A CRS Review of Ten States: Home and Community-Based Services — States Seek to Change the Face of Long-Term Care: Oregon

A CRS Review of Ten States: Home and Community-Based Services — States Seek to Change the Face of Long-Term Care: Oregon

Order Code RL32132
CRS Report for Congress
Received through the CRS Web
A CRS Review of Ten States: Home and
Community-Based Services — States Seek to
Change the Face of Long-Term Care: Oregon
October 26, 2003
Meridith Walters
Consultant
Domestic Social Policy Division
Carol O’Shaughnessy, Rob Weissert,
Julie Stone-Axelrad and Sidath Panangala
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

A CRS Review of Ten States: Home and Community-
Based Services — States Seek to Change the Face of
Long-Term Care: Oregon
Summary
Demographic challenges posed by the growing elderly population and demands
for greater public commitment to home and community-based care by persons with
disabilities of all ages have drawn the attention of federal and state policymakers for
some time. Spending on long-term care in both the public and private sectors is
significant. In 2001, spending for long-term care services for persons of all ages
represented 12.2% of all personal health care spending (almost $152 billion of $1.24
trillion). Federal and state governments accounted for almost two-thirds of this
spending. By far, the primary payor for long-term care is the federal-state Medicaid
program, which paid for almost half of all long-term care spending in 2001.
Many states have devoted significant efforts to respond to the desire for home
and community-based care for persons with disabilities and their families.
Nevertheless, the financing of nursing home care, chiefly by Medicaid, still
dominates most states’ spending for long-term care today. To assist Congress in
understanding the issues that states face in providing long-term care services, CRS
undertook a study of 10 states in 2002. This report, which will not be updated,
presents background and analysis about long-term care in Oregon.
Oregon is a recognized leader in home and community-based care and has more
than 20 years of experience in moving long-term care clients from institutional
settings to home and community-based settings. In 2002, 82% of Oregon’s Medicaid
long-term care clients were served in the community. Additionally, Oregon was the
only state in the nation whose spending for institutional care was less than half of the
state’s total Medicaid long-term care spending in 2000, with only 37.2% spent on
institutional care compared to the national average of approximately 70%.
In 1981, a clear preference for home and community-based services was
established by the state legislature in Senate Bill 955. This legislation streamlined
the administrative structure and established a clear vision for a long-term care system
that embodies the values of independence, dignity, privacy, and choice. It also
mandated that any cost-savings from reductions in institutional spending be
reinvested into a system that promotes home and community-based care. The various
functions of Oregon’s long-term care system are administered by a single division
(Seniors and People with Disabilities) housed within a single state agency (the
Department of Human Services). This centralized administration shares a common
vision to promote care in the community over institutions.
Oregon officials recognize that with the aging population and increasing costs,
they may need to rethink the design of their current system. They hope to incorporate
a concept of “bounded choice” where a person’s wishes are considered within the
boundaries of service capacity and fiscal constraints.

The 10-state study was funded in part by grants from the Jewish Healthcare
Foundation and the U.S. Department of Health and Human Services, Health
Resources and Services Administration, Office of Rural Health Policy.

Contents
Introduction: Federal Legislative Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
A CRS Review of Ten States: Report on Oregon . . . . . . . . . . . . . . . . . . . . . . . . . 4
Summary Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Demographic Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Administration of Long-Term Care Programs . . . . . . . . . . . . . . . . . . . . . . . . 6
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . . 7
Long-Term Care Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Issues in Financing and Delivery of Long-Term Care . . . . . . . . . . . . . . . . . . 8
Demographic Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Need for Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Administration of Long-Term Care Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
State and Local Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Management of Services for Seniors and Other Persons with
Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Local Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Management of Services for Persons with Developmental
Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Licensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Financial and Functional Eligibility Determinations . . . . . . . . . . . . . . . . . . 16
Changes in Functional Eligibility Requirements Due to Budget
Reductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Oregon’s Long-Term Care Services for the Elderly and Persons with
Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Implementation of the Medicaid 1915(c) Waiver Program for
Seniors and Adults with Physical Disabilities . . . . . . . . . . . . . . . 19
Pre-Admission Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Certificate of Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . 20
Medicaid 1915(c) Waiver for Seniors and Persons with
Physical Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Client Employed Provider Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Nurse Delegation and Contract Registered Nursing Services . . . . . . . 21
State Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Oregon’s Long-Term Care Services for Persons with Mental Retardation
and Developmental Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . 26
Medicaid 1915(c) Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Financing of Long-Term Care in Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Medicaid Spending in Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Medicaid Long-Term Care Spending in Oregon . . . . . . . . . . . . . . . . . . . . . 30
Medicaid and State Spending on Services for Persons with Mental
Retardation and Developmental Disabilities . . . . . . . . . . . . . . . . . . . . 35
Issues in Long-Term Care in Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Institutional Bias in Federal Funding and Oregon’s Response . . . . . . 37
Budget Cuts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medicaid Eligibility Requirements and Access to Services . . . . . . . . 38
Waiting Lists for Persons with Developmental Disabilities . . . . . . . . 39
Long-Term Care Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Centralization of Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Bounded Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Other Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Appendix 1. Major Home and Community-Based Long-Term Care Programs
for the Elderly and Persons with Disabilities in Oregon . . . . . . . . . . . . . . . 42
Appendix 2. Population in Large State Facilities for Persons with
Mentally Retardation/Developmental Disabilities, Closure Date, and
Per Diem Expenditures, 1960-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Appendix 3. About the Census Population Projections . . . . . . . . . . . . . . . . . . . 47
Additional Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
List of Figures
Figure 1. Percent Population Increase in Oregon, 2000-2025 . . . . . . . . . . . . . . . 10
Figure 2. Oregon Long-Term Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. Institutional and Home and Community-Based Services as a
Percent of Medicaid Long-Term Care Spending in Oregon, 1990-2000 . . . 32
Figure 4. Medicaid Long-Term Care Spending by Category in Oregon,
FY1990-FY2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Figure 5a. Medicaid Long-Term Care Spending in Oregon by Category,
FY1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Figure 5b. Medicaid Long-Term Care Spending in Oregon by Category,
FY2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Figure 6. Medicaid Home and Community-Based Services Waiver
Spending by Target Population in Oregon, FY2001 . . . . . . . . . . . . . . . . . . 35

List of Tables
Table 1. Oregon Population Age 65 and Older, 1990 and 2000 . . . . . . . . . . . . . . 9
Table 2. Elderly Population as a Percent of Total Population,
Oregon and the United States, 2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Table 3. Estimated Number of Persons with Two or More Limitations in
Activities of Daily Living (ADLs), by Poverty Status, in Oregon . . . . . . . . 11
Table 4. Service Priority Levels Eligible for Medicaid Services . . . . . . . . . . . . 17
Table 5: Eliminated Service Priority Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 6. Nursing Home Characteristics in Oregon and the United States . . . . . 19
Table 7. Medicaid Long-Term Care Caseload by Setting, July 2002 . . . . . . . . . 22
Table 8. Persons with Mental Retardation and Developmental Disabilities
Served in Residential Settings, by Size of Residential Setting, 1990,
1995, and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Table 9. Share of Federal and State Spending by Category, Oregon and the
United States, 1990-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table 10. State Spending for Medicaid as a Percent of Total State Spending,
Oregon and the United States, 1990-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table 11. Medicaid Long-Term Care Spending In Oregon, FY1990-FY2000 . . 31
Table 12. Medicaid Spending in Oregon, Total Spending and Long-Term
Care Spending, by Category, and Percent Change, FY1990-FY2001 . . . . . 32
Table 13. Federal and State Spending for Institutional and Community Services
for Persons with Mental Retardation/Development Disabilities in
Oregon, 1990 and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Acknowledgments
CRS wishes to acknowledge the generous time and contributions of the many
state officials and stakeholders who provided information on long-term care services
in Oregon. Without their invaluable experience and insight, this report would not be
possible. We would particularly like to acknowledge officials from Oregon’s
Department of Human Services — Seniors and People with Disabilities. We also
would like to thank the numerous advocates and service providers who offered
valuable perspectives on the long-term care service delivery system in Oregon.
The authors gratefully acknowledge the excellent assistance of Charlotte B.
Foote and Angela Harris in the production of this report.

Preface
Demographic challenges posed by the growing elderly population and demands
for greater public commitment to home and community-based care by persons with
disabilities of all ages have drawn the attention of federal and state policymakers for
some time. Spending on long-term care by both the public and private sectors is
significant. In 2001, spending for long-term care services for persons of all ages
represented 12.2% of all personal health care spending (almost $152 billion of $1.24
trillion). Federal and state governments accounted for almost two-thirds of this
spending. By far, the primary payor for long-term care is the federal-state Medicaid
program, which paid for almost half of all U.S. long-term care spending in 2001.
In FY2001, federal and state Medicaid spending for long-term care was about
$75 billion, representing over one-third of all Medicaid spending. Over 70% of
Medicaid long-term care spending was for institutions — nursing homes and
intermediate care facilities for the mentally retarded (ICFs/MR). Many believe that
the current federal financing system paid through Medicaid is biased toward
institutional care. State governments face significant challenges in refocusing their
long-term care systems, given the structure of current federal financing. In this
regard, many states have devoted significant efforts to expand home and community-
based services for persons with disabilities and their families. Nevertheless,
financing of nursing home care — primarily through the Medicaid program — still
dominates most states’ spending in long-term care today.
While advocates believe that the federal government should play a larger role
in providing support for home and community-based care, Congress has not yet
decided on whether or how to change current federal policy. One possibility is that
Congress may continue an incremental approach to long-term care, without major
federal involvement, leaving to state governments the responsibility for developing
strategies that support home and community-based care within existing federal
funding constraints and program rules.
To assist Congress in its consideration of options for any future federal policy,
and to assist policymakers in understanding issues that states face in the development
of long-term care services, the Congressional Research Service (CRS) undertook a
study of 10 states in 2002. The research was undertaken to review state policies on
long-term care as well as trends in both institutional and home and community-based
care for persons with disabilities (the elderly, persons with mental retardation, and
other adults with disabilities). The research included a review of state documents and
data on long-term care, as well as national data sources on spending. Interviews were
held with state officials responsible for long-term care, a wide range of stakeholders
and, in some cases, members or staff of state legislatures.
The 10 states included in the study are: Arizona, Florida, Illinois, Indiana,
Louisiana, Maine, Oklahoma, Oregon, Pennsylvania, and Texas. States were chosen
according to a number of variables, including geographic distribution, demographic
trends, and approaches to financing, administration and delivery of long-term care
services.
This report presents background and analysis about long-term care in Oregon
and is one of a series of CRS state reports on long-term care.

A CRS Review of Ten States: Home and
Community-Based Services —
States Seek to Change the Face of
Long-Term Care: Oregon
Introduction: Federal Legislative Perspective
States choosing to
modify their programs for
The Social Security Amendments of 1965, which
l o n g - t e r m c a r e f a c e
created the Medicaid program, required states to
signifi cant challenges.
provide skilled nursing facility services under their
state Medicaid plans, and gave nursing home care the
Financing of nursing home
same level of priority as hospital and physician
care has dominated long-term
services.
care spending for decades.
The federal financing
“Section 1902 (a) A State plan for medical assistance
structure that created
must provide for inclusion of some institutional and
some noninstitutional care and services, and, effective
incentives t o s upport
July 1, 1967, provide (A) for inclusion of at least . . .
institutional care reaches
(1) inpatient hospital services ...; (2) outpatient
back to 1965. A number of
hospital services; (3) other laboratory and X-ray
converging factors have
services; (4) skilled nursing home services (other than
services in an institution for tuberculosis or mental
supported reliance on nursing
diseases) for individuals 21 years of age or older; (5)
home spending. Prior to
physicians’ services ....;” P.L. 89-97, July 30, 1965.
enactment of Medicaid,
homes for the aged and other
public institutions were
financed by a combination of direct payments made by individuals with their Social
Security Old Age Assistance (OAA) benefits, and vendor payments made by states
with federal matching payments on behalf of individuals. The Kerr-Mills Medical
Assistance to the Aged (MAA) program, enacted in 1960, a predecessor to Medicaid,
allowed states to provide medical services, including skilled nursing home services,
to persons who were not eligible for OAA cash payments, thereby expanding the
eligible population.1
In 1965, when Kerr-Mills was transformed into the federal-state Medicaid
program, Congress created an entitlement to skilled nursing facility care under the
expanded program. The Social Security Amendments of 1965 required that states
provide skilled nursing facility services, and gave nursing home care the same level
of priority as hospital and physician services. Amendments in 1967 allowed states
to provide care in “intermediate care facilities” (ICFs) for persons who did not need
1 CRS Report 83-181, Nursing Home Legislation: Issues and Policies, by Maureen Baltay.
Archived and available from authors upon request.

CRS-2
skilled nursing home care, but needed more than room and board. In 1987, Congress
eliminated the distinction between skilled nursing facilities and intermediate care
facilities (effective in 1990). As a result of these various amendments, people
eligible under the state’s Medicaid plan are entitled to nursing home facility care; that
is, if a person meets the state’s income and asset requirements, as well as the state’s
functional eligibility requirements for entry into a nursing home, he or she is entitled
to the benefit.
These early legislative developments were the basis for the modern day nursing
home industry. Significant growth in the number of nursing homes occurred during
the 1960s — from 1960 to 1970, the number of homes more than doubled, from
9,582 to almost 23,000, and the number of beds more than tripled, from 331,000 to
more than one million.2
Today there are about 17,000
Since its inception, Medicaid has been the predominant
nursing homes with 1.8
payor for nursing home care. In 1970, over $1 billion was
million beds.3
spent on nursing home care through Medicaid and
Medicare. Federal and state Medicaid payments
During the latter part of
accounted for almost all of this spending — 87%.
Medicaid spending for nursing home care grew by 50% in
the 1960s and the 1970s,
the 3-year period beginning in 1967.
nursing home care attracted a
great deal of congressional
In FY2001, Medicaid spent $53.1 billion on institutional
oversight as a result of
care (for nursing homes and care in intermediate care
facilities for the mentally retarded).
concern about increasing
federal expenditures, and
instances of fraud and abuse
that were becoming evident. Between 1969 and 1976, the Subcommittee on Long-
Term Care of the Senate Special Committee on Aging held 30 hearings on problems
in the nursing home industry.4
Home care services received some congressional attention in the authorizing
statute — home health care services were one of the optional services that states
could provide under the 1965 law. Three years later in 1968, Congress amended the
law to require states to provide home health care services to persons entitled to
skilled nursing facility care as part of their state Medicaid plans (effective in 1970).
During the 1970s, the Department of Health, Education and Welfare (now Health and
Human Services, (HHS)) devoted attention to “alternatives to nursing home care”
through a variety of federal research and demonstration efforts. These efforts were
undertaken not only to find ways to offset the high costs of nursing facility care, but
also to respond to the desires of persons with disabilities to remain in their homes and
2 U.S. Congress, Senate Special Committee on Aging, Developments in Aging, 1970,
Report 92-46, Feb. 16, 1970, Washington, cited from the American Nursing Home
Association Fact Book, 1969-1970.
3 American Health Care Association, Facts and Trends 2001, The Nursing Facility
Sourcebook, 2001, Washington. The number of nursing homes is for 1999-2000 and number
of beds is for 1998. (Hereafter cited as American Health Care Association, The Nursing
Facility Sourcebook.)
4 U.S. Congress, Senate Special Committee on Aging, Nursing Home Care in the United
States: Failure of Public Policy, Washington, 1974, and supporting papers published in
succeeding years.

CRS-3
in community settings, rather than in institutions. However, it was not until 1981 that
Congress took significant legislative action to expand home and community-based
services through Medicaid when it authorized the Medicaid Section 1915(c) home
and community-based waiver program.
Under that authority (known then as the Section 2176 waiver program), the
Secretary of HHS may waive certain Medicaid state plan requirements to allow states
to cover a wide range of home and community-based services to persons who
otherwise meet the state’s eligibility requirements for institutional care. The waiver
provision was designed to alter the fact that the Medicaid program had emphasized
institutional care rather than care in home and community-based settings. Services
under the Section 1915(c) waiver include: case management, personal care,
homemaker, home health aide, adult day care, habilitation, environmental
modifications, among many others.5 These services are covered as an option of
states, and under the law, persons are not entitled to these services as they are to
nursing facility care. Moreover, states are allowed to set cost caps and limits on the
numbers and types of persons to be served under their waiver programs.
Notwithstanding wide use of the Section 1915(c) waiver authority by states over
the last two decades, total spending for Medicaid home and community-based
services waivers is significantly less than institutional care — about $14.4 billion in
2001, compared to $53.1 billion for nursing facility care services and care for persons
with mental retardation in intermediate care facilities (ICFs/MR). Despite this
disparity in spending, in many states the Section 1915(c) waiver program is the
primary source of financial support for a wide range of home and community-based
services, and funding has been increasing steadily. Federal and state Medicaid
support for the waiver programs increased by over 807% from FY1990 to FY2001
(in constant 2001 dollars).
The home and community-based waiver program has been a significant source
of support to care for persons with mental retardation and developmental disabilities
as states have closed large state institutions for these persons over the last two
decades. Nationally, in FY2001, almost 75% of Section 1915(c) waiver funding was
devoted to providing services to these individuals.
States administer their long-term care programs against this backdrop of federal
legislative initiatives — first, the entitlement to nursing home care, and requirement
to provide home health services to persons entitled to nursing home care, and,
second, the option to provide a wide range of home and community-based services
through waiver of federal law, within state-defined eligibility requirements, service
availability, and limits on numbers of persons served.
5 States may waive the following Medicaid requirements: (1) statewideness — states may
cover services in only a portion of the state, rather than in all geographic jurisdictions; (2)
comparability of services — states may cover state-selected groups of persons, rather than
all persons otherwise eligible; and (3) financial eligibility requirements — states may use
more liberal income requirements for persons needing home and community-based waiver
services than would otherwise apply to persons living in the community. For further
information, see CRS Report RL31163, Long-Term Care: A Profile of Medicaid 1915(c)
Home and Community-based Services Waivers, by Carol O’Shaughnessy and Rachel Kelly.

CRS-4
A CRS Review of Ten States: Report on Oregon
In the late 1970s and early 1980s, Medicaid expenditures for long-term care in
Oregon’s nursing homes were skyrocketing. From 1974 to 1979, the number of
Medicaid clients being served in nursing facilities increased by more than 30%, while
the population aged 75 and older was increasing by only 14%.6 The rate of inflation
for institutional long-term care was more than 100% annually.7 Although the Oregon
Department of Human Services (DHS) was created in 1971 to unify a fragmented
service delivery system in the state, the offices responsible for long-term care
continued to have separate budgets and administrative leadership.
In order to address these concerns, Oregon’s state legislature decided to
drastically reshape its Medicaid long-term care program. In 1981, the state
legislature combined the state’s unit on aging and its Medicaid long-term care
program. This new division within DHS was charged with containing the costs of
long-term care, while at the same time promoting the option of home and
community-based care over nursing facility care. Over the last 20 years, state
officials have strived to create a coordinated system of long-term care where nursing
homes are the placement of last resort.
The number of Medicaid clients receiving home and community- based services
has been steadily rising. In 2002, 82% of Medicaid long-term care clients were
receiving home and community-based care, compared with only 40% of clients in
1985-86.8 This dramatic increase is due, in part, to the diverse home and community-
based care options provided by the state. These options include a range of supported
housing arrangements such as: assisted living facilities, residential care facilities,
adult foster care, as well as in-home care where clients may select their own
caregivers.
In 2001, the state legislature directed the state’s principal long-term care agency
(Seniors and Disabled Services Division) to administer programs for persons with
developmental disabilities. This new agency (Seniors and People with Disabilities)
plans to increase the availability of home and community-based care for persons with
developmental disabilities by expanding one of the state’s Medicaid Section 1915(c)
home and community-based waivers.
State officials acknowledged that many of the barriers that have inhibited other
states’ attempts to develop comprehensive home and community-based service
options were not felt as acutely in Oregon. Initial opposition from the nursing home
industry was overcome by legislative and advocacy support; citizens and advocate
groups in Oregon worked collaboratively for increased home and community-based
6 Seniors and People with Disabilities, The Oregon Model, Dec. 2001.
[www.sdsd.hr.state.or.us/about/oregon_model.htm].
7 Ibid.
8 Barry Donnenfeld, The Economic Downturn and Its Impact on Seniors: Stretching Limited
Dollars in Medicaid, Health, and Senior Services, Testimony for the United States, U.S.
Senate Special Committee on Aging, Mar. 14, 2002.

CRS-5
options; and the state legislature has continued to be involved in shaping the direction
of the state’s long-term care system.
Over the last two decades, researchers and state officials have documented many
of the innovative policies the state has instituted in the development of its long-term
care system. A number of reports have concluded with similar findings. Among
other things, Oregon’s success in moving clients to home and community-based
settings can be attributed to:
! the legislative mandate to reinvest any cost-savings from reductions
in institutional care into the development of a system that promotes
home and community-based care;
! the centralization of administrative responsibility in providing long-
term care services;
! the use of public funds for services that are appealing to consumers,
such as assisted living facilities, adult foster homes, and in-home
services where clients may select their caregivers;
! the level of involvement of community-based area agencies on aging
(established by Title III of the Older Americans Act) in the local
administration of long-term care programs and their promotion of
home and community-based services through consumer-friendly
websites and telephone hotline services; and
! state legislation that allows unlicenced caregivers to be trained by
nurses to provide certain medical services to long-term care clients.
In spite of Oregon’s achievements in reorienting its long-term care system,
officials recognize that with the aging baby boom population and increasing costs of
long-term care, they may need to rethink the design of their current system to meet
the challenges ahead.
This report provides an analysis of Oregon’s long-term care system and is one
in a series of 10 CRS reports on state long-term care systems.

CRS-6
Summary Overview9
Overview
! Oregon, a recognized leader in home and community-based care, has
over 20 years of experience in shifting state resources from
institutional long-term care to home and community-based care. A
clear preference for promoting home and community-based services
over institutional care was established by the state legislature in
1981.
! Oregon’s guiding principles in long-term care are to “embody the
human values of independence, dignity, privacy, and choice.”
Demographic Trends
! An aging population poses challenges for the state. Its population
age 85 and older — the group in greatest need for long-term care
services — grew by 48% from 1990-2000, ranking 18th highest in
the nation. Persons aged 85 and over with two or more limitations
in activities in daily living (ADLs) are estimated to grow by 38% by
2010.
! Oregon’s population age 65 and older is expected to increase to
24.2% of the state’s population by 2025, compared to 18.5% in the
total United States population.
Administration of Long-Term Care Programs
! Unlike most other states, the various functions of Oregon’s long-
term care system are administered by a single division (Seniors and
People with Disabilities (SPD)) and housed within a single state
agency (the Department of Human Services). This centralized
administration shares a common vision to eliminate any bias towards
institutional care.
! Area agencies on aging (AAAs) have been given a strong leadership
role in Oregon’s long-term care system. AAAs can choose to
administer long-term care programs for the elderly and younger
people with disabilities.
Trends in Institutional Care
! Over the last two decades, the state has developed a number of
methods to control nursing home utilization. These include: a
certificate of need program, which requires nursing facilities to
9 Information based on Oregon data and documents, national data, and interviews with state
officials. This report does not discuss programs for persons with mental illness. It also
generally excludes discussion of programs for infants and children with disabilities, other
than those serving persons with mental retardation and developmental disabilities.

CRS-7
obtain permission from SPD before new facilities are built or old
facilities are expanded; a pre-admission screening program for both
private and Medicaid clients; extensive use of the Medicaid Section
1915(c) home and community-based waivers; and a state-funded
program (Oregon Project Independence) that encourages the use of
home and community-based services.
! As a result of Oregon’s strategies to control nursing home
utilization, state officials indicate that the disability levels of nursing
home residents have increased dramatically. This is attributed to a
greater use of home and community-based services that delay entry
into nursing facilities.
! Since the state first implemented its home and community-based
services waiver in 1981, the utilization of nursing homes for
Medicaid clients has steadily declined. Between 1996 and 2001,
there was a 17.2% decrease in the number of nursing home residents,
and a 10% decline in the nursing facility occupancy rate.
Trends in Home and Community-Based Care
! In 2002, approximately 82% of Oregon’s Medicaid long-term care
clients were served in the community, up from 53% in 1990.
! Oregon administers a wide range of home and community-based
services though a single Medicaid 1915(c) home and community-
based waiver for seniors and adults with disabilities. Services
include: adult foster care; assisted living facilities; residential care
facilities; and in-home services which allow residents to remain in
their homes and select their caregiver.
! The state has made extensive use of the Section 1915(c) Medicaid
waiver program to provide home and community-based services to
persons with developmental disabilities. As of June 2001, there were
only 50 clients with developmental disabilities being served in the
state’s only intermediate care facility for persons with mental
retardation (ICFs/MR).
! Oregon has developed a unique state-funded home and community-
based service program, Oregon Project Independence (OPI), which
provides services to persons who cannot afford the full cost of home
and community-based care and are not enrolled in Medicaid. The
program is designed to delay entry into the state’s Medicaid
program.
Long-Term Care Spending
! In FY2000, Oregon spent over $712 million on Medicaid long-term
care. Unlike most other states, Oregon spent approximately two-
thirds of these dollars on home and community based services, and
only one-third on institutional services.
! From 1990 to 2001, Medicaid spending for home and community-
based services increased by almost 560% in constant dollars,
whereas spending for institutional care increased by only 105%.

CRS-8
! In 2001, only 1% of Medicaid long-term care spending went to
intermediate care facilities for persons with developmental
disabilities compared with almost 14% for the U.S. as a whole.
! Unlike many other states where nursing home expenditures represent
a significant portion of both Medicaid spending as well as Medicaid
long-term care spending, in Oregon, spending for nursing home care
is significantly less, representing about 20% of Medicaid spending
and about one-third of Medicaid long-term care spending in
FY2000.
Issues in Financing and Delivery of Long-Term Care
! In Oregon, many of the staffing shortages experienced by other
states are ameliorated by the state’s nurse delegation program and
the client employed provider program. Nurse delegation allows
licensed registered nurses to delegate certain nursing tasks to
unlicenced caregivers. Through the state’s client employed provider
(CEP) program, individuals may select a caregiver with no formal
long-term care training. The caregiver is then trained to administer
the client’s care plan. In spite of the success of this program, state
officials are concerned about potential staffing shortages of frontline
long-term care personnel in the future.
! Waiting lists for services for persons with developmental disabilities
have been a persistent problem in Oregon. Recent litigation resulted
in a settlement agreement which requires the state to increase
funding for home and community-based services for persons with
developmental disabilities by a cumulative total of $350 million by
2007.
! Recent state budget cuts have greatly impacted Oregon’s long-term
care system. Long-term care spending was reduced by nearly 30%
for the current state fiscal year. As of April 2003, over 4,792 persons
were no longer eligible to receive Medicaid long-term care services
(over 16% of total program participants), with potentially more cuts
needed in the future. In addition to reducing the number of people
eligible for Medicaid, the state also eliminated in-home supports for
3,800 seniors who were not eligible for Medicaid; reduced
reimbursement rates to Medicaid long-term care providers by 15%
to 30%; and eliminated the state’s medically needy program for
8,757 individuals.
! Oregon administrators recognize that with the aging population and
increasing costs of long-term care, they may need to rethink the
design of their current long-term care system. They hope to
incorporate a concept of “bounded choice” where an individual’s
wishes are considered within the boundaries of service capacity and
fiscal constraints.

CRS-9
Demographic Trends
Oregon has a relatively small population of 3.4 million people, but ranks tenth
in the nation in terms of land area. Approximately 70% of its residents live in the
Willamette Valley between Portland and Eugene, an area that covers less than
one-third of the state from the Pacific seaboard to about 300 miles in-land. Much of
the rural, eastern area of the state is sparsely populated. In 2000, 12.8% of Oregon’s
residents were over the age of 65, only slightly above the national average of 12.4%.
From 1990-2000, Oregon’s total elderly population grew by 12%, but its
population age 85 and older, those in greatest need for long-term care services, grew
by 48%. The proportion of Oregon’s population aged 85 and older is the 18th largest
in the nation. From 1990 to 2000, the state experienced a 26% increase in the
population aged 75 to 84, those at near risk of needing assistance with daily tasks
(see Table 1).
Table 1. Oregon Population Age 65 and Older, 1990 and 2000
1990
2000
2000
population
1990-
rank in
Percent of
Percent of
2000
U.S.
total
total
percent
(based on
Age
Number
population
Number
population
change
percent)
65+
391,324
13.8
438,177
12.8
12.0%
25
65-74
224,438
7.9
219,342
6.4
2.3%
35
75-84
128,071
4.5
161,404
4.7
26.0%
18
85+
38,815
1.4
57,431
1.7
48.0%
18
Under 65
2,450,997
86.2
2,983,222
87.2
21.7%
27
Total
2,842,321
3,421,399
20.4%
28
Source: United States Census Bureau. Profile of General Demographics for Oregon: 1990-2000
[http://www.census.gov/census2000/states/or.html].
Like most states, Oregon will face a significant increase in its aging population
over the next 25 years. Between 2000 and 2025, Oregon’s 85 and older population
is expected to increase by 124% (see Figure 1). In 2025, 24% of Oregon’s
population will be 65 years or older, compared to 18.5% for the nation (see Table 2).

CRS-10
Figure 1. Percent Population Increase in Oregon, 2000-2025
160%
140%
120%
100%
80%
60%
40%
20%
0%
2005
2010
2015
2020
2025
65-74
75-84
85+
65+
Total
Under 65
Source: Congressional Research Service (CRS) calculations based on data from the U.S. Census
Bureau Projections at [http://www.census.gov/population/www/projections/st_yrby5.html]; analyzed
data from State Population Projection: Every Fifth Year.
Table 2. Elderly Population as a Percent of Total Population,
Oregon and the United States, 2025
Proportion of total
Proportion of total
population, Oregon
population United
Age
States
65+
24.2%
18.5%
65-74
13.3%
10.5%
75-84
8.0%
5.8%
85+
2.9%
2.2%
Under 65 population
75.8%
81.5%
Source: Congressional Research Service (CRS) calculations from census projections
released in 1996. See Appendix 2 for information about projections, their
methodology and limitations.
Need for Long-Term Care
Table 3 presents estimates of the number of persons aged 18 and over who have
limitations in two or more activities of daily living (ADLs) in Oregon. These
estimates were derived from data generated by The Lewin Group and combine
national level data on persons with disabilities with state-level data from the U.S.
Census Bureau on age, income, and broad measures of disability. Persons aged 85
and over with two or more limitations in ADLs are estimated to increase by 38%

CRS-11
from 2002 to 2010. This growth will place pressure on public and private long-term
care resources.
Table 3. Estimated Number of Persons with Two or More
Limitations in Activities of Daily Living (ADLs), by Poverty
Status, in Oregon
2002
2005
2010
Persons with 2+ ADLs by age and income
Percent
of poverty
18-64
65+
85+
18-64
65+
85+
18-64
65+
85+
Up to 100% 1,960
2,128
847
2,040
2,308
964
2,126
2,650
1,165
Up to 150% 2,763
4,620
1,555
2,876
4,976
1,771
2,999
5,626
2,139
Up to 200% 3,405
6,202
1,986
3,546
6,671
2,262
3,698
7,525
2,732
All income
7,174
13,513
3,843
7,469
14,511
4,376
7,789
16,445
5,286
Source: Congressional Research Service (CRS) analysis based on projections generated by The
Lewin Group through the HCBS State-by-State Population Tool, available on-line for subscribers at
[http://www.lewin.com/cltc]. The Lewin Group Center on Long Term Care HCBS Population Tool,
by Lisa M.B. Alecxih, and Ryan Foreman (2002).
Administration of Long-Term Care Programs
State and Local Administration
According to state officials, a large part of the success of Oregon’s long-term
care system stems from its administrative structure. Oregon’s system is one of the
few in the country to consolidate all of the various administrative and service
functions into a single state agency. The goal of state officials over the last 20 years
(partially in response to several state legislative mandates) has been the creation of
a seamless system for seniors and people with disabilities that favors care in
community settings rather than in nursing homes or other institutions.
In 1981, on the final day of one of the longest legislative sessions in Oregon’s
history, the state legislature passed Senate Bill 955, drastically reshaping Oregon’s
long-term care system. The bill consolidated the state’s unit on aging and its
Medicaid long-term care program creating the Senior Services Division (which later
became the Seniors and Disabled Services Division and is now Seniors and People
with Disabilities). The new division was charged with containing the costs of
long-term care, while at the same time creating a long-term care system that
supported the preference of people with disabilities for home and community-based

CRS-12
services. A vision was articulated in the legislation for a long-term care system that
embodies the “human values of independence, dignity, privacy, and choice.”10
In testimony to the U.S. Senate Special Committee on Aging in 1998, Roger
Auerbach, the director of the Seniors and Disabled Services Division stated that, “the
crisis Oregon faced was partially the product of the fragmentation and bureaucracy
created by piecemeal legislative responses, without a clear vision of how a system
should be built. The success we have to date is really proportionate to the clarity of
our vision. That vision, which is now very clear, is one of a consumer-centered,
individualized program delivered by a coordinated, accessible system.”11
The most recent reorganization spearheaded by the legislature in 2001
consolidated all state long-term care functions into the single division of Seniors and
People with Disabilities (SPD), one of seven divisions within the Department of
Human Services. It is unique among long-term care systems in the United States in
that it incorporates the state’s Medicaid agency, the state unit on aging, the state unit
on developmental disabilities, and the long-term care regulatory agency under a
single administrative structure and budget.
Figure 2 portrays the primary functions performed by SPD and local agencies
that collectively make up Oregon’s long-term care system. Those functions are:
financial and functional determination of eligibility; licensing and protective services;
financial reimbursement; management of services for elderly and disabled persons;
and the management of services for persons with mental retardation and
developmental disabilities. Each of these functions is described in detail in the
following sections.
10 Oregon State Legislature, Senate Bill 955, 1981.
11 Roger Auerbach, Reforming the Delivery System, Testimony before the U.S. Senate
Special Committee on Aging, Mar. 3, 1998

CRS-13
Figure 2. Oregon Long-Term Care System
Source: Chart prepared by the Congressional Research Service (CRS) based on Oregon’s State Documents.

CRS-14
Management of Services for Seniors and Other Persons with
Disabilities. At the state level, supervision of long-term care services for the
elderly and persons with disabilities resides within the division of Seniors and People
with Disabilities (SPD). SPD either contracts with area agencies on aging (AAAs)
to provide these services, or uses state employees housed within the county offices
of the Department of Human Services (DHS) to administer Medicaid and other long-
term care programs. These offices serve as “single points of entry” for a variety of
services available in state.
Local Administration. Oregon’s long-term care service delivery system is
built on a diverse network of community organizations and state offices to provide
care at the local level. The law creating the current long-term care system supported
a strong role for the state’s area agencies on aging (AAAs) and allows for significant
local control. SPD contracts with AAAs that wish to administer long-term care
programs in the state. In areas where the AAA chooses not to provide services
(primarily in the rural areas of Eastern Oregon), state employees within the county
human services office administer long-term care services and programs. The result
is that local service providers and administrators can choose the most appropriate
administrative structure for their localities. There are three types of service delivery
models in Oregon — Type A, Type B1, and Type B2. Each type of delivery system
is described below:
! Type A — In this service delivery model, the AAA administers
programs and services funded by the Older Americans Act and the
state-funded Oregon Project Independence (OPI) program for seniors
aged 60 and over. In a Type A area, the state operates a local multi-
service office (housed within the county human services office) to
administer Medicaid for long-term care clients. State employees
develop care plans, provide ongoing case management, and license
and monitor long-term care facilities for seniors and adults with
physical disabilities. There are 19 Type A areas in Oregon.
! Type B1 — In this service delivery model, the AAA administers
programs and services funded by the Older Americans Act, the state-
funded OPI program for persons 60 and older, and the state’s
Medicaid long-term care program for seniors 65 and over. It does
not provide Medicaid services to people with physical disabilities
who are under the age of 65 or to individuals with developmental
disabilities. In a Type B1 area, the state operates a local Disability
Service Office (housed within the county human services office) to
administer Medicaid and other state programs for long-term care
clients not served by the AAA. There are seven Type B1 areas in
Oregon.
! Type B2 — This service delivery model administers all of the same
programs that Type B1 agencies may administer, but also serves
adults aged 18 to 64 with physical disabilities. People with
developmental disabilities are served in the Disability Service
Office. There are eight Type B2 areas in Oregon.

CRS-15
For the last several decades, Oregon’s Department of Human Services has
attempted to integrate its service delivery systems throughout the state. Oftentimes,
clients with complex needs were forced to visit multiple social service offices and
provide the same information to multiple case workers. In order to make it easier for
clients to navigate the social service system in Oregon, the Department has developed
a “no wrong door” approach to service provision. A client should be able to walk
into any area agency on aging or county DHS office to determine initial eligibility for
a variety of programs, such as Medicaid, food stamps, TANF, and state-funded
programs such as OPI. Oregon has attempted to utilize the structure of the area
agencies on aging to serve as an information center for a variety of social service
programs in the state.
Management of Services for Persons with Developmental
Disabilities. In 2001, the state legislature mandated that SPD administer programs
for persons with developmental disabilities. At the local level, county DHS offices
employ staff to provide case management services. Other services are subcontracted
to local providers which typically specialize in serving individuals with
developmental disabilities.
Licensing. SPD is responsible for licensing long-term care facilities and
ensuring that quality care is delivered in both nursing homes and home and
community-based settings. Oregon’s licensing process includes inspection, reporting
on inspection outcomes or complaint investigations, and sanctioning deficient
facilities. In spite of these regulatory responsibilities, officials in the Office of
Licensing and Quality of Care (housed within SPD) have attempted to move away
from a strictly punitive approach, and adopt a model that offers technical assistance
and problem solving to encourage continuous quality improvement.
Protective Services. SPD is responsible for adult protective services for
seniors and people with disabilities in home and community settings and licensed
facilities. State laws provide for mandatory reporting of elder abuse. Local Area
Agency on Aging and state office personnel complete investigations and provide
needed protection. SPD is also responsible for abuse prevention and statewide
educational activities to strengthen awareness and partnerships for community
interventions.
Case Management. Case managers are critical to implementing Oregon’s
preference for home and community-based care over nursing home care. Case
managers take on a variety of roles in the state’s long-term care system. In addition
to managing clients’ care plans, performing pre-admission screenings, and
determining client eligibility for Medicaid, case managers also monitor nursing
facilities and community-based care facilities.
Because home and community-based care requires more rigorous oversight by
case managers to ensure the best placement of clients, SPD regulates the number of
individuals a case manager can serve depending on the type of care he or she is
receiving. In nursing facilities the staffing ratio is one case worker per 130 clients;
in adult foster care, the staffing ratio is one case worker per 79 clients; in residential
care facilities and assisted living facilities, the staffing ratio is one case worker per
100 clients; and for in-home services, the staffing ratio is one case worker per 69

CRS-16
clients. Depending on the type of service area where a client resides, case managers
are employed by either the local area agencies on aging, the disability service office,
or the multi-service office.
Financial and Functional Eligibility Determinations
Information about financial eligibility for Medicaid and other state programs is
gathered at the local level by caseworkers in the area agencies on aging, the disability
service office or the multi-service office. Although initial decisions on financial
eligibility are made locally, state officials within SPD make the final eligibility
determination.
Functional eligibility is also determined at the local level. In order to assist case
managers in making eligibility determinations, SPD has developed a number of
automated tools to streamline the process. The Client Assessment and Planning
System (CA/PS) is a computer system that assists caseworkers in determining
eligibility and assigning service priority levels. A service priority level is a number
between 1 and 11 that identifies an individual’s long-term care needs, based on
limitations in activities of daily living (ADLs). A caseworker will make a number
of assessments about a client’s need for assistance, input information into the
computer system, and CA/PS will automatically return a decision about eligibility,
and if appropriate, assign a service priority level. To be considered functionally
eligible for Medicaid services a client must be assigned a service priority level
(Table 4). Once the assessment is complete, case managers work with the client to
determine the most appropriate setting, incorporating a variety of factors such as
informal supports and client wishes. A service plan is developed and periodically
changed to meet the needs of the client. CA/PS also provides caseworkers with
assistance in developing service plans that are appropriate for each priority level.
Changes in Functional Eligibility Requirements Due to Budget
Reductions. After a state-wide ballot initiative to increase taxes was defeated by
voters in January 2003, Seniors and People with Disabilities had to reduce its long-
term care spending by nearly 30% for the current state fiscal year. SPD decided to
cut funding for individuals who were assigned service priority levels of 12 through
17 (Table 5). As of April 2003, over 4,792 persons had lost Medicaid long-term care
services (over 16% of total program participants), with potentially more cuts needed
in the future.
Of the residents who lost Medicaid services, 3,834 were receiving in-home
services; 765 were residing in community-based assisted housing arrangements; and
193 were residing in nursing facilities. SPD worked with the Centers for Medicare
and Medicaid Services (CMS) to make changes to their current waiver to provide
limited transitional services for those who no longer qualify for Medicaid.

CRS-17
Table 4. Service Priority Levels Eligible for Medicaid Services
Service priority level
Description of service priority level
Requires full assistance in all major activities of daily
Level 1
living
Level 2
Requires full assistance in mobility, eating and cognition
Requires full assistance in at least one of the following
Level 3
activities of daily living: mobility, cognition or eating
Level 4
Requires full assistance in elimination
Requires substantial assistance with mobility and eating
Level 5
and requires assistance with elimination
Level 6
Requires substantial assistance with mobility and eating
Requires substantial assistance with mobility and
Level 7
assistance with elimination
Requires assistance with mobility and eating and
Level 8
elimination
Level 9
Requires assistance with eating and elimination
Level 10
Requires substantial assistance with mobility
Requires assistance with elimination and minimal
Level 11
assistance with mobility
Source: Documents provided by Oregon Department of Human Services, SPD.
Table 5: Eliminated Service Priority Levels
Eliminated service
priority levels
Description of eliminated service priority levels
Requires minimal assistance with mobility and assistance
Level 12
with eating
Level 13
Requires assistance with elimination
Level 14
Requires assistance with eating
Level 15
Requires minimal assistance with mobility
Level 16
Requires full assistance in bathing or dressing
Level 17
Requires assistance in bathing or dressing
Source: Documents provided by Oregon Department of Human Services, SPD.

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Oregon’s Long-Term Care Services
for the Elderly and Persons with Disabilities
Trends in Institutional Care
Since the state first implemented its home and community-based services waiver
on December 21, 1981, the utilization of nursing homes for Medicaid clients has
steadily declined. Between 1996 and 2001, there was a 17.2% decrease in the
number of nursing home residents.12 According to the DHS Performance
Measurement Report, in June of 2001, only 22.1% of all seniors receiving Medicaid
long-term care services and 9% of all adults (aged 18-64) with disabilities were
served in nursing facilities.13
In 2001, there were 151 nursing facilities operating in Oregon serving
approximately 9,444 persons.14 The number of beds per 1,000 elderly persons is
considerably less than the national average. In 2000, there were approximately 31
beds per 1,000 persons aged 65 and older and 235 beds per 1,000 elderly persons
aged 85 and older, as compared to 53 and 435, respectively, for the United States
(Table 6). At the beginning of Oregon’s efforts to expand home and community-
based services in 1981, the number of nursing home beds per 1,000 persons aged 65
and older in Oregon was roughly equal to the national average.15 The occupancy rate
for Oregon’s nursing homes in 2001 was 72.8%, somewhat lower than the national
average of 80.8% (Table 6).
Over the last two decades, the state has developed a number of methods to
control nursing home utilization. These include: a certificate of need program, which
requires nursing facilities to obtain permission from SPD before new facilities are
built or old facilities are expanded; a pre-admission screening program for both
private and Medicaid clients; and extensive use of the Medicaid Section 1915(c)
home and community-based waiver. As a result of these strategies to control nursing
home utilization, state officials indicate that the characteristics of nursing home
residents have changed over the last 2 decades. Disability levels of patients have
increased dramatically. This is attributed, in part, to a greater use of home and
community-based services that delays entry into nursing facilities.
12 Steven R. Gregory and Mary Jo Gibson. Across the States 2002: Profiles in Long-Term
Care — Oregon. 2002, AARP Public Policy Institute, (Washington) 2002. (Hereafter cited
as Gregory and Gibson, Across the States 2002.)
13 Department of Human Resources, Performance Measurement Report, fall 2001. At
[http://www.dhs.state.or.us/publications/pm_reports/dhsfall2001.pdf].
14 Gregory and Gibson, Across the States 2002.
15 Robert Kane, et al., Oregon’s Long-Term Care System: A Case Study by the National
Long-Term Care Mentoring Program, at [http://www.ilru.org/pas/ltc.htm] 1996.

CRS-19
Table 6. Nursing Home Characteristics in
Oregon and the United States
(data are for 1999-2000 unless otherwise noted)
Characteristic
Oregon
United States
Number of residents
10,205
1,490,155
Number of facilities
151
17,023
Number of beds
13,493
1,843,522
Number of Medicaid beds
5,440
841,458
Number of total beds per 1,000 pop. aged 65 and older
30.8
52.7%
Number of total beds per 1,000 pop aged 75 and older
61.7
111.1
Number of total beds per 1,000 pop aged 85 and older
234.9
434.8
Occupancy rate
72.8% (2001)
80.8%
Source: Data comes from the following sources: Oregon’s occupancy rate — AARP, Across the
States 2002: Profiles in Long-Term Care — Oregon; all other information comes from the American
Health Care Association (AHCA), Facts and Trends: The Nursing Facility Sourcebook.
Implementation of the Medicaid 1915(c) Waiver Program for Seniors
and Adults with Physical Disabilities. In 1981, Oregon became the first state
in the nation to implement a Section 1915(c) waiver program on a statewide basis.
This waiver program resulted in decreased reliance on nursing homes, in part,
because, state officials decided at the program’s inception to offer residents equal
access to home and community-based care, with no caps on the number of people
who could be served by the waiver and no waiting lists for services.
Because area agencies on aging or state employees of SPD determine eligibility
for both home and community-based services and nursing facility services, they are
able to inform clients of all available long-term care options. According to state
officials, case managers are encouraged to arrange care plans so that individuals who
do not wish to enter a nursing facility are able to find suitable alternatives at home
or in the community.
Pre-Admission Screening. In 1989, Oregon adopted a pre-nursing home
admission screening program. Oregon requires all prospective nursing home
residents to be screened before entering a nursing facility. A patient’s level of
impairment is evaluated, and home and community-based service options are
discussed with the client and family members. Partially as a result of this screening
process, the rate of hospital discharges directly into nursing homes is significantly
lower than the national average.16
Certificate of Need. In the 1970s, Oregon instituted a certificate of need
(CON) program to control and downsize the number of nursing facilities in the state.
16 Unpublished documents from the Oregon Health Care Association. 2002.

CRS-20
In order to build a new nursing facility or expand an existing facility, a provider must
receive DHS approval for Medicaid beds. The state reviews an application from a
provider on a case-by-case basis using the following criteria: nursing facility bed
occupancy in the service area; availability of home and community-based services
in the area; and economic and financial feasibility. This procedure is intended to
complement SPD’s goal of promoting home and community-based services over
institutional care by controlling the number of nursing home beds that enter the
market.
Trends in Home and Community-Based Care
According to state reports, between 1985 and 2000, the number of Medicaid
clients in need of long-term care served in home and community-based settings
increased by 224%.17 In 2002, approximately 81.5% of the state’s Medicaid clients
received home and community-based services, as opposed to only 18.5% in nursing
facilities. Oregon supports a wide range of home and community-based services for
the elderly and persons with physical disabilities which are primarily provided
through a Medicaid Section 1915(c) waiver and a state-funded program — Oregon
Project Independence — for persons who are not receiving Medicaid. While many
states have multiple waivers targeted to specific eligibility groups, Oregon has a
single waiver to fund all home and community-based Medicaid services for seniors
and adults with physical disabilities.
The state has developed a variety of innovative polices that encourage home and
community-based care under its waiver. Oregon was one of the first states in the
nation to use its waiver to support services in assisted living facilities; it is one of the
only states to develop a large adult foster care system; and its use of unlicenced
caregivers (through its client employed provider program) has dramatically increased
the number of individuals that can be served in their homes.
Medicaid 1915(c) Waiver for Seniors and Persons with Physical
Disabilities. Oregon operates a single Medicaid waiver program for the elderly and
adults with physical disabilities. In order to qualify for Medicaid services, persons
must have income that does not exceed 300% of the Supplemental Security Income
(SSI) level ($1,656 per month in 2003) and must meet SSI’s resource limit of $2,000
for an individual.18 For some individuals who do not meet these requirements, the
state operates a Miller Trust that permits additional income and resources to be
recovered by the state, thereby allowing an individual to qualify for Medicaid
services.19
17 Seniors and People with Disabilities, The Oregon Model, Dec. 2001, at
[www.sdsd.hr.state.or.us/about/oregon_model.htm]
18 Certain items are excluded, such as an individual’s home; up to $2,000 of household
goods and personal effects; life insurance policies with a face value of $1,500 or less; an
automobile with value up to $4,500; and burial funds up to $1,500, among other things.
19 For more information on Miller Trusts and Medicaid eligibility, refer to CRS Report
RL31413, Medicaid: Eligibility for the Aged and Disabled, by Julie Lynn Stone.

CRS-21
Originally approved in 1981, this waiver has been the primary alternative to
nursing home care for adults with physical disabilities. In 2001, the estimated
average cost per client under the waiver was $5,558 per year. Approximately 42,242
persons are expected to receive long-term care services under this waiver for state
fiscal years (SFY) 2001 to 2003.
The waiver provides a wide range of home and community-based services
including: respite care, adult day health, specialized medical equipment,
environmental accessibility adaptations, transportation, home delivered meals,
specialized living services, and in-home services. For individuals who are not served
in their own homes, the waiver provides long-term care in community settings,
including adult foster care, residential facility care, and assisted living facility care.
In 2002, 81.5% of Oregon’s Medicaid long-term care clients received home or
community-based services under this waiver (see Table 7). Of these clients, 46.6%,
were served in their homes; 17% were served in adult foster homes; 12% were served
in assisted living facilities; and 6% were served in residential care facilities.
Client Employed Provider Program. The majority of Oregon’s in-home
services are provided through the client employed provider (CEP) program. The
CEP program allows Medicaid clients to hire and supervise their own care providers.
Clients may select their own caregiver (such as friends or relatives) or they can be
assisted in their search for a provider by the local AAA or county DHS office.
Although CEPs are self-employed, the state pays unemployment insurance and the
social security FICA payments on behalf of the CEP. State officials indicate that this
program, which allows unlicenced caregivers to provide long-term care services, has
greatly expanded the state’s ability to provide home and community-based services.
Nurse Delegation and Contract Registered Nursing Services. In
1987, the state legislature amended its Nurse Practice Act to allow licensed registered
nurses to delegate certain medical tasks to unlicenced caregivers, such as client
employed providers or workers in adult foster homes. As a result of this legislation,
nurses may train caregivers in certain home and community-based settings to perform
almost all nursing tasks except for certain types of injections. Once an assessment
is made by the nurse to ensure that a client is in stable condition, a care plan is
developed; hands-on training is provided to the caregiver; and nursing tasks are
delegated in writing. The nurse delegate must periodically assess a client’s health
and review the care plan.
In 1994, the state developed a system of contract registered nursing services,
which expanded the state’s ability to use nurse delegates for its Medicaid home and
community-based waiver program. There are currently 150 nurses under contract
with SPD providing nurse delegation services for Medicaid long-term care clients
around the state. State officials and providers maintain that the use of nurse
delegation has been essential to the expansion of home and community-based care
services in Oregon.

CRS-22
Table 7. Medicaid Long-Term Care Caseload by Setting,
July 2002
Total Medicaid
Percent
long-term care
of total
Setting
caseload
caseload
Total Medicaid Clients
31,266
100%
Institutional Services
5,782
18.5%
- Nursing Facilities
5,782
Home and Community-Based Services (HCBS)
25,484
81.5%
In-Home Care
14,556
46.6%
- Adult Foster Homes
5,399
17.3%
- Assisted Living Facilities
3,662
11.7%
- Residential Care Facilities
1,867
6.0%
Source: Congressional Research Service (CRS) calculations based on Seniors and People
with Disabilities Data Sheets, July 2002. Percentages do not sum to 100% due to rounding.
State Programs. Oregon Project Independence. Many state officials and
advocates believe that the eligibility requirements for Medicaid, particularly the asset
limits, are a barrier to persons in need of long-term care who want to live at home.
State officials indicated that many people in need of home and community-based care
do not feel comfortable depleting almost all of their liquid assets that may be needed
for household expenses and emergencies. One of the ways that Oregon has addressed
this concern is through a state-funded program, Oregon Project Independence (OPI).
OPI offers home and community-based services to persons with income up to 200%
of the poverty level with no resource or asset test.
Funded entirely by state revenues, OPI provides long-term care services for
Oregonians over the age of 60. Clients with net incomes between 100% and 200%
of the poverty level (between $8,869 and $17,720 per year in 2002) pay a sliding
scale fee for services based on income. Individuals with income over 200% of the
poverty may still enroll in the program but will pay the full rate of services. Services
provided by the program include: personal care, respite care, assisted transportation,
homemaker/home care services, chore, home health, adult day care, case
management, registered nursing services, home delivered meals, and other services
as authorized by SPD.

CRS-23
Oregon’s Long-Term Care Services for
Persons with Mental Retardation and
Developmental Disabilities
Overview
Services to persons with mental retardation and other developmental disabilities
in the United States have changed dramatically over the last half of the 20th century
as a result of a number of converging factors. These include the advocacy efforts of
families and organized constituency groups, various changes to the Social Security
law that provided payments to individuals through SSI and SSDI and to service
providers through the Medicaid program, and significant litigation brought on behalf
of persons with developmental disabilities.20
Oregon’s system of services for persons with developmental disabilities has
been influenced by a number of significant factors. These include:
! the initiation of the Section 1915(c) Medicaid home and community-
based waiver services option in 1981;
! the Plan for Universal Access to Services for People with
Developmental Disabilities initiated by the Oregon State legislature
in 1999;
! the 2000 settlement agreement of Staley v. Kitzhaber which requires
the state to increase funding for developmental disabilities services
by a cumulative total of $350 million by 2007; and
! the incorporation of the Mental Health and Developmental Disability
Services Division into the division of Seniors and People with
Disabilities in 2001.
There are an estimated 15,500 persons of all ages that meet Oregon’s definition
of developmentally disabled.21 Of these, approximately 8,400 are adults and 7,100
are children. In FY2000, total spending for services for persons with developmental
disabilities was $354.7 million (Table 13). Spending for home and community-
based services represented 90% of total expenditures. This is a dramatic shift from
1990 spending levels when only 41% of spending was devoted to community-based
services.22
20 For a detailed history of the development of services for persons with developmental
disabilities, see David Braddock, Richard Hemp, Susan Parish, and James Westrich, The
State of the States in Developmental Disabilities, University of Illinois at Chicago.
American Association on Mental Retardation (Washington) 1998. (Hereafter cited as
Braddock, et al., The State of the States in Developmental Disabilities.)
21 Oregon Department of Human Services, A Plan for Universal Access to Services for
People with Developmental Disabilities, 2000.
22 CRS calculations based on data presented in Braddock, et al., The State of the States in
Developmental Disabilities (Fifth Edition), (Washington) 1998, American Association on
Mental Retardation, p. 404 (for 1990 data). Unpublished data furnished by Richard Hemp,
University of Colorado (for 2000 data).

CRS-24
Trends in Institutional Care
The early history of services to persons with developmental disabilities is
characterized by large state institutions or training schools begun during the latter
part of the 19th century and continuing through the first part of the 20th century.
Between 1920 and 1967, institutions quadrupled in size and resident totals peaked
at almost 200,000 individuals nationwide in 165 free-standing state-operated mental
retardation institutional facilities.23 Today, some states are still faced with the legacy
of large state-operated institutions.
In many states and in Oregon, most state-operated institutions have been closed
or downsized, a development that has often been prompted by litigation. In 1908,
Oregon opened Fairview, its first state-funded institution to care for individuals with
developmental disabilities and mental retardation. By the early 1960s, thousands of
persons received care in three state-run institutions in Salem, Pendleton, and The
Dalles.
Today, after a decades-long process of moving persons with developmental
disabilities into community-based group homes and residential settings, there is only
one remaining state-operated institution in Oregon — the Eastern Oregon Training
Center in Pendleton — with 50 residents in 2001. (See Appendix 2 for a list of the
institutions that have been closed.) Persons living in large institutions with 16 or
more persons declined from 37% in 1990 to just over 8% in 2000 (Table 8).
The Medicaid home and community-based services waiver option has allowed
Oregon to focus on the development of small congregate care options. In 2000, over
90% of persons with developmental disabilities were living in group residential
settings, with the majority (78.5%) living in residences of six or fewer persons (see
Table 8).
23 Braddock, et al., The State of the States in Developmental Disabilities.

CRS-25
Table 8. Persons with Mental Retardation and
Developmental Disabilities Served in Residential Settings,
by Size of Residential Setting, 1990, 1995, and 2000
Persons served by setting
1990
1995
2000
4,168
4,239
4,562
Total
(100%)
(100%)
(100%)
1,556
904
384
16+ Persons
(37.3%)
(21.3%)
(8.4%)
Nursing facilities
443
300
180
State institutions
840
463
105
Private ICFs/MR
140
0
0
Other residential
133
141
99
697
600
597
7 - 15 Persons
(16.7%)
(14.2%)
(13.0%)
Public ICFs/MR
0
0
0
Private ICFs/MR
22
0
0
Other residential
675
600
597
1,915
2,735
3,581
<6 Persons
(45.9%)
(64.5)
(78.5)
Public ICFs/MR
0
0
0
Private ICFs/MR
0
0
0
Other residential
1,915
2,735
3,581
Source: David Braddock, Richard Hemp, Mary C. Rizzolo, Susan Parish, and Amy Pomeranz. The
State of the States in Developmental Disabilities: 2002 Study Summary, by Coleman Institute for
Cognitive Disabilities and Department of Psychiatry, University of Colorado, June 2002.
According to data compiled by Braddock et. al., Oregon ranked seventeenth in
the nation in its use of small facilities (residences of six or fewer persons) in 2000.24
There is a recognition on the part of Oregon state officials and stakeholders that the
use of larger facilities should be further reduced in keeping with the state’s
commitment to community-based care.
24 David Braddock, ed., Disability at the Dawn of the 21st Century and the State of the States,
American Association on Mental Retardation, (Washington), 2002, p. 86.

CRS-26
Trends in Home and Community-Based Care
Over the last two decades, Oregon has made significant use of Medicaid
financing to reduce the number and size of intermediate care facilities for persons
with mental retardation and developmental disabilities (ICFs/MR). As in many
states, the Medicaid Section 1915(c) waiver program has been the chief source of
revenue for home and community-based services for persons with developmental
disabilities. In 1981, Oregon applied for and received a waiver that would serve as
an alternative to one of the two state-run institutions. By 2001, the Fairview Training
Center in Salem had been closed and only 50 individuals remained in the Eastern
Oregon Training Center.
Unlike the waiver program for the elderly and physically disabled, where the
state has no waiting lists for services, persons with developmental disabilities often
face lengthy waiting lists due to limited resources. Since the focus of the 1981
waiver was to remove individuals from institutions, those who were not residing in
one of the two state ICFs/MR often spent years waiting to receive community-based
services.
In 2000, parents of individuals with developmental disabilities filed suit against
the state to challenge the existence of the current waiting lists. In Staley v. Kitzhaber,
the plaintiffs argued that Oregon violated federal Medicaid law and the Americans
with Disabilities Act (ADA) for failing to provide individuals with developmental
disabilities the option of home and community-based long-term care services with
“reasonable promptness.”25
The state and the plaintiffs settled the lawsuit in September 2000. The parties
agreed that the settlement would apply not only to the plaintiffs named in the suit but
also to “all other similarly-situated individuals with developmental disabilities under
the federal Medicaid program,” thereby treating the lawsuit as a class action.26 As
part of the agreement, Oregon agreed to implement its State Plan for Universal
Access to Services for People with Developmental Disabilities over a 6-year period
between 2001 and 2007. The plan provides for improved access to supportive
services, such as personal care, in-home care, respite care, and job coaching, so long
as cost of services does not exceed $20,000 annually per client.
By 2007, after the plan has been fully implemented, supportive services must
be provided within 90 days after the individual is determined eligible for services.
Comprehensive services — or services costing more than $20,000 per year — will
be offered to a limited number of individuals. This may include intensive in-home
care, 24-hour group homes, adult foster care homes, and environmental adaptation
services. Comprehensive services for about 50 adults per year will be phased-in over
the next 6 years.
25 National Center for Family Support at
[http://www.familysupport-hsri.org/resources/r_medicaid_dd-1.html].
26 Oregon Department of Health, SPD at
[http://oddsweb.mhd.hr.state.or.us/Pubs/settlement/settlement.htm].

CRS-27
The agreement also requires the state to improve its service delivery
infrastructure. Funding for case management will be increased so that caseloads will
drop from an average of about one caseworker per 95 clients to one per 45 clients.
Additional funding will also be used to improve the provider network at the local
level.
In 2001, the state legislature approved the plan and agreed to fund the settlement
agreement. The state will increase funding for developmental disabilities services
by a cumulative total of $350 million by 2007.
Medicaid 1915(c) Waivers.27 Oregon operates two 1915(c) waivers for
adults with developmental disabilities. Below is a brief description of each waiver’s
average costs and the types of services offered.
! 1981 Waiver for Developmentally Disabled Individuals. For the
2002 waiver year, it is estimated that 5,762 persons with
developmental disabilities received long-term care services under
this waiver. Originally approved in 1981, the waiver was designed
as an alternative to intermediate care facilities for the mentally
retarded (ICFs/MR) with the goal of reducing the number of
individuals in state-run institutions. A wide range of services are
provided under the waiver including: respite care, day habilitation,
prevocational services, supported employment, adult foster care,
adult group homes, supported living services, specialized medical
equipment and supplies, environmental accessibility adaptations,
transportation, family training, in-home support services, crisis
diversion services, and extended state plan services. This program
addresses some of the most complicated cases to serve in community
settings and is consequently the most expensive of Oregon’s three
waivers. For the 2002 waiver year, the estimated average cost per
client under the waiver was $49,274.
! 2001 Waiver for Developmentally Disabled Individuals.. This
waiver came about in response to Staley v. Kitzhaber. Approved in
2001, 951 developmentally disabled individuals received long-term
care services during the first year of the waiver’s implementation.
Average annual costs were $6,371 per case. By the third year of the
waiver it is estimated that 6,081 individuals will be served at an
annual cost of $11,691 per case. Services provided under the waiver
include: respite care, supported employment, community living
supports, specialized medical equipment and supplies,
environmental accessibility adaptations, transportation, chore,
homemaker, personal emergency response systems, family training,
in-home support services, crisis diversion services, and extended
state plan services.
27 In addition to these waivers, Oregon operates two 1915(c) waivers for children with
developmental disabilities under the age of 18, as well as an additional waiver for medically
fragile children. This report generally excludes discussion of programs for infants and
children with disabilities.

CRS-28
Financing of Long-Term Care in Oregon
In most states, Medicaid is the chief source of financing for long-term care. In
addition to the state’s matching of federal Medicaid funds, many states also devote
significant resources to long-term care. In Oregon, the Medicaid program accounted
for $1 billion in long-term care spending in FY2001.
Medicaid Spending in Oregon
Medicaid is a significant part of state budgets. After elementary, secondary and
higher education spending, Medicaid spending was the largest share of state budgets
in 2001. According to data compiled by the National Association of State Budget
Officers (NASBO), federal and state Medicaid spending represented 19.6% of state
budgets for the United States as a whole in 2001.
In Oregon, Medicaid spending is the largest single category of federal and state
spending. Of the state’s $17 billion budget in 2001, federal and state Medicaid
spending represented 14.9%. Federal and state spending for Medicaid doubled as a
proportion of the state’s budget from 1990 to 2001, outranking spending for
elementary and secondary education (Table 9).
State spending for Medicaid services in Oregon contributed from state funds
only (excluding federal funds)28 also increased during the 1990s. As a percent of
spending for all categories of state spending, state Medicaid spending increased from
3.3 % in 1990 to 7.6% in 2001 (Table 10).
28 Federal and state governments share the costs of Medicaid spending according to a
statutory formula based on a state’s relative per capita income (federal medical assistance
percentage, or FMAP). In FY2001, the federal share for Medicaid in Oregon was 60%.

CRS-29
Table 9. Share of Federal and State Spending by Category,
Oregon and the United States, 1990-2001
Oregon
All states
Expenditure category
1990
1995
2000
2001
2001
Total expenditure
(in millions)
$6,987
$9,937
$16,557
$17,033
$1,024,439
Medicaid
7.5%
15.3%
13.0%
14.9%
19.6%
Elementary and secondary
education
10.6%
17.7%
14.8%
13.7%
22.2%
Higher Education
14.8%
11.9%
10.9%
12.4%
11.3%
Public assistance
2.2%
3.1%
1.7%
1.7%
2.2%
Corrections
2.2%
2.8%
4.4%
3.6%
3.7%
Transportation
7.6%
8.0%
6.9%
5.2%
8.9%
All other expenses
55.2%
41.2%
48.3%
48.4%
32.1%
Source: Congressional Research Service (CRS) calculations based on data from the National
Association of State Budget Officers (NASBO), State Expenditure Reports for 1992, 1997 and 2001.
Data reported are for state fiscal years. Numbers may not sum to 100% due to rounding.
Table 10. State Spending for Medicaid as a Percent of Total
State Spending, Oregon and the United States, 1990-2001
Oregon
All states
State spending
1990
1995
2000
2001
2001
Total state spending
(in millions)a $5,944
$7,569
$13,397
$13,580
$760,419
State Medicaid spending
(millions)b $194
$578
$819
$1,032
$85,141
State Medicaid spending as a
percent of total state
spending
3.3%
7.6%
6.1%
7.6%
11.2%
Source: CRS calculations based on data from the National Association of State Budget Officers (NASBO), State
Expenditure Reports for 1991, 1997 and 2001. Data reported are for state fiscal years.
a Total state spending for all categories, excluding federal funds.
b Includes local funds in FY1995; NASBO notes that local funds are a very small part of the program.

CRS-30
Medicaid Long-Term Care Spending in Oregon29
Long-term care spending represented 33.2% of the $2.1 million spent for
Medicaid services in Oregon in FY2000,30 down from 50.7% in FY1990. (Tables
11 and 12) Many state officials
maintain that this decline is due, in
part, to Oregon’s commitment to
Medicaid long-term care financing in
home and community-based services
Oregon at a glance:
and decreased reliance on expensive
institutional care.
Long-term care spending represented almost
40% of Medicaid spending in FY2001, a
decline from slightly more than half of all
Institutional spending as a
Medicaid spending in FY1990.
percent of total long-term care
spending has also declined
Unlike most other states, Oregon spends
dramatically from FY1990 to
more on home and community-based
FY2000. In 1990, almost 80% of
services through Medicaid than for
long-term care dollars were spent on
institutional care. In FY2000, almost two-
institutional care. This dropped to
thirds of Medicaid long-term care dollars
37.2% in FY2000. During this same
were spent on home and community-based
10-year period, spending for home
services, with only one-third of that spending
and community-based services
devoted to institutional care.
increased from 22.1% in 1990 to
Between 1990 and 2001, there was a 559%
62.8% in 2000 (Table 11). Today,
increase in state and federal Medicaid
more than 80% of Medicaid clients
spending for home and community-based
receive long-term care in the
services.
community.
According to state officials,
these trends are due to a number of factors implemented at varying times during the
1980s and 1990s. These include a legislative mandate that called for a preference in
providing community-based care over nursing home care; implementation of the
state’s pre-admission screening program to divert patients from nursing homes;
implementation of Oregon Project Independence for persons who do not meet
Medicaid financial eligibility requirements; significant use of Medicaid’s Section
1915(c) home and community-based waiver services for persons with mental
retardation; and closure of large state institutions for the developmentally disabled.
Note that between FY2000 and FY2001, spending for institutional care almost
doubled, however, this is not representative of actual spending trends in Oregon
(Figure 4 and Table 12). According to state officials, this increase is largely due to
Oregon’s use of Medicaid Upper Payment Limits. Under Medicaid provisions, states
can be reimbursed by the federal government at the “upper payment limit” for
nursing home services, while the providers in the state are reimbursed at a lower rate.
States can use excess funds that result from the gap between the Medicare Upper
29 This section discusses total Medicaid spending, both federal and state.
30 Total Medicaid spending using National Association of State Budget Officers (NASBO)
data differs from data shown in this table due to differences in data collection methods.

CRS-31
Payment Limit — the maximum Medicare rate paid to nursing homes — and the
actual Medicaid reimbursement rate paid to providers. In Oregon, the difference
between the upper payment limit and the state’s reimbursement rate to nursing homes
was transferred back to DHS in 2001 and used to fund increases in the
reimbursement rates to nursing facilities and community-based care facilities.
Because of these transfers of state and federal funds, the 28% increase in institutional
spending between 2000 and 2001 is not representative of actual spending trends. In
2001, the Centers for Medicare and Medicaid Services (CMS) tightened the
regulations that apply to Medicaid Upper Payment Limits. Future budgetary
documents may be more representative of spending trends for institutional and home
and community-based services.31
Table 11. Medicaid Long-Term Care Spending In Oregon,
FY1990-FY2000
State spending
1990
1995
2000
Long-term care spending as a percent of Medicaid
spending
50.7%
32.7%
33.2%
Institutional care spending as a percent of long-term
care spending
77.9%
50.1%
37.2%
Nursing home spending as a percent of long-term
care spending
42.3%
34.0%
33.7%
ICFs/MR* spending as a percent of Long-term
care spending
35.5%
16.1%
3.4%
Total home and community-based services spending
as a percent of long-term care spending
22.1%
49.9%
62.8%
HCBS waivers spending as a percent of Long-
term care spending
21.3%
44.8%
59.3%
Source: Congressional Research Service (CRS) calculations based on CMS/HCFA 64 data provided
by The Medstat Group, Inc. For 2000 and 2001, Brian Burwell et al., Medicaid Long-Term Care
Expenditures in FY2001, May 10, 2002. For 1995, Brian Burwell, Medicaid Long-Term Care
Expenditures in FY2000, May 7, 2001. For 1990, Brian Burwell, Medicaid Expenditures for FY1991,
Systemetrics/McGraw-Hill Healthcare Management Group, Jan. 10, 1992. Total 1990 Medicaid
spending, based on HCFA 64 data provided by Urban Institute, Washington, D.C.
*Intermediate care facilities for the mentally retarded.
31 For additional information on Medicaid Upper Payment Limits, see CRS Report RL31021,
Medicaid Upper Payment Limits and Intergovernmental Transfers: Current Issues and Recent
Regulatory and Legislative Action, by Elicia J. Herz.

CRS-32
Figure 3. Institutional and Home and Community-Based Services
as a Percent of Medicaid Long-Term Care Spending
in Oregon, 1990-2000
90%
$212.1 million
80%
70%
$235.3 million
60%
50%
40%
$234.6 million
30%
20% $60.2 million
10%
0%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Institutional Care (Nursing Home and ICFs/MR)
Home and Community-Based Services (Home Health, Personal Care and HCBS
Waivers)
Source: Congressional Research Service (CRS) calculations based on Burwell, Medicaid
Expenditures FY1991-FY2001.
Table 12. Medicaid Spending in Oregon, Total Spending and
Long-Term Care Spending, by Category, and Percent Change,
FY1990-FY2001
(dollars in millions)
Percent
change
1990-2001
(in constant
Spending category
1990
1995
2000
2001
2001 dollars)
Total Medicaid
$536.6
$1,437.7
$2,144.1
$2,668.5
291.2%
Total long-term care*
$272.3
$469.9
$712.1
$1,058.3
205.7%
Total institutional care
$212.1
$235.3
$264.8
$554.0
105.4%
Nursing home
$115.3
$159.7
$240.3
$542.8
270.2%
ICFs/MR**
$96.8
$75.6
$24.5
$11.2
-90.9%
T o t a l h o m e a n d
$60.2
$234.6
$447.3
$504.3
559.0%
community-based services
Home health
$0.8
$1.8
$0.7
$0.7
-31.2%
Personal
care
$1.5
$22.1
$24.0
$32.2
1613.7%
HCBS waivers
$57.9
$210.8
$422.6
$471.4
540.5%
Source: The Congressional Research Service (CRS) calculations based on Burwell, Medicaid
Expenditures FY1991-FY2001. Total 1990 Medicaid spending, based on HCFA 64 data provided by
Urban Institute, Washington.

CRS-33
Figure 4. Medicaid Long-Term Care Spending by Category
in Oregon, FY1990-FY2001
(in constant 2001 dollars)
$1,200
$1,000
$800
$600
Millions
$400
$200
$0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Nursing Home
ICF-MR
Home Health
Personal Care
HCBS Waivers
Source: Congressional Research Service (CRS) calculations based on Burwell, Medicaid
Expenditures FY1991-FY2001.
Figures 5a and b depict changes in long-term care spending patterns from
FY1990 to FY2000. In 1990, 35.5% of Medicaid long-term care spending was
devoted to care for persons with mental retardation in ICFs/MR; this decreased
dramatically to 3.4% in 2000. At the same time, nursing home spending decreased
from 42.3% in 1990 to 33.7% in 2000.
Between 1990 and 2000, spending on home and community-based services
more than doubled as a share of long-term care spending, increasing from 22.1% in
1990 to 62.8% in 2000. This is primarily due to expansion of the Section 1915(c)
waiver for persons with physical disabilities in Oregon. Waiver spending increased
from 22.1% of long-term care spending in 1990 to 59.3% in 2000.

CRS-34
Figure 5a. Medicaid Long-Term Care Spending in Oregon by
Category, FY1990
Total Medicaid LTC Spending: $272.3 million
ICFs/MR
Hom e Health
35.5%
0.3%
Personal Care
HCBS
0.5%
22.1%
HCBS Waivers
Nurs ing Home
21.3%
42.3%
Source: Congressional Research Service (CRS) calculations based on Burwell, Medicaid
Expenditures FY1990-FY2000.
Figure 5b. Medicaid Long-Term Care Spending in Oregon
by Category, FY2000
Total Medicaid LTC Spending: $712.1 million
ICFs/MR
Home Health
3.4%
0.1%
Personal Care
HCBS
3.4%
62.8%
HCBS Waivers
59.3%
Nursing Home
33.7%
Source: Congressional Research Service (CRS) calculations based on Burwell, Medicaid
Expenditures FY1990-FY2000.
In the nation as a whole, approximately three-quarters of Medicaid waiver
spending is for persons with mental retardation and developmental disabilities. In
Oregon, 52.8% of waiver spending for persons with mentally retardation and
developmental disabilities, and 47.2% is devoted to spending on other disability
groups (Figure 6). This is largely due to the commitment of state officials to ensure
that no waiting lists exist for the elderly and physically disabled waiver, while
allowing waiting lists to be used for persons with developmental disabilities. The
waiver for the developmentally disabled initiated in 1981 was primarily used to
remove individuals from Fairview and the Eastern Oregon Training Center. In 2001,
the state legislature approved a plan to increase funding for a new MR/DD waiver.

CRS-35
The plan outlines the state’s intent to increase funding for developmental disabilities
services by a minimum of $350 million by 2007.
Figure 6. Medicaid Home and Community-Based Services
Waiver Spending by Target Population in Oregon,
FY2001
Total Medicaid HCBS Waiver Spending: $471.4 m illion
Aged Waivers
47.2%
MR/DD Waivers
52.8%
Source: Congressional Research Service (CRS) calculations based on Burwell,
Medicaid Expenditures FY1990-FY2000
Medicaid and State Spending on Services for Persons with
Mental Retardation and Developmental Disabilities
In 2000, spending for home and community-based services made up 90% of
total Medicaid expenditures for persons with developmental disabilities. This is a
dramatic shift from 1990 spending levels when only 41% of spending was devoted
to home and community-based services. These funds serve approximately 9,654
persons in a variety of community, residential, and institutional settings. Combined
federal and state spending in Oregon for persons with developmental disabilities was
$354.7 million in 2000 (Table 13). This represented more than a 57% increase (in
constant 2000 dollars) since 1990. Of total 2000 spending, a significant share —
45.5% — was contributed by the state.
The state has used the waiver to maximize federal Medicaid reimbursement for
home and community-based services, while at the same time it has decreased federal
spending for institutional services. Federal spending for institutional services
decreased by 70.4% from 1990 to 2000.

CRS-36
Table 13. Federal and State Spending for Institutional and
Community Services for Persons with Mental Retardation/
Development Disabilities in Oregon, 1990 and 2000
(millions in current dollars)
Percent
1990
2000
Percent of
change
(current
(current
FY2000
(in constant
dollars)
dollars)
total
2000 dollars)
Total funds
$181.3
$354.7
100.0%
57.7%
Congregate/institutional services
$106.8
$34.5
9.7%
-74.0%
Federal fund
$60.0
$22.1
6.2%
-70.4%
State funds
$46.7
$12.4
3.5%
-78.6%
Community services
$74.5
$320.3
90.3%
246.3%
Federal funds
$33.0
$171.2
48.3%
318.4%
ICFs/MR funds
$0.4
$0.0
0.0%
-100.0%
HCBS waiver
$20.7
$113.6
32.0%
342.6%
Title XX/SSBG funds
$1.8
$0.0
0.0%
-100.0%
Other
$10.0
$57.6
16.2%
362.3%
State funds
$41.5
$149.0
42.0%
189.0%
Source: Congressional Research Service( CRS) calculations based on data presented in The State of
the States in Developmental Disabilities (Fifth Edition), by David Braddock et al. (1998) Washington,
American Association on Mental Retardation, p. 404 (for 1990 data). Unpublished data furnished by
Richard Hemp, University of Colorado (for 2000 data).
* Intermediate care facilities for the mentally retarded.
** Home and community-based waiver (Section 1915(c)) of the Medicaid statute.
*** Social Services Block Grant (Title XX of the Social Security Act).

CRS-37
Issues in Long-Term Care in Oregon
Oregon officials and stakeholders identified issues in the state’s long-term care
system in a series of reports over the years. The following discussion highlights
selected issues identified in reports by researchers, task forces and advocacy groups,
as well as issues that surfaced in CRS interviews with state officials, providers, and
consumers.
Institutional Bias in Federal Funding and Oregon’s Response. A
recurring theme in discussions of long-term care with state officials is the view that
the federal financing system is biased towards institutional care. This is largely due
to the fact that nursing facility care is an entitlement under Medicaid for persons
meeting its eligibility criteria. Financing of institutional care is a federal mandate;
home and community-based care is not. Although states may choose to provide
home and community-based services under various Medicaid options, state officials
indicate that state funding constraints and the provider system that was created as a
result of the institutional entitlement make it difficult to reorient the system.
Although Oregon has been successful in providing the majority of its long-term care
clients with home and community-based services, many officials believe that the
federal system should equally support a consumer’s choice to stay at home or in the
community.
For most states, the impetus for heavy reliance on institutional care is embedded
in the structure of the federal Medicaid system resulting in vast funding disparities
between institutional care and home and community-based care. Over the last 20
years, Oregon has relied on a number of strategies to ameliorate the institutional bias
embedded in that system. For example, rather than relying on providers to refer
hospital patients directly into nursing homes, Oregon requires most residents to be
screened before entering a nursing home. A patient’s level of impairment is
evaluated, and home and community-based service options are discussed with the
client and family members. Partially as a result of this screening process, the rate of
hospital discharges directly into nursing homes is significantly lower than the
national average.
Another method to counter institutional bias is to control or downsize
institutional capacity. Oregon controls its institutional capacity by requiring the
approval of Medicaid beds through the Certificate of Need process (described earlier)
and through limitation on reimbursements. Controlling the supply of state
institutions for the developmentally disabled differs somewhat from that for nursing
homes. The state has closed all but one intermediate care facility for persons with
developmental disabilities over the past several decades, and as of 2001, fewer than
1% of persons with developmental disabilities were served in institutions. The state
could do so because these facilities were operated by state government. Virtually all
nursing homes in the state are privately owned and therefore controlling or
downsizing institutional capacity is not as direct as in the case of state-operated
facilities.
State officials indicated that federal entitlement to nursing home care should be
changed so that nursing homes are an exception rather than the rule. In Oregon,

CRS-38
home and community-based care is considered first, and then, if services are judged
to be inappropriate or unavailable, the alternative is an institutional placement.
Budget Cuts. Recent state budget cuts have greatly impacted Oregon’s long-
term care system. After a statewide ballot initiative to increase taxes was defeated
by voters in January 2003, the state has been forced to make up its revenue shortfall
with drastic cuts in a number of social service programs. Seniors and People with
Disabilities (SPD) had to reduce its long-term care spending by nearly 30% for the
2003 state fiscal year (SFY). SPD decided to cut funding for individuals whose
impairment levels fell within service priority levels 12-17 (Table 5). As of April
2003, over 4,792 persons had lost Medicaid long-term care services (over 16% of
total program participants), with potentially more cuts needed in the future.
By choosing to restrict Medicaid enrollment through functional eligibility
criteria (as opposed to caps on 1915(c) waiver spending, for example), Oregon was
able to ensure that institutional services, as well as home and community based
services, were effected by these budget reductions. Of the residents who lost
Medicaid services, 3,834 were receiving in-home services; 765 were residing in
community-based assisted housing arrangements; and 193 were residing in nursing
facilities. SPD worked with the Centers for Medicare and Medicaid Services (CMS)
to make changes to the state’s current waiver program to provide limited transitional
services for those who no longer qualify for Medicaid.
In addition to reducing the number of people eligible for Medicaid, the state also
eliminated in-home supports for 3,800 seniors who were not eligible for Medicaid;
reduced reimbursement rates to Medicaid long-term care providers by 15% to 30%;
and eliminated the state’s medically needy program for 8,757 individuals.
Medicaid Eligibility Requirements and Access to Services. A number
of issues identified by state officials relate to Medicaid eligibility for home and
community-based services. Persons needing long-term care services paid for by
Medicaid must meet countable income and resource limits established by the state
within federal requirements. States may allow persons with income up to 300% of
the federal SSI level to become eligible for Section 1915(c) home and community-
based waiver services. This level in 2003 is $1,656 per month and is the level used
by Oregon for its waiver programs. The resource level used by Oregon for the waiver
programs is the same as that for nursing home care; that is, in order to qualify for
Medicaid, a person may have resources that do not exceed $2,000 for an individual
and $3,000 for a couple.32
While these requirements limit the number of persons who may become eligible
for Medicaid, they also act as a barrier to many persons in need of long-term care
who live at home. For example, state officials indicated that persons in need of home
and community-based care who live in their own homes do not feel comfortable
32 Certain items are excluded, such as an individual’s home; up to $2,000 of household
goods and personal effects; life insurance policies with a face value of $1,500 or less; an
automobile with value up to $4,500; and burial funds up to $1,500, among other things.

CRS-39
depleting almost all of their liquid assets that may be needed for household expenses
and emergencies.
Oregon, through its state-funded Oregon Project Independence program, has
addressed some of these Medicaid financial eligibility issues. The Oregon Project
Independence program allows persons with income up to 200% of the federal poverty
level (up to $17,720 per year in 2002) to become eligible for state-funded home and
community-based services, with no resource or asset test. Individuals pay a sliding
scale fee for each service based on income. This allows persons needing long-term
care to receive services and gradually become eligible for Medicaid, rather than
having to wait until all countable resources are depleted to the $2,000 Medicaid level.
Waiting Lists for Persons with Developmental Disabilities. Waiting
lists for services for persons with development disabilities have drawn attention
across many states and in Oregon. Despite the sizable amount of funding devoted to
home and community-based services for persons with developmental disabilities in
Oregon, waiting lists for services have been a persistent problem.
According to state reports, as of June 13, 2002, 4,773 individuals were waiting
to receive home and community-based services. Of those, 750 had been on the
waiting list for less than 2 years; 763 had been on the waiting list between 2 and 4
years; and 3,260 had been waiting for services for more than 4 years.33 As a result
of the Staley lawsuit, approximately 5,000 persons with developmental disabilities
are to be removed from the waiting list and receive services by 2007.
Long-Term Care Staffing. Across the country, states are faced with the
challenge of finding sufficient numbers of qualified staff to provide long-term care
services. Many of the staffing shortages experienced in other states, however, are
ameliorated in Oregon by the state’s client employed provider (CEP) program and
nurse delegation program. In 2001, approximately 20,000 individuals needing long-
term care were served in their home by client employed providers. State officials
indicate that this program, which allows clients to select unlicenced caregivers to
provide long-term care services, has greatly expanded the state’s ability to serve
individuals in their homes. The state has also addressed issues of staffing shortages
through its nurse delegation program. This program allows licensed registered nurses
to delegate certain medical tasks of nursing to unlicenced caregivers. State officials
and providers maintain that the use of nurse delegation has been essential to the
expansion of home and community-based care services in Oregon.
In spite of the success of these two initiatives, state officials expressed concern
about finding adequate numbers of direct care workers (defined as home health aides,
nurse aides, personal attendants and personal care aides), particularly to serve persons
with developmental disabilities in residential settings.
33 Oregon Department of Human Services, Seniors and People with Disabilities. At
[http://oddsweb.mhd.hr.state.or.us/Pubs/CPMS/waitsum.htm].

CRS-40
Centralization of Responsibility. Many states confront issues of
fragmentation in the administration of long-term care programs. Oregon’s system,
however, is one of the few in the country to consolidate all of the various functions
of its long-term care system into a single state agency. Many state officials credit
the success of Oregon’s long-term care system to the centralization of responsibility
within a single administrative structure and budget. The goal of state officials over
the last 20 years (partially in response to several state legislative mandates) has been
the creation of a seamless system for seniors and people with disabilities that favors
care in community settings rather than in nursing homes or other institutions.
Bounded Choice. State administrators recognize that with the aging
population and increasing costs of long-term care, they may need to rethink the
design of their current system. In the coming years, administrators hope to
incorporate a concept of “bounded choice” into the system where an individual’s
preferences for services are considered within the boundaries of service capacity and
fiscal constraints.
The Governor’s Task Force on the Future of Services to Seniors and People
with Disabilities made a number of recommendations for incorporating a concept of
bounded choice in Oregon’s long-term care system. The concept raises some
difficult questions in light of the state’s ongoing commitment to promoting a system
that values consumer choice. The task force hopes to pursue changes in federal
regulations and the state’s waiver programs that would allow service packages to be
designed within certain financial constraints.
Other Issues. Other issues raised by advocates, providers, and state officials
are:
! Consumer Choice. In the fall of 2001, Oregon initiated a Medicaid
pilot project — Independent Choices — to offer consumers the
option of expanded control over their long-term care services. In
this program, SPD authorizes clients to receive lump monthly
payments in their bank accounts. Participants are then responsible
for meeting their long-term care needs within that monthly
allotment. Consumer-directed care of this kind — often referred to
as “cash and counseling” programs — is not currently available on
a larger scale in Oregon, although state officials expressed their
ongoing commitment to expand consumer choice within their long-
term care system.
! Estate Planning and Avoidance of Estate Recovery. State officials
reported that although there may be a small number of people
sheltering assets in order to qualify for Medicaid long-term care
services sooner than they otherwise would, the number is growing.
An increasingly popular way of sheltering assets in Oregon is to
shelter assets in trusts (i.e., Pooled Trusts), annuities and other
financial instruments that are deemed “not available” to the
Medicaid applicant to pay for long-term care, or transferring assets
to community spouses and other individuals. Particular concern was
expressed about the use of special needs trusts among younger

CRS-41
individuals with disabilities. State officials also provided anecdotal
evidence of increasing avoidance of Medicaid Estate Recovery
requirements.
! Provider Costs and Liability Insurance. In Oregon, as in many
states, nursing home providers were unanimous in their concern
about the increasing costs of liability insurance and the absence of
state caps on punitive damages. This issue was raised by many of
the provider groups that were interviewed for this study.
! Integration of Medicare and Medicaid. Advocates and state officials
expressed an interest in eliminating the administrative inefficiencies
associated with using multiple payers and delivery systems in a
poorly coordinated system between Medicare and Medicaid. One
option might be to pool Medicare and Medicaid financing to
promote financial and service integration, and revising program rules
to promote administrative integration. This, advocates asserted,
could help reduce incentives to use institutional care, improve the
quality of care, and streamline administration and oversight.
! Assisted Living as an Alternative to Nursing Home Care. Some
providers and advocates in Oregon expressed concern about an
upward swing in the disability levels of clients in community-based
settings in recent years. Anecdotal evidence suggests that this
upward swing is particularly apparent in assisted living facilities in
Oregon. Caring for persons with acute disabilities in potentially less
regulated home and community-based settings raises concerns for
some long-term care advocates and providers.

CRS-42
Appendix 1. Major Home and Community-Based Long-Term Care Programs
for the Elderly and Persons with Disabilities in Oregon
Functional eligibility
Financial eligibility
Annual cost
Income/
No. of persons
cap
Target
Determined
resource
Determined
enrolled/slots
(aggregate/
Admin.
Financial
Program
group
Criteria
by
limits
by
Services
approved
individual)
Oversight
oversight
Home and
Seniors
Nursing
Area agencies
Individuals must
Area agencies
Personal care,
34,676 persons/
$245,899,253/
Seniors and
Seniors and
community-
aged 65 and
facility
on aging
have income at or
on aging under
respite care,
2002 waiver
2002 waiver
People with
People with
based waiver
older with a
level of
under
below 300% of the
contract with
assisted
year estimates
year
Disabilities
Disabilities
care
contract with
federal SSI level
SPD or state
transportation,
for the
disability
SPD or state
($1,656 in 2003)
employees in a
homemaker/
elderly and
and
(Aggregate
employees in
and resources of
Multi-Services
home care
physically
individuals
a Multi-
$2,000 or less per
Office or a
services, chore,
cost cap)
disabled
aged 18 to
Services
individual or
Disability
home health,
[1915(c)]
64 with a
Office or a
$3,000 per couple.
Services
adult day care,
physical
Disability
Office.
case
disability.
Services
management,
Office.
registered
nursing
Initiated
services, home
statewide in
delivered meals,
1981
and other
services as
authorized by
Seniors and
People with
Disabilities.
Source: Prepared by the Congressional Research Service (CRS) based on data provided by Oregon Department on Human Services.

CRS-43
Functional eligibility
Financial eligibility
Annual cost
Income/
cap
Target
Determined
resource
Determined
No. of persons
(Aggregate/
Admin.
Financial
Program
group
Criteria
by
limits
by
Services
served
individual)
Oversight
oversight
1981 waiver
Persons with
Applicants
SPD
Individuals
SPD
Respite care,
5,762 persons/
$255,479,779/
Seniors
Seniors and
for develop-
develop-
must be
employees
must have
employees
habilitation (day
2002 Waiver
2002 Waiver
and People
People with
mentally
mental
diagnosed
housed
income at or
housed
habilitation,
Year Estimates
Year
with
Disabilities
disabilities of
with a
within a
below the
within a
prevocational
Disabilities
disabled
all ages as an
develop-
Multi-
federal SSI
Multi-
services,
(Aggregate
individuals as
alternative to
mental
Services
level ($1,656
Services
supported
cost cap)
an alternative
an
disability by
Office or a
in 2003) and
Office or a
employment,
to an
intermediate
a psychiatrist.
Disability
resources of
Disability
adult and child
intermediate
care facility.
In Oregon, a
Services
$2,000 or less
Services
foster care, adult
care facility
developmenta
Office.
per individual
Office.
and child group
for the
l disability is
and $3000 per
homes, supported
mentally
defined as
couple.
living services)
having an IQ
specialized
retarded or
of 69 or less
medical
persons with
or an IQ of
equipment and
related
75 or less
supplies,
conditions
with
environmental
complicating
accessibility
(1915(c))
conditions.
adaptations,
transportation,
family training,
in-home support
Initiated
services, crisis
statewide in
diversion
1981
services, and
extended state
plan services.
Source: Prepared by the Congressional Research Service (CRS) based on data provided by Oregon Department on Human Services.

CRS-44
Functional
Financial
Eligibility
Eligibility
Annual Cost
Income/
No. of
Cap
Target
Determined
resource
Determined
Persons
(Aggregate/
Admin.
Financial
Program
Group
Criteria
by
Limits
by
Services
Served
Individual)
Oversight
Oversight
2001 waiver
Persons with
Applicants must
SPD
Individuals
SPD
Homemaker,
951 persons/
$27,302,365/
Seniors and
Seniors and
for develop-
develop-
be diagnosed
employees
must have
employees
respite care,
2002
2002 Waiver
People with
People with
mentally
mental
with a develop-
housed
income at or
housed
habilitation
Waiver Year
Year
Disabilities
Disabilities
disabilities
mental
within a
below 300%
within a
(supported
Estimates
disabled
aged 18 and
disability by a
Multi-
of the
Multi-
employment,
(Aggregate cost
individuals
older who live
psychiatrist. In
Services
federal SSI
Services
community living
cap)
as an
on their own
Oregon, a
Office or a
level
Office or a
supports,
alternative
or with a
developmental
Disability
($1,656 in
Disability
community
to an
family member
disability is
Services
2003) and
Services
inclusion)
intermediate
as an
defined as
Office.
resources of
Office.
specialized
care facility
alternative to
having an IQ of
$2,000 or
medical equipment
for the
an
69 or less or an
less per
and supplies,
intermediate
IQ of 75 or less
individual
environmental
mentally
care facility
with
and $3000
accessibility
retarded or
complicating
per couple.
adaptations,
persons with
conditions.
transportation,
related
chore, personal
conditions
emergency
response systems,
(1915(c))
family training, in-
home support
services, crisis
Initiated
diversion services,
statewide in
and extended state
2001
plan services
Source: Prepared by the Congressional Research Service (CRS) based on data provided by Oregon Department on Human Services.

CRS-45
Functional
Financial
Eligibility
Eligibility
Income/
No. of Persons
Target
Determined
resource
Determined
Enrolled/Slots
Admin.
Financial
Program
Group
Criteria
by
limits
by
Services
Approved
Oversight
Oversight
Oregon project
Aged 60 or
Nursing
Area agencies
Clients with net
Area agencies
Personal care,
4,538 persons/
Seniors and
Seniors and
independence
older
facility
on aging.
incomes between
on aging.
respite care, assisted
State Fiscal Years
People with
People with
or patients
level of
100% and 200% of
transportation,
(SFY) 2001-2003
Disabilities
Disabilities
State-funded
with
care
FPL pay a sliding
home maker/ home
program
Alzheimer’s
scale fee for each
care services, chore,
or related
service; individuals
home health, adult
Statewide
conditions
with income over
day care, case
200% of FPL pay the
management,
Initiated
full rate of each
registered nursing
statewide in
service; no resource
services, home
1977
caps. Cannot be
delivered meals,
receiving benefits
and other services
from Medicaid,
as authorized by
Medicare Beneficiary
Seniors and People
or Supplemental Low
with Disabilities.
Income Medicare
Beneficiary Program.
Source: Prepared by the Congressional Research Service (CRS) based on data provided by Oregon Department on Human Services.

CRS-46
Appendix 2. Population in Large State Facilities for
Persons with Mentally Retardation/Developmental
Disabilities, Closure Date, and
Per Diem Expenditures, 1960-2001
Average
Average per
Large state MR/DD
Year
Residents
daily MR/DD
diem
facilities or units
facility
Year
with MR/DD
residents
expenditures
operating 1960-2001
opened
closed
on 6/30/01
FY2001
FY2001 ($)
C o l u m b i a P a r k
Hospital and Training
Center (The Dalles)
1963
1977
E a s t e r n O r e g o n
T r a i n i n g C e n t e r
(Pendleton)
1964
50
50
540.10
Fairview
T r a i n i n g C e n t e r
(Salem)
1908
2000
Source: Census information provided by the Office of Seniors and People with Disabilities. Average
per Diem Expenditure data from: Residential Services for Persons with Developmental Disabilities:
Status and Trends Through 2001. Research and Training Center on Community Living, Institute on
Community Integration/UCEED. University of Minnesota (June 2002).

CRS-47
Appendix 3. About the Census
Population Projections
“The projections use the cohort-component method. The cohort-component
method requires separate assumptions for each component of population change:
births, deaths, internal migration (Internal migration refers to state-to-state migration,
domestic migration, or interstate migration), and international migration .... The
projection’s starting date is July 1, 1994. The national population total is consistent
with the middle series of the Census Bureau’s national population projections for the
years 1996 to 2025.” Source: Paul R. Campbell, 1996, Population Projections for
States by Age, Sex, Race, and Hispanic Origin: 1995 to 2025, U.S. Bureau of the
Census, Population Division, PPL-47. For detailed explanation of the methodology,
see same: at [http://www.census.gov/population/www/projections/ppl47.html].

CRS-48
Additional Reading
State of Oregon. Oregon Bluebook: Agency History of the Seniors and Disability
Services Division. 2001-2002 edition.
State of Oregon. Oregon Bluebook: Agency History of the Mental Health and the
Developmental Disability Services Division. 2001-2002 edition.
Donenfeld, Barry. Testimony before the Senate Special Committee on Aging.
March 14, 2002.
National Health Policy Forum. Caring for the Elderly: Oregon’s Pioneers.
November 2000.
Kane, Robert, et al., Oregon’s Long-Term Care System: A Case Study by the
National Long-Term Care Mentoring Program.
Oregon Department of Human Services, Seniors and People with Disabilities.
Report of the Governor’s Task Force on the Future of Services to Seniors and
People with Disabilities. September 2000.
Oregon Department of Human Services, Seniors and People with Disabilities.
The Oregon Consumer Guide for Assisted Living and Residential Care
Facilities. 2001.
Oregon Department of Human Services, Seniors and People with Disabilities.
Oregon Project Independence. 2000.
Oregon Department of Human Services, Seniors and People with Disabilities.
Client Employed Provider Program. 2000.
Auerbach Roger, Testimony before the Senate Special Committee on Aging.
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