The Forgotten Health Issue

Why is no one talking about long-term care?

The Los Angeles Times provided a wide opening for the media to ask the candidates about their plans for long-term care, a topic that has hardly been mentioned in the campaign. It’s almost like there’s a conspiracy of silence surrounding this looming problem—how the country is going to finance care for its aging population, who should provide it, and how good should that care be? All the candidates have made platitudinous comments about improving the quality of medical care, but they have not linked it to the kind of care elders receive now and will get in the future. A study by RAND Corp. draws an ugly picture: vulnerable adults receive about half of the care that is recommended; preventive care suffers the most; care for conditions like incontinence and falls is poorer than care for general medical conditions; and physicians often fail to prescribe medications for older adults.

The Times piece is important; it shows that spending more money in nursing homes may not always bring better quality, and it points the way for journalists to take a deep look at what makes care good or bad—and what the candidates have to say about it. Times staff writer Jordan Rau looked at a study by Charlene Harrington, a professor at the University of California, San Francisco, who found that even when the state increased payments to California nursing homes through its Medicaid program, they did not always use that money to improve care. The amount spent on direct patient care actually decreased by nearly four percent, while substantiated complaints about mistreatment in the state’s nursing homes increased by 38 percent. Deficiency citations issued by regulators also went up. Although the average wages for nursing assistants rose from $10.61 an hour to $11.32, the study showed it was not enough to keep up with inflation, and staff turnover, a perennial problem, continues to be a problem.

Panelists at a recent conference of the Association of Health Care Journalists also tried to ignite some interest in exploring long-term care. One panelist Joshua Wiener, a long-term-care expert who works for RTI International, a research and consulting firm, drove home the point about the candidates’ silence on the topic. Hillary Clinton has shown an interest in the issue, speaking about its importance last summer in an Iowa campaign speech. Her Web site lists specific proposals including tax credits for care givers and hiring state advocates to help people with long-term care insurance policies. Barack Obama, in his role as senator, asked the GAO to study why sellers of long-term care insurance policies were not paying claims. He hasn’t talked much about the subject, and his Web site is full of blah-blah campaign speak—he will strengthen long-term care options, work to reform financing, and improve quality. John McCain’s Web site doesn’t address long-term care.

This week at a symposium sponsored by Harvard’s Shorenstein Center, former Harvard president Lawrence Summers told a group of New York journalists and members of the financial community that “the aging of the country and the preparation for the aging of the country is as critical an issue as it has ever been.”

I asked Weiner why so little interest. “Most real solutions to long-term care require spending more money, which has not been a popular notion over the last fifteen years or so,” he said. “There are no magic bullets.” He added that most people who’ve had to cope with long-term care see it as a personal issue rather than a policy or political issue. Wiener says that he has argued for years that when the parents of the baby boom generation started to need long-term care, it would become a political issue. That hasn’t yet happened.

Is it too boring or complicated? No, Wiener, said. “But it needs a new slant.” Although there have been what he calls “endless victim articles” about poor quality in nursing homes, there’s been little focus on new programs for home and community-based care such as letting Medicaid recipients choose their own home health attendants. In his presentation to health journalists, Wiener offered a menu of questions and story ideas, including, for example:

• About twice as many people are receiving care at home than in nursing homes, and the trend will continue. Is that where money should be redirected?

• Germany and Japan finance long term care through social insurance. England has a system similar to ours, but the British government has taken steps to reform its “social care” system, putting that country way ahead of us in terms of policy discussions.

• Ineffective tax incentives and problematic regulation will continue to plague the market for long-term care insurance.

These topics should stimulate journalists’ appetites for creative coverage in their communities, and offer fresh ideas for pushing the candidates to talk about long-term care during the campaign. The subject of long-term care cries out for leadership from both the press and the candidates.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.