Mass. lags on homes for assisted living

Study reveals most sites located in upscale areas

By Kay Lazar
Globe Staff / January 5, 2010

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Assisted living has rapidly emerged over the past decade as the long-term care of choice for older Americans, but a Harvard Medical School study reveals that in Massachusetts, this type of housing is far less available than it is nationwide.

The research, published today in the journal Health Affairs, also finds that assisted-living facilities - one of the fastest-growing forms of senior housing because they offer more privacy, freedom, and flexibility than nursing homes - are disproportionately located in more upscale areas.

Because of that, the lead researcher was surprised that Massachusetts, which is relatively affluent, had about half as many assisted living slots per resident 65 or older as the national average.

The study did not delve into the reasons for disparities among specific states, but some long-term care specialists said developers held off building in Massachusetts until the late 1990s because of uncertainty. The state didn’t pass a law regulating assisted-living centers until 1994, long after many other states had done so.

Also, Massachusetts’ relatively high property taxes, specialists said, have probably muted development.

“Our property costs up here are tremendous,’’ said Scott Plumb, senior vice president of the Massachusetts Senior Care Association, a trade organization that represents more than 500 assisted-living residences and nursing homes.

“You want to be in the Lexington, Needham, and Winchester parts of Massachusetts,’’ Plumb said, “because you need private-pay residents.’’

The assisted-living boom in Massachusetts and across the country has been fueled by private dollars, because Medicaid typically does not pay for such care. That means developers have built where the money is.

And that trend, said lead author David Stevenson, an assistant professor of health policy at Harvard, raises some troubling questions.

“It comes down to what kind of long-term care we as a society think people should have access to,’’ Stevenson said. “Anyone who can avoid being in a nursing home does, whereas assisted living is hugely appealing to people, as are community-based and home services.’’

The study found that assisted living is unavailable to most poor and minority elders and those living in rural areas.

The cost of assisted living can vary considerably depending on the amenities and services provided, but industry surveys put the average annual cost nationwide at about $34,000 in 2009, according to the Harvard study, making this type of care largely out of reach for lower- and even middle-income seniors. By contrast, the study said, Medicaid pays about half of the nation’s nursing home bill.

States with a higher concentration of assisted-living centers tend to make the facilities more accessible to residents by devoting a greater proportion of their Medicaid long-term care money to home- and community-based care, the study said.

In Massachusetts, Medicaid covers the medical services for fewer than one in five adults, or about 17 percent, who reside in assisted-living centers, according to the state’s Executive Office of Elder Affairs. Roughly 12,300 Massachusetts elders reside in assisted living.

Ann L. Hartstein, the state’s secretary of elder affairs, was unable to say what percentage of the state’s total Medicaid budget for long-term care is spent on community-based services, which are programs aimed at keeping seniors out of nursing homes. But, she said, Massachusetts has a strong commitment to keeping elders in their communities, devoting about $1 billion annually to such services, including home-based care for seniors in 31 public housing projects statewide.

Popular as they are, assisted-living facilities are largely unregulated by state and federal authorities, compared with nursing homes, which undergo strong government oversight, including inspections every 9 to 15 months. Under Massachusetts law, assisted-living sites are regulated in much the same way that rental properties are. Because of the lack of rigorous oversight, there is no central database or website for consumers to glean information or compare facilities the way they can for nursing homes.

“Consumers are making these decisions largely in the dark about the best facility to go into,’’ said Stevenson.

From a consumer standpoint, there is a trade-off, he said.

“If assisted living were more regulated, consumers would have more reliable data and better oversight,’’ Stevenson said, “but the flexibility of assisted-living facilities to innovate and tailor care to individual needs may be lost.’’

The recession has decimated retirement savings for many baby boomers and retirees, and many can no longer count on selling their homes to fund their entry into assisted-living centers. The downturn also means states have even fewer dollars to devote to assisted-living care, just as the oldest boomers reach retirement age, said Emily Meyer, who heads the Massachusetts Assisted Living Federation of America.

“A lot of people are advocating for different pieces of the pie,’’ she said, “and that pie . . . is shrinking.’’

Kay Lazar can be reached at