policymakers are addressing in the late 1990s. This analysis is part of a larger study conducted by the Urban Institute to assess health care in the District. The information included in this paper was collected in 1998 from public documents and interviews with representatives of District agencies, long-term care providers, advocates for the elderly, and experts. To encourage candor in the interviews, respondents were told that no one would be quoted by name. Wiener, the senior author, was co-chair of the Long-Term Care, Elderly, and Adult Protective Services Subcommittee of the Human Services Action Group of Mayor Anthony Williams' transition effort. In that capacity, the senior author interviewed a number of knowledgeable individuals. He is also a member of the Long-Term Care Committee of the Mayor's Health Policy Council, where he has been involved in home care and nursing home issues, especially certificate-of-need standards for nursing homes.
The first section of this paper presents background information on the elderly population, the supply of nursing homes and other providers, and Medicaid expenditures. The next section briefly describes the principal agencies involved with long-term care in the District. The next five sections of the paper analyze issues related to policy development and implementation, home- and community-based services, nursing homes, and other topics, including the D.C. Office on Aging and Adult Protective Services in the Department of Human Services. The paper concludes by examining the District of Columbia's challenges for the future in organizing, financing, and assuring quality of care in long-term care for the elderly.
Background
The total population in the District was 528,964 in 1997, of which 73,375 were ages 65 or older (table 1).1 The District had a slightly higher proportion of elderly than the nation did (13.9 percent compared with 12.7 percent). Although the number of older people is expected to increase in virtually every state, the District's elderly population is projected to fall by 12.4 percent between 1996 and 2002.2
Reflecting its urban setting, the District of Columbia's elderly population is quite different from those of the 50 states and the nation as a whole. In particular, minorities (especially African Americans) make up a much larger portion of the District's elderly population than the national average—only one-third of the District's elderly population is white, compared with nearly 90 percent nationwide.3 In addition, although the District has many upper-income residents, the older population in the District is much more likely to be low income than in the 50 states: Nearly 20 percent of the District's elderly population is below the federal poverty level, almost twice the national average.4
Characteristics of the long-term care market in the District are shown in table 2. In 1998, the District's 23 nursing facilities (17 nonfederal, freestanding nursing facilities and 6 hospital-based or hospital-affiliated skilled nursing or sub-acute units) and 3,101 beds—123.1 beds per 1,000 elderly ages 75 and over—put the District below the national average of 131.3 beds per 1,000 elderly ages 75 and over. Moreover, approximately 15 percent of District Medicaid enrollees who use nursing home care live in facilities in Maryland and Virginia. The city is above the national average in its supply of licensed nonmedical residential care beds (known as community residence facilities in the District), with 62.4 beds per 1,000 elderly ages 75 and over compared with 54.8 beds per 1,000 elderly ages 75 and over nationwide. In addition, the city has several "naturally occurring retirement communities," where individuals have aged in place, creating a substantial concentration of older residents.5 Finally, the District had 26 home health agencies in 1998.6
Because its population is lower income, a larger portion of the District of Columbia's population relies on Medicaid for health care than the national average. In 1996, an average of 10,000 elderly District residents were Medicaid eligibles (table 1). The proportion of elderly Medicare beneficiaries also eligible for Medicaid was nearly twice the national average in 1994 (23.9 percent compared with 12.5 percent).7 Still, in 1996, the proportion of Medicaid beneficiaries in the District who were elderly was below the national average (7.3 percent compared with 9.9 percent), which reflects the large number of nonelderly adults and children on the program. Even though a greater portion of elderly residents in the District are Medicaid enrollees than the national average, the high number of nonelderly enrollees in the District dwarfs the number of elderly enrollees.
Despite the lower proportion of Medicaid beneficiaries who are elderly, the proportion of overall Medicaid dollars for long-term care services was similar to the national average. This similarity results from the high long-term care spending per elderly enrollee in the District—$12,611 compared with $7,601 nationwide in 1996. Similarly, the District spends $1,800 per elderly resident on long-term care compared with $915 per elderly resident for the nation as a whole (table 3). Thus, spending levels are high.
In 1996, the District spent about $131 million for services for the elderly, about 21 percent of Medicaid expenditures. The vast majority of expenditures are for long-term care services. Almost all District Medicaid long-term care expenditures for the elderly were for institutional care in 1996; only 2.6 percent of Medicaid long-term care expenditures for the elderly were for home care, much less than the national average of 12.1 percent (table 3). In 1996, about three-fourths of all Medicaid home care expenditures in the District were for home health, while personal care accounted for the remaining one-fourth.8 Medicaid long-term care expenditures for the elderly grew at an average rate of 3.4 percent annually in the District from 1990 to 1996—well below the national growth rate of 9.1 percent over the same period. Medicaid nursing home spending growth outpaced home care expenditures in the District during this same period (table 4).
Agencies
Five main agencies address the long-term care and social needs of the elderly in the District of Columbia: the D.C. Office on Aging, the Medical Assistance Administration (Medicaid) of the Department of Health, the State Health Planning and Development Agency of the Department of Health, the Licensing Regulation Administration of the Department of Health, and Adult Protective Services of the Department of Human Services.
D.C.Office on Aging
The Office on Aging is the District's State and Area Agency on Aging as authorized by the federal Older Americans Act and D.C. Law 1-24. It is a small agency with a budget of about $18.2 million in fiscal year 1999, which has remained roughly constant in nominal terms over the past several years. The D.C. Office on Aging's ability to effectively advocate for older persons depends heavily on the executive director's position as a member of the mayor's cabinet.
Most services it funds are delivered by private, nonprofit organizations, each of which provides private matching funds in the form of client contributions, fundraising, and donated space and services. Six lead agencies provide focal points throughout the city for assessing needs, targeting services, and responding to the public. The Office on Aging provides funding for the following programs:
- In-home and extended services for the homebound elderly, including visiting nurses, homemakers, home-delivered meals, telephone reassurance, heavy house cleaning, minor home repairs, geriatric day care, and respite aid.
- Transportation services for elderly to and from medical appointments, dialysis clinics, and personal business trips for public benefits.
- Community services, including senior wellness centers, congregate meals, counseling, health promotion, nutrition screening, socialization, literacy, transportation, a senior center for the homeless, and an emergency shelter.
- Supportive services, including case management and long-term care ombudsman advocacy.
- Special services, including special events during Older Americans month.
- Older workers employment and training programs.
The D.C. Office on Aging also oversees operation of the Washington Center for Aging Services nursing home and adult day center, although the funds for its operation do not appear in its budget.
Medical Assistance Administration of the Department of Health
The Medical Assistance Administration (also known as the Commission on Health Care Finance) operates the District's Medicaid program, the federal-state health care program for the poor. Medicaid covers the following long-term care services that are used primarily by the elderly: nursing facilities, home health, personal care, and adult day health care. The District Medicaid program will begin operating a Medicaid home- and community-based services waiver for the elderly in 1999. In addition, Medicaid pays Medicare premiums and cost-sharing for the low-income elderly and covers certain acute care services (e.g., prescription drugs) that are not covered by Medicare. Elderly persons with incomes below the federal poverty level are eligible for Medicaid in the District. Despite a budget approaching $1 billion, Medicaid has only 68 staff members, including operations and auditing personnel.
State Health Planning and Development Agency of the Department of Health
The State Health Planning and Development Agency of the Department of Health is responsible for operation of the District's certificate-of-need program and development of the state health plan. The State Health Coordinating Council, which is composed of government and nongovernment officials, advises the director. Until recently, the State Health Planning and Development Agency was an independent agency; even now, final decisions on certificate-of-need applications are made by the director of the agency rather than by the director of the Department of Health. Most new health providers must obtain a certificate of need before they can operate.
Licensing Regulation Administration of the Department of Health
The Licensing Regulation Administration of the Department of Health licenses community residence facilities and nursing facilities and certifies nursing facilities and home health agencies for participation in Medicare and Medicaid. It is the primary quality-assurance authority for the District. Until 1998, these functions resided in the Department of Consumer and Regulatory Affairs rather than the Department of Health.
Funding for nursing facility quality assurance comes primarily from the federal government, while funding for community residence facilities comes from the District. Although understaffing for nursing home quality assurance is not a major problem, the Licensing Regulation Administration does not have adequate staff to license community residence facilities in a timely manner. Staff assigned to community residence facilities also must inspect child day care centers and adoption agencies.
Adult Protective Services of the Department of Health
Adult Protective Services is a branch of the Family Services Administration within the Department of Human Services. Its mission is to prevent or remedy neglect, abuse, and exploitation of vulnerable adults, as authorized by the Protective Services Act of 1984. The law requires that Adult Protective Services initiate investigations of life-threatening abuse within 24 hours of complaint receipt.
Over three-quarters of the population served are people over 60 years of age, although an increasing proportion of the caseload is made up of younger disabled adults, including those who are mentally ill or mentally retarded. Most of the older clientele are low-income females. The large majority of the clients live in the community, although some complaints are received regarding nursing home and community residence facilities.
Notes from this section
1. Population Estimates Program, Population Division, U.S. Bureau of the Census. Washington, D.C.: U.S. Bureau of the Census. Internet release date: July 21, 1998.
2. D.C. State Health Planning and Development Agency. "Nursing Facility Services." Draft State Health Plan. Washington, D.C.: D.C. State Health Planning and Development Agency, October 1998.
3. D.C. Office on Aging. Demographic Profile of the Elderly in the District of Columbia. Washington, D.C.: D.C. Office on Aging, Policy, Planning, and Evaluation Branch, 1996.
4. Ibid.
5. For example, Van Ness North Cooperative and other apartments along Connecticut Avenue in Northwest Washington. Mary Beth Franklin. "NORC, Sweet NORC." Washington Post, January 13, 1998, p. Z7.
6. D.C. State Health Planning and Development Agency. "Home Health Care." Draft State Health Plan. Washington, D.C.: D.C. State Health Planning and Development Agency, February 18, 1998.
7. R.W. Bectel and N.G. Tucker. Across the States 1998: Profiles of Long-Term Care Systems. Washington, D.C.: American Association of Retired Persons, 1998.
8. Urban Institute calculations based on Health Care Financing Administration form 2082 and 64 data.
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