The way we care for older adults in the US is, self-evidently, not working. In just the past three months, at least 44,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19. Hundreds of thousands have been sickened. And millions have been isolated from family and friends for months.
Yet, this crisis did not spring from nowhere. The COVID-19 epidemic has amplified and exposed an already deeply-flawed system for long-term supports and services (LTSS) in the US. As tragic as this episode is, it has created an opportunity to rethink our care model from the ground up. But what would it look like?
In short, long-term care in the US needs more money and a new model for delivering care. Our system never will provide adequate care for frail older adults and younger people with disabilities as long as it remains so severely underfunded. And those with chronic disease and physical or cognitive limitations should have services well-coordinated and tailored to their individual needs, not driven by an outdated and dysfunctional payment system.
Starting from scratch
Imagine no entrenched business or bureaucratic interests struggling to protect an existing system. No legacy regulatory and payment systems. What sort of care system would we create? Not the one we have, for sure.
It might look like this: Frail older adults and younger people with disabilities, with support from family and a case manager, would choose the care setting and supports that would help them live the best life possible.
Long-term supports and services would be well integrated with medical treatment, with no regulatory or payment barriers, and through a financial model that creates incentives for strong chronic care management. This could be delivered through managed care plans, such as Medicare Advantage, fully integrated programs such as the Program for All-Inclusive Care for the Elderly (PACE), or special needs plans (SNPs). It might also be possible in traditional Medicare through Medicare Supplement (Medigap) insurance.
More home care
A public program such as Medicaid still would support this care for those with very low incomes. But Medicaid would be far more flexible than today, and the default setting for care would be people’s own homes, not nursing homes. Today, Medicaid home and community-based service (HCBS) programs provide insufficient benefits and often suffer from long waiting lists. They need more money. But with state budgets in deep trouble as a result of COVID-19, Medicaid funding is likely to go down, not up.
States should better align Medicaid LTSS with other public services, such as low-income housing, transportation, home delivered meals, adult day, and primary medical care.
State and local governments provide these services today, but in a disconnected way. Like specialist physicians, each cares for a slice of a person, not a whole life. The agencies that deliver these programs need to work with one another to provide flexible, holistic care. California is working to design such a model.
Everyone else would pay for their long-term services and supports through a mix of private savings (including home equity) and self-funded, universal public insurance. It could be run through Medicare or as a separate government program.
Redesigning care delivery
Such a model would fundamentally redesign the delivery of long-term care.
Start with where older adults get their supports and services. Today, 85 percent to 90 percent—or about 12 million–of those with long-term care needs get care at home. About 700,000-800,000 live out their days in nursing homes, and another 700,000 live in assisted living or other congregant care.
Roughly 80 percent those long-stay residents of nursing homes receive Medicaid. The vast majority have no clinical reason to live in such a facility. They are there because Medicaid puts them there.
Many could get their care at home—if they had a safe and accessible place to live and the necessary caregivers. For others, it would be more appropriate (and probably less costly) to live in a beefed-up assisted living facility or a group home.
The vast majority of those receiving long-term care at home are getting their support from relatives. Today, those family members are providing personal assistance with great love—and little or no skill. Like paid caregivers, they need training. Perhaps, they should even be paid.
And about those direct care workers, such as home care aides and nursing assistants: They need to be paid more and get benefits and opportunities for advancement. Without those changes, the current shortage will only get worse.
Where will the money come from?
Where will the additional funding for all this come from? The reality is that few Americans have saved sufficiently for the cost of long-term care in old age, few have private long-term care insurance, and Medicaid does not have the resources to fund this care for the fast-growing Baby Boom generation.
A public long-term care insurance program could supplement out-of-pocket spending, especially for those with true catastrophic costs that few private long-term care insurance policies cover. A cash benefit (with care management) would let older adults themselves decide where to live and give them the flexibility to purchase the services they need. Such a program could supplement managed LTSS benefits delivered through a health plan.
Some people would continue to need Medicaid, but many would not. Over the long run, the Urban Institute estimated a mandatory public catastrophic LTC benefit could reduce Medicaid LTSS spending by as much as one-third.
The long-term care system in the US was failing long before COVID-19. But now that this terrible disease has exposed the flaws in our system, we have an opportunity to fix them. We may not get all the way to the ideal system, but many intermediate solutions already are on the table. With the political will, we can change a failed system that is needlessly killing our seniors before their time.