I heard a great presentation this morning by Shawn Bloom of the National PACE Association on how goverment tries to coordinate care for those elderly who are both frail and very poor–among the most at-risk people in the country.

PACE is an innovative program that is geared to seniors still living at home. It combines adult day services with medical care and other assistance. PACE so unusual because it is jointly financed by both Medicare, the federal health program for seniors, and Medicaid, the state/federal health program for the poor. This is a lot more complicated than it seems and, because the two program often work so badly together, the more than 7 million frail and poor elderly who are not in programs like PACE often get very poor care.

Here is the problem: Most of these seniors suffer from multiple chronic conditions. They may have heart failure, diabetes, arthritis, and perhaps some dementia. Health experts agree they desparately need someone to coordinate their care, including both medical treatment and non-medical services, such as transportation, housing, and meals. Without this full package, they will almost certainly lose their ability to stay at home.  

Success for these patients often means keeping them out of the hospital. And that’s the problem. Because of the crazy way Medicare and Medicaid work–an artifact of a backroom political deal made in the early 1960s–it is easy for these seniors to fall through the cracks.

Take a heart failure patient. When her medications are not working properly, she is very likely to have trouble breathing and, inevitably, will end up in the hospital emergency room. This can be easily prevented by a skilled health aide, who can identify early warning signs simply by checking to see if the patient is gaining weight–a dead giveaway that trouble is ahead. 

But building a system of coordinated care can be expensive, and it usually falls to the state Medicaid program. But because it is Medicare, not Medicaid, that would pay for her visit the emergency room, it is Medicare that receives the financial benefit of keeping her out of the ER.

So states are reluctant to commit to PACE and programs like it. Once, governors talked about a grand bargain: They would turn care of the frail elderly and disabled adults over to the federal government while keeping responsibility for poor mothers and their children. But Washington is not likely to accept such a deal.

Millions of sick and low-income seniors are caught in the middle. Many were once middle-class people who have spent through their assets and now find themselves in these government programs. They deserve better.