AARP Public Policy Institute INSIGHT on the Issues A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Ari Houser AARP Public Policy Institute Produced by the AARP Public Policy Institute with support from The SCAN Foundation and The Commonwealth Fund The affordability of private pay services is an important component of long-term services and supports system performance. This Insight on the Issues presents data on private pay affordability for every state and more than 400 markets in the United States. There is wide variation in affordability between states and markets. Private pay nursing home care is not affordable for middle-income families anywhere. While less costly than nursing homes, home health care is still unaffordable for middle-income older people at typical levels of use. The affordability of private pay services  Nationally, private pay nursing home is an important component of long-term costs in 2012 averaged 252 percent services and supports (LTSS) system of median age 65+ household performance. When private pay services income, and the cost of home health are relatively more affordable (or less services averaged 88 percent of unaffordable), people with moderate to median income. high incomes are more able to access the services they need. As well, those with  There is wide variation in affordability between states and low incomes are more able to afford markets. additional or noncovered services to supplement those that may be available  Private pay nursing home care is not through public programs. affordable for middle-income families anywhere. The AARP Public Policy Institute (PPI) developed two indicators of private pay  While less costly than nursing affordability for the 2011 scorecard, homes, home health care is still Raising Expectations: A State Scorecard unaffordable for middle-income on Long-Term Services and Supports for older people at typical levels of use. Older Adults, People with Physical  There is a no relationship between Disabilities, and Family Caregivers income and nursing home (hereafter, the Scorecard), funded by affordability. The Commonwealth Fund and The SCAN Foundation. 1 This Insight on the  There is a clear relationship between income and home health Issues presents data on these indicators affordability. Higher-income regions of private pay affordability for every tend to have relatively more state and more than 400 markets in the affordable home health services. United States. 1 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Role of Private Pay Services $100 buys significantly more care in a lower-cost-of-living area than in a Private pay spending on LTSS includes higher-cost-of-living area. However, amounts that individuals with disabilities those living in a higher-cost area are pay out of their own pockets for care, as likely to have more income and assets well as services that are paid for by their available, so that services with a higher families, their private long-term care nominal price might actually be more insurance policies (for the few that have affordable. To control for the regional them), or private charity. This spending effects of income and cost of living, plays a significant role in financing LTSS. private pay LTSS affordability can best be understood as a ratio of the cost of Most formal LTSS are paid for by public services to the amount of money that programs such as Medicaid; in 2010, people who need LTSS have to spend. Medicaid alone made up about 46 percent of LTSS spending for all PPI developed two indicators of private populations. 2 But Medicaid and most pay affordability for the Scorecard. These other public programs provide services indicators compare the cost of services only to those meeting stringent income, (measured by the median private pay cost asset, and disability criteria. For an in each market) with the available individual with moderate to high resources of the population in that market income, moderate to high assets, or a (measured by the median income of age moderate level of disability (one that 65+ households, the population with the requires assistance with daily activities highest likelihood of LTSS needs). but does not meet nursing home Household income is not a perfect eligibility criteria), private pay may be measure of resources, as most private pay the only option for receiving services, at users of LTSS have to draw down assets least until the cost of paying for services to pay for services, but asset data are not sufficiently drains income and assets so available at the geographic level needed that the person qualifies for Medicaid. to include in the indicator calculation. Out-of-pocket spending represents the The median cost of services is obtained third largest source of payment for LTSS, from the Genworth 2012 Cost of Care after Medicaid and Medicare, 3 and Survey. 6 It gives market-level estimates private pay spending from all sources for 425 markets, defined by county or accounts for 27 percent of total national equivalent, in the 50 states and District spending on LTSS. 4 When surveyed of Columbia, as well as 9 markets in directly, many more individual users of Puerto Rico. 7 The data include the LTSS report spending their own money median private pay cost of six types of on services than report payment by public LTSS: hourly cost for (1) homemaker programs (56 percent vs. 33 percent). 5 and (2) home health aide services; daily cost for (3) adult day health care and (4) New Indicators of Private Pay semiprivate and (5) private rooms in Affordability nursing homes; and (6) monthly base cost for assisted living. When evaluating the relative affordability of private pay LTSS in The median household income is different markets, it is important to computed from the 2010 American realize that the cost of living, the cost of Community Survey (referencing income services, and the typical amount of in years 2009–2010). Though the years income and assets vary significantly do not match, we wanted to use the most from market to market. For example, recently available data for both sources. 2 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports When the Scorecard was being household income, and affordability developed, the most recent data were measures. from the 2010 Cost of Care Survey and 2009 American Community Survey, Private Pay Affordability across which were used in the computation for Markets and States the Scorecard. We believe it is more important to have the most current data Nationally, private pay nursing home on cost of services than to have the same costs in 2012 averaged 252 percent of data year for cost and income. median age 65+ household income. For individual markets, the affordability We chose one measure of home and ratio ranged from 141 percent to community-based services (HCBS) and 638 percent. Even in the most one measure of institutional services for “affordable” market (Provo/Orem, UT), inclusion in the Scorecard. Most people the median nursing home cost far express a preference for receiving exceeded median income. The first services in their own homes or in conclusion from these data is that homelike settings that enable private pay nursing home care is not independence with support. Yet affordable for middle-income families regardless of the setting, the cost of anywhere. Nowhere in the country can a paying for LTSS can overwhelm a median-income older household afford family’s finances. to pay for nursing home care out of their For HCBS, we compared the median cost income. However, in a region that is of 30 hours per week of home health aide relatively more affordable, people services to the median age 65+ household paying out of pocket for a nursing home income. Among people with activities of will draw down their savings more daily living (ADL) disabilities who use slowly, and are more likely to be able to paid home care services, 30 hours per preserve some assets and avoid spending week is a typical level of use. 8 down to Medicaid eligibility. In relatively unaffordable regions, private- For institutional services, we compared pay nursing home residents will more the median cost of one year in a private quickly deplete their assets and room in a nursing home to the median potentially qualify for Medicaid. age 65+ household income. Although semiprivate rooms in nursing homes are In 2012, the cost of home health services more common, we use the private room averaged 88 percent of median age 65+ cost in the measure because we believe it household income. For individual is important that people with disabilities markets, the affordability ratio ranged be able to choose a private room if they from 49 percent to 145 percent. The pay prefer. 9 private cost of a typical amount of home care is about one-third that of nursing Table 1 lists the median LTSS costs, home care. 10 median age 65+ household income, and affordability ratios for each market. For While less costly than nursing homes, the Scorecard, these values were rolled home health care is still unaffordable for up to a state-level affordability measure: middle-income older people at typical The affordability ratios were averaged levels of use. People who receive home across all regions in a state, weighted by care services must add these costs to all the proportion of the state population in of their other living expenses—including each region. Table 2 shows the state food, housing, medical care, median LTSS costs, median age 65+ transportation, and other costs—and may find themselves unable to pay for 3 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports services while continuing to pay their health affordability. This report, using utility, insurance, food, and other bills. more recent data, confirms this As is the case with nursing home observation (see figures 1 and 2). The services, people who cannot afford the higher the state median age 65+ home care services they need may household income, the more affordable ultimately turn to Medicaid or other home services are in the state. No such public programs for help. If these relationship appears for nursing home programs have not invested adequately affordability. in HCBS, there may be limited alternatives to entering a nursing home; At the market level, the relationship is in this way, unaffordable home care can much clearer and stronger (see figures 3 lead to unnecessary institutionalization. and 4). There is a fairly strong Unaffordable home care services also relationship between income and home place added burdens on family health affordability and a very weak caregivers. relationship between income and nursing home affordability. 11 One might expect higher-income markets to be more affordable, because Policy Implications the denominator of the affordability ratio (income) is high. To some extent this is States have a stake in ensuring true. Bethesda, MD, the highest-income affordable private pay options for LTSS, market (median age 65+ household because the less affordable services are, income $60,457 compared with $34,381 the more likely—and more quickly— nationally) is also one of the most people with moderate means will spend affordable (62nd most affordable for through their income and assets to nursing homes and third most affordable qualify for public LTSS at taxpayer cost. for home health services), as the cost of care is only slightly above the national One way to help control costs in Medicaid average. Washington, DC/Alexandria- LTSS programs and to make sure services Arlington, VA, the second highest- are available for those who need them income market, is the 11th most most is to increase the affordability of affordable for nursing homes and most private pay services. This would delay or affordable for home health. prevent spend-down. State policy cannot directly set private pay costs, but states However, this is not a universal finding. can take actions to indirectly affect the Nursing home care in a number of the cost of services. highest-income markets (including Anchorage, AK; Long Island, NY; and Minnesota has a rate equalization policy Bridgeport, CT) is less affordable than for nursing homes: Facilities cannot the national average. Madison, WI charge private pay residents more than (median age 65+ household income the Medicaid rate. While it is not clear $47,157) has the same affordability that rate equalization is the cause, ratios as Macon, GA (median income private pay nursing home care is $32,244) and Fayetteville, NC (median relatively more affordable in Minnesota income $32,647). than in similar states; this is not the case for home care, which is relatively less One observation from the Scorecard was affordable in the state. that, at the state level, there is no relationship between income and nursing Another way to reduce the amount of paid home affordability, and only a moderate care needed in the community is by relationship between income and home supporting family caregivers (especially 4 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports working caregivers) through respite care, in effect for people of all ages, 12 education and training, and employment compared to a population of more than supports such as paid family leave and 40 million people age 65 or older, 13 most flexible work schedules. Allowing of whom will need LTSS in their delegation of nursing tasks to trained direct lifetime. 14 The cost of premiums is cited care workers can both support caregivers as a main reason for not buying LTCI. and reduce the cost of services purchased, Rate stabilization provisions, so that since direct care workers are much more people can be assured that their affordable than private duty nurses. premiums will not rise too quickly before any benefit is received, are Private long-term care insurance (LTCI) important because they help to ensure can make private pay services affordable affordability of premiums. As of 2012, for those with policies, but market 40 states and Washington, DC, have penetration is low. In 2010, there were adopted provisions, while 10 states approximately 8 million LTCI policies require no such protections. 15 Endnotes 1 Susan C. Reinhard, Enid Kassner, Ari Houser, and Robert Mollica, Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers (Washington, DC: AARP Public Policy Institute, The Commonwealth Fund, The SCAN Foundation, 2011) (http://www.longtermscorecard.org). 2 AARP Public Policy Institute analysis of 2010 National Health Expenditure data, and Steve Eiken, Kate Sredl, Brian Burwell, and Lisa Gold, Medicaid Expenditures for Long-Term Services and Supports: 2011 Update (New York, NY: Thomson Reuters, 2011). 3 Medicare, the second largest public payer of nursing home and home health care, does not cover most long-term services. Medicare coverage is limited to rehabilitative services (in home or in a nursing home) for no more than 100 days after an acute event, and does not include personal care services for someone with a permanent disability. Some analyses (e.g., Carol V. O’Shaughnessy, National Spending for Long- Term Services and Supports (LTSS) (Washington, DC: National Health Policy Forum, 2012)) do not classify Medicare-paid services as LTSS. 4 AARP Public Policy Institute analysis of 2010 National Health Expenditure data, and Eiken et al., Medicaid Expenditures. 5 Ari Houser, Mary Jo Gibson, and Donald L. Redfoot, Trends in Family Caregiving and Paid Home Care for Older People with Disabilities in the Community: Data from the National Long-Term Care Survey (Washington, DC: AARP Public Policy Institute, 2010). It is not clear why private sources are much more prevalent in the National Long-Term Care Survey (NLTCS) data than in the National Health Expenditure (NHE) data. Possibilities for the discrepancy include that a large “other” category in the NLTCS (21 percent of respondents reported that payment source was unknown) may be predominantly public sources; or the NHE data may underestimate private pay spending, as many home-based services and supports are nonmedical or may not be delivered by a licensed home health agency. 6 Cost of care data were obtained by personal communication with Genworth Financial. The most recent year of cost data is also accessible on the Genworth Cost of Care website (http://genworth.com/costofcare). 7 Market or region definitions for 2012 are accessible on http://genworth.com/costofcare. The region definitions were identical in 2011 and very similar in 2010 (there were a few changes in the San Francisco area). 8 Mitchell P. LaPlante, Charlene Harrington, and Taewoon Kang, “Estimating Paid and Unpaid Hours of Personal Assistance Services in Activities of Daily Living Provided to Adults Living at Home,” Health Services Research (2002) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1430364/pdf/hesr_029.pdf) found an average of 30.4 hours of paid care per week for people with ADL disability. Houser, Gibson, and Redfoot, Trends in Family Caregiving, found an average of 30.2 hours of formal care for people age 65+ with ADL or instrumental activities of daily living disability paying out of pocket. 5 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports 9 From a technical standpoint, the choice is not particularly important, as private rooms cost about 10 percent more than semiprivate rooms on average. This different is fairly constant across markets, and is small compared to between-market variation in nursing home costs. 10 The 3:1 nursing home: HCBS cost ratio has long been observed in Medicaid spending per person served. See, for example, Ari Houser, Wendy Fox-Grage, and Mary Jo Gibson, Across the States 2009: Profiles of Long-Term Care and Independent Living (Washington, DC: AARP Public Policy Institute, 2009). 11 The R2 statistic can be used to measure the strength of the relationship between income and affordability. At the market level, the R2 value for the relationship between median age 65+ household income and private pay home health affordability is 0.37, meaning that income explains more than one-third of the variation in home health affordability. For nursing homes, the R2 value is 0.06, meaning that income explains less than 1/16 of the variation in affordability between markets. 12 Kathleen Ujvari, Long-Term Care Insurance: 2012 Update, (Washington, DC: AARP Public Insight on the Issues 67, October, 2012 Policy Institute, 2012). AARP Public Policy Institute 13 U.S. Census Bureau, 2010 Decennial Census. 601 E Street, NW, Washington, DC 20049 14 Peter Kemper, Harriet L. Komisar, and Lisa www.aarp.org/ppi Alecxih, “Long-Term Care Over an Uncertain 202-434-3890, ppi@aarp.org Future: What Can Current Retirees Expect?” © 2012, AARP. Inquiry 42, no. 4 (December 2005): 335–50. Reprinting with permission only. 15 Ujvari, Long-Term Care Insurance. 6 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 Nursing Home and Home Health Affordability by Market Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Alabama Anniston-Oxford $32,042 $63,875 199% $24,882 78% Auburn-Opelika $34,461 $63,236 184% $24,882 72% Birmingham-Hoover $32,345 $68,503 212% $24,960 77% Decatur $29,221 $70,445 241% $24,960 85% Dothan $27,206 $72,635 267% $24,960 92% Florence-Muscle Shoals $31,337 $66,795 213% $23,400 75% Gadsden $28,314 $67,525 238% N/A N/A Huntsville $44,436 $72,653 164% $24,539 55% Mobile $33,252 $65,700 198% $24,336 73% Montgomery $40,305 $70,697 175% $24,180 60% Tuscaloosa $33,806 $63,875 189% $25,740 76% Rest of State $26,501 $62,780 237% $25,740 97% Alaska Anchorage $47,459 $164,980 348% $39,000 82% Fairbanks $48,366 N/A N/A $37,440 77% Rest of State $44,739 $285,613 638% $39,780 89% Arizona Flagstaff $48,567 $90,064 185% $31,496 65% Lake Havasu City-Kingman $32,647 $82,125 252% $32,760 100% Phoenix-Mesa-Glendale $38,088 $82,125 216% $32,682 86% Prescott $39,600 $84,680 214% $29,671 75% Tucson $36,174 $89,790 248% $31,793 88% Yuma $34,662 $76,285 220% $42,900 124% Rest of State $30,229 $76,285 252% $29,640 98% Arkansas Fayetteville-Springdale-Rogers $35,065 $70,445 201% $27,690 79% Fort Smith $28,717 $54,568 190% $26,130 91% Hot Springs $30,128 $60,225 200% $25,553 85% Jonesboro $25,191 $56,969 226% $25,896 103% Little Rock-North Little Rock-Conway $37,685 $60,225 160% $27,300 72% Pine Bluff $30,329 $54,020 178% $26,520 87% Rest of State $25,997 $54,750 211% $26,520 102% 7 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income California Bakersfield-Delano $35,267 $96,725 274% $29,640 84% Chico $36,577 $83,950 230% $29,640 81% East Bay $47,761 $98,550 206% $39,000 82% El Centro $23,075 $56,210 244% $23,790 103% Fresno $35,267 $92,710 263% $31,200 88% Hanford-Corcoran $29,090 $78,475 270% $34,320 118% Los Angeles County $38,390 $87,600 228% $31,200 81% Madera-Chowchilla $32,445 $75,920 234% N/A N/A Merced $27,911 $78,840 282% $31,964 115% Modesto $30,229 $82,308 272% $28,470 94% Napa $44,436 $108,474 244% $39,780 90% Orange County $45,948 $102,682 223% $32,370 70% Oxnard-Thousand Oaks-Ventura $44,275 $89,425 202% $34,320 78% Redding $33,554 $89,425 267% $28,470 85% Riverside-San Bernardino-Ontario $36,476 $74,825 205% $31,200 86% Sacramento—Arden-Arcade— $40,003 $94,900 237% $37,440 94% Roseville Salinas $44,436 $100,375 226% $32,370 73% San Diego-Carlsbad-San Marcos $43,328 $96,970 224% $34,710 80% San Francisco $34,259 $146,000 426% $41,340 121% San Jose-Sunnyvale-Santa Clara $44,940 $109,865 244% $39,000 87% San Luis Obispo-Paso Robles $43,328 $89,425 206% $37,440 86% San Mateo $48,870 $108,588 222% $39,000 80% Santa Barbara-Santa Maria-Goleta $47,056 $127,750 271% $40,560 86% Santa Cruz-Watsonville $43,227 $87,600 203% $39,000 90% Santa Rosa-Petaluma $47,761 $118,625 248% $38,610 81% Stockton $37,484 $85,775 229% $28,860 77% Vallejo-Fairfield $51,087 $95,539 187% $36,660 72% Visalia-Porterville $33,755 $73,610 218% $31,106 92% Yuba City $39,197 $72,270 184% $34,804 89% Rest of State $34,259 $94,535 276% $35,100 102% Colorado Boulder $42,723 $102,164 239% $35,880 84% Colorado Springs $42,421 $85,775 202% $35,100 83% Denver-Aurora-Broomfield $37,584 $86,323 230% $34,320 91% Fort Collins-Loveland $39,600 $87,235 220% $31,980 81% Grand Junction $36,274 $79,023 218% $31,200 86% Greeley $36,174 $86,870 240% $35,100 97% Pueblo $27,609 $80,300 291% $24,180 88% Rest of State $35,569 $78,110 220% $26,520 75% Connecticut Bridgeport-Stamford-Norwalk $46,744 $166,258 356% $36,660 78% Hartford-West Hartford-East Hartford $38,995 $145,909 374% $31,980 82% New Haven-Milford $34,562 $151,931 440% $33,540 97% Norwich-New London $38,794 $140,525 362% $34,320 88% Rest of State $34,965 $137,058 392% $28,548 82% Delaware Dover $39,096 $93,440 239% $33,056 85% Rest of State $41,514 $97,090 234% $37,050 89% District of Washington-Arlington-Alexandria $59,954 $96,908 162% $29,640 49% Columbia 8 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Florida Cape Coral-Fort Myers $40,809 $83,950 206% $28,470 70% Crestview-Fort Walton Beach-Destin $44,839 $73,000 163% $28,985 65% Deltona-Daytona Beach-Ormond $34,360 $89,133 259% $28,080 82% Beach Gainesville $40,003 $74,825 187% $31,122 78% Jacksonville $39,096 $82,545 211% $29,843 76% Lakeland-Winter Haven $32,244 $86,870 269% $28,860 90% Miami-Fort Lauderdale-Pompano $31,942 $96,725 303% $24,960 78% Beach Naples-Marco Island $50,633 $105,591 209% $32,760 65% North Port-Bradenton-Sarasota $38,693 $97,090 251% $32,760 85% Ocala $32,244 $87,600 272% $28,080 87% Orlando-Kissimmee-Sanford $34,965 $84,863 243% $28,860 83% Palm Bay-Melbourne-Titusville $37,484 $89,060 238% $27,690 74% Palm Coast $35,569 $83,950 236% $27,222 77% Panama City-Lynn Haven-Panama City $33,957 $81,395 240% $29,219 86% Beach Pensacola-Ferry Pass-Brent $34,864 $77,563 222% $30,420 87% Port St. Lucie $36,859 $78,475 213% $25,740 70% Punta Gorda $37,927 $94,900 250% $31,013 82% Sebastian-Vero Beach $38,189 $83,950 220% $29,640 78% Tallahassee $38,894 $82,125 211% $28,080 72% Tampa-St. Petersburg-Clearwater $32,949 $86,140 261% $29,640 90% Rest of State $33,151 $78,475 237% $30,716 93% Georgia Albany $29,423 $64,240 218% $26,239 89% Athens-Clarke County $36,476 $80,311 220% $26,910 74% Atlanta-Sandy Springs-Marietta $36,980 $69,350 188% $27,300 74% Augusta-Richmond County $31,942 $62,050 194% $28,080 88% Brunswick $32,647 $65,061 199% $28,283 87% Columbus $27,206 $61,638 227% $25,740 95% Dalton $28,213 $69,715 247% $26,442 94% Gainesville $31,639 $60,225 190% $28,283 89% Hinesville-Fort Stewart $29,221 $66,613 228% $28,860 99% Macon $32,244 $67,525 209% $24,960 77% Rome $23,881 $59,130 248% $28,080 118% Savannah $33,856 $65,335 193% $26,910 79% Valdosta $27,407 $78,464 286% $29,640 108% Warner Robins $36,274 $62,780 173% $30,763 85% Rest of State $27,307 $57,488 211% $26,723 98% Hawaii Honolulu $55,419 $118,505 214% $37,440 68% Rest of State $44,739 $147,825 330% $39,390 88% Idaho Boise City-Nampa $35,771 $85,228 238% $30,420 85% Coeur d'Alene $32,949 $85,666 260% $28,080 85% Idaho Falls $37,383 $80,300 215% $26,520 71% Lewiston $29,725 $73,000 246% $25,397 85% Pocatello $38,693 $82,125 212% $26,520 69% Rest of State $33,554 $75,040 224% $27,300 81% 9 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Illinois Bloomington-Normal $40,204 $73,000 182% $31,590 79% Champaign-Urbana $40,748 $62,963 155% $31,200 77% Chicago-Joliet-Naperville $35,771 $87,600 245% $32,760 92% Danville $31,236 $58,035 186% $28,470 91% Decatur $27,508 $70,810 257% $29,640 108% Kankakee-Bradley $32,405 $69,715 215% $28,283 87% Peoria $34,965 $73,000 209% $28,860 83% Rockford $28,113 $77,380 275% $30,623 109% Springfield $37,584 $66,065 176% $28,080 75% Rest of State $31,035 $58,400 188% $31,200 101% Indiana Anderson $35,569 $75,555 212% $30,030 84% Bloomington $33,252 $75,099 226% $28,080 84% Columbus $30,229 $95,995 318% $30,888 102% Elkhart-Goshen $32,647 $97,189 298% $30,420 93% Evansville $30,531 $82,125 269% $28,080 92% Fort Wayne $32,244 $83,768 260% $31,013 96% Indianapolis-Carmel $34,662 $78,475 226% $29,640 86% Kokomo $31,841 $86,870 273% $26,130 82% Lafayette $31,136 $94,900 305% $28,860 93% Michigan City-La Porte $28,213 $95,218 337% $31,793 113% Muncie $31,035 $81,760 263% $28,860 93% South Bend-Mishawaka $28,919 $93,604 324% $31,980 111% Terre Haute $33,957 $83,950 247% $30,888 91% Rest of State $31,639 $72,088 228% $28,860 91% Iowa Ames $37,081 $68,438 185% $31,200 84% Cedar Rapids $35,065 $60,864 174% $29,453 84% Davenport-Moline-Rock Island $31,136 $60,225 193% $28,860 93% Des Moines-West Des Moines $34,058 $60,773 178% $33,930 100% Dubuque $31,337 $61,503 196% $28,860 92% Iowa City $34,965 $67,708 194% $31,403 90% Sioux City $25,090 $57,670 230% $31,200 124% Waterloo-Cedar Falls $33,302 $60,043 180% $34,320 103% Rest of State $31,236 $57,305 183% $31,980 102% Kansas Lawrence $46,351 $70,445 152% $28,470 61% Manhattan $35,670 $70,263 197% $29,640 83% Topeka $39,902 $63,875 160% $28,080 70% Wichita $35,670 $60,225 169% $27,659 78% Rest of State $29,926 $57,853 193% $28,080 94% Kentucky Bowling Green $26,904 $77,198 287% $24,960 93% Elizabethtown $33,252 $77,380 233% $24,960 75% Lexington-Fayette $31,438 $76,650 244% $27,300 87% Louisville/Jefferson County $32,849 $80,300 244% $27,690 84% Owensboro $27,367 $82,673 302% $23,400 86% Rest of State $25,493 $68,620 269% $24,960 98% 10 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Louisiana Alexandria $32,647 $58,126 178% $21,840 67% Baton Rouge $33,755 $57,634 171% $24,960 74% Houma-Bayou Cane-Thibodaux $30,047 $56,042 187% $23,010 77% Lafayette $27,307 $54,750 201% $22,620 83% Lake Charles $28,012 $58,400 208% $23,400 84% Monroe $31,337 $53,272 170% $27,300 87% New Orleans-Metairie-Kenner $31,236 $63,875 204% $24,960 80% Shreveport-Bossier City $31,942 $57,287 179% $23,400 73% Rest of State $26,349 $51,710 196% $21,840 83% Maine Bangor $27,710 $110,139 397% $30,030 108% Lewiston-Auburn $26,601 $93,440 351% $38,610 145% Portland-South Portland-Biddeford $34,562 $109,500 317% $35,880 104% Rest of State $28,062 $99,736 355% $31,200 111% Maryland Baltimore-Towson $38,290 $100,010 261% $29,640 77% Bethesda $60,457 $113,880 188% $33,930 56% Cumberland $29,423 $87,600 298% $28,298 96% Hagerstown-Martinsburg $33,554 $93,075 277% $27,409 82% Salisbury $40,003 $78,840 197% $29,640 74% Rest of State $42,623 $83,950 197% $31,980 75% Massachusetts Barnstable Town $41,494 $133,886 323% $40,092 97% Boston-Cambridge-Quincy $38,894 $131,765 339% $39,000 100% Pittsfield $32,445 $118,625 366% $37,440 115% Springfield $31,841 $127,750 401% $35,880 113% Worcester $30,934 $116,800 378% $36,660 119% Rest of State $40,204 $149,650 372% $35,880 89% Michigan Ann Arbor $45,242 $90,520 200% $31,980 71% Battle Creek $34,259 $93,075 272% $34,320 100% Bay City $39,499 $89,425 226% $29,843 76% Detroit-Warren-Livonia $34,562 $86,140 249% $31,200 90% Flint $34,461 $85,228 247% $27,752 81% Grand Rapids-Wyoming $34,763 $97,273 280% $28,080 81% Holland-Grand Haven $33,856 $90,520 267% $30,420 90% Jackson $36,274 $91,615 253% $28,080 77% Kalamazoo-Portage $34,461 $98,550 286% $29,640 86% Lansing-East Lansing $40,406 $77,563 192% $30,420 75% Monroe $33,292 $85,775 258% $31,200 94% Muskegon-Norton Shores $30,833 $89,608 291% $30,420 99% Niles-Benton Harbor $28,818 $83,950 291% $28,860 100% Saginaw-Saginaw Township North $29,523 $80,300 272% $32,760 111% Rest of State $31,478 $86,870 276% $32,760 104% Minnesota Duluth $31,236 $93,163 298% $35,630 114% Mankato-North Mankato $34,692 $85,782 247% $32,760 94% Minneapolis-St. Paul-Bloomington $38,290 $91,969 240% $43,290 113% Rochester $36,879 $85,228 231% $37,019 100% St. Cloud $29,120 $77,417 266% $39,000 134% Rest of State $29,423 $81,724 278% $32,760 111% 11 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Mississippi Gulfport-Biloxi $36,577 $76,650 210% $24,960 68% Hattiesburg $26,904 $76,650 285% $28,080 104% Jackson $30,027 $69,350 231% $25,740 86% Pascagoula $33,252 $83,038 250% $24,960 75% Rest of State $24,888 $74,825 301% $25,646 103% Missouri Cape Girardeau-Jackson $26,652 $55,480 208% $32,760 123% Columbia $37,987 $59,678 157% $29,640 78% Jefferson City $35,569 $57,944 163% $28,080 79% Joplin $27,921 $58,400 209% $28,860 103% Kansas City $36,274 $58,948 163% $33,150 91% Springfield $26,904 $52,925 197% $27,690 103% St. Joseph $29,624 $53,108 179% $26,879 91% St. Louis $34,763 $65,700 189% $30,420 88% Rest of State $26,501 $49,823 188% $28,080 106% Montana Billings $35,166 $79,388 226% $32,760 93% Great Falls $34,864 $91,604 263% $31,200 89% Missoula $33,554 $90,246 269% $32,760 98% Rest of State $33,453 $68,438 205% $30,420 91% Nebraska Lincoln $36,476 $69,350 190% $34,710 95% Omaha-Council Bluffs $34,058 $71,175 209% $33,150 97% Rest of State $31,539 $68,985 219% $31,200 99% Nevada Carson City $44,537 $81,640 183% $33,150 74% Las Vegas-Paradise $38,995 $87,600 225% $31,200 80% Reno-Sparks $39,499 $98,886 250% $33,540 85% Rest of State $39,499 $82,063 208% $31,980 81% New Hampshire Manchester-Nashua $36,476 $118,625 325% $37,440 103% Rest of State $34,380 $102,200 297% $36,660 107% New Jersey Atlantic City-Hammonton $35,670 $98,550 276% $31,200 87% Northern New Jersey $41,816 $122,275 292% $31,200 75% Ocean City $35,871 $104,025 290% $27,300 76% Trenton-Ewing $43,529 $112,420 258% $35,880 82% Vineland-Millville-Bridgeton $34,259 $109,500 320% $32,760 96% New Mexico Albuquerque $39,600 $84,863 214% $31,434 79% Farmington $32,244 $70,445 218% $29,453 91% Las Cruces $30,229 $80,337 266% $24,383 81% Santa Fe $38,390 $78,475 204% $34,679 90% Rest of State $26,642 $66,795 251% $31,200 117% 12 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income New York Albany-Schenectady-Troy $37,987 $124,100 327% $35,880 94% Binghamton $33,252 $111,508 335% $35,490 107% Bronx $23,679 $136,875 578% $28,080 119% Brooklyn $23,478 $136,875 583% $26,130 111% Buffalo-Niagara Falls $31,236 $109,712 351% $35,100 112% Elmira $31,740 $122,823 387% $32,760 103% Glens Falls $34,058 $107,310 315% $35,880 105% Ithaca $42,219 $98,550 233% $37,440 89% Kingston $36,274 $130,882 361% $33,930 94% Long Island $51,490 $160,600 312% $35,100 68% Manhattan $33,252 $164,250 494% $34,320 103% Outer New York City Area $49,374 $146,000 296% $36,504 74% Poughkeepsie-Newburgh-Middletown $41,917 $144,540 345% $36,660 87% Queens $32,546 $130,488 401% $27,300 84% Rochester $34,360 $114,063 332% $35,662 104% Staten Island $40,305 $133,225 331% $27,690 69% Syracuse $32,345 $116,070 359% $34,601 107% Utica-Rome $30,733 $101,288 330% $33,743 110% Rest of State $30,027 $108,040 360% $35,880 119% North Carolina Asheville $35,166 $84,315 240% $31,980 91% Burlington $30,934 $81,030 262% $27,503 89% Charlotte-Gastonia-Rock Hill $36,174 $76,650 212% $29,250 81% Durham-Chapel Hill $41,313 $75,738 183% $28,080 68% Fayetteville $32,647 $67,890 208% $25,100 77% Goldsboro $27,206 $76,650 282% $24,960 92% Greensboro-High Point $32,244 $82,921 257% $26,723 83% Greenville $30,229 $67,708 224% $27,019 89% Hickory-Lenoir-Morganton $25,997 $73,913 284% $26,489 102% Jacksonville $33,856 $73,548 217% $29,640 88% Raleigh-Cary $37,786 $77,380 205% $28,860 76% Rocky Mount $24,485 $76,468 312% $27,300 111% Wilmington $38,854 $68,438 176% $27,659 71% Winston-Salem $30,229 $75,738 251% $28,080 93% Rest of State $27,911 $70,565 253% $26,489 95% North Dakota Bismarck $28,022 $90,936 325% N/A N/A Fargo $36,375 $67,525 186% N/A N/A Grand Forks $35,065 $92,294 263% $37,440 107% Rest of State $29,020 $75,438 260% $37,253 128% 13 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Ohio Akron $32,849 $88,148 268% $28,860 88% Canton-Massillon $32,244 $75,190 233% $26,520 82% Cincinnati-Middletown $31,670 $92,163 291% $30,420 96% Cleveland-Elyria-Mentor $30,934 $86,140 278% $29,734 96% Columbus $36,274 $82,125 226% $31,122 86% Dayton $32,556 $88,148 271% $29,640 91% Lima $32,748 $81,395 249% $28,860 88% Mansfield $32,853 $65,335 199% $25,740 78% Sandusky $30,934 $69,350 224% $24,180 78% Springfield $34,763 $78,475 226% $29,640 85% Steubenville-Weirton $29,020 $67,890 234% $23,400 81% Toledo $32,748 $85,045 260% $29,063 89% Youngstown-Warren-Boardman $28,415 $81,943 288% $25,007 88% Rest of State $28,818 $70,993 246% $29,640 103% Oklahoma Lawton $32,244 $53,327 165% $29,640 92% Oklahoma City $36,375 $57,670 159% $28,860 79% Tulsa $31,337 $61,444 196% $29,640 95% Rest of State $27,810 $52,286 188% $28,080 101% Oregon Bend $36,174 $91,250 252% $33,930 94% Corvallis $33,252 $123,735 372% $27,300 82% Eugene-Springfield $34,461 $96,451 280% $35,100 102% Medford $31,841 $99,463 312% $31,980 100% Portland-Vancouver-Hillsboro $37,887 $91,250 241% $33,150 87% Salem $39,620 $86,505 218% $34,320 87% Rest of State $31,639 $87,235 276% $30,420 96% Pennsylvania Allentown-Bethlehem-Easton $33,252 $128,235 386% $32,760 99% Altoona $29,725 $97,090 327% $25,740 87% Erie $31,639 $94,170 298% $30,420 96% Harrisburg-Carlisle $34,360 $96,553 281% $31,793 93% Johnstown $26,601 $88,830 334% $26,520 100% Lancaster $34,360 $109,774 319% $34,710 101% Lebanon $34,128 $104,116 305% $28,938 85% Philadelphia-Camden-Wilmington $36,980 $120,633 326% $33,618 91% Pittsburgh $30,733 $107,675 350% $32,760 107% Reading $31,136 $121,180 389% $31,200 100% Scranton—Wilkes-Barre $27,407 $92,163 336% $30,420 111% State College $36,879 $88,513 240% $28,080 76% Williamsport $28,818 $102,930 357% $32,604 113% York-Hanover $31,186 $106,945 343% $30,420 98% Rest of State $28,617 $80,300 281% $27,815 97% Rhode Island Providence-New Bedford-Fall River $30,229 $123,735 409% $37,830 125% 14 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income South Carolina Anderson $24,385 $76,650 314% $24,570 101% Charleston-North Charleston- $39,066 $73,000 187% $29,640 76% Summerville Columbia $33,554 $81,760 244% $26,520 79% Florence $25,191 $65,700 261% $26,099 104% Greenville-Mauldin-Easley $31,539 $71,518 227% $26,520 84% Myrtle Beach-North Myrtle Beach- $33,453 $72,088 215% $27,300 82% Conway Spartanburg $31,438 $67,525 215% $26,520 84% Sumter $22,873 $69,533 304% $20,873 91% Rest of State $30,027 $64,970 216% $29,640 99% South Dakota Rapid City $33,252 $77,902 234% $33,540 101% Sioux Falls $32,345 $67,890 210% $31,200 96% Rest of State $29,523 $68,255 231% $33,150 112% Tennessee Chattanooga $30,219 $81,815 271% $27,690 92% Clarksville $29,020 $71,175 245% $31,200 108% Cleveland $28,113 $72,635 258% $28,470 101% Jackson $35,771 $69,715 195% $24,773 69% Johnson City $26,702 $66,613 249% $31,153 117% Kingsport-Bristol-Bristol $27,710 $68,985 249% $25,740 93% Knoxville $31,942 $73,913 231% $26,832 84% Memphis $34,380 $74,643 217% $25,740 75% Morristown $26,198 $64,240 245% $25,740 98% Nashville-Davidson—Murfreesboro— $34,461 $74,095 215% $27,300 79% Franklin Rest of State $27,105 $66,978 247% $24,960 92% 15 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Texas Abilene $28,617 $59,130 207% $23,369 82% Amarillo $36,274 $60,225 166% $28,080 77% Austin-Round Rock-San Marcos $43,026 $68,620 159% $29,640 69% Beaumont-Port Arthur $30,430 $61,776 203% $26,520 87% Brownsville-Harlingen $25,594 $70,719 276% $20,280 79% College Station-Bryan $39,600 $58,400 147% $28,080 71% Corpus Christi $31,236 $72,270 231% $26,520 85% Dallas-Fort Worth-Arlington $39,297 $63,875 163% $29,390 75% El Paso $25,594 $63,236 247% $20,670 81% Houston-Sugar Land-Baytown $37,796 $74,095 196% $28,080 74% Killeen-Temple-Fort Hood $35,771 $51,830 145% $26,489 74% Laredo $21,996 $54,750 249% $31,200 142% Longview $31,740 $52,834 166% $24,960 79% Lubbock $36,436 $62,050 170% $24,960 69% McAllen-Edinburg-Mission $28,717 $78,840 275% $23,400 81% Midland $36,073 $80,300 223% $26,442 73% Odessa $25,090 $58,035 231% $26,520 106% San Angelo $29,926 $73,365 245% $24,882 83% San Antonio-New Braunfels $35,267 $63,875 181% $28,080 80% Sherman-Denison $30,934 $52,013 168% $26,520 86% Texarkana $28,012 $56,575 202% $26,520 95% Tyler $34,314 $56,758 165% $28,080 82% Victoria $31,035 $67,525 218% $28,080 90% Waco $33,655 $60,225 179% $24,944 74% Wichita Falls $31,136 $60,773 195% $25,490 82% Rest of State $29,322 $51,100 174% $26,520 90% Utah Logan $40,103 $66,613 166% $28,470 71% Ogden-Clearfield $44,134 $73,000 165% $31,980 72% Provo-Orem $46,048 $64,788 141% $33,540 73% Salt Lake City $38,058 $69,350 182% $33,540 88% St. George $32,647 $63,693 195% $32,760 100% Rest of State $32,647 $60,225 184% $28,470 87% Vermont Burlington-South Burlington $35,166 $108,040 307% $33,150 94% Rest of State $32,445 $101,507 313% $32,760 101% Virginia Blacksburg-Christiansburg-Radford $30,682 $87,600 286% $31,122 101% Charlottesville $40,708 $77,858 191% $31,200 77% Danville $27,407 $83,413 304% $24,180 88% Harrisonburg $35,267 $94,170 267% $27,300 77% Lynchburg $31,539 $70,080 222% $24,960 79% Richmond $37,826 $87,600 232% $28,860 76% Roanoke $31,720 $79,023 249% $28,080 89% Virginia Beach-Norfolk-Newport News $43,036 $83,220 193% $29,640 69% Winchester $40,003 $88,148 220% $27,269 68% Rest of State $27,810 $68,682 247% $26,520 95% 16 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 1 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Market Age 65+ Home Income Care Income Washington Bellingham $42,018 $87,965 209% $39,000 93% Bremerton-Silverdale $43,126 $110,548 256% $36,660 85% Kennewick-Pasco-Richland $43,328 $85,775 198% $31,013 72% Longview $37,887 $80,300 212% $31,980 84% Mount Vernon-Anacortes $45,545 $95,813 210% $33,540 74% Olympia $38,995 $120,450 309% $35,490 91% Seattle-Tacoma-Bellevue $43,328 $105,635 244% $38,969 90% Spokane $37,887 $107,536 284% $33,150 87% Wenatchee-East Wenatchee $34,320 $88,513 258% $30,420 89% Yakima $29,423 $81,213 276% $30,810 105% Rest of State $34,562 $99,269 287% $34,039 98% West Virginia Charleston $27,911 $88,071 316% $25,428 91% Huntington-Ashland $25,896 $72,635 280% $25,350 98% Morgantown $34,259 $88,513 258% $26,520 77% Parkersburg-Marietta-Vienna $25,191 $78,654 312% $27,503 109% Wheeling $28,818 $72,088 250% $22,620 78% Rest of State $24,888 $93,119 374% $24,180 97% Wisconsin Appleton $32,546 $88,695 273% $31,200 96% Eau Claire $29,120 $74,643 256% $34,320 118% Fond du Lac $31,579 $82,125 260% $29,640 94% Green Bay $31,367 $89,425 285% $31,980 102% Janesville $31,841 $97,820 307% $31,590 99% La Crosse $30,632 $81,304 265% $31,169 102% Madison $47,157 $98,550 209% $35,880 76% Milwaukee-Waukesha-West Allis $32,647 $107,274 329% $35,880 110% Oshkosh-Neenah $32,546 $95,630 294% $31,980 98% Racine $30,733 $107,493 350% $31,980 104% Sheboygan $27,407 $101,715 371% $28,782 105% Wausau $29,362 $100,193 341% $24,960 85% Rest of State $30,229 $84,680 280% $33,150 110% Wyoming Casper $32,647 $79,753 244% $25,350 78% Cheyenne $33,050 $85,410 258% $31,122 94% Rest of State $34,158 $72,927 213% $32,760 96% Sources: Cost of Care (2012 Genworth Cost of Care Survey), Median Income, Affordability Ratios (AARP Public Policy Institute calculations using data from 2010 American Community Survey) 17 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 2 Nursing Home and Home Health Affordability by State Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Age 65+ Home Income Care Income Alabama $30,763 $65,839 212% $24,960 80% Alaska $43,987 $232,505 464% $38,610 84% Arizona $37,134 $82,308 224% $31,200 88% Arkansas $29,452 $58,900 195% $26,520 89% California $40,255 $93,988 232% $35,100 84% Colorado $37,684 $84,315 227% $32,183 87% Connecticut $39,235 $145,818 386% $32,760 85% Delaware $40,301 $96,725 290% $35,880 89% District of Columbia $41,128 $94,353 162% $31,980 * 49% Florida $35,024 $84,552 257% $28,080 81% Georgia $32,183 $63,875 200% $26,520 82% Hawaii $51,293 $125,925 249% $39,390 74% Idaho $33,725 $80,300 231% $28,860 82% Illinois $34,673 $69,350 229% $31,200 92% Indiana $32,172 $82,125 247% $29,640 91% Iowa $32,487 $60,773 186% $32,370 99% Kansas $34,653 $60,225 175% $28,080 86% Kentucky $27,920 $75,555 262% $26,520 92% Louisiana $29,788 $56,721 190% $23,400 79% Maine $30,644 $105,120 345% $34,320 111% Maryland $44,712 $95,995 224% $31,200 68% Massachusetts $35,683 $127,750 356% $38,220 106% Michigan $33,381 $87,600 256% $31,169 91% Minnesota $34,397 $85,534 253% $39,390 113% Mississippi $27,529 $74,825 270% $25,740 93% Missouri $31,324 $55,480 183% $28,579 95% Montana $32,423 $75,008 220% $32,370 92% Nebraska $32,745 $70,263 210% $32,042 98% Nevada $38,951 $87,600 226% $32,760 81% New Hampshire $37,119 $105,120 319% $36,660 103% New Jersey $41,452 $114,975 297% $31,980 78% New Mexico $33,447 $75,526 231% $30,810 94% New York $34,518 $123,005 402% $34,320 96% North Carolina $31,694 $76,650 233% $27,300 86% North Dakota $30,669 $80,607 253% $37,346 125% Ohio $31,798 $81,213 260% $29,453 93% 18 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Table 2 (continued) Median Median Median Cost of Household Cost of Percent of Home Percent of Income Nursing Median Health Median State Age 65+ Home Income Care Income Oklahoma $31,486 $53,597 180% $29,250 92% Oregon $34,901 $91,250 257% $32,760 91% Pennsylvania $31,364 $99,280 326% $31,200 97% Rhode Island $33,192 $114,975 409% $37,440 125% South Carolina $31,691 $71,175 225% $27,737 87% South Dakota $29,950 $68,620 226% $31,200 106% Tennessee $30,160 $69,806 233% $26,879 86% Texas $34,178 $61,503 186% $28,080 79% Utah $40,784 $67,343 171% $32,760 82% Vermont $33,474 $101,507 311% $32,760 99% Virginia $39,274 $82,125 205% $28,470 70% Washington $39,207 $96,842 252% $34,320 90% West Virginia $26,796 $88,308 321% $24,960 92% Wisconsin $32,315 $93,075 290% $32,760 103% Wyoming $33,777 $80,391 225% $31,980 93% United States $34,381 $81,030 252% $29,640 88% * Home Health Cost Data for DC are for 2011. The Affordability Ratios (Percent of Median Income) are computed at the market level and then averaged across all markets in the state, weighted by in-state market population, and therefore do not necessarily equal the state median cost divided by the state median income. Markets may include parts of multiple states. Sources: Cost of Care (2012 Genworth Cost of Care Survey), Median Income (2010 American Community Survey), Affordability Ratios (AARP Public Policy Institute calculations) 19 A New Way of Looking at Private Pay Affordability of Long-Term Services and Supports Figure 1 Home Health Affordability by State INSIGHT on the Issues Figure 2 Nursing Home Affordability by State Figure 3 Home Health Affordability by Market Figure 4 Nursing Home Affordability by Market 20