Election 2008: Long-Term Care? Huh?

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Election 2008: Long-Term Care? Huh?
Election 2008: Long-Term Care? Huh?
As time winds down to the 2008 presidential election, it's fair to ask which candidate would best improve the lives of those in the long-term care field.

Lots of luck.

With Nov. 4 just days away, candidates Barack Obama and John McCain have offered only vague outlines of long-term care policies, leaving big question marks in the minds of those in the industry.

“It's extremely difficult to honestly assess what each candidate means to long-term care in general and nursing home facilities in particular,” said Alan Rosenbloom, president of the Alliance for Quality Nursing Home Care, in late August. “At this point, neither has a detailed plan and neither platform offers much … You see broad declarations of political goals and objectives and not a lot of specifics.”

It seems reasonable to deduce certain attitudes from the candidates' general views on healthcare, but long-term care experts still hedge.

“Generally speaking, the Republicans look at market-oriented solutions and the Democrats look at government programs,” said Dave Hebert, chief lobbyist for the American Health Care Association. “That's not necessarily a hard and fast rule, but that has been a hallmark of the Democratic and GOP solutions in the past. But it's a new world and the old solutions won't work anymore. Whoever is president will have to look at private and government programs.”

Providers, for their part, are not so interested in whether the solutions lie in the government or the private sector. At this point, they would settle for a dialogue. Specifically, they want to talk about integrating the topic of long-term care into general healthcare reform, and discussing a new payment system, as well, as the clock seems to be ticking for Medicaid, long-term care's largest payment source.

“People tend to bifurcate it,” Hebert said of long-term care and healthcare. “They look at acute care and post-acute care differently. Given the amount spent on Medicaid and Medicare, they should look at long-term care.”

Both the American Association of Homes and Services for the Aging and the American Health Care Association have submitted financing reform proposals to the nominees. AAHSA has proposed a broad-based national insurance trust that would provide a daily cash benefit for people needing assistance with two or more activities of daily living.

AHCA's plan calls for a “personal responsibility requirement” that requires individuals to either purchase a long-term care policy or dedicate funds into qualifying long-term care savings vehicles dedicated for future long-term care costs.

Whether these programs will receive public airing is anyone's guess, but it seems pretty clear that healthcare will be on the table for discussion. It will be up to long-term care providers to grab a seat.

“The odds are good we will see a serious healthcare reform debate over the next four years, regardless of who wins the election,” Rosenbloom said. “The inference I draw from that is it is important for us, the provider community, to assure that when that debate happens, there is serious consideration given to long-term care.”

And even though the candidates' plans are short on specifics, there are some encouraging signs for reform from both camps. Both candidates and their parties address the importance of information technology and Medicaid and Medicare payment reform. Also, last month the candidates dispatched advisers for a long-term care symposium given by Genworth Financial Inc. While they didn't expand on candidates' positions, they acknowledged that long-term care is a vital healthcare issue.

Obama's plans

Obama has addressed the need to expand long-term care options, including home care; paying caregivers a fair wage; and training more nurses and caregivers to work in long-term care. (See his Web site www.barackobama.com.)

The Democratic party platform also talks about closing the “doughnut hole” of the Medicare Part D prescription drug program. The hole represents the gap in coverage between $2,250 and $5,100 in costs in which seniors must pay for their drugs solely on their own.

Perhaps of most interest to providers, the platform mentions a need for long-term care finance reform. It is the first time that a Democratic platform has mentioned long-term care financing, according to AAHSA.

The Obama campaign gave assurances that the Democratic nominee is thinking about it.

“Long-term care is definitely on his mind,” said a spokeswoman for the campaign who declined to be named.

One sign Obama could be serious about long-term care reform is the Community Living Assistance Services and Supports (CLASS) Act of 2007, a bill he sponsored this year. The legislation would establish a national insurance program to pay for those with long-term care costs. Voluntary payroll deductions of $30 per month would finance the program. Benefit eligibility would kick in after five years of program contributions.

The legislation “is a close relative of the long-term care financing plan that AAHSA's financing cabinet came up with a year ago,” said Barbara Gay, director of advocacy information for AAHSA. “They are like first cousins. We take that as a promising sign.”

Last month, however, Gay expressed concern that Obama had not “connected the dots,” still considering the legislation a disability policy and not a long-term care issue.

McCain's message

Republican nominee McCain also touched on “seniors” issues, though not as much as his rival. McCain has hit upon the need to move away from institutional care. He has expressed his support for Cash and Counseling and the Program of All-Inclusive Care for the Elderly (PACE). The programs allow seniors to receive a monthly stipend to spend as they see fit, whether it be hiring workers or purchasing care-related services and goods.

Web site www.johnmccain.com talks about reforming the payment systems in Medicaid and Medicare to “compensate providers for diagnosis, prevention and care coordination.”

The Republican platform also speaks about finding new ways to allow seniors to stay in their homes.

“This is true not only with regard to Medicaid, where we spend $100 billion annually on long-term care, but also for those who do not qualify for that assistance,” according to the platform.

Interestingly enough, it is the first time since 1996 that the platform hasn't called for private long-term care insurance, according to AAHSA.

A spokesman for the McCain campaign was reached repeatedly for comment but had not responded to questions by press time. To Gay's knowledge, McCain has not introduced long-term care-related legislation in the last Congress. 

Speaking in specifics

While the candidates' ideas might sound promising, experts caution that the devil is in the details.

The candidates “both have a desire to expand access to the uninsured. I think that's a laudable goal,” said Robert Kramer, president of the National Investment Center for the Seniors Housing & Care Industry. “The question is how are we going to pay for it?”

If finding funding means cutting Medicare, “long-term care could pay the price for expanding healthcare coverage to the uninsured,” he said. “These are some of the tough questions in front of the candidates.”

One of the problems with the current payment system is it is a “silo” method, he added. It becomes dangerous policy to cut one because of its effect on the other.

“We have payment silos and you may only look at Medicaid or Medicare or private pay or managed care, but basically it's that payer mix that allows most nursing homes to stay open. If you lose sight of that, you may enact some very bad policy,” Kramer said.

Along these lines, it's worth keeping in mind that the next president's ideas are only one part of the equation. While his views would be important, how Congress votes and performs will be equally, if not more, important.

“When all is said and done, a good portion of long-term care policy will continue to come from Capitol Hill,” Hebert reminded. “The administration always has a bully pulpit, but at the end of the day, there is the old saying, ‘The president proposes and Congress disposes.'”

Change ahead

The possibility for healthcare reform may be more real than it's ever been. People seem to be clamoring for change from all corners—even from the business community. That is a contrast to the early 1990s, when then-First Lady Hillary Clinton crafted a healthcare overhaul that failed.

“I think since that time, there has been a growing realization that companies in this country have become less competitive with companies from countries whose governments do provide health benefits that citizens have, so, in reality, our companies are bearing a burden that their international competitors don't have,” AAHSA's Gay said.

So what about long-term care? It may just be the toughest nut to crack in the healthcare system—particularly the financing angle—which is why no one may want to touch it.

But the next occupant of the White House might not have a choice. With the first baby boomers turning 65 in 2011, a caregiver shortage worsening, and pressure continuing to build on Medicaid and Medicare funding, long-term care might finally have its day.
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