Update: Commission on Long-Term Care

Back in January I wrote a blog post entitled, Such is Hope, sarcastically ascribing what I felt then was the eventual reality for the Commission on Long-Term Care. Wish I could say I was wrong, but that was fairly put to rest this afternoon in a webinar sponsored by the Friday Morning Collaborative and underwritten by the SCAN Foundation.

Entitled, Long-Term Care Commission: Learn More About It and How You Can Engage, it felt very much like a perfunctory effort to engage public discourse while candidly acknowledging there isn’t much time left available for such input to really matter.    I would say it was like trying to make a silk purse out of sow’s ear, but that would be unfair to the pig. Just as it would be grossly unfair to pin blame for such an outcome on the Commission.

I can only imagine that webinar presenter and Commission Staff Director, Larry Adkins, must have felt like the general manager of a small market baseball team trying to explain to local sportswriters why his team with a $40 million budget can’t be as competitive as the Yankees with a $400 million budget. Because from a policy – and politics – vantage the Commission was set up for failure from the very start.

Created pursuant to the Taxpayer Relief Act of 2012 it was given six months post appointment of its 15 members (which meant the clock started ticking in mid-March) to assess, analyze and report on one of the most vexing social challenges this nation has ever faced. And then Congress did not fund its work efforts until mid-June, leaving three months instead of six. Now, if that doesn’t make it clear where long-term services and support ranks as a public policy concern in Washington, then I don’t know what would.

It was widely held (or at least this was my assertion) that the Commission’s establishment was little more than placation to those stakeholders and constituencies smarting from having given much to see the CLASS Act included in the Affordable Care Act, only to watch it repealed in the Taxpayer Relief Act when shown to be actuarially unviable. And that is truly a shame because failure to address the financial realities of long-term services, support and care is the poison pill that has the potential to dramatically impact the US economy (see graph below depicting potential impact on GDP).

This is a social issue with very stark realities that has been unwittingly discounted as a national policy concern for far, far too long. Though emerging technologies can help improve the lives of those individuals with disabilities and/or chronic disease, the primary cost component of long-term services and support will remain human resources – compensated and uncompensated (both carry economic costs). There is no sliver bullet solution waiting in the wings to change that reality.

After several decades now of floundering around in the dark just how many ways are there to describe an elephant!? We need to take the damn blindfolds off and look at what’s in front of us. Or maybe we leave the blindfolds on and wait for the elephant to make its move. It doesn’t take a great deal of imagination to know how that plays out for those in its way – but apparently more than we currently have at our collective disposal.


Accepting the Realities of Aging

head-in-sand . . . or not.  The Associated Press-NORC Center for Public Affairs Research last week released the report, Perceptions, Experiences and Attitudes among Americans 40 or older. Sponsored by the SCAN Foundation, the report presents research based upon interviews of just over 1,000 individuals aged 40 and older regarding their views on aging.

From a public policy perspective, the key takeaway underscores a phenomenon common to discussion and debate over how to finance the future long-term care needs of an aging population. At a time in our lives when we are at our peak earning potential we typically also have the highest propensity to spend – quite often as a necessity of family survival. The past half-decade has heightened further that reality for many of us.

Of those interviewed, fully 30% would rather just not think about aging – while an additional 32% were only somewhat comfortable thinking about getting older. Not surprisingly, there was an apparent correlation between being more comfortable (I would posit, willing) to think about and discuss aging and the respondent’s age. Ailments and infirmities tend to be quite effective at breaking down one’s belief in mind over matter as a plausible substitute for the elusive fountain of youth.

In what I interpret as a perceptual vote of no confidence in government’s ability to effectively address the looming cost crisis attendant to long-term care, 51% of interviewees between the ages of 40 and 54 – and 48% between the ages of 55 and 64 – are a great deal or quite a bit concerned about affording the long-term care they may require as they age. This is compared to only 30% of those over the age of 65 (i.e., Medicare eligible) who share the same concern.

Whether that represents a false sense of security or not, it is worth noting the research also highlighted the continuing misperceptions that many individuals have regarding their probability of needing future long-term care, its costs, programs available to provide assistance and how to plan for future needs. For those directly involved in providing long-term care services and support those perceptions are accepted realities.  But for those in positions of public policy influence and responsibility the consequential understanding of those realities is a lot less clear.

Of course, I am thinking of the Commission on Long-Term Care, which pursuant to Section 643 of the Taxpayer Relief Act, is charged with developing, “a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who require assistance to perform activities of daily living, and individuals desiring to plan for future long-term care needs.”"

There is widespread belief that a key element of any successful plan should include efforts to create greater awareness and education surrounding the individual realities of long-term care. The research shared above serves to underscore that belief. What is largely unknown, however, is whether such investments are worthwhile. We have so far seen the relatively disappointing results of investments in health and wellness (as an aside, I wonder whether Senator Harkin has seen that research).

Sometimes things that seem to be intuitively correct are disproved by empirical evidence. The failure of long-term care insurance to gain greater traction may be an indicator that education and awareness regarding the need to plan for long-term care will have a limited ability to overcome the strong human inclination to stay in the moment.

Since it is also true, however, that intuition often bears fruit only through successive efforts to overcome obstacles, I do believe education and awareness, along with wellness and prevention, should continue to be encouraged from a healthcare and long-term care public policy perspective.  In making those investments, however, programs with tighter feedback loops that help measure relative effectiveness are not only prudent but will help accelerate the desired outcomes of those investments.


Such is Hope

Among the numerous provisions included in the Taxpayer Relief Act of 2012 impacting healthcare organizations was the establishment of a new Commission on Long-Term Care.  Now we can rest easy that the demographic tidal wave threatening to destroy our society has (or at least can now) be averted.  Excuse the sarcasm, but it seems I’ve been here before, haven’t you?

While there are specific expectations and deliverables outlined in creating this new commission (see below), vesting authority in 15 individuals to investigate and discuss the problems and then suggest what are sure to be already well-documented ideas offered as solutions doesn’t quite seem to have the legislative teeth one would expect if this effort were to be any more seriously supported than was CLASS.  Assigning yet another committee to tackle the fiscal realities of our nation’s future long-term care challenges is a bit like – well, like the way our elected leaders addressed the Fiscal Cliff.

As I predicted in my post on December 26th, what played out during the first few days of January in Washington was largely just another political fiasco of kicking the can down the road once again.  And if you have had any experience in long-term care you most likely consider that par for the public policy course, so from that vantage I guess the new Commission should be taken in stride.

Section 642 of the Taxpayer Relief Act permanently eliminated the CLASS Act, which was included as Title VIII of the Affordable Care Act.  CLASS (Community Living Assistance Services and Supports) was developed as a voluntary, government-administered program that would have provided a basic lifetime benefit of at least $50 a day (indexed for inflation) in the event of prolonged physical illness, disability, or severe cognitive impairment (e.g., Alzheimer’s disease).  At its core, CLASS was an attempt to provide individual savings incentives to defray the potential future costs of long-term care where private long-term care insurance has largely failed as an aggregate solution.

As may be recalled, in October of 2011 HHS informed Congress that it was unable to ensure the program’s financial solvency over the 75-year period that was statutorily required.  Shortly thereafter (as in the time it takes between a green light and the New York cabbie behind you to honk his horn crossing 42nd Street during rush hour), Secretary Sebelius and the White House quickly abandoned whatever support there may have been.  And thus, death be to CLASS.

The sad financial irony of this, of course, was that CLASS comprised roughly one-third of the projected $210 billion in savings the ACA was to garner between 2013 and 2019.  Indeed, substantial projected savings were verified by the CBO during the 10-year scoring window, but that did not account for the program’s benefit obligations over a 75-year period (i.e., the program would not limit the benefit duration and all future payouts had to be funded entirely by premiums paid by individual participants).

So in what can only be seen as a standard course of appeasement, Section 643 of the Taxpayer Relief Act created the Commission on Long-Term Care.  The Commission’s objective is to, 

“…develop a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who require assistance to perform activities of daily living, and individuals desiring to plan for future long-term care needs”"

See, I told you you’d feel better.

The Commission is to consist of 15 members appointed not later than February 2nd by the President and majority and minority leadership from both Houses of Congress.  Further, it is to be comprised of individuals representing  consumers, older adults, individuals with cognitive or functional limitations, family caregivers, direct caregivers, private long-term insurance providers, employers, state insurance departments and State Medicaid agencies (all represented by 15 individuals mind you – what an eclectic group that will be).

In developing a plan to address future long-term care needs, the Commission is to provide recommendations that address where and how needed services and supports are currently provided for (or not) through existing governmental programs; improvements necessary in such programs to ensure future availability; and a variety of issues related to workforce adequacy, skills and capabilities (the most important element of this effort, in my opinion).

Then, no later than six months following appointment (i.e., early August of this year) the Commission is to provide (assuming it is in majority agreement) a comprehensive and detailed report, including any legislative or administrative action necessary to carry out its recommendations or proposals.  Subsequent to that (within 10 days) the “Commission bill” will be given to the President, the Vice President, the Speaker of the House of Representatives and the majority and minority Leaders of each House of Congress – and then subsequently introduced as proposed legislation into the House and Senate (by request).  The bill will also be made available to the general public at or around the same time.

I don’t know whether this new Commission holds out any greater promise of addressing the monumental challenges we face in trying to accommodate the future long-term care needs of an aging population without bankrupting this country.  My skepticism is not so thinly veiled in what I share above.

But I am more than willing to take the high road and give it my best shot.  I would like to think that readers stopping by the Policy Pub have a lot to offer in the way of input and ideas the Commission should consider.  To that end, I will do what I can in this space to track its formation and progress – and advise when and how those ideas might best be communicated collectively.

Until then, a quote from someone I know would have made a wonderful Pub patron:
”Such is hope, heaven’s own gift to struggling mortals, pervading, like some subtle essence from the skies, all things both good and bad – as universal as death, and more infectious than disease!”
  ~ Charles Dickens