TL: We’ve had a lot of talk about how care is delivered, and the Affordable Care Act has made money available for organizations that improve the way care is delivered.

CS: The thing policy people in the NHS talk about the most is the need to reorganize the system. They want to reorganize the system away from the strict primary and secondary care division that was set up years ago in the old industrial-accident world, where people would get sick, come in and get better, and go away. They want a system and a way to manage people with longterm conditions. Those people account for two-thirds of the NHS spending. Their care is often done inefficiently, particularly for elderly people.

Theoretically it should be easy to improve healthcare at home in the community in a sort of top-down system. But in fact, it’s proven extremely difficult, because people are resistant to any sort of change in the way health systems are set up. The infrastructure for community care is not as good as it should be. Lots of efforts are being made to change that, so far, with limited success, really. Presumably those pressures exist in the US, and I’m wondering how dominant they are.

TL: In the US, if you ask people where they want to be cared for, it’s in the community. And yet our financial payment structure is not set up to support that. People go to nursing homes because federal and state dollars are directed toward nursing homes rather than toward home and community care.

This is going to be a big issue going forward—especially since states can now decide if they want to expand their Medicaid programs. States are really balking at spending much more on Medicaid.

CS: Who does pay for residential and nursing home care?

TL: Medicaid pays for about half of all nursing home stays. Private long-term care insurance pays for a small portion, and families pay the rest.

There hasn’t been much attention to long-term care in the press here. I tried to urge the press to cover it during the debate, but few reporters did. It’s like it’s not that interesting— and yet it’s going to be very interesting as time goes on, as America gets older and the costs of care outstrips what families can afford to pay.

CS: It’s been a big political issue in Britain lately. Essentially two things came together. There’s the fact that a lot of social care is underfunded and lots of people didn’t like that, and the fact that many people would find that if they had to go to a nursing home, they have to sell their home. What they wanted to pass onto their heirs would be gone very quickly. That kind of thing causes political waves in Britain.

TL: What happens in the US is that if a person goes to a nursing home, the spouse remains in the home. But after he or she dies, the home is fair game for Medicaid in something called “estate recovery.” Medicaid can come in and sell the house and use the proceeds to defray the costs of the owner’s nursing home stay that the state paid for.

CS: That’s interesting.

TL: That’s not very well known in the US, and you don’t hear many people talking about it. It’s a shame, really. We’re focused on bad nursing homes and have been for four decades now. So the stories you see—and some are legitimate stories—are about poor care given in nursing homes, and there’s a lot of it. But you don’t see a lot of reporting on the financial side of long-term care, and there should be.


Press coverage

TL: As we wrap up, let’s talk some about press coverage—especially about coverage of your reforms and ours.

CS: I think a lot of debate in Britain over our new health reforms was driven—sometimes for good, sometimes for bad—by the press coverage that the reforms got, and by the government’s presentations about reform. At first the government spun them as being a big, bold, radical proposal revolutionizing the NHS. In fact, they could have been easily spun as a cautious, evolutionary change from the approach being pursued by labor. Both are probably fair descriptions. They chose to sell it as a radical one and they very much later regretted that.

People didn’t want radical change in the NHS. The government hadn’t really talked about it before the election, so people were very suspicious and mistrusted the conservatives. That was a theme of a lot of press coverage.

Trudy Lieberman is a fellow at the Center for Advancing Health and 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. Follow her on Twitter @Trudy_Lieberman.