Gov. Tom Corbett's plan to extend taxpayer-paid health insurance to hundreds of thousands of the working poor came with his repeated warnings that it is not an expansion of Medicaid and that he would not expand an entitlement program that he views as already too costly, bloated and ineffective.
What went without mention by Corbett, however, is the driving force behind the cost of Pennsylvania's Medicaid program: the elderly who need nursing home care or something like it on a long-term basis.
“When you talk about the escalating cost of the (Medicaid) system, you can't get around it without attacking the long-term care problem that we have,” said Michael Rosenstein, who represents the arms of private insurers and hospitals that are paid by Pennsylvania to manage the care of 1.6 million Medicaid enrollees.
Nearly half of the state's 2.2 million Medicaid enrollees are children. More than 900,000 elderly and disabled receive Medicaid services, whether for health care, to stay in a nursing home or get help in their homes with tasks they have difficulty doing.
Then there's the cost.
Statistics from the Medicaid and CHIP Payment Access Commission in Washington, D.C., or MACPAC for short, show Pennsylvania spent more than $23,000 in 2009 for each elderly person on Medicaid _ among the costliest in the nation - and $15,700 per year for each disabled person on Medicaid. The 2009 data was the latest available. The price tag for someone to stay in a nursing home is around $60,000 a year.
Those figures dwarf the cost of covering the kind of working-age, able-bodied adult who would primarily benefit from the use of Medicaid expansion money that becomes available Jan. 1 under President Barack Obama's signature health care law. For example, each able-bodied adult who is already on Medicaid because they are destitute or are a low-income parent cost $4,600 in 2009 to insure, according MACPAC's information.
Meanwhile, the elderly continue to be the fastest growing group of Medicaid recipients in Pennsylvania, which is among the nation's oldest states.
The question of what to do about the cost to care for the growing number of elderly on Medicaid is not a new one.
The Medicaid managed care companies in Rosenstein's group are lobbying to extend their services to also include nursing care for the elderly and disabled, a move they say would save money and improve quality of life.
The AARP is pressing for Pennsylvania to catch up to other states in expanding the role of attendants who take care of the elderly in private or community homes.
Meanwhile, some nursing home operators insist the Medicaid enrollees in their care cannot get the 24-hour care that they need anywhere else. Rather, they say the growth of the elderly on Medicaid is due to the expansion of in-home services that has displaced the role once filled by family and friends.
Ronald Barth, whose organization represents not-for-profit businesses that provide various services to the elderly, said the state needs to update its Medicaid reimbursement system so that the elderly get better access to a wider range of services that often cost less than a nursing home. The reimbursement system is rooted in the 1960s, when people didn't live as long and were more likely to have able-bodied family members nearby, Barth said.
“We have the old-old to care for now,” Barth said. “Medicaid and Medicare were created when the lifespans of people were not reaching the mid-80s and the 90s and mid-90s the way they are today.”
Tucked into Corbett's plan to use the federal Medicaid dollars to extend health insurance to an estimated 520,000 low-income adults is a pledge to create a “Long-Term Care Commission to recommend best practices that improve the coordination of care for all Pennsylvanians in need of long-term care services and support.”
There were few details beyond that.
“We don't know what the results of that could be, as far as policy changes,” said Ray Landis of the AARP of Pennsylvania. “I'm hoping that, since that was in there, it's a recognition that that is a big cost driver in Medicaid.”