The ACA's 'comprehensive' long-term care failure
Staff Writer Tim Mullaney
There's been a lot of talk lately about what constitutes “comprehensive” health insurance coverage — and long-term care notably has not been part of this national conversation.
The heated debate stems from President Obama's claim that, under the Affordable Care Act, people would not be kicked off insurance policies they liked. Last week, the president apologized for making that promise, in light of the fact that millions of people recently have received cancelation notices from their insurers. The issue: Their plans weren't up to snuff, as defined by the ACA.
The healthcare reform law seeks to ensure that each plan bought by individuals meets a certain quality threshold. This means they include benefits deemed “essential,” such as habilitative services, prescription coverage, pediatric care and maternity/newborn care.
While the plan cancelations provoked a wide range of responses, one aspect of the ensuing furor has been a heightened scrutiny of these essential benefits. People are asking just how essential some of them are. Maternity care, for example. An expert on NPR fielded a question from listeners about why they should be on a plan covering maternity costs, when they are senior citizens and their children are grown. They would never use this benefit.
The expert — Karen Pollitz, senior fellow at the Kaiser Family Foundation — responded that the basic principle of insurance is buying in to cover risks and lower costs for a whole group of people.
“Maybe I don't want to buy a policy that's going to cover prostate cancer even though I'm never going to have that,” she said, making a point about why policies need a certain level of blanket protection. “So the policy takes care of people and all of the conditions that can happen to people, and we all kick in a premium so that there will be enough to take care of any one of our conditions when they arise.”
I wish that a senior had actually been on the line with Pollitz and had asked this follow-up question: That's all well and good, but if I'm kicking in for other beneficiaries' pediatric and maternity care, shouldn't my prospective long-term care needs also be covered? Why isn't this one of the essential benefits?
If more people would ask questions like this, it would put increased and much-needed pressure on policymakers and insurance companies to really tackle the issue of long-term care financing. They're clearly not going to do so otherwise. Not any time soon, at least. Democrats obviously aren't going to open the LTC can of worms as they're scrambling to get the healthcare reform implemented; or perhaps I should say they aren't going to re-open this can of worms, which they tried to address initially in the CLASS Act, an ill-conceived ACA component lopped off the law with little ceremony. The White House has not followed up on the report from the Congressional Long-Term Care Commission, established when CLASS got the ax. (To be fair, even the commissioners could not agree on financing-related recommendations.) And Republicans are making political hay with the catastrophic rollout but seem to have adopted a wait-and-see approach and aren't pushing any concrete Obamacare alternatives. (See what GOP Sen. Kelly Ayotte of New Hampshire told David Gregory on Sunday's “Meet the Press.”)
While the topic of the long-term care payment system stays on the back burner, it only grows closer to the boiling point — last week, two major insurers announced significant premium increases for LTC policyholders. And it stands to reason that policymakers should be able to stake out a plan here. Liberals ought to be moved by their desire to see universal, comprehensive coverage. Conservatives ought to be appalled by the proportion of public dollars going toward long-term care; the single-payer system is all but a reality in this realm, in which about two-thirds of skilled nursing residents are paid for by Medicaid. But, if we've learned anything from recent events, leaders in Washington are not motivated by reason these days.
So it likely will be up to citizens to demand action. That there hasn't already been a groundswell could be because people are just so confused about how long-term care is paid for. This could be changing, as more people become caregivers for family and friends or otherwise interact with long-term care infrastructure. But, as prominent leaders in the field have noted, raising public awareness should be a top goal.
One of the nation's largest long-term care provider associations is launching a campaign to boost community engagement in long-term care financing reform. This is laudable, but the effort will take time to gain momentum, and I believe the current moment presents a special window for drawing attention to this issue. The rocky start to the federal online insurance marketplace, the cancelation (or not) of plans and the constriction of Medicare Advantage networks mean that public discourse is right now focused, with remarkable intensity, on the nuts and bolts of health insurance.
I think it's a wasted opportunity if the LTC lobby and senior advocates don't join in this debate more forcefully than they have, even if it's just to point out the glaring, routine omission of long-term care from discussions of what a “comprehensive” health plan looks like.
Tim Mullaney is Staff Writer at McKnight's. Follow him @TimMullaneyLTC.