This year’s Texas Legislature adjourned without addressing the largest demographic shift confronting the state. In Texas the number of seniors 65 and older is expected to diversify and more than double from 3.9 million in 2020 to 8.3 million by 2050. Evidence shows that longer lives are increasingly accompanied by longer periods of compromised health and declining physical and cognitive capacities.
Texas, like many other states, will be forced to reassess its ability to provide the care that a rapidly aging population needs. The central question is: Who will pay the bill for how the state provides at least basic services to those in need?
This session focused on nursing home regulation but not community-based long-term services, meaning staying home as you age with care coming to you. According to AARP, 76% of Americans age 50 and older want to stay in their homes as they age. In Texas, the Medicaid program provides many of these services including physical/speech therapy, cleaning and bathing to those who need assistance in order to remain at home.
Our research reveals that these long-term services and supports make up close to a third of Texas’ Medicaid budget. To contain costs while keeping enrollment high, Texas provides full benefits only to the poorest of those individuals who rely on Medicaid and for a certain fraction of low-income Medicare beneficiaries eligible for nursing facility-level of care. The most comprehensive plans have over 35,000 people (2018) on their “interest” (waiting) lists, which can take years to move through.
The problem for Texas is that while the vast majority (more than 70%) of individuals reaching normal retirement age can expect to use some form of long-term care, many people believe that Medicare will pay for their long-term care. But that is simply not the case. Demographers also project that older parents will have fewer grown children to rely on for support in the coming decade. Plus, low-income families who are caring for parents, working and raising children are unable to deal with their increasing care needs, which means that many people will be dependent on Medicaid, a joint federal-state program.
Given these aging trends and the fact that state expenditures for Medicaid, the primary financing mechanism for long-term care, are growing at an alarming pace, we need a task force on aging to take a fresh look at new and cost-beneficial options for caring for low-income seniors and people with disabilities, based on managed care principles. These encompass both public and private solutions, including Medicaid waivers, state-funded home and community-based long-term care insurance, family caregiver credits, and expanded access to geriatric social workers, among others.
Although home and community-based care was not taken up this legislative session, lawmakers have an opportunity to tackle this issue in the coming months. Specifically, they can explore many of the services that are not a permanent fixture of our Medicaid program.
Texas operates these Medicaid community care services through experimental waivers, which are agreements between the federal and state governments to fund these programs. The 1115 Medicaid Transformation waiver is one example, giving states flexibility to transform, support and improve the quality of a coordinated care delivery system for the most vulnerable seniors.
However, the waiver was recently revoked by the Biden administration due to lack of sufficient public input prior to the waiver’s approval in January 2021, and now they are asking for more public comments. The cost of the state’s long-term care services and supports, including for dementia care, may be worth the investment if sufficient resources are prioritized.
The explosive growth of Texas’ senior population will place an increasing fiscal and care burden on the state. The state cannot do it alone and must collaborate with local governments, the private sector and the nonprofit sector to promote financial options for a healthy aging and productive economy. New programs that address this growing need must be developed so we take the opportunity to rethink senior care before 2050. Texans can build on our strengths while seeking solutions to improve the lives of those we care for most.
Jacqueline Angel is the Wilbur J. Cohen Professor of Health and Social Policy at The University of Texas at Austin.
Jason Castillo is a graduate student in the LBJ School of Public Affairs at The University of Texas at Austin.