Last week, MarketWatch did the kind of report we have been urging the media to do on a subject they’d prefer to avoid—paying for long-term care. We’ve called long-term care the stepchild of health reform, and noted what little coverage there had been of the of the now-departed CLASS Act, and effectively killed off by the Obama administration last month.
The CLASS Act would have allowed people to pre-fund future nursing home and home care services. But it was voluntary, and the administration concluded that the high cost of premiums would have prevented people from signing up, making the risk pool too small to cover the care at a reasonable cost. This week a House subcommittee voted to repeal the CLASS Act for good. Michigan Republican Fred Upton, who chairs the full Energy and Commerce Committee, declared the subcommittee had voted to “start over on long-term care reform.”
The question is whether Republicans—and Democrats as well—are really serious. If so, what exactly do they propose to do about the growing need? MarketWatch explored that question in an interview with long-term care expert Howard Gleckman, a resident fellow at the Urban Institute. “No politician seemingly has any vision for solving the long-term care problem. But ignoring it doesn’t mean we avoid the cost,” Robert Powell reported. Gleckman told him: “We can kick the can down the road, but we can’t make the problem go away.” With the demise of the CLASS Act, Gleckman said, “This issue will just go back in the closet where it had been for many years, and I don’t know what will get it out of the closet again.”
What made the MarketWatch piece stand out was that it connected the dots between the policy discussions inside the Beltway and the real world, something I urged in last month’s post. Medicaid, which covers medical care for the poor, is also the default payer for long-term care. Middle-class families “spend-down” their income and assets on care, and then they become poor enough to qualify for Medicaid benefits. It’s a demeaning and unwelcome experience. But I noted that even Medicaid as a source of payment for long-term care might become less available, with all that deficit-cutting chatter and talk about block-granting Medicaid. If that happens, most likely there will be less money to pay for long-term care. Powell asked Gleckman about that. He told the MarketWatch audience: “Medicaid is getting shredded in the states. It’s getting cut even more by the feds as part of the whole deficit-reduction process. We don’t know how, but we know it’s going to get cut.” Where will that leave families if there are fewer Medicaid dollars for nursing home care?
Another point I made was that public discourse this year about Medicare and Social Security has swirled around raising ages of eligibility for those programs because people are living longer. But longer life means the need for more assistance in those later years, and that has not been talked about. MarketWatch wove that point throughout its report making clear that now was the time to act. “We are running out of time,” Gleckman warned. “If we are going to have a national insurance program, you need to get going on that.”
MarketWatch brought up a new point to ponder—the fact long-term care is already rationed. Gleckman noted that health care professionals often find elderly people in their houses; they’ve been dead for a week or more because they hadn’t received the care they needed. Perhaps this kind of rationing hasn’t made it to talk news shows yet because it doesn’t affect the incomes of sellers who would be affected by another kind of “rationing.” If a government authority ruled on the costs and benefits of new technology and said certain interventions might not be cost effective or clinically effective, you can imagine the cries of “rationing” and how Americans are being denied life-saving treatments. But then, this is long-term care we’re talking about, not the latest and greatest—and possibly not so great—medical procedure.
I particularly like the way Powell reported other funding ideas that the country might consider, such as increasing the amount people pay into Social Security to pay for long-term care, or redesigning Social Security so that it pays less in the early retirement years when people have other savings and don’t need care, and more in the later years when they do. Even though Social Security has been one of the dominant topics in Washington this year, the policy elites have kept to a narrow discussion that has not included talk of strengthening Social Security or using it in a different way, such as funding long-term care. The only acceptable dialogue has revolved around cuts, not on ways to strengthen it or how it can be used to pay for long-term care. And the media have followed that framing.
All these are good story ideas for a hungry reporter. Maybe with their help we can really have that adult discussion politicians like to talk about. This one will be about how the country will care for all those people who are living longer.
Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.