I spent today with the New Hampshire legislature’s long-term care caucus and a group of  stakeholders as they wrestled with the challenges of expanding the state’s Medicaid home and community based care program for the elderly and adults with disabilities. Thanks to a kind invitation from State Representative Kate Miller, who chairs the caucus, AARP executive vp John Rother and I were able to give the group our sense of what is going on with long-term care issues in Washington. In return, we heard their views from the grassroots.

New Hampshire faces some special challenges. Only about 13 percent of its Medicaid dollars for adults with disabilities and the elderly are spent on home and community care. The rest goes to county-run nursing homes, which receive Medicaid payments that are among the highest in the nation. On top of that, it is not easy to deliver home care in a state that is both overwhelmingly rural and faced with snowy and cold winters. Finally, New Hampshire faces a very difficult budget environment in the current recession, in part because of its very narrow tax base.  

At the same time, like many other states, New Hampshire also must also deal with a severe shortage of health aides and other dirct care workers–a resource that is key to any successful home care program.

The caucus would like to find ways to expand the state’s Medicaid home care program, but skeptical lawmakers fear it would only increase overall Medicaid spending. Already worried  that federal health reform will put new pressure on that part of Medicaid that provides health care for poor mothers and their children, the state is especially wary of taking on new, and potentially more costly, obligations to seniors. 

There are no easy answers, but it is good to see a group of commited legislators trying to come to grips with a tough set of issues.