Everyone wants to age in place — their own place. As age and infirmity take their toll, more people want to face those challenges in their own homes with help.
Before 1999, Marylanders who need as little help as someone to assist in bathing and dressing could only get that help in a nursing home. In 1999, the Maryland legislature created what is now known as the “Medicaid Home and Community Based Options Waiver” (HCBOW) program. What is “waived” is the federal requirement that someone be in a nursing home to get the help they need. Aging in place was now possible.
Except that it isn’t possible. It hasn’t been possible.
Even though it costs the government much less to provide the services people want in their own homes than in a nursing home (HCBOW services cost on average about 50 percent less than services provided in a nursing home), Maryland doesn’t fund the program. Studies consistently show that with the right controls, the state will see substantial savings after three years, and people get to age in place with the help they need. But in fact, in 2016, Maryland was still paying 71 percent of its Medicaid long-term care bills on nursing homes for older adults and adults with physical disabilities. If Maryland had shifted its spending 20 years ago from nursing home care to home and community-based care, it would have saved hundreds of millions in taxpayer dollars by now — all the while preparing the program to serve the incoming “wave” of Marylanders over age 65.
More specifically, the real savings can be seen when the state adopts a policy of avoiding unnecessary nursing home admissions. In 2016, the state’s annual average per person cost of providing home and community-based care was $28,835. In 2016, the state’s annual average per person cost of providing nursing home care was $72,635. This means that the state would have saved $43,800 per preventable nursing home admission that year.
To make matters worse, the lack of funding and attention to the HCBOW program discourages people who would otherwise seek HCBOW services. There is currently an over 22,000-person, eight-year waiting list for people who desperately want these services. Once on the waiting list, there is no way to find out where you are on the list or how much longer you would have to wait to receive services. In 2017, only 344 of the 2,068 people called off the nearly 22,000-person waiting list — after eight years — were able to enroll in the HCBOW program. The rest of those called were found to be dead, could not be reached, ended up in a nursing home or were otherwise ineligible.
The shameful reality today is as it was prior to 1999: Marylanders are unable to “age-in-place” in their own homes — not even when the need for services to avoid an unnecessary nursing home admission can be shown. Instead, the government continues to pay their Medicaid bills in the most expensive setting, when people really just want help to stay in their own homes.
The Maryland legislature must act to make up for lost time if it wants to give Marylanders the ability to age in place and preserve the public coffers for future generations. When state treasury is now flush with an unexpected influx of money, now is the time to incur short-term upfront costs to ensure substantial savings in as little as three years. This means expanding the HCBOW program to meet the rising demand of an aging population with disabilities, including and especially those on the eight-year waiting list. Or at the very least, calling 1,500 persons per month off the waiting list instead of 300 per month, that way the waiting list can be eliminated within a year or two.
Above all, it means finally listening to the wishes of millions of Marylanders.
Jason A. Frank (firstname.lastname@example.org) is president of Frank, Frank & Scherr, an elder law and estate and special needs planning law firm. He serves as assistant Baltimore County attorney to the Baltimore County Department of Aging, co-chairs the Public Policy Committee of the National Academy of Elder Law Attorneys (NAELA) and is the author of “Elder Law in Maryland” and “Maryland Medicaid Long-Term Care.”