- Associated Press - Saturday, June 6, 2015

CONCORD, N.H. (AP) - Whether protesting budget cuts to Meals on Wheels or fighting for higher reimbursement rates for nursing homes, advocates for New Hampshire’s aging residents have found themselves on the defensive as lawmakers craft the next state budget.

The short-term budget battles illuminate a broader issue: What kind of long-term care will best serve New Hampshire’s rapidly aging population, and who will pay for it?

About 7,100 people - roughly 7 percent of the state’s population over 65 - receive long-term care services fully or partially covered by Medicaid. The total has changed little in recent years, but the state is shifting away from putting people into nursing homes and focusing on keeping people in their homes, a much cheaper option.

By 2030, more than twice as many New Hampshire residents are expected to be older than 65 compared to 2010, according to a study by the New Hampshire Center for Public Policy Studies. That same study predicts the number of older residents needing Medicaid services will grow by 30 percent in the next 10 years.

“There’s no question if you look at the demographic data that we’ve got a potential issue on our hands here,” said George Maglaras, a Strafford County commissioner and vice president of the New Hampshire Association of Counties.

New Hampshire’s 10 counties are deeply invested because county property taxes foot most of the non-federal share of long-term care bills. The federal government pays 50 percent of all Medicaid costs and the counties handle most of the rest, with the state kicking in just a small share. The counties and state shared the burden equally until 2008, when they struck a deal making counties responsible for long-term care and the state responsible for juvenile delinquents and other costs related to young people.

Knowing the state is aging, lawmakers set a cap on how much counties have to kick in each year and created a credit program meant to help poorer counties. But lawmakers often trim the state’s share during the budget process, and the cap goes up on a regular basis - often meaning county property taxes go up, too.

Between 50 to 60 percent of all county taxes go toward long-term care, Maglaras said. Taxpayers in a county with a higher need for long-term care services or a smaller tax base get hit hardest.

The state also sets provider payment rates. Nursing homes have received several rate increase in recent years, but home and community care providers haven’t seen one since 2010. That is likely to change in the next state budget.

This all creates a system that the counties aren’t happy with, and they’re now seeking a stronger voice in the future of long-term care.

“This is a terrible scenario if you want the state to plan because they’ve got no skin in the game,” said Steve Norton, executive director of the New Hampshire Center for Public Policy Studies.

Lori Shibinette, Merrimack County Nursing Home’s administrator, said the state’s move to prioritize home and community-based care will help. In 2014, the average cost per nursing home resident was $61,000 compared to $18,000 for someone in home and community care, according to the state’s Department of Health and Human Services.

But causing more concern is the state’s planned move next year to a managed care system, where an outside company will manage the entire continuum of an individual’s care, from doctor’s visits to prescription drug purchases. Health and Human Services Commissioner Nick Toumpas says the move is intended to create more of a “whole person” approach. State budget writers are projecting about $7.5 million in savings in the next budget from the switch.

Counties worry the shift will further reduce their influence over how the system operates and that money currently spent on care will go toward fees for the managed care companies.

“We’re the ones paying for it,” Shibinette said. “We would like a bigger voice in eligibility and case management.”

The state has been working with the counties on the issue and Toumpas said addressing the future of long-term care is a top question facing the state. As the state works to keep people in their homes longer, he said the discussion must focus on payment mechanisms, available providers and the workforce that cares for the state’s older residents.

“It is probably one of the most strategic, significant questions that we as a state need to address,” he said.

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