A strong advocate for aging in place has just moved into a top policy position in Washington.

Kathy Greenlee, who was confirmed by the Senate on Thursday as U.S. assistant secretary for aging at the Department of Health and Human Services (HHS), says helping older Americans live independently at home for as long as possible will be among her top priorities as the new head of the Administration on Aging.

Greenlee, who was the Kansas secretary of aging, says policymakers must consider long-term care rebalancing, in which states allocate a greater portion of Medicaid funds to home and community services rather than to institutional care such as nursing homes.

“There has to be a way to create policy to allow people to stay at home and age in place that’s more manageable,” Greenlee says in an exclusive interview with AARP Bulletin Today before her confirmation.

“The services people want are often the least expensive to deliver if we can figure out to how to do it—how to shape that program so it works and sustains the increasing number of seniors who ask for those services.”

Studies have found that older adults overwhelmingly prefer to live independently in their homes as they age, an alternative that costs the government less than financing care at a public nursing home. Yet a disproportionate amount of Medicaid spending on long-term care goes toward institutional care, according to an AARP report released in July 2008.

Nursing home costs triple that of home care

Medicaid, which uses state and federal funds to pay for long-term care for low-income adults, spends $9,000 a year for home and community services that help an individual age in place. It spends three times more, at $26,000 a year, on nursing home care, the report says.

Consumers’ out-of-pocket costs for long-term care are also considerable. In Kansas and around the nation, Greenlee says, people often spend between $30,000 and $50,000 for a nursing home in the first year—their life savings, in many cases—before Medicaid kicks in. That money would be better spent and last longer, she says, if older adults could use it for home-based services.

“How we can help them—that’s the interesting puzzle right now for me,” Greenlee says. “Seniors have money, but they don’t have enough money. How do we go back and strengthen the system so we can maximize the use of their money and keep them in the community longer?”

Enid Kassner, director of the Public Policy Institute at AARP, says the current government model addressing Americans’ long-term care needs a major overhaul. She says that federal regulations cause people to “impoverish themselves and spend down a lifetime of savings, and only then do they get Medicaid funding.” AARP has strongly encouraged lawmakers to fund programs that help people remain independent in their homes.

Greenlee says that additional government funding for a broader range of long-term care services will be hard to come by, given the recession and the constraints on state budgets. But these are “genuine issues that we all need to discuss,” she says.

Worked closely with HHS secretary

At HHS, Greenlee will likely have the ear of Secretary Kathleen Sebelius, former governor of Kansas, who appointed Greenlee to head the state’s Department of Aging in 2006.

“Kathy Greenlee has vast experience advancing and promoting the security, dignity and independence of older Americans in Kansas," Sebelius said. "I am pleased the Senate has confirmed her today as Assistant Secretary for Aging. She will be an outstanding advocate for older Americans across the country, and a valued leader at the U.S. Department of Health and Human Services.”

Before that, the two also worked together when Greenlee served as the state’s long-term care ombudsman and its insurance commissioner.

As Kansas’ secretary of aging, Greenlee traveled around the state to get input from advocates and experts about how her department’s $495 million budget could best be spent to meet the older population’s greatest needs.

That led to her proudest achievement: working with state lawmakers in 2007 to expand Medicaid dental benefits to frail older recipients who qualify for the Home and Community-Based Services waiver. Before then, only people with disabilities and low-income children were eligible for public dental benefits.

“We had a public policy that supported other people,” Greenlee says. “Seniors needed to be included in this conversation. It wasn’t appropriate to leave them out because of the connection between their dental care, their health and their remaining at home.”

Booster for dental care

“I accidentally became an advocate for dental services because that’s what the greatest need was,” she adds. “If we’re going to support good health and staying at home, we have to support good dental health.”

The lack of access to affordable dental care has been called a silent public health epidemic. An estimated 130 million Americans have no dental insurance, according to Elizabeth Rogers, a spokeswoman for Oral Health America. Critics say the oral health needs of the uninsured who cannot afford to pay for dental treatment have long been ignored.

Older adults are particularly affected, since only a fraction of them retain their employer-sponsored dental insurance once they retire. Without dental coverage, many say they can’t afford the high cost of preventive care and treatment.

Yet there is mounting evidence that bacteria from gum disease can travel through the bloodstream to other organs in the body, causing or exacerbating certain heart conditions, strokes and diabetes.

Greenlee says the political environment in Kansas was ripe for her to push for expanded dental benefits for certain older adults on Medicaid, but whether a similar landscape will emerge in Washington remains to be seen.

It would have been difficult for Kansas legislators debating public dental benefits for the disabled “to say no, you can’t give it to seniors,” Greenlee says. “You have to have the need and the [political] opportunity. That will lead you to which issues you can address right now.

“I’ll be open-minded and receptive about it” on the federal level, she adds. “I have a strong interest in the topic.”

(Photo: Courtesy Kansas Department of Aging)

Carole Fleck is a senior editor at the AARP Bulletin.