Universal Health Care: What About Long Term Care?

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Where Is Long Term Care In Universal Health Care Proposals?

A Modest Proposal That's Long Overdue:

Part E Medicare; Modifications in Existing Medicare; Title 40 Social Security Act.

Information Bulletin #226 <10/07>

The Democratic Presidential candidates are proposing to expand health benefits for all citizens, but one critical component - long term care for elderly Americans and persons with disabilities - has been glaringly absent.

Here are three options, focusing primarily on Medicare, about which advocates for older Americans and for people with disabilities might want to ask the candidates.

Part E, Medicare- Long-Term Care Insurance. Add a new Part E to Medicare to ensure universal coverage for long-term care through an entitlement program for all older Americans and people with disabilities. (Presently Medicare does not provide most LTC services or meet our basic LTC needs.) Part E services would be provided to help maintain people in an independent, community-based setting or to prevent the need for institutional care. Services could include personal care assistance in home (for bathing, eating, walking), or other home care services (homemaker, nutritional services). If the person wishes, s/he could go into a nursing facilities .

Determinations of eligibility would be based on specific functional eligibility criteria. All persons found to need care would have the option where they wish to be served, with an emphasis on maintaining dignity and independence and saving funds.

This insurance program would be financed in the same way as Medicare's other parts, although States could pay some portion of program costs. Copayments/supplemental programs could be considered, similar to Medicare's Parts A, B and D. To minimize the exclusion of low-income people, all people who fall below minimum income levels and who are certified to need noninstitutional services could receive supplemental cash benefits, similar to food stamps, to assist them in meeting any copayment requirements.

As a national program with uniform eligibility standards, the variation in eligibility in each State under Medicaid would not exist. The ultimate cost of Part E would depend on the definition of need <3 ADLs? 2 ADLs plus..?> (Activities of Daily Living), the same as other Parts of Medicare depend, e.g., on how many days a person requires hospitalization or rehabilitation.

Modifying Existing Medicare

Eliminate all existing Medicare requirements that persons be "homebound," expand the definition of long-term care services to include personal care and assistance, and expand concept of skilled services so all homemaker services could be permitted after skilled services were no longer necessary.

To minimize the exclusion of low-income people, Medicaid could be altered to require all states provide reimbursements for LTC services people require to stay at home, if that were more economical than institutionalization and the person wanted to remain at home.

Title 40, Social Security Act, A Comprehensive Long-Term Care Grant

A new Title 40 would combine Medicaid long-term care funds and existing funds from Title XX social services to older Americans, as well as funds from the Older American Act that relate to long-term care needs and Title XX services to people with disabilities. Each state would be eligible to receive a share of federal funds, based on the number of aged and people with disabilities in the state, their income distribution relative to the local cost of living, local cost of long-term care services, and current federal funds received for long-term care. States would have to match the federal grant.

As a condition of receiving grants, states would have to establish long-term care centers which would be the sole channel of federal long-term care funds. These centers would assess the needs and authorize levels of care, and monitor quality of services delivered. Cost-effectiveness would be mandated. Minimum eligibility for services would be set.

This would eliminate the divisions between health and social services that are necessitated by current financing arrangements and establish a uniform set of services to be covered.

The number of people served could be limited by federal appropriations. This would induce assessments and service authorizations to focus on the lowest-cost care consistent with quality. Obviously, if federal funds were not adequate, people needing services would not be able to get them through this public program.

By this point, if you're still with this, you probably think this is totally a dream and without any contact with reality. So let me tell you that all of the above is virtually verbatim from a 1977 (yes, 30 years ago) Congressional Budget Office report entitled "Long-Term Care for the Elderly and Disabled." The CBO proposed these three options and Congress has never responded. So much for caring about older Americans and people with disabilities!

We have a great opportunity to get the long term care reform issue on the political radar screen. Democrat and Republican candidates for President all agree healthcare reform will be an issue in the November 2008 election.

It is our job to make sure long term care reform (especially eliminating the institutional bias) is part of every candidate's healthcare reform agenda. The ideas above are 30 years but have lots of merit. Obviously there are other ideas to be considered.

A FOUR STEP STRATEGY:

The 1st step is to make the candidates aware that long term care needs to be part of their healthcare reform package. Have people tell them their stories.

The 2nd is to get the issue publicly debated. Write some op-eds and letters to the editors, go on the blogs, and use the above as you like.

3rd is to develop specific recommendations that candidates can include in their reform package.

4th is to hold their feet to the fire. Let's not wait another 30 years! The above 30 year old proposals have these positive aspects:
- ending the discrimination against similarly disabled personssimply because they live in one state rather than another.
- ending the extraordinary financial eligibility variation bystate (some people on SSI, some 3 times SSI, some federalpoverty level).
- recognizing that very low-income older Americans and people withdisabilities need the same LTC as people with moderate incomes.
- dealing with the dual eligibles in a way that States mightapplaud.
- recognizing that functional need and impairments, and not diagnoses, should trigger the services.
- ending the "optional" aspects of LTC services.
- ensuring that older Americans and people with disabilities makethe choice where they want to live and receive services, insteadof service industries and political pressures influencing thedecisions.
- letting older Americans and people with disabilities know that LTC services will be available.

SOURCE: Steve Gold
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