READ THE ATTACHED ARTICLE, THEN FOLLOWING THE BELOW INSTRUCTIONS: 1) Summarize the article. 2) Discuss the service delivery explored in the article. 3) Examine how human service profession

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Katherine Kero, BSN, RN, is Doctoral Student, Wayne State University, College of Nursing, Detroit, MI.

Joy Swanson Ernst, PhD, MSW, is Associate Professor and Associate Dean for Academic Affairs, Wayne State University, School of Social Work, Detroit, MI.

Social Services for Older Adults: Utilization and Future Directions

Katherine Kero

Joy Swanson Ernst

T he number of Americans age 65 and older is increasing rapidly. Older adults are expected to account for 20% of the U.S. population by 2030

(Vespa, Armstrong, & Medina, 2018). As adults are likely to require more health care as they age, these demo- graphic shifts represent a challenge for health care and its funding. Outdated funding mechanisms for public social services, such as Medicare, Medicaid, and Social Security, are likely to require modification in coming years (Hoagland, 2017). Understanding the purpose and funding of social programs will help nurses appreciate the constraints and needs of their patients, and develop informed opinions about future healthcare funding for older adults and other vulnerable patients.

Social Services

Social Security Social Security is a federal program that provides

income to vulnerable groups, including older adults. The Social Security Act of 1935 was passed in response to the extreme poverty experienced by older adults liv- ing through the Great Depression in the 1930s (Social Security Administration [SSA], 2017). Since then, the program has expanded to provide income support for families of deceased workers, disabled workers, children with disabilities, and supplemental security income for older Americans with limited financial resources. Social Security currently provides income to one in every six Americans (64 million beneficiaries) and pays $1 trillion annually. Retired workers make up 43.7 million recipi- ents who are paid $64 billion; on average, these retirees receive $1,661 each month (SSA, 2019a). All Social Security beneficiaries also qualify for Medicare (SSA, 2017).

In 2016, Social Security expenses composed about 24% of the total federal budget (Cubanski & Neuman, 2017). Funding for Social Security programs is provided through the Federal Insurance Contributions Act (FICA), which established a federal payroll tax to be deducted from workers’ paychecks and matched by

employers (SSA, 2017). As workers pay the FICA tax, credits are earned toward their Social Security benefits for retirement. The FICA tax also funds Medicare. Money collected from taxes does not fund individual savings accounts; it is deposited into the Old-Age and Survivors Insurance and Disability Insurance trust funds that pay beneficiaries.

When the Social Security program was created, a small proportion of Americans were retirees eligible for benefits. These retirees were supported through FICA taxes paid by the larger proportion of the population who were working Americans. As the demographics have shifted to a larger percentage of the population reaching retirement age, the number of workers sup- porting each beneficiary is shrinking; this gap is expect- ed to continue to grow (SSA, 2019a). The current system of taxes and payments thus will continue to function as intended only until the year 2034, when point funds will be depleted (SSA, 2017). Funding mechanisms for the Social Security program have reached the brink of insolvency in the past, and Congress responded by repeatedly passing laws to continue funding the pro- grams (Ruffing & Van de Water, 2014). Congress will need to agree how to modify the system again in the near future.

Medicare Medicare is a health insurance program that bene-

fits older adults and persons with disabilities (Centers for Medicare & Medicaid [CMS], 2017a). It has several parts. Medicare Part A, which is paid through the FICA payroll tax, covers hospitalizations, skilled nursing facil- ity admissions, hospice, and home health care (in cer- tain circumstances), and does not require payment of monthly premiums. Medicare Part B covers outpatient care, some home health care, durable medical equip- ment, and preventive services, but recipients must pay a monthly premium (CMS, 2019). Some individuals choose to pay for additional private insurance known as Medigap policies to cover expenses not included in Medicare Parts A or B. Medicare Part C (Medicare Advantage) is another supplementary health insurance provided by private insurance companies to limit annu- al out-of-pocket costs (CMS, 2017a). Medicare Part D is a supplementary insurance that can be purchased to defray the costs of prescription drugs. Medicare Parts B and D are funded through the federal government’s general tax revenues as well as premiums paid by recip- ients (Cubanski & Neuman, 2017).

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Approximately 58 million Americans use Medicare. Most expenditures benefit individuals with multiple chronic health conditions. Analysis of records from 2014 found 15.4% of Medicare beneficiaries who have six or more chronic conditions accounted for 51% of total Medicare expenditures (Matthews et al., 2016). Of the estimated $709 billion in net benefit payments made by Medicare in 2017, $131 billion (approximately one-fifth) was spent on care related to Alzheimer’s dis- ease (Alzheimer’s Association, 2017). Recipients of Medicare with Alzheimer’s disease incur three times more medical costs than peers without dementia symp- toms.

Although it is a publicly funded program, recipients of Medicare still pay many costs. In 2019, hospitaliza- tions are subject to a $1,344 deductible paid by benefi- ciaries plus additional daily expenses for hospitaliza- tions over 60 days. The costs of skilled nursing facility admissions are covered for the first 20 days, then are subject to $170.50 daily for up to 100 days; all costs then are assumed by the beneficiary for longer admis- sions. Medicare Part B premiums cost a minimum of $135.50 each month; premiums are more expensive for recipients with higher incomes (CMS, 2019). There are also additional costs for Medigap, Medicare Part D, and supplemental private insurance policies.

Medicare expenses compose about 15% of the total federal budget. Although total expenditures nearly dou- bled in the past 10 years due to increased beneficiaries, the cost per person has grown slower than in previous decades as a result of changes in the program through the Affordable Care Act (Cubanski & Neuman, 2017). The present balance of Medicare spending and revenues from taxes and premiums is expected to sustain the pro- gram until 2026 (SSA, 2019b). Although many variables could change the status of Medicare over the next 10 years (e.g., use of healthcare services, tax revenue), pro- gram funding will require future changes to taxing and/or spending to remain viable.

Medicaid Medicaid is a federal and state program to pay med-

ical costs for individuals with limited income. Beneficiaries include persons with limited income who are older adults, parents of minor children, pregnant women, disabled individuals, and children (CMS, 2017a). Hospitals serving mostly uninsured and low- income patients also receive additional Medicaid fund- ing (CMS, 2017b). Older adults with limited financial resources can enroll in Medicare and Medicaid programs at the same time. Medicaid pays for some services not covered by Medicare, such as nursing home placement and long-term care (CMS, 2017a).

Each state designs the details of its Medicaid pro- gram. While healthcare services for children as well as low-income women who are pregnant are essential com- ponents of Medicaid covered without any limitations, other aspects are determined by individual states (e.g., enrollee income qualifications, reimbursement rates to healthcare providers, specific covered services). This

results in great variability between different states in the details of their Medicaid programs (Young, Rudowitz, Rouhani, & Garfield, 2015). States receive federal fund- ing to match state spending on Medicaid, but reimburse- ment rates depend on the relative wealth or poverty of the state (based on citizens’ average income); this further complicates scrutiny of Medicaid use and spending. Overall, Young and colleagues noted Medicaid expenses for older adults are over four times higher than for younger adults without disabilities because of complex acute care and costly long-term care.

To qualify for Medicaid assistance in the long-term care setting, older adults must spend down assets, pay their entire Social Security income, and pay most of any other sources of monthly income before Medicaid will assist in paying any remaining costs (Alzheimer’s Assoc – iation, 2017). The cost of long-term care is very high, approximately $82,000-$92,000 per year (Gen worth, 2016). About 62% of long-term care residents are cov- ered by Medicaid (Rudowitz & Garfield, 2018).

Spending on Medicaid accounts for about 10% of the federal budget (Cubanski & Neuman, 2017). Because more people became eligible for Medicaid support through the Affordable Care Act, one of every five Americans now receives these benefits (Rudowitz & Garfield, 2018). Fourteen states (AL, FL, GA, KS, MO, MS, NC, OK, SC, SD, TN, TX, WI, and WY) opted out of Medicaid expansion, which prevents citizens in these states from accessing the expanded benefits (The Kaiser Family Foundation, 2019). Despite expanded access to health care through increased enrollment in Medicaid, Rudowitz and Garfield noted the program is more effi- cient than private health care with lower costs per enrollee due to lower payments to healthcare providers and a slower rate of growth.

Maintaining Social Services for the Future While Social Security, Medicare, and Medicaid pro-

grams are crucial to most adults in providing income and paying for their medical needs in their later years, these programs are costly. Because these social services have endured changes in the past to adapt to different social and political circumstances, it is likely they will evolve further in the future (Hoagland, 2017). To evalu- ate the practicality and utility of proposed modifica- tions, nurses need to understand how changes might benefit or disadvantage different stakeholders. While not a universal list, the following provides a broad overview of possible alterations to social service pro- grams and likely implications.

Maintaining Social Security Several suggestions have been proposed to support

Social Security benefits to current recipients and main- tain its future funding. When the funds in the pro- gram’s reserves become depleted, two options could be considered: reduce benefit payments or collect addition- al assets. Strategies for reducing benefit payments include paying beneficiaries a smaller portion of their

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Social Services for Older Adults: Utilization and Future Directions

expected benefit, eliminating benefits for wealthy retirees, increasing the age at which retirees become eli- gible for benefits (encouraging them to remain in the workforce longer), or reducing the annual cost-of-living increases in benefit payments. Revenues into the pro- gram can be increased through collecting additional taxes (Tsai, 2015).

Each option results in some groups receiving a greater benefit and other groups experiencing a greater burden. If means-testing is used as a criterion for Social Security benefit eligibility, some wealthy taxpayers will pay into the system but receive no benefits. If the age of eligibility for benefits is increased, persons with lower life expectancies (particularly men and individuals from racial or ethnic minority groups) will receive little to no benefits from their tax contribution as they are less like- ly to survive to retirement age (Steinbuch, 2013). As Steinbuch explained, increased taxes would cause per- sons earning over $100,000 annually to pay more for the same benefits, but would sustain the system overall. Further, increased tax revenue will be effective in sup- porting the system only if these tax revenues are used specifically to support the Social Security trust funds and not diverted to other government spending pro- grams as they have been in the past. In the end, a com- bination of approaches is likely.

Others have argued for not only sustaining the Social Security program, but also increasing payments to retirees as a mechanism to reduce expenditures on care by Medicaid. Care in the community often is provided by informal caregivers such as family members. These family members limit their own employment opportu- nities, thus jeopardizing their own future retirement security because they are paying less into the Social Security system (Poo & Kalipeni, 2017). Informal home care provided by family members can be replaced or supplemented by paid professional caregivers when Social Security payments are increased (Tsai, 2015). Without the availability of informal caregivers or ade- quate income to afford formal caregivers in the commu- nity, disadvantaged retirees rely on Medicaid funding for costly care provided in institutions (Alzheimer’s Association, 2017).

Maintaining Medicare Because the largest consumers of health care within

Medicare are persons with multiple chronic conditions, addressing costs through efficient management of mul- tiple health conditions offers a key savings opportunity. The Multiple Chronic Conditions Framework has been used to optimize resource use and care for older adults with multiple chronic conditions through four strate- gies: foster healthcare systems that improve the care of individuals with chronic conditions; support self-care; disseminate information about best practices to health- care providers, social workers, and public health agents to manage multiple health concerns; and encourage research to improve interventions and support systems for individuals with multiple chronic conditions (Parekh, Kronick, & Travenner, 2014).

Healthcare systems can improve interprofessional coordination of care with Patient-Centered Medical Homes, Accountable Care Organizations, and integra- tion between behavioral health and primary care. Health information technologies (e.g., electronic med- ical records, patient portals) help coordinate care by allowing efficient communication between specialists and to patients. Managing chronic conditions through self-care may be supported by empowering individuals to take a proactive role in their own health care. Examples of outpatient services to promote self-care include physical exercise activities, support groups, and telemonitoring. Adequate adherence to complicated medication regimens also can be supported through improved patient and caregiver education. The work of healthcare providers, social workers, and public health agents can be supported by disseminating information about best practices for the care of complex patients. Training programs for these professionals must include focused instruction about chronic conditions, patient- centered models of care, and palliative care (Parekh et al., 2014). Finally, research for the care of persons with multiple chronic health conditions is important to iden- tify interventions, compare treatments, evaluate care delivery models, and track improvements in outcomes. Improving care will result in cost savings and is crucial to improving health outcomes.

Reducing Medicaid Costs A wide range of cost-saving strategies has been pro-

posed to reduce Medicaid costs, including work require- ments for recipients, insurance premiums, coverage lockouts, advanced directive requirements, and cost- sharing strategies. Because the largest cost to Medicaid is long-term care expenses, this category offers a great opportunity for targeted cost savings. Long-term care can be seen as different levels of care across a continu- um from independence in the community, to moderate assistance, to completely dependent care in a nursing home. Because increased levels of care correspond to increasing expenses, interventions to prevent or delay the need for costly institutional care are likely to reduce costs (Szanton et al., 2018).

In the community, many older adults receive care from family members. These informal caregivers largely are uncompensated, and are at a high risk for caregiver burnout, depression, anxiety, immune dysfunction, stroke, increased pain symptoms, and death (Fonareva & Oken, 2014; Hong, Han, Reistetter, & Simpson, 2016; Ivey, Allen, Liu, Parmelee, & Zarit, 2017; Sallim, Sayampanathan, Cuttilan, & Ho, 2015). Caregiver burnout also leads to early institutionalization and increases the risk of elder abuse (Arai, Noguchi, & Zarit, 2017; Vandepitte et al., 2018).

Supporting the work of formal and informal care- givers can help decrease Medicaid expenses by reducing unnecessary hospitalizations or emergency department visits, and delay or prevent institutionalizations. Their work can be sustained through workplace flexibility, and they can be supported financially through state and

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federal agencies. In addition, respite care from caregiv- ing may be indicated. Emotional and social support for caregivers through support groups or counseling is also beneficial (Alzheimer’s Association, 2017). Family care- givers may be supplemented by adult day service pro- grams or hired in-home caregivers; such unlicensed home health workers now provide 70%-80% of all pro- fessional direct patient care (Khan, Marquand, & Camp – bell, 2015).

Conclusion Older adults have costly healthcare needs. With

their income-earning years in the past, options funding their own health care and living expenses are limited. The social support programs on which many older adults rely on have serious financing issues (Hoagland, 2017). Understanding how these programs help older adults and what role they play within the healthcare system can help nurses advocate for changes in the best interest of vulnerable individuals.

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Centers for Medicare & Medicaid Services (CMS). (2019). 2019 Medicare costs. Retrieved from https://www.medicare.gov/ Pubs/pdf/11579-Medicare-Costs.pdf

Cubanski, J., & Neuman, T. (2017). The facts on Medicare spending and financing. Retrieved from http://files.kff.org/attachment/Issue-Brief- The-Facts-on-Medicare-Spending-and-Financing

Fonareva, I., & Oken, B.S. (2014). Physiological and functional conse- quences of caregiving for relatives with dementia. International Psychogeriatrics, 26(5), 725-747.

Genworth. (2016). Cost of care survey 2016: Summary findings. Retrieved from https://www.genworth.com/dam/Americas/US/ PDFs/Consumer/corporate/131168_050516.pdf

Hoagland, G.W. (2017). The economic, fiscal, and financial implications of an aging society. Generations, 40(4), 16-22.

Hong, I., Han, A., Reistetter, T.A., & Simpson, A.N. (2016). The risk of stroke in spouses of people living with dementia in Korea. International Journal of Stroke, 12(8). doi: 10.1177%2F1747 493016677987

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givers’ daily pain experience. The Gerontologist, 58(5), 913-922. doi:10.1093/geront/gnx099

Kahn, K., Marquand, A. & Campbell, S. (2015). Paying the price: How poverty wages undermine home care in America. Retrieved from https://phinational.org/sites/default/files/research-report/paying- the-price.pdf

Matthews, K.A., Holt, J., Gaglioti, A.H., Lochner, K.A., Shoff, C., McGuire, L.C., & Greenlund, K.J. (2016). County-level variation in per capita spending for multiple chronic conditions among fee-for- service Medicare beneficiaries, United States, 2014. Preventing Chronic Disease, 13, 160240. doi:10.5888/pcd13.160240

Parekh, A.K., Kronick, R., & Tavenner, M. (2014). Optimizing health for persons with multiple chronic conditions. JAMA, 312(12), 1199- 1200.

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Rudowitz, R., & Garfield, R. (2018). 10 Things about Medicaid: Setting the facts straight. Retrieved from http://files.kff.org/attachment/ Issue-Brief-10-Things-to-Know-about-Medicaid-Setting-the-Facts- Straight

Ruffing, K., & Van de Water, P.N. (2014). Congress needs to boost dis- ability insurance share of payroll tax by 2016. Retrieved from https://www.cbpp.org/research/congress-needs-to-boost-disability- insurance-share-of-payroll-tax-by-2016

Sallim, A.B., Sayampanathan, A.A., Cuttilan, A., & Ho, R.C.M. (2015). Prevalence of mental health disorders among caregivers of patients with Alzheimer disease. Journal of the American Medical Directors Association, 16(12), 1034-1041.

Social Security Administration (SSA). (2017). Educator toolkit. Retrieved from https://www.ssa.gov/thirdparty/educators.html

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Social Security Administration (SSA). (2019b). A summary of the 2019 annual reports. Retrieved from https://www.ssa.gov/ OACT/TRSUM/index.html

Steinbuch, R. (2013). “Reforming” Social Security. Journal of the National Medical Association, 105(1), 96.

Szanton, S.L., Alfonso, Y.N., Leff, B., Guralnik, J., Wolff, J.L., Stockwell, I., … Bishai, D. (2018). Medicaid cost savings of a preventive home visit program for disabled older adults. Journal of the American Geriatrics Society, 66(3), 614-620.

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Tsai, Y. (2015). Social security income and the utilization of home care: Evidence from the social security notch. Journal of Health Economics, 43, 45-55.

Vandepitte, S., Putman, K., Van Den Noortgate, N., Verhaeghe, S., Mormont, E., Van Wilder, L., … Annemans, L. (2018). Factors asso- ciated with the caregivers’ desire to institutionalize persons with dementia: A cross-sectional study. Dementia and Geriatric Cognitive Disorders, 46(5-6), 298-309.

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Ethics, Law, and Policy

Emotional and social support for caregivers through support groups or counseling is also beneficial.

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