Editor’s note: On Mar. 8, 2024 the Legislature passed House Bill 1078 which creates the Georgia Program of All-Inclusive Care for the Elderly (PACE). The bill awaits the governor’s signature.

The Gist

The House Human Relations & Aging Committee explored several legislative and regulatory solutions to address the long-term care needs of Georgia’s rapidly expanding elderly population last week. A big focus was on how to best use Medicaid funds to provide more care for seniors who don’t yet need to be in a nursing home, and are trying to stay in their homes, assisted living facilities or personal care homes.

What’s Happening

Lawmakers, leaders of state health and welfare agencies and a variety of long-term senior care facilities and associations spent four hours discussing how to provide better care for the growing population of low- and middle-income Georgia seniors who have a range of medical, housing and social service needs. 

Some need modest support that can be provided in their homes by relatives or other paid caregivers, while others, including people with dementia, need ready access to medical services and constant oversight, but not the more intensive, expensive and skilled care that’s provided in nursing homes.

Much of the discussion centered around HB 582, a bill introduced in the last legislative session by House Public Health Committee Chair Rep. Sharon Cooper, R-Marietta. It would allow assisted living communities, personal care homes and other providers of home- and community-based services to enroll as Medicaid providers and receive Medicaid funds, which is currently prohibited by state law. 

Access to Medicaid funds would help Georgians who need these services, but can’t afford them, “to age in place without moving to a skilled nursing facility,” according to the bill. 

Nursing homes are currently funded by state-managed Medicaid dollars, comprised of about two-thirds federal funds and one-third state funds. And some personal care homes that have up to 24 beds serving elderly people who are frail are also allowed to receive Medicaid funding in Georgia through waivers granted by the federal Centers for Medicare and Medicaid Services. 

Meanwhile, some  larger assisted living providers want much wider access to Medicaid funds to meet the ever-increasing demand for affordable housing and supportive care that aging residents need.  

Among them is Wesley Woods Senior Living, which provides apartment homes and care to about 1,800 older adults in Georgia, ranging from seniors with extremely low incomes to the affluent. CEO Terry Barcroft told the aging committee that she has 172 beds categorized as assisted living or personal care homes, where staff provide daily living support services to residents. 

Many of their units are occupied by seniors on fixed incomes who depend on subsidized housing assistance, she said, and can’t afford to pay for supportive services. Wesley Woods provides more than $1 million in charitable care to make sure such people can stay in their homes,” said Barcroft.

But there are many more seniors in Georgia who need assisted living care but who don’t qualify for Medicaid waivers. The passage of HB 582 would create more accessible options within long-term care programs for thousands of people “who don’t need 24-hour skilled nursing but do need 24-hour watchful, protective oversight,” Barcroft said.

Why It Matters

The state’s senior population is rapidly growing. Georgians aged 60 or older currently represent more than 15% of the total state population of 11 million, said Debra Stokes, executive director of the Georgia Council on Aging. Numbering 1.7 million in 2020, the senior population will expand by more than 500,000 people by 2030, when they’ll outnumber the under-20 population. By 2040, older Georgians will number 2.8 million, with the greatest rate of growth among those 80 and older.

Meanwhile, the number of Georgians age 65 or older living with Alzheimer’s disease and dementia is also expected to climb to 190,000 people in 2025 from 150,000 in 2020, a 27% increase, said Nancy Pitra, government relations director for the Alzheimer’s Association of Georgia.  At the same time Georgia’s Medicaid costs to care for seniors with Alzheimer’s, $1.2 billion in 2020, are expected to increase 26% by 2025, she said. 

People with moderate to severe dementia need constant oversight, Pitra noted, and allowing them to access Medicaid-funded services in assisted living facilities would mean living and receiving care in more affordable, less isolated, home-like environments.

This swelling of the aging population will elevate the demand for affordable housing that is already tough to come by in Georgia. It will also exacerbate the existing shortage of skilled nurses, nursing assistants, memory care providers and other caregivers that serve seniors. 

Finding new ways to finance the cost of long-term care for seniors is crucial, said MaryLea Boatwright Quinn, assistant deputy commissioner of the Division of Aging Services in the Department of Human Services. She leads the agency’s home- and community-based services program for vulnerable adults, which has a budget of $114 million, and allocates state and federal funds to aging-related agencies in Georgia.  

Home- and community-based services positively impact seniors’ health and reduce health care costs by reducing hospitalizations and getting people to be more compliant with disease management, said Quinn, a licensed medical social worker.

“We’re trying to help people … stay in their home of choice and avoid institutionalization as long as possible,” she said. 

What’s Next

One of the newer models relying on Medicaid, and Medicare, to provide long-term, community-based care for seniors is PACE, or Programs of All-Inclusive Care for the Elderly, which provides, often at an adult day health center, comprehensive medical and wraparound services to medically frail elderly people through an interdisciplinary team of caregivers. 

Most patients enrolled in PACE programs live at home. Costs for their care are capped at a flat per diem rate, instead of being paid per service, and providers are required to deliver all the medical, social, transportation, food, physical therapy, memory care and other services that seniors in the program require. 

The FY 2024 state appropriations bill mandated that the Department of Community Health conduct a needs assessment on the establishment of one or more PACE programs.

Brian Dowd, deputy commissioner of the department, told lawmakers that his team has been studying some of the PACE programs operating in 32 states for several months, and determined that the model could be viable in several Georgia counties they looked at, including Fulton, Dekalb, Cobb, Bibb, Chatham, Richmond, Gwinnett and Muscogee. 

Because “they’re essentially on the hook for everything” that patients need, Dowd said, providers are also incentivized to use case management and other efficiencies to keep costs down.

Adopting PACE wouldn’t rely on a Medicaid waiver, which typically lasts five years, he said. It would more likely involve amending the state Medicaid plan. Dowd said the Department of Community Health is examining the need for legislation to authorize PACE programs in Georgia, and also developing cost projections for the program.

Kathleen Benton, CEO of Savannah Hospice, told lawmakers that she had spent two years researching PACE programs, and hopes the state will fund a pilot program.

She estimated the per person cost of a PACE program in Georgia would be $4,700 per month. “That’s much different than the $6,100 spent on nursing homes right now,” she said, adding that with PACE, patients and providers are more satisfied, attrition for both groups is low, and the supportive family members of patients aren’t overwhelmed with trying to provide or coordinate all of their care.

“We’re in a perfect storm in Georgia,” she said. “Beyond the aging population, we have a labor shortage,” and no good solutions on the horizon to solve it, Benton said. “We must look for inherent caregivers in the home. We have to support them and provide them respite.” 

Rep. John LaHood, R-Valdosta, who manages several assisted living and senior care centers in Georgia, told State Affairs he sees pros and cons in the PACE model.

“In one way it makes it more predictable for the state to put a price tag on one person and say, ‘Alright, they’ve been taken care of at this price, no matter what they need,’ ” he said. “I think my concern would be that a PACE provider might be incentivized to be so efficient, to mitigate the risks of overspending, that they might avoid necessary care and getting that person engaged with the necessary providers. We would need some accountability, some kind of backstop for that.”

While all lawmakers and others who spoke at the committee meeting agreed that providing more independent living situations, medical care and social supports for seniors is important to pursue, not everyone was sure that using Medicaid funding to do it would work.

Some were not clear if repealing the state prohibition on funding assisted living and large personal care homes with Medicaid monies is permitted by the federal Medicaid agency. Others pointed out that 45 states are already using Medicaid funds for assisted living and a variety of home- and community-based services, with no regulatory backlash. 

Catie Ramp, CEO of the Georgia Senior Living Association, a nonprofit trade association representing private pay senior living facilities, said her association is concerned about the potential negative consequences of allowing more Medicaid spending in the senior living market. 

She said Medicaid’s low reimbursement rates might lead providers to “minimize quality of care and care options” in order to avoid passing on costs to residents. Otherwise, their labor costs will rise significantly, she said.

Barcroft said that labor shortages since the pandemic have led Wesley Woods to raise its base pay to $15 an hour, costs which “can only be passed on to residents and their families,” she said, adding that she hoped the state would continue to promote medical career pathways “to help students understand what CNAs [certified nursing assistants] and med techs do,” and draw more people into the field.

Read this related story:

Mobile program launched in Georgia to help Medicaid recipients keep coverage

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Header photo: A nurse assists a resident at Fellowship Home at Brookside, an assisted living center in Valdosta. (Credit: The Fellowship Family)