Amid the vast human wreckage wrought by the pandemic, those of us among the senior set who have managed to survive may be heartened to see that policymakers and public-health experts are beginning to take a fresh look at the yawning gaps in our nation’s long-term-care system. I’m even willing to overlook the fact that it took almost 175,000 COVID-related deaths in nursing homes to get their attention. At this point, almost any package of reasonable reforms is worth considering.
The obstacles to quality long-term care are formidable, both for the individual and for the nation as a whole. Once you reach the age of 65, there’s a 50-50 chance that you’ll eventually need help handling basic personal-care needs as frailty and cognitive dysfunction take their toll. That assistance comes with some daunting costs unless you’ve drained your assets and joined the ranks of the destitute. That’s the route nearly one in five seniors take, while about one in four will spend more than $50,000 for long-term care in the waning years of their life. Medicare does not cover these expenses, and though there are insurance plans that do, the premiums can be steep ($2,700 per year on average) and often spike without warning — factors that have limited demand to about 7.2 million Americans.
All of this is a product of the nation’s patchwork public-health system, in which state and federal agencies set various — and often conflicting — guidelines while seldom finding reasons to collaborate on service delivery. These government agencies are notoriously underfunded and tend to focus more of their limited resources on children, families, and the homeless than on the elderly. The pandemic brought all of this into sharp relief, of course, as states vied with each other for personal protective equipment, COVID tests, vaccines, and other urgent needs while confusion reigned in Washington and the Grim Reaper enjoyed unlimited visiting privileges at our nursing homes.
Though they’re clearly not as sexy as infrastructure, the long-term-care initiatives tucked neatly in the Biden administration’s American Jobs Plan are anything but insignificant. As Howard Gleckman notes in Forbes, the proposed $400 billion boost for home-based long-term care over eight years represents a 70 percent annual increase in Medicaid’s home and community-based services (HCBS) budget. When combined with the one-year $12 billion infusion Congress passed in March as part of the American Rescue Plan, Gleckman argues, “the two initiatives are by far the biggest expansion of Medicaid HCBS the United States has ever seen.”
But because it focuses solely on Medicaid’s role in long-term care, the massive budget increase offers no options for those of us who can’t afford — or are skeptical of — long-term care insurance or aren’t poor enough to qualify for Medicaid services. What’s really needed, Gleckman explains, is a publicly funded national long-term-care insurance program. “That would make it possible for people to get the care they need without relying on Medicaid at all.”
Walt Dawson, PhD, and his team of researchers at Oregon Health & Science University would certainly concur. Universal long-term-care coverage is just one of several recommendations they believe would improve the current system. Their new report, published in the Milbank Quarterly, discusses the toll COVID-19 has exacted on the nation’s long-term-care system, crippling state budgets and burdening unpaid caregivers. The inequities across race, ethnicity, and socioeconomic status are clear, they note, as is the need to better integrate long-term-care services with the nation’s healthcare, social service, and public-health systems.
“It is widely accepted that the long-term service and supports (LTSS) financing and delivery system in the United States is broken,” Dawson writes. “Despite several attempts at reform over the past 30 years and a growing population of older adults living with multiple, chronic health conditions who will need some form of LTSS during their lifetime, a patchwork system has prevailed.”
Better coordination between public-health agencies and LTSS providers would remedy some of that problem, as would identifying and supporting unpaid caregivers. Among the other near-term recommendations:
- Require uniform public reporting of COVID-19 cases in all LTSS settings.
- Bolster protections for the direct-care workforce.
- Reduce remaining barriers to telehealth in LTSS settings.
- Provide incentives to care for our most vulnerable populations.
Dawson’s long-term recommendations are far more aspirational. Creating an “age-friendly” public-health system, for instance, may be a bit of stretch. He points to progress made in ambulatory care, emergency rooms, and hospital settings, but notes that it has not yet extended to public-health agencies.
“Public-health departments must recognize the heightened health risks that the older adult population faces, particularly during public-health emergencies,” he explains. “Over the long term, they must take strong action to prepare older adults for future public-health emergencies while also monitoring their day-to-day health needs with an eye toward aggressively promoting wellness and preventing disease.”
On the aspirational front, Dawson may actually be able to make a stronger argument for universal long-term-care insurance as part of a Medicare expansion, which is currently getting serious consideration on Capitol Hill. Not only would it provide needed support for the elderly, regardless of socioeconomic status, but it would also relieve the long-term-care fiscal responsibilities currently burdening states and the Medicaid system.
“This approach would protect against financial catastrophe and end the current system that is based on the need to be financially destitute in order to access coverage with Medicaid,” he writes. “Such an approach would benefit both individuals and families and would also create a far more stable and more generous funding stream to providers.”
There’s widespread support for expanding Medicare coverage — until lawmakers start talking about raising taxes. Perhaps the pandemic has changed that conversation, as it has changed so much else. Here’s hoping we won’t have to struggle through another one to create a long-term-care system that works for everyone.
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