The Congressional long-term care commission will finally hold its first meeting in late June. However, the panel must conclude its meetings in the fall and commission members are increasingly pessimistic that they will reach agreement on any substantial reforms to the nation’s troubled system of supports and services for the frail elderly or younger people with disabilities.
Last Friday, I participated in a panel discussion at the American Enterprise Institute (AEI) on long-term care and the prospects for the commission. If anything, that discussion reflected the vast gaps the commission must close in a short time if it is to accomplish anything at all. Not only do LTC experts disagree on solutions, they can’t even agree on facts.
I was joined on the AEI panel by Commission member Mark Warshawsky, director of retirement research at the consulting firm Towers Watson. Other panelists included Josh Wiener, who directs long-term care research at the consulting firm RTI International; Matt Salo, executive director of the National Association of Medicaid Directors; and Stephen Moses, president of the Center for Long-Term Care Reform.
Part of my role was to remind Mark and other commission members to consider the needs of care recipients and caregivers. This seems obvious enough. But it is remarkable how often they are forgotten in these discussions. Indeed, of the Commission’s 15 members, only a handful represent care recipients and their families.
But much of our discussion focused on two issues that turned out to be quite divisive—both focused on who pays for long-term services and supports.
Mark made two arguments that I think reflect a misunderstanding of the data. The first was that Medicare pays for a large share of LTC costs. Mark reached this conclusion from the National Health Expenditure Accounts that show who pays for care provided by skilled nursing facilities and home health care agencies.
It is not easy to tease out, but much of that spending is for post-acute care, not long-term supports and services. Imagine someone who breaks her hip. She’ll have treatment in the hospital, perhaps followed by rehabilitation and other treatment in a nursing facility. If she is discharged home, she may receive more treatment from a visiting nurse or therapist as well as some personal assistance.
Where is the line between post-acute care and long-term services and supports? It is hard to tell, but Mark assumes that all nursing facility and home care is long-term care, and that is not right.
The other controversy focused on whether wealthy people artificially dispose of or hide assets in order to become eligible for Medicaid. Stephen Moses frequently makes this claim and he did again on Friday based on what he says are interviews with state Medicaid officials. Unfortunately, Mark echoed those views.
However, many studies, including a new one by Josh Wiener, tell a different story. The vast majority of those who enroll in Medicaid long-term care never had much in the way of assets, and thus had very little to give away. While it is true that some abuse the system, the problem is much smaller than critics assert.
These abuses should be stopped. But with all of the problems of long-term care, it is hard to see how this one rises to the top. Yet, it seems typical of the challenges the Commission will face.
The commission has been hamstrung since it was created last January, as part of a deal that also repealed the CLASS Act. The panel was given a lifespan of only six months from the time its members were appointed. It had no budget, no staff, and a charge to reform both financing and delivery of long-term supports and services and address pressing workforce issues. There is no requirement that Congress vote on any of its recommendations.
The commission will have access to some limited Senate funds to pay for commissioners’ travel expenses and the like. Staffers are likely to be detailed from congressional offices with aides from Senator Jay Rockefeller (D-WV) taking the lead. Rockefeller was the commission’s primary supporter.
Warshawsky, who was appointed by Senate GOP leader Mitch McConnell (R-KY) raised several concerns about the panel: He said it would need at least 18 months to do its work rather than four, its staff should be non-partisan, and any decisions should be made by consensus rather than by majority vote (the panel has 9 Democratic appointees and only 6 Republican appointees).
While Mark and I disagree about some important issues of substance, he is absolutely right about those three process issues. But I fear none of them will be satisfied.
Howard, thanks for your contribution on the AEI panel. Warshawsky’s selective use of data was disturbing, as was his research methodology (Google, really?).
If nothing else, this commission could make a major contribution by laying to rest the myths that people like Steve Moses continue to perpetuate, despite overwhelming evidence to the contrary. Josh Wiener’s presentation was a good first step. The rest of the commission could benefit greatly from Josh’s presentation, which was a concise literature review of what the data actually shows.
I do find Warshawsky’s requests to change how the commission operates interesting. Would he do the same if the Republicans had a majority of appointees? Why should members of the commission who may have ideologically extreme views (on either end of the spectrum) be given veto power over the decisions of the commission? That doesn’t seem like a recipe for progress.