Steve Gold, The Disability Odyssey continues
Information Bulletin #226 [10/07]
The Democratic Presidential candidates are proposing to expand health
benefits for all citizens, but one critical component - long term care for
elderly Americans and persons with disabilities - has been glaringly
absent.
Here are three options, focusing primarily on Medicare, about which
advocates for older Americans and for people with disabilities might want
to ask the candidates.
Part E, Medicare- Long-Term Care Insurance.
Add a new Part E to Medicare to ensure universal coverage for long-term
care through an entitlement program for all older Americans and people
with disabilities. (Presently Medicare does not provide most LTC services
or meet our basic LTC needs.) Part E services would be provided to help
maintain people in an independent, community-based setting or to prevent
the need for institutional care. Services could include personal care
assistance in home (for bathing, eating, walking), or other home care
services (homemaker, nutritional services). If the person wishes, s/he
could go into a nursing facilities [without the existing 100 day cap].
Determinations of eligibility would be based on specific functional
eligibility criteria. All persons found to need care would have the
option where they wish to be served, with an emphasis on maintaining
dignity and independence and saving funds.
This insurance program would be financed in the same way as Medicare's
other parts, although States could pay some portion of program costs.
Copayments/supplemental programs could be considered, similar to
Medicare's Parts A, B and D. To minimize the exclusion of low-income
people, all people who fall below minimum income levels and who are
certified to need noninstitutional services could receive supplemental
cash benefits, similar to food stamps, to assist them in meeting any
copayment requirements.
As a national program with uniform eligibility standards, the variation in
eligibility in each State under Medicaid would not exist. The ultimate
cost of Part E would depend on the definition of need [3 ADLs? 2 ADLs
plus..?], the same as other Parts of Medicare depend, e.g., on how many
days a person requires hospitalization or rehabilitation. Modifying Existing Medicare
Eliminate all existing Medicare requirements that persons be "homebound,"
expand the definition of long-term care services to include personal care
and assistance, and expand concept of skilled services so all homemaker
services could be permitted after skilled services were no longer
necessary.
To minimize the exclusion of low-income people, Medicaid could be altered
to require all states provide reimbursements for LTC services people
require to stay at home, if that were more economical than
institutionalization and the person wanted to remain at home. Title 40, Social Security Act, A Comprehensive Long-Term Care Grant
A new Title 40 would combine Medicaid long-term care funds and existing
funds from Title XX social services to older Americans, as well as funds
from the Older American Act that relate to long-term care needs and Title
XX services to people with disabilities. Each state would be eligible to
receive a share of federal funds, based on the number of aged and people
with disabilities in the state, their income distribution relative to the
local cost of living, local cost of long-term care services, and current
federal funds received for long-term care. States would have to match the
federal grant.
As a condition of receiving grants, states would have to establish
long-term care centers which would be the sole channel of federal
long-term care funds. These centers would assess the needs and authorize
levels of care, and monitor quality of services delivered.
Cost-effectiveness would be mandated. Minimum eligibility for services
would be set.
This would eliminate the divisions between health and social services that
are necessitated by current financing arrangements and establish a uniform
set of services to be covered.
The number of people served could be limited by federal appropriations.
This would induce assessments and service authorizations to focus on the
lowest-cost care consistent with quality. Obviously, if federal funds
were not adequate, people needing services would not be able to get them
through this public program.
* * *
By this point, if you're still with this, you probably think this is
totally a dream and without any contact with reality. So let me tell you
that all of the above is virtually verbatim from a 1977 b yes, 30 years
ago b Congressional Budget Office report entitled "Long-Term Care for the
Elderly and Disabled." The CBO proposed these three options and Congress
has never responded. So much for caring about older Americans and people
with disabilities!
We have a great opportunity to get the long term care reform issue on the
political radar screen. Democrat and Republican candidates for President
all agree healthcare reform will be an issue in the November 2008
election.
It is our job to make sure long term care reform (especially eliminating
the institutional bias) is part of every candidate's healthcare reform
agenda. The ideas above are 30 years but have lots of merit. Obviously
there are other ideas to be considered.
A FOUR STEP STRATEGY:
The 1st step is to make the candidates aware that long term care needs to
be part of their healthcare reform package. Have people tell them their
stories.
The 2nd is to get the issue publicly debated. Write some op-eds and
letters to the editors, go on the blogs, and use the above as you like.
3rd is to develop specific recommendations that candidates can include in
their reform package. 4th is to hold their feet to the fire. Let's not
wait another 30 years!
The above 30 year old proposals have these positive aspects:
- ending the discrimination against similarly disabled persons simply
because they live in one state rather than another.
- ending the extraordinary financial eligibility variation by state (some
people on SSI, some 3 times SSI, some federal poverty level).
- recognizing that very low-income older Americans and people with
disabilities need the same LTC as people with moderate incomes.
- dealing with the dual eligibles in a way that States might applaud.
- recognizing that functional need and impairments, and not diagnoses,
should trigger the services.
- ending the "optional" aspects of LTC services.
- ensuring that older Americans and people with disabilities make the
choice where they want to live and receive services, instead of service
industries and political pressures influencing the decisions.
- letting older Americans and people with disabilities know that LTC
services will be available.
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