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State Slipping as Leader in Home- and Community-Based Care

Budget cuts are threatening those programs

The $200 worth of state-provided monthly care has kept Willis out of a nursing home and in her apartment, where she'd like to stay, she said, " 'til my toes curl up."

As she's become more prone to dangerous falls, Willis has requested five more hours of assistance from the care worker, but she's been put on a waiting list.

Her situation illustrates the challenges facing Oregon's long-term care system, which has been a national leader in caring for people in home- and community-based settings. Since 1981, the state has helped residents stay in their homes, but now the system is under pressure as the state grapples with a projected $3.5 billion two-year budget shortfall (PDF).

States are required to offer nursing home care by federal Medicaid regulations. But home- and community-based care is not mandated, so it's easier to cut.

Cutting payments to providers could cause home-care workers to leave the profession or refuse patients with complex needs, said James Toews, policy adviser for the Seniors and People with Disabilities Division. That could lead older people to "bump up to a higher level of care, which ends up costing more."

Nursing home care, at about $6,400 a month, costs the state two to three times more, on average, than home-based care.

As the population ages, the number of Oregonians who need long-term care is expected to double within 20 years.

A 2010 human services report (PDF) warned: "If Oregon's in-home and community care system falters, the migration into nursing facility settings at two to three times the cost cannot be stopped … without jeopardizing the operation of the entire state Medicaid program."

Oregon spends about $3.2 billion on long-term care, with $1 billion from the state general fund and most of the balance from federal funds, mainly Medicaid. In his proposed two-year budget, Gov. John Kitzhaber, D, has called for deep cuts in payments to nursing homes and home- and community-based services for long-term care.

"These cuts are disproportionate and hurt poor seniors, mostly women, while eliminating thousands of home-care workers' jobs," said Rick Bennett, director of government relations for AARP Oregon.

In 2003, Oregon's last major recession, the state cut long-term care spending by eliminating some prevention and outreach services, increasing caseloads, reducing payments to providers and tightening eligibility requirements. That last move cost 5,000 people their home and community care.

Next: Penny-wise and pound-foolish. >>

In 2007, Oregon still boasted the nation's lowest nursing facility occupancy rate, at 65 percent. But that year Medicaid nursing facility caseloads grew by about 5 percent. This time, changes in federal health care law prevent Oregon from restricting eligibility. But cutting state spending for Medicaid not only makes programs like the one helping Willis vulnerable, but also will reduce the amount of money Oregon receives from the federal government. For every $1 Oregon spends on Medicaid, the federal government contributes $1.67.

"Oregon is among a few other states that have been identified for years as innovative leaders in keeping people at home, which is far less costly than nursing homes," said Jerry Cohen, AARP Oregon state director. "Reducing support for home and community care means going into the nursing home sooner, which costs us all more. We're not only tarnishing our reputation, we're being penny-wise and pound-foolish."

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Paige Parker is a freelance writer based in Portland, Ore.

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