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The health-care tangle // Affordable long-term care

Curt Kiser, the former state senator from Palm Harbor, speaks as the numbers flash on the overhead projector screen during a recent meeting of the House Aging & Human Services Committee. They are big, round scary numbers, and Kiser delivers them with the same rat-a-tat-tat precision and booming Midwestern voice he used in the House and Senate chambers for 20 years.

He is charting the future of long-term care for disabled adults, the mentally ill and the elderly in Florida. Kiser moves quickly through the numbers: a 42 percent increase in the number of severely disabled elders by 2010; a 32 percent increase in severely disabled adults under age 60; perhaps a doubling of the number of people, of all ages, with acquired immune deficiency syndrome; and, a 19 percent increase in developmentally disabled people.

"These are staggering numbers," Kiser says. "Where in the world are we going to come up with the services?"

It is a question Florida has heard again and again in recent years. How can the state and federal government _ and you, the taxpayer _ afford the rising cost of long-term care?

Long-term care already costs Florida $4-billion a year in public funds, twice as much as five years ago. But that will look like a bargain if the projections are accurate: By 2010, the annual tab could reach $24.7-billion.

Without reform, "somebody will get the opportunity to pass some taxes that will really stand some people's hair on end," says E. Bentley Lipscomb, the secretary of the state Department of Elder Affairs.

Florida has studied such reforms for years, always arriving at basically the same answer: Divert some people headed for government-financed nursing home care into less expensive care in congregate residential centers, called assisted living facilities. Pay for it with money that would have gone to pay for those people if they were in nursing homes.

Again and again and again, that was the main answer to the question about how to pay for such services. But until this year, when a unique convergence of political, financial and social forces seemed to re-energize reform-minded advocates, nothing much had been done.

Kiser, Lipscomb and a growing host of advocates, bureaucrats and politicians are hoping this is the year Florida starts to solve its long-term care problem.

Gov. Lawton Chiles, a Democrat, has included $25-million in his state budget to start diverting the elderly into more home-like care centers. Kiser, a Republican respected in both parties, is working the halls and committee rooms of Tallahassee. He is pitching a reform package developed by his Commission on Long Term Care in Florida, a panel the Legislature created in 1994, Kiser's last year as a legislator.

There are sponsors for House and Senate bills lining up on both sides of the aisle in Tallahassee. And the atmosphere in Congress supports such innovative, state-run programs.

"There are policy decisions you can take now to have impact on these numbers in 15 years," says Larry Polivka, director of the Florida Policy Exchange Center on Aging in Tampa.

In January, Polivka provided the Commission on Long Term Care with some jaw-dropping numbers. Commission members saw a slide that projected long-term costs to taxpayers ranging from a low of $11.1-billion to a high of $24.7-billion in 2010, depending on inflation, cost and type of services.

The question is: Are the numbers scary enough to prompt action when the Legislature meets next month?

The path to reform

In the late 1980s, there was a commission that studied long-term care insurance in Florida. Such insurance was one way government hoped to shift the cost of long-term care off taxpayers and onto private individuals.

In 1992, Pinellas and Pasco counties were proposed as a site for a model program to provide home-care services to the elderly instead of institutional care. The next year, an innovative program called extended congregate care was under way, offering another alternative to nursing homes. There also was an unsuccessful fight to move most long-term and elder care services into Lipscomb's 1-year-old Department of Elder Affairs.

During the summer of 1993, Lipscomb toured the state, holding workshops on how to move toward more home-like care instead of nursing homes, and how to combine care for the disabled adults under age 60 into his department. Talk and study continued, buoyed by President Bill Clinton's proposed health care reform, which included exactly the same types of home and community care.

A November 1993 long-term care summit _ yet again _ reached the same conclusions, that the rising cost of nursing home care was "like a freight train coming down the track at us at 90 mph," according to one participant. Chiles told the summit he would pursue long-term care reform with vigor, making Florida a model for the nation, but it took him until this year to propose a large chunk of money to divert elders from nursing homes. His proposal came at the same time the Commission on Long Term Care's report was circulating in Tallahassee.

Many things have slowed reforms.

Advocates for the disabled and mentally ill were wary about becoming part of a department devoted to the elderly. Nursing homes were in a battle over Medicaid reimbursement rates, which they say are too low. Hospitals wanted more nursing home-type beds in their facilities to transfer patients. But stand-alone nursing homes, worried hospitals only wanted such beds for the higher-paying private and Medicare patients, resisted.

Clinton's health care plan also stalled state efforts, because most thought long-term care reform would be a part of national health care reform.

Meanwhile, in the state Capitol, some legislators feared a new home and community care program _ even one supposedly financed with money that would have gone to pay for care in nursing homes _ simply would become another entitlement, with the same out-of-control cost problems as Medicaid.

So after so much study and failed promises, is it really different this year?

Kiser, who left the Legislature for an unsuccessful campaign with GOP gubernatorial candidate Tom Gallagher, says he thinks so.

"New ideas very seldom make it through the first time," says Kiser, now a lawyer with Holland & Knight in St. Petersburg. "Sometimes there is a lot of opposition to changing the status quo, sometimes the number of people who really pay attention needs to be enlarged each year. Sometimes people will say we don't need to do that because this is going to take care of the problem."

The commission's plan foresees a managed care system for long-term care that will track people into the proper level of care. If they need full-time custodial care or short-term rehabilitation, a nursing home is right. If a person can get along well with less intensive care _ perhaps assistance with eating, bathing and medication, but not with a host of other services available in a nursing home _ then that person could be tracked into an assisted living facility. Or for some older people, regular home visits from nurses or homemaker aides would be enough.

The point is to serve people in the best setting possible, at the most affordable price to government. The annual cost to keep someone in a nursing home in Florida can reach $33,000, while the cost for an assisted living facility might cost $17,000 to $22,000 a year. Regular home care might average $10,000 yearly.

The cost of long-term care is important to budget planners and taxpayers because 65 percent of the nursing home bills in Florida are paid by Medicaid, a federal-state program for the indigent. That nursing home program cost $1.3-billion in 1995, plus government paid another $400-million for home and community care for the elderly.

Programs for the mentally ill and disabled show similar government tabs ($1.6-billion for the mentally ill and $450,000 for the developmentally disabled in 1995, for example).

The Kiser commission report goes further than past reports. It calls for long-term care insurance reform, more personal and estate responsibility for nursing home bills, and structural reforms to simplify how a person moves into and through the various levels of long-term care.

It makes strong statements about the value of family caregivers, who still provide 75 to 85 percent of the care for the disabled and frail in Florida _ usually without government assistance. And it acknowledges that some people who are in a government-subsidized program probably don't need the care they are receiving, or can be handled with less intensive, less costly care.

"It's one thing to deliver something that is a whole bunch of platitudes," Kiser says. "But this commission didn't do that. They set priorities, said what we should do first, etc."

If anything, Kiser is worried the reform proposal is attracting too much attention. In the way laws are made in Florida, a popular bill can become a target for legislators looking to include related but not-as-popular proposals, hoping to pass them in the frantic final week of the session.

But he is not complaining.

"I'd rather have that problem, than have no one listening to us," Kiser says.

John A. Cutter writes about elder affairs for the Times.

The future for elderly care in Florida

IN 1995:

Number of elderly residents: 2.7-million

Have incomes below the poverty threshold for medical care: 50 percent

Number of the elderly were disabled: 11 percent

Living in nursing homes: 2.5 percent

Living alone (two-thirds are women): 33 percent

IN 2010:

The number of people over 65 will increase by: 33 percent.

The number of people over 85 will increase by: 91 percent.

The number of disabled elderly will increase by: 42 percent.

The number of disabled elderly living at home will increase by: 45 percent.

The number of disabled elderly living in nursing homes will increase by: 34 percent.

Source: The Commission on Long Term Care in Florida