Whatever the fate of Obamacare under President Donald Trump and congressional Republicans, one piece of it was repealed long ago — and nobody has yet dared to try to replace it. That piece was called the CLASS Act — and it was a small down payment on the most intractable, yet neglected, problem in American health care: long-term care.
The question of how to care for seniors and Americans with disabilities who need support with the basic activities of daily life — eating, dressing, keeping track of their medicine — has stymied policymakers for decades. The costs are daunting, and time after time, legislative fixes have foundered before they even get off the ground. These days, many seniors and people with disabilities, who find themselves needing daily services and supports, including nursing care, have to essentially impoverish themselves before the government can step in.
That is wrong, both financially and morally. With the number of older Americans forecast to double in coming years, the debate over the future of Obamacare should also reconsider the problem of long-term care, both the care provided at home and in other settings in the community.
Policymakers faced with new challenges often look to build upon current law. Obamacare, formally known as the Affordable Care Act, was based on a “three-legged stool’’ — preventing insurers from excluding people by denying coverage or raising premiums; strongly encouraging all Americans to participate; and providing federal subsidies to make insurance more affordable. Inasmuch as the ACA has provided additional coverage to millions of Americans, it is because the policies in the law support the implementation of the three-legged stool.
We were both deeply involved in the legislative debates over the ACA as well as previous attempts to find a system to support long-term care, one of us on the Republican side and one on the Democratic side. We think any new effort to solve the problem of long-term care needs to be based on what we’re calling “four pillars,” and we think these principles could provide a structure for a bipartisan solution.
First, a new system should provide health care services and supports across the life span. Medicare, Medicaid, and commercial insurance are silo programs that do not interact well together and face significant budgetary challenges to be efficient. Medicare focuses on acute spending needs for older Americans while Medicaid provides long-term supports for low income individuals — many of whom must spend down their resources to become Medicaid eligible to access needed services. None of the current health care programs are designed to provide the most efficient, high quality care across the continuum from youth to old age. A number of models, such as the Program of All-Inclusive Care for the Elderly and Institutional Special Needs Plans, have shown progress by working across the divides created by Medicare and Medicaid. They demonstrate how a multitude of service providers can work efficiently to deliver comprehensive care.
Commercial insurance should also consider the positive impact of including a defined long-term services and supports (LTSS) benefit for those under 65. The same fragmentation of care we see in Medicaid and Medicare exists within the commercial insurance market as well. Commercial insurance provides acute illness and injury coverage, drugs and some prevention, but lacks coverage of the services and supports beneficiaries need to maintain their function and prevent deterioration of their health status resulting from an illness or disability. This lack of an integrated care approach to health services causes the revolving door syndrome of health care as well as a dependency on Medicaid as the only program providing those needed services and supports. Forcing people into poverty to access needed services and supports is just not American. Health insurance coverage must break down the walls between acute and long-term needs beneficiaries face.
Second, the system should encourage and incentivize equitable risk for providers. For years, experts have argued that appropriate provider risk drives efficient behavior in a way that cannot occur under a fee-for-service model. Through the Medicare and Chip Reauthorization Act, Accountable Care Organizations, the Merit-Based Incentive Payment System, the Comprehensive Primary Care Plus program, and others, CMS is looking to create more risk arrangements for providers, rapidly moving away from the fee-for-service model. Providers that bear risk across the full continuum of integrated care should have greater financial incentives to reduce the intensity of long-term utilization. These incentives need to be embedded in Medicare, Medicaid, and commercial insurance as they are structured going forward.
Third, as providers move toward providing care across the continuum and bearing greater risk, there also needs to be a level of assignment of beneficiaries that allows risk bearers to have control of data and achievement of quality outcomes that matter to people. Current retirees and people with disabilities not covered under Medicaid, have spent much of their commercially insured lives in some degree of an assigned relationship — either through a Health Maintenance Organization or a Preferred Provider Organization. As individuals in Medicaid are now being included in managed care, they too are beginning to understand the concept of networks and how to navigate them. By incentivizing some level of assignment, the provision of care for seniors and people with disabilities can become more efficient, equitable, and better attuned to measure quality outcomes.
Finally, reform must be based on full availability and participation — much like Medicare. As policymakers consider changes to these programs, they need to take into consideration the overwhelming number of baby boomers who will soon become eligible for Medicare and how it could affect the system — particularly when it comes to long-term care.
Medicare, Medicaid, and commercial insurance function today as they were designed. All the programs have edges. They all leave gaps. A more efficient, quality system of care needs to address the health needs of the individual across the lifespan. Acute and Long-Term Services and Supports need to be provided under the same program available to all and encouraging all to participate. Coverage needs to be provided by risk-bearing providers, and those providers need to have some level of dependable assignment and financial incentive.
These four pillars won’t solve all the challenges we face, but they are building blocks towards an infrastructure that looks out for the consumer’s best interests within a more efficient, quality-driven system of care and treatment.
Connie Garner is policy director for Foley Hoag LLP in Washington, D.C. She is a former Senate Health, Education, Labor and Pensions Committee policy director for the late Sen. Edward M. Kennedy (D-Mass.). Rodney L. Whitlock is vice president for health policy for ML Strategies in Washington, D.C. He is a former health policy director for Sen. Chuck Grassley (R-Iowa).
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