Want to live out your final days at home?

If your income is low and you live in Virginia, you're much more likely to spend the end of your life in a nursing home.

Virginia ranks 47th in the nation in Medicaid funding of home care. Unlike states that have tried to shift funding toward home care and away from nursing homes, Virginia spends just 27 percent of its Medicaid budget on home health and personal care. By comparison, it spends 42 percent on nursing facilities, according to the National Center on Caregiving.

There's an obvious problem with that funding formula, home care advocates say: Not only do people prefer to live at home for as long as they can, but it's also much cheaper for them to do so.

Because Virginia's reimbursement rate for home care doesn't cover all the costs of providing it, many home-care companies opt out of accepting Medicaid patients altogether. The companies that do accept Medicaid are plagued by worker shortages.

Because of low reimbursements, service providers say they have a hard time paying their aides a living wage and providing mileage. In Virginia's rural areas especially, providers report that many Medicaid-eligible seniors simply go without home care because there's no one willing to provide it for such low pay locally.

Shortage cycle

The reimbursement shortfall "creates a cycle of people who can't afford to do the job and therefore the providers shy away from providing the service," said Lisa Sprinkel, who directs Carilion's Home Care Services, one of the region's larger home-care providers.

Sprinkel was disappointed when the Virginia General Assembly did not approve recommendations this year that she and other members of Gov. Tim Kaine's long-term care planning task force had made to increase Medicaid home-care reimbursements. Reimbursement rates for home-care services have to be approved annually by the General Assembly, and the task force estimated it would take a 40 percent increase in the rate to cover their costs and allow providers to pay their aides more, thus attracting more people to the field.

The group ended up reducing its request, asking for a 10 percent increase instead. "We knew the budget was so tight this year; we thought our chances would be better asking for less," Sprinkel said. But even the request for a 10 percent increase died in a budgeting committee.

"Increasingly, we're seeing more of a resistance [from seniors] to going anywhere but home," Sprinkel said. "But unfortunately, our state budget has not been able to keep up with the demand."

Faced with booming senior populations that are projected to grow even larger in the coming decades, many states are working toward balancing the funding of home care and nursing-facility care, according to Rosalie Kane, a health policy professor at the University of Minnesota.

Such states have reconfigured their Medicaid offerings to provide home-care training for friends and relatives of home-bound seniors -- and to pay them higher wages, starting at about $9.50 an hour. (The average rate in Virginia is $7.73.) Oregon even allows nurses to delegate nursing tasks to unlicensed aides, Kane said.

'Sickest of the sick'

But it's not so simple in Virginia, nursing-home industry leaders argue, pointing to a host of complex reasons why Virginia has always been thrifty in its funding of home care.

"Because we're a stingy state and our program is already so lean, by default that means that we only take care of the sickest of the sick," said Hobart Harvey, vice president of the Virginia Health Care Association, which represents nursing facilities.

Federal dollars for Medicaid are portioned out to states according to per-capita income: The poorer a state's residents, the more money the federal government gives it for Medicaid.

Virginia, the ninth-wealthiest state in the country, ranks 47th for Medicaid spending. West Virginia ranks 49th in per-capita income and 10th in the nation for Medicaid spending.

In Virginia, criteria for nursing-home admittance are more stringent, meaning that a person entering a nursing home on Medicaid typically requires more health care assistance than those in most other states, Harvey said. Virginia's nursing homes likewise suffer from the same underfunding of Medicaid, reporting a $10 loss per Medicaid patient every day.

"You would be hard-pressed to walk through any nursing home in Virginia and find one or two people that you'd believe could be cared for at home," asserted Roanoke civic leader Heywood Fralin, whose Medical Facilities of America owns facilities in Virginia and North Carolina.

'Induced dependency'

But Kane argues that many people are sick in nursing homes precisely because they've been rendered incapable of going back to the community -- by the very nature of nursing-home life.

"It's not due to malevolent efforts by the nursing home people," Kane said. "Many seniors just don't function as well in nursing homes because the nursing homes have induced dependency -- seniors don't bathe themselves or take their own medications ... and therefore many become de-conditioned, demoralized and depressed."

While they don't doubt that nursing-home residents are ill, home-care aides point out that many of the frail clients they serve manage to stay home with just 10 or 12 hours of home-care assistance per week.

"Most of my clients right now, they've been told at one time or another that they needed to live in a nursing home," aide Cheryl Jones said. Allowing them to stay home, with fairly minimal assistance, has prolonged their lives, she added -- and saved government dollars.

Advocates blame the long-established and well-funded nursing-home lobby for the state's sluggish response to serving frail seniors at home. "In Virginia, more money has to be coughed up" for home care Medicaid reimbursements, Kane said. "That's the only way to fix it."

But the issue is complex -- for the public and politicians alike. "You're lucky to find two people in any state legislature who understand long-term care," Kane said. "Most politicians get most of their information from the nursing-home lobby."

News researcher Belinda Harris and data delivery editor Matt Chittum contributed to these stories.