Will efforts to modernize home health programs survive insurance reform’s end game? Providing insurance coverage to as many low-income uninsureds as possible has been an organizing principle in 2009’s health reform discussions, and reconciliation of the House and Senate versions will require satisfying some members that sufficient subsidies will be available to permit the promise of extended coverage to reach the neediest. The ripple effects of those discussions may reach other reform issues, as leadership attempts to meet budgetary targets. It would be a shame if this process led to a retreat from the current bills’ innovative long-term care provisions.
As I’ve described previously, the reform effort has contemplated an interesting mix of Medicare and Medicaid improvements to expand access to community based care for people with disabilities and chronic illness. And the CLASS Act’s inclusion in the mix gives some hope to those with needs for assistance with Activities of Daily Living (ADLs), as well as their family caregivers. Those involved in caregiving for a chronically ill family member can testify that they’re not looking to dodge responsibility; to the contrary, they’re hoping to gain assistance to continue providing assistance in the community, to avoid the need for isolating and expensive institutional care for their loved ones.
Health Affairs’ January 2010, Volume 29, Number 1 — “Advancing Long-Term Services & Supports” - (subscription required for some content) is a welcome source of information and analysis in this area. H. Stephen Kaye and coauthors provide timely data filling out our understanding of who is served, and where. It is clear that people in need of nursing and personal care assistance prefer to live at home rather than in a nursing home. About 8.4 million people of all ages with ADL difficulties receive services in their communities, while about 1.6 million receive services in nursing homes. The median monthly cost in the home care setting, in 2009 dollars, is $928, compared to $5,243 in nursing homes. About 75% of those in the community live with relatives. 90% have mobility impairments, 55% have cognitive impairments, and 31% have sensory impairments. Other articles shed some light on programmatic and financial barriers to improving access to home services.
The January issue of Health Affairs helps to highlight the growing importance of the financing of long-term care. As we age, and as our needs shift from acute to chronic care, we must wean ourselves from a financing perspective that emphasizes dazzling high-tech interventions and instead embrace the human-scale care offered by home health aides, visiting nurses, and physical therapists. The pending bills don’t make this shift, but they nudge the battleship a bit. They leave long-term care financing fragmented among various public and private programs, but they do support some promising programs.
The CLASS Act (Senate bill Section 8002) is a voluntary, opt out social insurance program that would provide some support for home care services. For the reasons described last year by Howard Gleckman, the CLASS Act is incomplete; among other things, its voluntary nature could create selection problems. It is a start, however, and would put a useful if imperfect patch on a torn system. I’ll cite to one final article from the Health Affairs issue to point to a better way. John Creighton Campbell and coauthors‘ discussion of public long-term care insurance in Germany and Japan contains the germ of a solution to the woes our system suffers. Both the German and Japanese systems have universal coverage, support family caregivers, and accord beneficiaries a large degree of control over services received. And they do so at a cost roughly comparable to that experienced by American public payers (Germany a bit less, Japan a bit more). Organizing long-term care financing through one social insurance program yields efficiency dividends, eliminates stigma concerns, and encourages care at the level and location preferred by recipients. Maybe it’s too early to be pushing for the next step in long-term care reform, but why can’t we do what the Germans and Japanese have done? At the very least, let’s not cut back on the progress made in the current bills as we strain for the finish line.