Yesterday, I joined three of the most creative thinkers in the long-term care policy world to discuss the future of  personal care services for the elderly and disabled in an era of shrinking government resources. My fellow panelists at the event, sponsored by The Urban Institute, were Robyn Stone, author of Long-Term Care for the Elderly and senior vice president for research at Leading Age, the trade group that represents many non-profit senior service providers; Josh Weiner director of RTI International’s Program on Aging, Disability, and Long-Term Care; and Len Fishman, CEO of Hebrew Senior Life in Boston.

Len, Josh, and Robyn acknowledged the difficult political reality: Federal spending for Medicare, Medicaid, and non-Medicaid services such as transportation, subsidized housing, meals programs, and the like face severe budget cuts as Congress looks for ways to reduce the federal deficit. And no matter what happens with Congress’s so-called supercommittee over the next month, chances are good that lawmakers will make even deeper cuts after the 2012 elections.

As Len put it, “Advocates like us for decades have been pointing out that for every frail elder in a nursing home, there are four living in the community–and the implication is that eventually government will accept more responsibility for that 80 percent…. That isn’t going to happen.”

The question is how will providers, communities, and families respond? Len and Robyn agreed that, if government spending is cut, communities will have to pick up a larger share of the responsibility for some levels of assistance. 

There is no doubt that most of the burden will fall on families, who already provide the vast bulk of care–often at great physical, emotional, and financial sacrifice. But, increasingly, communities may find themselves stepping up–perhaps through grassroots movements such as senior villages and faith communities, or in partnership with traditional senior service providers.   

“Communities do a lot now,” Robyn said, “In times of constrained resources–and we have to be real about … the near future for Medicare and Medicaid– investment at the community level has to be front and center.”  

Already, she said, some low-income housing programs on very limited budgets have been able to provide supportive services for elderly and disabled residents . “I have been amazed, ” she said, “that with so few resources what can be cobbled together.” 

Make no mistake, Robyn and Len were deeply troubled by the coming cuts in government assistance for long-term care. But they do see some opportunities for communities to make the best of what will be a very difficult situation.

By contrast, Josh was much more skeptical, and he wondered how well these very creative solutions can be copied. “I don’t see it out there on a large scale,” he said, “and I don’t know how you make it go to scale.”

And he’s even more doubtful given the size of the challenge: “If we’re talking about dealing on a nationwide basis with a disabled population that’s going to double in the next 30 years, I just don’t see this as a truly meaningful way of supplying the kinds of services people need.”

My own take: While it isn’t reasonable to expect many people to change the adult diapers of their neighbors, with guidance and encouragement they can provide transportation, meals, friendly visits, and other assistance. This won’t eliminate the need for some  frail elders to move to care facilities, but perhaps it can keep some of them at home for an extra six months or a year. And that is both good for them and for those who worry about costs of long-term care.