by Grace Vitaglione, North Carolina Health News
October 24, 2024

By Grace Vitaglione

Carol Moore has always had “a heart for seniors.” When she was a teenager, she took care of her grandmother. Then she looked after her mother in law who had rheumatoid arthritis. Now a senior herself at 73, she said her peers are often “overlooked.” Moore has lived in Harnett County for over 43 years. She and her husband, both retired, live on Social Security.

They — and other older adults on fixed incomes — can often struggle with paying for food, bills and medicine.

“If anything else comes up that we haven’t got worked out, we’re having to pray up the money,” she said.

Moore said paying for her 16 medications is difficult because she falls into the “donut hole,” or a gap in Medicare prescription drug coverage. Once an individual and their Medicare Part D drug plan has spent a certain amount of money for covered drugs, the person has to pay all costs out-of-pocket for their prescriptions up to a yearly limit. 

“It’s money I don’t have,” she said.

That coverage gap is supposed to end in 2025, thanks to the 2022 Inflation Reduction Act. The act also capped out of pocket drug costs, and in North Carolina, Medicare enrollees saved more than $33 million on prescription drugs in the first half of 2024, according to a White House spokesperson.

Moore and her husband live at home and would like to stay there as long as their health allows. She might consider a home health aide if needed, she said, but the cost would likely be too much.

Strengthening the network of care for seniors like Moore and her husband is a key step in North Carolina government’s Multisector Plan for Aging called “All Ages, All Stages NC – A Roadmap for Aging and Living Well” that was released Sept. 27. Gov. Roy Cooper issued an executive order in May 2023 with the goal of making North Carolina an age-friendly state.

The goals of the plan are to improve home- and community-based services for people who need them, address workforce shortages and help people afford the care they need, among other priorities. 

Plan priorities

The state’s Division of Aging puts out a federally mandated aging plan every four years, but the Multisector Plan for Aging is separate. It will require several state agencies to work together and legislative approval to make some of the changes.

Cooper’s executive order designated the Department of Health and Human Services Division of Aging and the Division of Health Benefits to lead the planning process.

The 10-year plan was released just as rains from the remnants of Hurricane Helene began to fall in western North Carolina. DHHS Secretary Kody Kinsley stopped by the kickoff event Sept. 27 before heading to the western part of the state. He talked about how his mother struggled with stress after becoming the primary caregiver for his grandmother, who has dementia. 

Kinsley’s grandmother now lives in a skilled nursing facility, the cost of which is supported by programs operated by Veterans Affairs and NC Medicaid. That’s not uncommon.

“One of the fastest growing parts of our Medicaid budget is supporting individuals in long-term care,” Kinsley said.

While the plan establishes guidelines for the next decade, it has eight key priorities for the next two years with dozens of recommended action steps. Those are divided into immediate and longer-term efforts.

State aging rapidly

North Carolina Coalition on Aging’s Board of Directors Chair Mary Bethel said at the plan’s unveiling that it carries the weight of the state’s demographics. 

Advocates made an aging plan around 25 years ago, she said, but it didn’t have the impact they wanted. Now, however, the numbers can’t be ignored.

The population of people ages 65 and older in North Carolina is projected to grow from 1.9 million in 2022 to more than 2.8 million by 2042, according to data from the N.C. Office of State Budget and Management cited in the plan. By the early 2030s, the population of people older than 65 is projected to surpass the number of residents who are younger than 18.

The plan projects that growth will be especially concentrated in urban areas, such as Wake and Mecklenburg counties, as people pursue amenities such as health care facilities and proximity to their families.

The aging plan’s priorities align with needs in the recovery period from Helene’s damage in western N.C., according to a newsletter DHHS released Oct. 14.

The department is closing gaps in access to transportation, particularly in more remote areas such as Mitchell, Yancey and McDowell counties, as well as expediting food benefits for individuals who lost access to them during the storm.

Federal flexibilities are also in effect, such as expediting long-term care admissions, allowing out-of-state health care practitioners to provide care and allowing less stringent requirements for replacing medical equipment and medications.

Home- and community-based services

A research team sponsored by the North Carolina chapter of AARP conducted a statewide survey of North Carolinians aged 45 and older in 2022. Ninety-nine percent of respondents said it’s important to live independently in their own homes as they age.

But in order for that to happen, many people will need some sort of home or community support. 

The North Carolina General Assembly created the Home and Community Care Block Grant in 1992 to combine federal funding from the Older Americans Act with state and local dollars to fund home- and community-based services like home delivered meals, in-home aides and transportation.

But the aging plan says the grant doesn’t have enough funding to meet rising demand. There are at least 10,000 older adults on N.C.’s waiting lists for the grant’s services, according to a priority sheet of 2023-24 legislative priorities from the NC Senior Tar Heel Legislature.

Kathleen Collins, supervisor of the Anderson Creek Senior Center in Spring Lake, said the government hasn’t done enough to make these services accessible.

“The government has been telling us for years that studies show it’s cheaper in the long run to allow them to age in place [rather than in a facility]. But have they done anything to help them do it?” she asked. “No.”

The plan recommended increasing funding and modernizing the program.

Workforce shortages

Direct care workers, such as home health aides, can be part of a network of home and community-based services that enable some seniors to age at home rather than a nursing home. But those services aren’t affordable or accessible for many. 

Home- and community-based services also depend on those who provide them, and North Carolina has a shortage of direct care workers, the plan noted. 

Denise Lugo, 63, has worked in home health since 2004. She makes $15 an hour and doesn’t receive health benefits from her agency. Lugo stays because of the connection to her clients.

“The best part is getting to know my clients, getting to hear their stories and just being there to help them,” she said. “The hardest part is when they get sick and they pass away, because they’re like family now.”

Her agency lost workers during the pandemic; people were scared of contracting COVID-19 and could get better pay elsewhere. 

North Carolina’s annual mean wage for home health and personal care aides as of May 2023 is over $29,000, below the national mean of over $33,000, according to the Bureau of Labor Statistics.

Meanwhile, the demand for these services is only growing.

The NC Center on the Workforce for Health is leading a study on a comprehensive Medicaid rate and wage analysis, which NC Medicaid could use to inform its rate setting for long-term services and supports, the plan said.

The plan also recommended expanding financial incentives for those pursuing a career in health care, such as loan repayment programs, tuition reimbursement and stipends.

Affording care

Paying for these services can pose another barrier. Medicare does not usually cover nonmedical long term services and support, which include home and community-based services, as well as nonmedical care in an assisted living facility or nursing home. 

Many seniors don’t realize that Medicare won’t pay for them to stay in a nursing home. The plan also called for increased education around Medicare coverage, partly through promoting the Senior Health Insurance Information Program. 

Medicare may only cover up to 100 days of care in a skilled nursing facility under certain conditions. 

An individual could spend the rest of their savings and assets until their income is low enough to qualify for Medicaid to cover their nursing home care. After the person dies, Medicaid is allowed to file a claim against their estate to recover any Medicaid dollars paid on behalf of the person, a process called “estate recovery.” 

Seventy percent of adults who survive to age 65 develop severe needs for long-term services and support before they die, according to a report by the Urban Institute. This has potentially large implications for the state Medicaid program, as two-thirds of residents in skilled nursing facilities in the state rely on NC Medicaid, according to the plan.

The plan also recommended addressing challenges to a continuum of services and support, including fragmented service delivery, inconsistent and limited funding mechanisms and institutional barriers.

Pushing for legislative support

Bethel of the NC Coalition on Aging said some of the action steps will require state and federal dollars.

One is channeling state funding to Adult Protective Services. No state dollars were appropriated for adult protective services, according to the aging plan. County departments of social services that provide adult protective services must rely on inadequate federal funding and county resources to protect seniors from abuse. 

From July 2022 through June 2023, county departments of social services received 35,400 reports of alleged mistreatment of adults, with neglect being the most common, according to the plan.

Securing state funding means making aging a priority at the legislature, which it has not been traditionally. At a NC Coalition on Aging meeting Sept. 27, Rep. Donna White (R-Clayton) recalled how when she pushed for aging priorities in the budget, the response she got at the legislature was “nauseating.”

“What I was told is, ‘We don’t care about the aging people, because they don’t pay taxes and they don’t do anything for the community,’” she said.

White has also advocated for creating a Legislative Study Commission on Aging, another step in the plan. Currently, aging issues are rolled into a House committee along with family and child policy.

The Division of Aging is producing a data dashboard that will track the progress of “All Ages, All Stages NC.” 

Bethel said it’s important for the aging plan to lay a foundation for the work before the transition in government this year.

“If we don’t want this plan to sit on a desk or a bookcase and draw cobwebs, it’s going to be imperative on all of us that we take action,” she said. “Or else it will just become another paper document that becomes a doorstop.”

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