The concept of the article titled, “Preparing to Age in Place: The Role of Medicaid Waivers in Elder Abuse Prevention” seems to be a stretch to the average practitioner, as the title implies a connection among aging in place, Medicaid waiver programs and elder abuse. While perhaps there could be some connection among these three concepts, the article never explains the concept of aging in place, what’s needed to age in place or how “elder abuse” is defined. Without having knowledge of those concepts or how the authors defined them for purposes of the research, the connection among the concepts is lost. Even using common definitions, the article fails to make logical connections based on research.
“Aging in place” is defined as staying in one’s own home as an individual grows older.1 There are any number of challenges associated with this concept, which range from assisting an individual with an uneven gait in a two-story home, to preparing meals for someone who’s no longer able to drive, to appropriately managing money for someone who has vision impairment. In addition to these practical hurdles to remaining at home, there are hurdles that exist with respect to access to medical care: for example, transportation to and from doctors’ appointments for an individual who can no longer drive or the ability to properly administer medication that’s given by injection. Many of the hurdles that exist can be overcome by simply having the funds to pay for home modifications, private caregivers and an executive assistant. Such luxuries aren’t often available to households of low-to-moderate income and to those households that are most in need of Medicaid services. It’s often not a medical issue that prevents aging in place but instead practical, non-medical problems, and the authors don’t discuss this issue at all. However, if the authors are considering access to health care as part of what’s needed to age in place, then perhaps Medicaid waivers can assist, and there may be some connection to be made.
The article does cover the history of Medicaid waiver programs, which isn’t often known, even by practitioners who focus their practices in elder and special needs law. However the article doesn’t address, even in passing, general eligibility criteria for Medicaid waiver programs. Of late, there are a number of legislative efforts to reduce access to waiver programs by changing eligibility rules that are critical to understanding how waiver programs may work.2 In addition, the article fails to discuss the types of long-term services and support that are offered by waiver programs. Having a firm understanding of the legislative origins of waiver programs is critical for anyone who wishes to help clients in locating all possible benefits; therefore, Section II of the article, titled “Evolution of Medicaid HCBS Waivers,” is worth reading.
The article goes on to discuss the Learning Health Care System (LHCS) concept and how Medicaid waiver programs should be a type of LHCS. The discussion regarding LHCS and the concept as a part of health care is fascinating and is recommended for anyone practicing in the field of health law. However, the article fails to address the realities of how waiver programs work and how they’re most decidedly not LHCS at this time.
The article indicates that “the aim of this study was to identify and describe current state practices to promote aging in place policies, including efforts to mitigate risks associated with elder abuse.” Ignoring the failure to adequately explain why Medicaid waiver programs promote aging in place, the authors don’t offer suggestions as to why elder abuse would prevent aging in place. While I certainly agree that elder abuse is horrific and should be criminalized, there’s nothing to suggest that there’s a correlation among it and remaining at home and Medicaid waiver programs. In fact, if one focuses on the concept that Medicaid is a needs-based program, only available to those meeting certain financial criteria, and that elder abuse often involves financial exploitation, the authors’ hypothesis is counterintuitive. One who meets the financial eligibility criteria for Medicaid has little or nothing that can be financially exploited. However, if the authors’ elder abuse concerns are related to physical abuse, then perhaps there’s a connection. That’s one reason why failing to understand how the authors are defining certain concepts, such as aging in place or elder abuse, makes the article difficult to follow.
In addition, while the article provides little in the way of explaining elder abuse, it does concede that one of the hallmarks of elder abuse is isolation of the abused, which is more likely to occur if the abused is living in her home alone. So, while the article examines state action such as background checks for caregivers, quality assurance measures and methods by which complaints are investigated, it doesn’t connect how these affect the ability of an individual to remain in her home as she ages.
Throughout the article, the authors claim that states should more readily share information and data regarding their Medicaid waiver programs so that other states can evaluate what’s been successful. Based on the LHCS discussion and some of the data studied such as caregiver background checks, this suggestion makes sense and appears to be more the focus of the article.
The authors should be applauded for the manner in which they discuss the history of Medicaid waiver programs, and the discussion of LCHS was enlightening. However, the article title was confusing and, in general, the article doesn’t provide information that busy practitioners need to know to be successful in their practices.
Endnotes
1. www.nia.nih.gov/health/aging-place-growing-older-home.
2. See Gresham v. Azar, 363 F. Supp.3d 165 (D. D.C. 2019); Stewart v. Azar, 366 F. Supp.3d 125 (D. D.C. 2019); Philbrick v. Azar (D.D.C. July 29, 2019).