Opinion Column

Will Long-Term Care Be Included In Health Reform?

President Obama may have jump-started health reform with his speech to Congress last Wednesday but, sadly, he ignored the need to repair our tattered system of long-term care. He said nothing about improving ways to finance this critical personal assistance, nothing about making Medicaid benefits more accessible to the frail elderly and those with disabilities who want to continue living at home, and nothing about improving the lot of direct care workers.

Just as discouraging, Senate Finance Committee Chairman Max Baucus, D-Mont., also seems uninterested in these critical issues. Momentum for health reform may be building again, but interest in improving our system of long-term care supports and services is still lagging.

Of the three long-term care issues on the table-financing, Medicaid home care incentives and help for health aides -financing reform is the most likely to pass. The idea was dealt a blow with the death of Senate Health, Education, Labor and Pensions Committee Chairman Edward M. Kennedy, who was a powerful advocate for the CLASS Act, a national long-term care insurance program. Still, the measure has two things going for it: the Obama administration endorsed the idea over the summer, and, according to the arcane scoring of the Congressional Budget Office, the measure generates nearly $60 billion in revenue over the next 10 years.

Key changes have been made to the CLASS Act since it was first considered by the health panel last July. The committee bill contemplated an average $65 monthly premium for a $50 daily cash benefit that would increase based on a patient’s need. The latest version does not propose any specific premium. Rather, it gives the Secretary of Health and Human Services broad authority to set premiums and benefits. CLASS Act backers now expect average monthly premiums will be closer to $100. A final version may try to hold down premium costs by placing some restrictions on who is eligible to participate in the program.

Premium prices are critical because the program is designed so that all workers would be automatically enrolled, though they could choose to opt-out of the insurance. The higher the premium, the more likely workers would withdraw from coverage.

The CLASS Act has so far avoided the overheated flap over a health insurance public option, but some backers fear it may eventually fall victim to this controversy. This issue has become so radioactive that Obama has backed away from a government insurance alternative, much to the dismay of liberal Democrats. The CLASS Act, however, is more than just a public option. It is an insurance program built on a foundation of public coverage, although consumers could buy private insurance to supplement its benefits. One way to defuse this criticism: Hill aides say the measure would allow the Secretary of HHS to turn over operation of the insurance program to a private carrier.

Expanding Medicaid benefits for those living at home faces a much tougher battle. Today, Medicaid is required to provide long-term care only to nursing home residents. Because states are under no legal obligation to offer home care, this assistance is often limited and poorly funded. The Senate health committee’s new chairman, Tom Harkin, D-Iowa, has made greater accessibility to Medicaid home care a signature issue for many years. Sens. John Kerry, D-Mass., and Chuck Grassley, R-Iowa, back a more modest effort to shift benefits to those at home or in other community settings. But expanding this assistance has one big downside: money.

With Obama capping the cost of health reform at $900 billion over 10 years and so many other interests pushing for federal dollars, advocates of long-term care are in a difficult box: Unless Congress acknowledges potential savings from the shift to home care, spending for these benefits could come at the cost of deeper cuts in Medicare and other Medicaid programs.

But the real challenge for long-term care reform remains indifference, rather than outright opposition. Overwhelmed by the passionate, high-stakes debate over health reform, many lawmakers remain reluctant to even confront long-term care issues. They are making a major mistake by failing to recognize that the chronically ill need a full range of care that does not end at hospital discharge or when they leave their physician’s office. An elderly widow suffering from Parkinson’s or a young man struggling with multiple sclerosis doesn’t distinguish between personal care and medical treatment. For them, it is all essential care. Congress needs to recognize this, but, at least for now, the odds that it will do so in 2009 remain long.

Howard Gleckman, a senior research associate at the Urban Institute, is author of Caring For Our Parents and a frequent writer and speaker on long-term care issues.

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