February 2011, Number 11-3 WHAT IS ‘CLASS’? AND WILL IT WORK? By Alicia H. Munnell and Josh Hurwitz* Introduction Long-term care is the major uninsured expense for This brief proceeds as follows. The first section most retirees. Neither private health insurance nor discusses how families currently cover the burden of Medicare covers long-term care expenses, although long-term care. The second section describes CLASS Medicare provides for care in a skilled nursing facility and compares it to private insurance. The third sec- for up to 100 days following hospitalization. Long- tion identifies adverse selection – that is, participation term care insurance is available in the private market, mainly by the less healthy – as the major stumbling but few people purchase plans due to high premiums block facing CLASS. The fourth section presents a and limited benefits. As a result, many turn to fam- simple actuarial model to demonstrate the sensitivity ily members for care or are forced to deplete their of the premiums to the health and age distribution resources to qualify for Medicaid to pay for nursing of participants. The final section concludes that the home care. program faces enormous challenges, but a number of Although not yet commonly known to the public, programmatic changes and a major advertising cam- the new health care reform legislation establishes a paign could improve its chances of success. Without voluntary, long-term care insurance program known adjustments, adverse selection will create a death spi- as the Community Living Assistance Services and ral of rising premiums and declining participation.1 Supports, or CLASS. CLASS is designed to overcome the major problems in the existing system, which forces families of those needing long-term care to Paying for Long-term Care impoverish themselves, places an enormous burden on relatives caring for loved ones, and supports insti- Today tutionalization over home care. This brief explores the Long-term care helps those with chronic illnesses or potential for CLASS to solve the nation’s long-term injuries manage their daily lives. About two-thirds of care challenge. today’s 65-year-olds will need care at some point in their lives, and one-third will need to enter a nursing home for three or more months (see Table 1 on the next page). * Alicia H. Munnell is the Peter F. Drucker Professor of Management Sciences in Boston College’s Carroll School of Man- agement and Director of the Center for Retirement Research at Boston College (CRR). Josh Hurwitz is a research associate at the CRR. The authors would like to thank Francesca Golub-Sass for her work on the model. 2 Center for Retirement Research Table 1. Probability of Nursing Home Use for Only 8 percent of costs are covered by private Individuals Turning 65, 2010 long-term care insurance. This type of insurance is a relatively recent phenomenon that has grown slowly Length of stay Probability of nursing home use over the last 20 years. Initially, policies covered only Three months or longer 33 % nursing home care, but today over three-quarters of policies cover home care as well.5 One year or longer 24 Researchers have explored reasons for the slow Five years or longer 9 growth of private long-term care insurance. On the supply side are the limitations in the product and the Source: Congressional Budget Office (2004) based on data cost. For example, the typical policy purchased covers from Spillman and Lubitz (2002). only one-third of the expected present discounted value of long-term care expenditures, since many Medicaid pays for almost 40 percent of current policies have a daily cap in nominal dollars. Also, the long-term care expenditures (see Figure 1). It pays loads are high – amounting to about 18 percent of virtually the entire amount for nursing home care for premiums on the typical policy purchased at age 65 the poor. Some states also cover home-based care, and held until death.6 But the key factors appear to but are not required to do so under the program.2 be on the demand side. The first is people’s general The only way middle-class people can qualify for Med- reluctance to think about the possibility of becoming icaid is to spend down their assets – in most states to disabled as they age. The second is the existence of less than $2,000 for an unmarried individual – and Medicaid. Simulations suggest that even if compre- meet strict income limits.3 hensive private policies were available at actuarially fair prices, at least two-thirds of the wealth distribu- tion would not buy them because of Medicaid.7 Figure 1. Long-Term Care Expenditures by The lack of private insurance coverage is a serious Source, 2008 concern – especially for married couples. For those Other private, 3.1% with adequate resources, nursing home care means an additional expenditure of up to $75,000 per year. Out-of-pocket, Less than 15 percent of elderly households could 21.4% withstand such a drain, so Medicaid becomes the Medicaid, backstop but at the risk of impoverishing the spouse 38.7% remaining in the community.8 Reliance on Medicaid Private insurance, also limits the type of nursing home that the recipi- 7.9% ent may enter. Studies suggest that along a variety of Other public, 3.1% dimensions, the quality of nursing homes for those with the resources to pay – at least for a year or two Medicare, 25.8% – is far superior to the institutions available to those individuals who enter reliant on Medicaid.9 Note: “Other public” includes veterans’ health care. Source: Centers for Medicare and Medicaid Services (2010a). The CLASS Program Medicare is an important provider of skilled home CLASS addresses the shortcomings of the existing health services for the elderly, but covers only tem- system by helping people remain financially indepen- porary stays in nursing homes following hospitaliza- dent, relieving the burden on families, and offsetting tions. the bias toward institutionalization. The legislation Individuals pay out-of-pocket for more than 20 creates a voluntary government insurance benefit that percent of total long-term care expenses. More could provide the base for long-term care support, importantly, experts estimate that over half of long- with private insurance serving as a supplement for term care is provided without payment by spouses or middle-class participants and Medicaid serving as a other relatives – primarily daughters, and this source supplement for low-income individuals.10 The pro- of support does not appear at all in Figure 1.4 So the gram will be financed by participant premiums with major burden of out-of-pocket costs is borne by the no subsidy from the federal government. recipients or their families. Issue in Brief 3 The legislation took effect January 1, 2011, but the 2009, it estimated an average monthly premium of Secretary of Health and Human Services (HHS), who $123 (assuming that about 10 million people or about has been delegated broad authority, does not have to 3.5 percent of those eligible chose to enroll). How- present full rules and regulations until October 2012. ever, as demonstrated below, estimates of the required Many expect enrollment to begin in 2013, but it could premium are very sensitive to the age and health of occur earlier. Nevertheless, the broad outline of the participants. For low-income workers and working program is available. students, the contribution will be set at $5.13 Once people enroll, their premiums will stay the Coverage same over time, unless they need to be adjusted to ensure that the program is solvent for 75 years, or Coverage will be available to all working people age 18 if individuals stop participating for three or more and over. The work requirement, however, is mini- months and re-enroll.14 The young will pay less than mal; people need to earn only enough to pay Social the old to compensate for a longer expected contribu- Security taxes for one quarter, a threshold that is tion period. For example, using the CBO average of currently about $1,200 per year. The law specifically $123, the premium might be $105 for someone in his prohibits underwriting that would exclude people or her 20s compared to $180 for a person in his or her with existing disabilities. Non-working spouses, re- 60s.15 Premiums will not vary by gender. tired persons, and the unemployed will not be eligible to participate. Enrollment Benefits Individuals whose employers elect to participate will be automatically enrolled in the program and will Participants will be eligible for benefits after paying have premiums deducted directly from their pay- premiums for five years and meeting the minimum checks, unless they decide to opt out. An alternative work requirement for at least three of those years. procedure will be established for workers whose em- Benefits will be triggered once a participant needs help ployers choose not to participate, the self-employed, performing two or three activities of daily living (ADLs) and those with more than one employer. (eating, bathing, dressing, etc.) or needs comparable CLASS differs from private long-term care insur- assistance because of cognitive impairment. These ance in a number of ways. First, eligibility depends functional limitations must be expected to last for at only on minimal employment requirements, while least 90 days, as certified by a licensed health care prac- private insurance underwriting often disqualifies titioner. The Secretary of HHS will determine a scale those with health problems. Second, benefits are for the benefit amounts, based on the level of impair- paid in cash through a debit card and can be used ment. The Congressional Budget Office (CBO) in its for a variety of purposes, such as modifying a home analysis of the legislation assumed an average daily or payment to family caregivers, while the majority benefit of $75 that would increase each year with infla- of private plans are service-based. Third, benefits tion.11 (The law specifies that the average minimum will amount to only $75 a day compared to, say, $160 benefit must be at least $50.) The benefits continue for under private insurance.16 But benefits continue for as long as the individual needs care. life instead of three to four years with most private Beneficiaries will receive cash benefits through insurance plans, which may not be so important for a debit card account, giving them the freedom to older people but extremely valuable for a younger choose how to allocate their funds. For more expen- person with a disability, such as cerebral palsy. (To- sive services, beneficiaries will be able to roll over day, about 40 percent of those individuals needing benefits from month to month, within a one-year long-term care are not elderly.) Fourth, the CBO- period.12 estimated premium of $123 is slightly lower than the average premium paid for private long-term care insurance; however, the CBO estimate may well be Premiums low, as discussed in the next section.17 Finally, CLASS has an implicit vesting period in that participants The premium level will be set by the Secretary to en- have to contribute for five years (three of them while sure that the program is self-financing over a 75-year working) in order to qualify for benefits, while private period. When the CBO analyzed CLASS in November insurance enables the purchaser to claim benefits im- mediately if disabled. 4 Center for Retirement Research If CLASS succeeds, it should meet its goal of help- ing the disabled to be financially independent, relieve CLASS and the Federal Budget pressure on families, and keep people out of nursing homes by offsetting the Medicaid bias of paying only The relationship between CLASS financing and the for institutionalized care. The question is whether or federal budget is complicated. CLASS is self-financ- not the program will succeed. ing over 75 years, meaning that incoming premiums plus the interest earned on those premiums must exceed benefit outlays in any given year. However, The Challenge of Adverse the federal budget operates on a cash basis, with all available revenues – including trust fund in- Selection come – being considered as an offset to total federal spending commitments. This practice means that The success and solvency of CLASS will depend pri- if benefit outlays exceed incoming premiums in any marily on the extent of participation from American given year, it would appear as a net cost to the fed- workers, especially the young and healthy. For broad eral budget, regardless of whether or not the Trust participation, employers must decide to offer the plan Fund has sufficient assets to cover the difference. and individuals automatically enrolled must not opt In the short run, when premiums exceed payments, out. Broad participation is an ambitious goal given CLASS would improve the budget numbers. the voluntary nature of the program, people’s natural reluctance to think about the possibility of becoming disabled, the backstop of Medicaid, and insufficient funds to market the plan effectively to a large base of for CLASS are limited to no more than 3 percent of Americans. premiums. Experts say this amount will be totally The concern is that without underwriting to inadequate to cover basic functions, much less to exclude those with health problems, a greater pro- advertise the availability of the product. Without ad- portion of the less healthy will be attracted to the vertising, however, the program is doomed to failure. program (adverse selection). Disproportionate Therefore, the administrative budget would need to participation by those with health problems will drive be increased significantly. up per-participant cost and, given the requirement of 75-year actuarial balance, require an increase in pre- miums. Premium increases will discourage healthy A Simple Model people from signing up and encourage healthy participants in the program to drop their coverage as The following section discusses the output of a simple their perception of value declines. Such continued financial model that was constructed to project the shifts in the composition of the covered population claims costs, annual premiums, and trust fund bal- would eventually necessitate even steeper premium ances for CLASS over the first 75 years.19 (The details hikes, a cycle known as the “death spiral” and cited as of the model are described in Appendix A.) Changing a serious risk by the Chief Actuary for the Centers for the underlying assumptions highlights the sensitivity Medicare and Medicaid Services and by a joint work of required premium amounts to the age distribu- group from the American Academy of Actuaries and tion and health status of enrollees. The program is the Society of Actuaries.18 assumed to begin in 2013 and pay an initial average Two approaches could mitigate the tendency for benefit of $75 as assumed by the CBO.20 adverse selection. On the program side, requiring 20- The model starts with the current working popula- 30 hours of work per week rather than one quarter at tion and participation rates by age, based on today’s $1,200 would help insure that participants were really purchase of private long-term care insurance. Ben- healthy enough to be actively engaged. And increas- efit payments are projected for the 75-year horizon; ing the waiting period for benefits from five years to then, these amounts are used to derive the premiums 10-15 years would discourage those who need benefits required to keep the program solvent. (Premiums are in the near future from signing up. An alternative or based on age at enrollment. Premiums for the work- supplement to program changes would be a mas- ing poor and full-time students under age 22 are set sive advertising campaign. Administrative expenses Issue in Brief 5 at $5.) The benefit trigger is an inability to perform Table 3. Estimated Monthly Premiums for CLASS two or more ADLs, based on age-specific data from by Age, under Alternative Scenarios the National Long-Term Care Survey (NLTCS) and the Survey of Income and Program Participation (SIPP). Scenario 1 Scenario 2 Scenario 3 An adjustment factor is also included to account for Minimal adverse selection. The base scenario assumes a 6-per- Age Inflation-indexed Mandated premiums coverage participation cent overall participation rate and an annual lapse rate from the young of 1.5 percent.21 Under these assumptions, an aver- 18-29 $89 $84 $215 age premium of $194 is required to ensure solvency through 2087 (see Table 2). 30-39 $89 $84 $215 40-49 $94 $89 $227 50-59 $99 $94 $240 Table 2. Estimated Monthly Premiums for CLASS 60-69 $151 $143 $365 by Age, under Base Scenario 70-79 $181 $171 $437 Age Premium 80+ $200 $188 $481 18-29 $142 Average $121 $94 $312 premium 30-39 $142 40-49 $150 Source: Authors’ calculations. 50-59 $159 60-69 $241 enroll. Under this scenario, the average premium 70-79 $289 rises to $312, which would likely deter most healthy 80+ $318 workers from participating. Average premium $194 Source: Authors’ calculations. Conclusion More than two-thirds of today’s 65-year-olds will Three additional exercises are conducted using the require long-term care at some point in their lives, model. Under the current legislation, only benefits yet it remains the major uninsured expense for most are indexed for inflation, while premiums are de- retirees. Private health insurance and Medicare signed to remain constant upon enrollment. The first generally do not cover long-term care, and Medicaid scenario involves a change in premium design so that is only available once applicants have spent down the premiums are adjusted annually based on changes majority of their resources. Private long-term care in the CPI-U. This adjustment lowers the initial pre- insurance is an option, but is too expensive for many mium from $194 to $121 in 2013 (see Table 3). to afford and often limited in the benefits it provides. A more extreme (and controversial) approach to To help Americans manage their long-term care a national insurance program would be to mandate needs, the recent health reform legislation introduced coverage, completely eliminating the potential for ad- CLASS – a national, voluntary, long-term care insur- verse selection and insolvency.22 The second exercise ance program that is designed to serve as an afford- simulates this design among the full population of able supplement. Simulations using a simple model workers, and yields an average premium of $94. Even highlight the sensitivity of the plan’s required premi- this low-end estimate would not be viewed as afford- ums to the age distribution and health of participants. able by many households. To keep premiums down, CLASS must attract a pool The final exercise reveals the sensitivity of premi- of young and healthy participants. Attracting a broad ums to the age distribution of participants. An overall pool will require programmatic changes, such as participation rate of 6 percent is maintained; however, more stringent work requirements and longer vesting it is assumed that just 1 percent of participants are be- periods, as well as an effective national advertising low age 40. This assumption is based on the idea that campaign. However, even if all of these suggestions younger workers do not tend to view long-term care are adopted, premiums may never reach an affordable insurance as a priority and subsequently very few will level for middle-class households. APPENDIX Issue in Brief 7 The basic model created for this brief projects the claims costs, required monthly premiums, and trust fund balance for the CLASS program over a 75-year horizon. We break down the starting population by age group and include all active workers age 18 and over, as estimated by the Current Population Survey.23 Participation in the program varies by age and is estimated based on take-up rates in the private sector.24 We assume an initial overall participation rate of 6 percent in the base scenario, with a 1.5 percent annual lapse rate.25 In order to project claims costs for the program, we assume an initial average daily benefit of $75, based on the Congressional Budget Office report.26 Each year, the daily benefit amount increases by an assumed 2.8 per- cent change in the CPI-U, following the 2009 Federal Supplementary Medical Insurance Trust Fund Trustees Report.27 The benefit trigger is an inability to perform two or more Activities of Daily Living (ADLs), estimated separately by sex and age group using data from the National Long Term Care Survey and the Survey of Income and Program Participation. We adjust the morbidity rates extracted from these data for expected levels of ad- verse selection, based on the scenario being tested. Mortality rates are derived from Social Security Population- Level Cohort Mortality Tables. We subject both the morbidity and mortality rates to an annual improvement factor of 0.5 percent, corresponding with the analysis from the American Academy of Actuaries and the Society of Actuaries. Beginning after the initial five-year vesting period, the model projects the sum of expected benefit payments in each year based on the prevalence of claims suggested from the morbidity data. Using a nominal discount rate of 5.7 percent,28 we discount the benefits in each year to calculate their net present value (2013 dollars) and then total them to get a lump sum (Benefits). The pool of payees for each year (Payees) consists of the remaining participants after excluding beneficiaries and the deceased. We assume that 5 percent of these participants will pay the $5 subsidized rate and adjust the level of full required premiums (MonthlyPrem) to cover the subsidy (PremSub). We then discount the required premiums to net present value using the nominal interest rate (i) and multiply by 0.97 to account for the ad- ministrative expense, set at 3 percent of premiums. Finally, for each age group within the payee pool, we apply a pre-determined scaling factor (Age) to weight the required contributions so that initial premium amounts are higher for older participants. [Payees] * {( 1 (1+i)n ( { * 0.97 * [Age] * [MonthlyPrem] * 12 + [PremSub] = [Benefits] As shown by the equation above, for the program to remain solvent over the 75-year horizon, the discounted sum of total premiums plus the interest earned on these premiums must equal the discounted lump sum of benefits. By rearranging this equation, the model calculates a monthly premium, which we then adjust for each age group using the scaling factor (Age). 8 Center for Retirement Research Endnotes 1 Since eligible individuals can choose to opt-in to 9 Weissert and Scanlon (1985) find that receiving CLASS at any time, it poses an even greater risk for Medicaid support is positively correlated with the the program than a traditional death spiral. If people probability of having an unfavorable discharge status decide to enroll only once they expect a need for (such as death or entering another nursing home). long-term care, premiums could rise, even with fairly Also see Norton (2000) for a comprehensive survey of stable participation. quality of care models. 2 Despite the desire of most older people to stay at 10 The CBO expects nearly $2 billion in Medicaid home as long as possible, nearly three-quarters of the savings during the first 10 years of the CLASS pro- program’s long-term care benefits for the elderly are gram (Congressional Budget Office, 2009). paid to nursing facilities. See Houser, Fox-Grage, and Gibson (2009). 11 The inflation adjustment will be based on year- over-year changes in the CPI-U. 3 These tests are complicated and vary by state. Some states use the federal guidelines to qualify 12 Examples of the supports and services covered for Supplemental Security Income, which in 2008 by these funds include home modifications, assistive amounted to $637 in countable income and $2,000 technology, accessible transportation, homemaker ser- in countable assets for a single person. Other states vices, respite care, personal assistance services, home provide Medicaid long-term care services for individu- care aides, nursing support, and consultation regard- als up to 300 percent of the SSI threshold. Those ing medical care and payments to caregivers. individuals with incomes too high to qualify initially can enter a nursing home, spend down their assets, 13 A primary goal for the program is to overcome and then be eligible for benefits as medically needy. the crowd-out effect of Medicaid, particularly among low- and middle-income Americans. With premiums 4 Johnson, Tooney, and Weiner (2007). adjusted to a nominal rate of just $5 for those at or below the poverty line, this affordable option should 5 LifePlans, Inc. (2000). help encourage participation among the poorest. However, low-income Americans whose salaries 6 This means that, on average, a buyer will receive 82 exceed the poverty line by even 1 percent will pay the cents in expected present discounted value benefits normal monthly premium of nearly 25 times this per dollar of expected present discounted value premi- amount (based on CBO estimates), making them ums paid. more likely to forego the plan and wait for Medicaid eligibility. A sliding scale could be implemented on 7 Brown and Finkelstein (2007). In addition, others premiums up to a higher multiple of the poverty line have suggested that people may be reluctant to buy a to smooth out this cliff and encourage participation private policy due to concerns about the longevity of among more low-income Americans. insurance providers. 14 The $5 premium for low-income individuals and 8 Under Medicaid, the community spouse can college students will increase annually with changes retain only half of the couple’s non-housing assets in the CPI-U. Regular premiums, on the other hand, at the time the spouse enters a nursing home, up to will only be adjusted for inflation following enroll- a federally specified maximum ($109,560 in 2010, ment if a lapse in payment of three or more months adjusted annually for inflation) or the state standard, occurs. In this case, to become eligible for benefits, whichever is less (Centers for Medicare and Medicaid participants must pay premiums for two consecutive Services, 2009a). In terms of income, the community years at a higher rate that is age-adjusted for inflation. spouse can keep up to $2,739 of the couple’s com- bined monthly income. Furthermore, many states 15 Authors’ estimations based on Congressional also claw back funds when the Medicaid patient dies. Budget Office (2009). Issue in Brief 9 16 More than two-thirds of long-term care insurance plans sold in the private market have daily benefits that average or are capped between $100 and $200 (LIMRA International, 2010). 17 The average premium paid in 2007 across all long-term care insurance plans was about $184. The average policy provided $160 in daily benefits for up to five years and came with some form of inflation protection (LIMRA International, 2008). 18 Centers for Medicare and Medicaid Services (2010b) and American Academy of Actuaries and the Society of Actuaries (2009). 19 In 2009, the SCAN Foundation commissioned Avalere Health, LLC to construct an interactive model, which allows the user to project premiums for any national long-term care program of their design. We concluded that a simpler model was necessary to iso- late the known provisions of CLASS and demonstrate the key factors that will affect the premium level. 20 Due to the five-year vesting period, no benefits will be paid out until 2018. 21 These assumptions are modeled after the Ameri- can Academy of Actuaries and the Society of Actuaries (2009). 22 Gleckman (2009) endorses a mandatory system in order to avoid the same market failures as private insurance. 23 U.S. Bureau of the Census (2010). 24 LIMRA International (2010). 25 American Academy of Actuaries and the Society of Actuaries (2009). 26 Congressional Budget Office (2009). 27 Centers for Medicare and Medicaid Services (2009b). 28 Centers for Medicare and Medicaid Services (2009b). 10 Center for Retirement Research References American Academy of Actuaries and the Society of Gleckman, Howard. 2009. Kaiser Health News. “The Actuaries. 2009. “Letter to the U.S. Senate Com- CLASS Act: A Flawed but Powerful Game-Chang- mittee on Health, Education, Labor and Pensions.” er for Long-Term Care,” November 30. Available at: http://www.actuary.org/pdf/health/ class_july09.pdf. Houser, Ari, Wendy Fox-Grage, and Mary Jo Gibson. 2009. “Across the States: Profiles of Long-Term Care Brown, Jeffrey R. and Amy Finkelstein. 2007. “Why and Independent Living.” Washington, DC: AARP. Is the Market for Long-Term Care Insurance So Small?” Journal of Public Economics 91(10): 1967- Johnson, Richard W., Desmond Toohey, and Joshua 1991. M. Wiener. 2007. “Meeting the Long-Term Care Needs of the Baby Boomers: How Chang- Centers for Medicare and Medicaid Services. 2009a. ing Families Will Affect Paid Helpers and “1998-2010 SSI and Spousal Impoverishment Institutions.” Washington, DC: Urban Insti- Standards.” Washington, DC: U.S. Department of tute. Available at: http://www.urban.org/url. Health and Human Services. cfm?ID=311451&renderforprint=1. Centers for Medicare and Medicaid Services. 2009b. LifePlans, Inc. 2000. “Who Buys Long-Term Care In- “2009 Annual Report of the Boards of Trustees surance in 2000? A Decade of Study of Buyers and of the Federal Hospital Insurance and Federal Nonbuyers.” Washington, DC: Health Insurance Supplementary Medical Trust Funds.” Washing- Association of America. ton, DC: U.S. Department of Health and Human Services. Available at: https://www.cms.gov/Re- LIMRA International. 2008. Chicago, IL: LIMRA In- portsTrustFunds/downloads/tr2009.pdf. ternational. Available at: http://www.longtermcare. gov/LTC/Main_Site/Paying_LTC/Private_Pro- Centers for Medicare and Medicaid Services. 2010a. grams/LTC_Insurance/index.aspx. “National Health Expenditure Web Tables,” Tables 4 and 11. Washington, DC: Department of Health LIMRA International. 2010. “U.S. Individual Long- and Human Services. Available at: http://www. Term Care Insurance: Final 2009 Supplement.” cms.gov/NationalHealthExpendData/downloads/ Chicago, IL: LIMRA International. tables.pdf. U.S. Bureau of the Census. National Long Term Care Centers for Medicare and Medicaid Services. 2010b. Survey, 2004. Washington, DC. “Estimated Financial Effects of the ‘Patient Pro- tection and Affordable Care Act,’ as Amended.” U.S. Bureau of the Census. Survey of Income and Pro- Memorandum of Richard S. Foster, April 22. gram Participation, 2004. Washington, DC. Compilation of Patient Protection and Affordable Norton, Edward C. 2000. “Long-Term Care.” In Hand- Care Act. 2010. Prepared by the Office of the Leg- book of Health Economics, Volume IB, edited by An- islative Counsel for the Use of the U.S. House of thony J. Culyer and Joseph P. Newhouse, 956-994. Representatives. Available at: http://www.health- New York, NY: Elsevier Science B.V. care.gov/center/authorities/title_viii_class_act.pdf. Spillman, Brenda C. and James Lubitz. 2002. “New Esti- Congressional Budget Office. 2004. Financing Long- mates of Lifetime Nursing Home Use: Have Patterns Term Care for the Elderly. Washington, DC: Govern- of Use Changed?” Medical Care 40(10): 965-975. ment Printing Office. U.S. Bureau of the Census. 2010. Current Population Congressional Budget Office. 2009. Letter from CBO Survey Table Creator. Washington, DC. Available at: Director Douglas W. Elmendorf, November 25. http://www.census.gov/hhes/www/cpstc/cps_ta- Available at: http://www.cbo.gov/ftpdocs/107xx/ ble_creator.html. doc10769/CLASS_Additional_Information_Mill- er_letter.pdf. Weissert, William G. and William J. Scanlon. 1985. “Determinants of Nursing Home Discharge Sta- tus.” Medical Care 23(4): 333-343. About the Center Affiliated Institutions The Center for Retirement Research at Boston The Brookings Institution College was established in 1998 through a grant from Massachusetts Institute of Technology the Social Security Administration. The Center’s Syracuse University mission is to produce first-class research and forge Urban Institute a strong link between the academic community and decision-makers in the public and private sectors around an issue of critical importance to the nation’s Contact Information Center for Retirement Research future. To achieve this mission, the Center sponsors Boston College a wide variety of research projects, transmits new Hovey House findings to a broad audience, trains new scholars, and 140 Commonwealth Avenue broadens access to valuable data sources. 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