By Thomas Goldsmith
Among many potential benefits to older North Carolinians, long-term care industry representatives and state officials have different takes about the possibilities of a single additional 8 ounces of milk for assisted living residents.
Specifically, the industry would like to know, who’s going to pay for it?
To be sure, no one has directly opposed the concept of supplying an extra glass of milk to people who live in assisted living centers with help from Medicaid. The proposal is part of the ongoing revamp of state regs, so what’s holding it up?
Details and cost are the bumps in the road for the change proposed by the state Department of Health and Human Services. Ongoing discussions over a milk mandate generally represent the way such changes get made, or are blocked, with practiced voices speaking up for their constituents.
“Based on what I’ve seen in my involvement on the Rules Committee, the industry only cares about how the rules impact costs,” said Steve Gugenheim, a Raleigh attorney who is among advisers to the state Rules Review Commission.
New costs eyed by industry
Hearings at the state-chartered Rules Review Commission only hit the news occasionally, but they can be closely watched when a guideline is to be changed, added or shot down.
“This was initially raised by the industry in response to rule modification,” Gugenheim, often a plaintiff’s attorney in long-term-care cases, said in an email exchange. “So, due to industry objection, a fiscal impact study is done, any time changes to rules increase costs.”
Although far from being a household name, the 10-member rules commission can reject proposals such as the one to increase dairy consumption for residents of assisted living facilities. An important cog in the wheel of government action, the Rules Review Commission is charged with periodic examination of state rules to make sure they are still necessary.
Coming down from the federal level, there’s support from the Food and Drug Administration for giving more dairy products to older people. For industry representatives, the rub comes with a likely lack of state funding for any such mandate.
Preferences, inclusion and budget considered
“Basically, the new guidelines say that you need three servings of dairy (daily) and we just pointed out that this is going to cost money,” Jeff Horton, executive director of the N.C. Senior Living Association, said in a phone interview.
State research prepared in the wake of questions about the proposal showed that the change would cost a total of about $5.7 million annually across the state, based on the extra expense of some $1.28 per resident per day. To complicate things further, some facilities already provide three servings.
“Then we’ll say, ‘You’re going to help us pay for this?’” Horton said. “And they’ll probably say no, but I was just pointing out that they made these rules without concern for what it costs.”
State DHHS presented the proposal to increase dairy servings from two to three daily, and to add equivalents to the list of “yogurt, cheese, low-lactose or lactose-free dairy products, fortified soy beverages, and soy yogurt.” The update would put the state in line with U.S. Department of Agriculture standards, as well as give residents more food choices.
The USDA hit other policy notes in citing the change as a framework “for dairy recommendations to include personal preferences, cultural inclusion, and budget-conscious options.”
Bring on the calcium
Upping the ante, the feds also say that dairy foods help strengthen teeth and bones by bringing more calcium and Vitamin D to the table. With damage from falls a major concern for older people, USDA also cites a two-year randomized trial from Australia that shows a striking risk reduction of one-third of all fractures and 46 percent of possibly deadly hip fractures. That’s important because research has shown that older adults are as much as 3 to 4 times more likely to die in the year following a hip fracture.
“The agency proposes to adopt those guidelines because the benefits of increased dairy intake have been proven to reduce falls and fractures among older adults residing in residential care,” says a report from the state DHHS’s Adult Care Licensure Section on the proposed change.
But wait, says Horton, with the assisted living industry: Lots of older people are lactose-intolerant or simply don’t drink a lot of milk.
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However, a study of dozens of different data-based looks at the question says it’s far from certain that older people are more apt to have bad reactions to milk.
“The evidence suggests that women, the elderly or specific racial groups are not more susceptible to lactose, but rather dose, body size and genetic differences in lactase non-persistence (LNP) are the primary drivers of intolerance symptoms,” say the authors of a study in the academic journal Nutrients.
Got milk? How much?
How much milk do older people in fact drink? According to the USDA, about half of people 50 and older drink milk, a higher rate than those from 20 to 49, although both declined between 1978 and 2006.
How much milk should older people drink? The USDA says two glasses a day supply enough calcium for adults.
However, that comprehensive Australian study of long-term care residents showed significant improvements in all fractures and in particular, hip fractures, incurred by residents whose daily allocation of milk and milk products increased from 2 to 3.5 cups a day. That’s an increase half again as much as the one proposed by the state of North Carolina.