Guest Columns

Part Two: Have we not been through this before?

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James Lomastro
James Lomastro

Editor's Note: This is part two of two blogs exploring how today's healthcare debate mirrors historical issues. Read Part One here.

Like the Affordable Health Care Act, the Medicare Catastrophic Coverage Act would have implemented both program benefits and financing. It would have phased in changes over a several-year period beginning in 1989. Although there were some modest changes in the Medicare nursing home benefit, one of the primary complaints about the legislation was that it did not extend Medicare coverage to long-term nursing home care.  This care is most likely to impoverish the elderly – a benefit that ACA also did not address. Congress did not repeal one final noteworthy benefit enhancement. It was the liberalization of Medicaid regulations to allow the spouse of a nursing home resident to retain enough income to avoid impoverishment.

Initially many thought that the Medicare Catastrophic Coverage Act will be a popular piece of legislation. However, as we indicated, while provisions were popular with providers and some seniors, many were not especially among seniors who had coverage, those who will pay more (so-called wealthy seniors), and the insurance lobby.  Congress, with the unpleasantness of the repeal process, was not willing to resurrect reform legislation and did not for 20 years. It tweaked the system allowing coverage to expand and passed Medicare D. However, much of that happened in a haphazard way geared to what it was able to pass and not what was needed.

So what has changed and what will lead us to believe that ACA will last? What changed was that Medicare became increasing expensive and limited. Access and coverage have become limited. Insurance companies including managed care pushing their agendas no longer provided the cost advantage and left seniors to the “market” without any protection. Many of the provisions of the Affordable Care Act were in the Catastrophic Health Act. As far as those of us involved with Catastrophic Health Act, its demise was not this provision or even its catastrophic coverage as much as the time was not right. Further, it did not build a constituency in the same way as ACA is through its expansion of access and coverage. Moreover, the provider community while they supported it with some exceptions was not willing to expend political capital to prevent its repeal.

Like Catastrophic Health there are significant implications particularly for post acute care embedded in how ACA works through ACOs. ACA has already lasted longer than CHA and will be in effect at least until 2017. While there is opposition, it is not as organized or as directed as it was and is more ideological than provider or consumer based. Catastrophic health provided a great deal of opportunity to change the way post-acute providers care in a systemic and sustainable way. Unfortunately, many did not see the advantage of it. As ACA is implemented, many more will be advantaged by it. It has already lasted longer than CHA.  Looking back while repealed, many of its provision reemerged in Medicare D and now in ACA. This time if providers particularly in post-acute sector decide to wait out ACA, they may find themselves left out.

James Lomastro, Ph.D., has worked in acute, community based and long-term care for 33 years. He has held an administrator license since 1991. Prior to involvement in administration, he held academic and research appointments at Boston University School of Medicine and Northeastern University.
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