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Congress: The ball is in your court

September 17, 2014
by Bob Gatty
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Just over a year ago the federal Commission on Long-Term Care issued a report, ordered by Congress, making 28 recommendations to address a growing crisis in the United States—to make certain that America’s older adults receive the long-term services and supports (LTSS) most undoubtedly will need.

It’s a crisis that is undeniable, with today’s 12 million LTSS recipients expected to grow to some 27 million by 2050, and with 70 percent of Americans requiring long-term care for an average of three years, according to the commission.

The report, produced in just 100 days instead of the intended six months because Congress delayed funding for the commission’s work, does not provide the answers—not in an overall plan, nor in funding to support the solutions. At the outset, it recognized the very political realities that led to its funding delay—that partisan politics on Capitol Hill render difficult and costly solutions virtually impossible to achieve. In fact, the upcoming congressional mid-term elections could even exacerbate that problem.

And so, the chairman of the panel, Bruce A. Chernof, MD, and its vice-chairman, Mark J. Warshawsky, PhD, made a strategic decision to focus on areas of strong bipartisan agreement on ways to build a better LTC system, rather than cataloging partisan viewpoints for which no plausible political path forward exists. The Commission was established after Congress repealed the Community Living Assistance Service and Supports (CLASS) program, which had been included in the Affordable Care Act (ACA), due to concerns about its solvency and estimated cost. However, CLASS provided a framework for creating a voluntary, guaranteed-issue LTC insurance program to provide at least some financial support for Americans with serious disabilities or functional limitations.

In an article published by Oxford University Press on behalf of the Gerontological Society of America, Chernof and Warshawsky discuss the commission’s recommendations and the importance of Congress following through with the hard work of developing a workable and effective plan. “The Commission believes that the time to restructure the financing and delivery of long-term care is now, while many boomers are still working and have time to plan,” they wrote.

Real challenges lie ahead, the commission’s leaders said, noting that the current system is “fragmented, leading to care that can be inefficient, ineffective, and not person-centered.”

“Most people are not financially prepared for these needs, and families play a significant and often taxing role in the provision of care,” they wrote. “When individuals spend down their personal resources, the costs of long-term care are shouldered by Medicaid and to a lesser degree Medicare.”

The commission called for a fiscally sustainable and effective LTSS service delivery system built on the concepts of:

  • person- and family-centered care;
  • well-trained and adequately supported array of family caregivers and paid workers; and
  • a comprehensive financing approach that would balance public and private financing to insure the most catastrophic expenses, encourage savings and insurance for more immediate LTC costs, and provide a strong safety net for those without resources.

Regarding service delivery, the Commission recommended changes that would lead to a balance of home- and community-based care and institutional care options, Chernof and Warshawsky said. The recommendations also call for integrating LTSS and medical care, implementing a uniform assessment tool to support the LTSS care plan, using information technology more effectively, ensuring consumer and caregiver access to information and improving LTSS quality through outcomes-focused care management.

The commission recommended changes that focus on individuals with cognitive or physical functional limitations and the family caregiver, whom it said should be involved in care planning and be included in the care team. It proposed improving caregiver training and encouraging interventions to support family caregivers. It recommended changes to improve the paid workforce, including broadening opportunities for advancement, integrating workers in care teams and encouraging states to improve worker standards.

Financing should provide tools and protections to enable Americans to better prepare for LTSS needs and ensure that those with limited resources or for whom the cost of care exceeds resources have access to needed high-quality services and support, according to the report.

The commission recommended several changes focusing on Medicare and Medicaid, including clarifying access to Medicare skilled nursing facility and home healthcare benefits, providing support through Medicaid for working adults with LTSS needs, and allowing families to save through tax-favored accounts for LTSS expenses.

Chernof and Warshawsky pointed out that the commission did not agree on a single comprehensive financing plan. “By and large, commissioners asserted that designing a viable approach to LTSS risk protection, public or private, is possible, although it would require a considerable amount of new data, design work and careful analysis of costs and consequences before a fiscally responsible proposal could be put forward that would lead to broad support,” they wrote.

They added that, however, the commission did develop “a bipartisan vision and core principles that should guide” future work needed to develop viable policy solutions.

All of that assumes, of course, that members of both parties on Capitol Hill look beyond the next election and their own political ideology, recognize that this is a building crisis that affects virtually every one of us, and then that they actually do something constructive.