It’s no secret that the U.S. population is aging, and rural America is aging at an even faster rate. Currently, 15 percent percent of the country as a whole is over 65, compared with nearly 20 percent in the most rural areas.
The number of adults over 65 is expected to double by 2050 to nearly 100 million and they will disproportionately live in rural areas. Getting older doesn’t automatically mean that someone will need long-term care (including home care and nursing home care), but the majority of us will.
Still, most Americans have unrealistic expectations about needing long-term care and even fewer have made any concrete plans, financial or otherwise, for that care. The government hasn’t done much better.
The original version of the Affordable Care Act (ACA) included a provision for increasing uptake in long-term care insurance; that was taken out before it could be enacted. Experts and policy-makers have since wrestled with how to sustainably fund and support an adequate long-term care system going forward and have so far come up short of putting a long-term, workable solution into place.
This is scary on an individual level. Unrealistic expectations and lack of planning mean that people can easily be caught off-guard when and if they have a health crisis. This can be devastating to families and can quickly cause people to spend down their savings, as long-term care services don’t come cheap. The median cost for one year of home health services is more than $45,000; the median cost for a one-year nursing home stay is more than double that.
On a societal level, lack of planning for long-term care is terrifying and will be felt most in rural areas where the need is greatest. Proposed GOP policies around healthcare and immigration will only make this issue worse.
Currently, Medicaid pays for more than half of all long-term care and nearly two-thirds of nursing home care. (These numbers don’t include the approximately $500 billion in uncompensated care provided by family caregivers, a topic that deserves attention in its own right.) Medicaid spending on long-term care totals more than $150 billion a year and counting.
Restructuring Medicaid into a per-capita cap, the plan put forth in the American Health Care Act, will amount to significant funding cuts for states, which will not begin to keep pace with healthcare costs. These cuts will directly impact the ability of older adults to access long-term care. This will be felt more deeply in rural areas, where there are more older adults and higher disability rates, where Medicaid enrollment is higher, and where a greater percentage of people of all ages, including older adults, live in poverty.
On top of the damage that could be done to long-term care access in rural areas by changes to the Medicaid program, rural older adults and people with disabilities will be directly and dangerously impacted by the proposed travel ban and by tightening of immigration laws. Both rural areas and the long-term care system face historic shortages in the healthcare workforce, from doctors to nursing assistants; immigration restrictions will exacerbate those shortages.
These physicians play an especially important role in rural healthcare, where they disproportionately work in underserved areas, filling gaps in the rural healthcare workforce that might otherwise go unfilled. The currently proposed travel ban will directly impact more than 7,000 physicians from the six countries on the “banned” list. It may also dissuade other foreign-born physicians from immigrating to the U.S. if they perceive a hostile environment.
The issue goes beyond the travel ban, however. In his address to Congress on February 28, Trump spoke about his desire to change the immigration system to a merit-based system. While details have been scarce, this would likely not include certified nursing assistants, nearly 20 percent of whom are born outside of the US. In some facilities, fully 100 percent of nursing assistants are foreign-born. These workers, who make up the backbone of the long-term care system, are usually trained once they arrive in the US.
Rural areas are already struggling with how to best care for their aging populations. They face hospital and nursing home closures, alarming workforce shortages, higher mortality rates, and higher disability rates than urban areas. Cutting Medicaid funding and dampening the supply of long-term care workforce will hurt rural older adults, families, and communities – the very people that the GOP relies on for support and claims to serve.
Dr. Carrie Henning-Smith is a Research Associate in the Division of Health Policy and Management at the University of Minnesota School of Public Health and a member of the Scholars Strategy Network. Follow her on Twitter @Carrie_H_S.
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