The Covid-19 pandemic has been a catastrophe for frail older adults. More than 170,000 residents and staff of long-term care facilities have died from the virus, and adults over age 65 living in all settings have accounted for about 80 percent of the nation’s deaths, or about 400,000 fatalities.

But what lessons have we learned? And how can we build on this public health disaster to repair a long-term care system that has been broken for decades? Last fall, the Urban Institute brought together 31 experts in long-term care to discuss how the US can fix the fractured system, given the hard lessons of covid-19.

Participants included some of the nation’s leading scholars and researchers, policy analysts, and representatives of senior living communities, family caregivers, direct care workers, and managed care plans. The project was funded by The John A. Hartford Foundation.

Critical reforms

While participants brought many different perspectives, they agreed on several critical areas for reform. They broadly agreed on the importance of fundamentally redesigning Medicaid; expanding home- and community-based services (HCBS); integrating medical care with long-term services and supports (LTSS); enhancing pay, benefits, and training for direct-care workers; reimagining nursing homes; and supporting older adults along the full continuum of care.

More broadly, the group said any reforms should focus on how to improve the quality of life for frail older adults and younger people with severe disabilities, rather than merely focusing on medical treatment. And they felt it is critical to reverse profound racial and ethnic disparities in access to high-quality long-term care.

There was much more to unpack from this four-hour session than I can describe in a short blog, but let me highlight just a few of the priorities:

Medicaid LTSS

The participants agreed that Medicaid LTSS needs to be better funded and accelerate its shift away from nursing home care and toward home-based care. Nursing homes remain the default setting for Medicaid LTSS, and while all states have created home-based care programs, many fail to provide necessary levels of community-based supports or have long waiting lists. In the pandemic relief bill, Congress is taking a step in this direction by temporarily increasing federal funding by about $9 billion for home-based Medicaid programs.

The roundtable participants agreed that community  care should become the default setting for Medicaid. They also agreed that effective home-based care requires a broad-based infrastructure of supports including appropriate housing, transportation, nutrition, and adult day, as well as respite support for family caregivers.

However, this recommendation came with several caveats. Some participants felt that states should create fully-coordinated systems of social supports across agencies, rather than relying on Medicaid alone to deliver the full range of services. California, which has recently adopted a Master Plan for Aging, may be a model for such an initiative.

Integrating medical care and LTSS

The group was divided on the question of whether Medicaid should be providing long-term supports and services at all. Some felt that LTSS should be address at the federal level through Medicare, while others felt that the Medicare program already is under severe financial stress and should not be called on to provide additional services.

Participants broadly agreed on the importance of fully integrating LTSS with medical care, a barrier that rarely is breached in today’s health care system. However, there was no consensus on how best to accomplish this goal.

Many felt that functional and physical limitations should be considered public health issues and thus integrated into the nation’s public health system. Others worried that this model risks medicalizing LTSS.

Still others focused on the benefits of enhancing services and supports through Medicare managed care, such as Medicare Advantage plans and Special Needs Plans. MA plans have been expanding these benefits and several roundtable participants recommended payment and regulatory reforms to accelerate change.

Racial inequities

Participants broadly agreed on the importance of improving pay and working conditions for direct care workers. This need was exposed by the pandemic where many aides died while others may have inadvertently infected residents of the long-term care facilities where they worked, often because many need to work two or three caregiver jobs to make a sufficient income.

The group broadly agreed on the need to address racial inequities in the long-term care system. Here too, the covid-19 experience amplified a long-standing problem. Extensive research has found that facilities with a larger percentage of Black residents were far more likely to have outbreaks and deaths than those with larger shares of White residents.

Finally, while participants disagreed about the future viability of traditional nursing homes, they broadly agreed that some form of congregate care will be necessary for many frail older adults. These settings may be small homes such as Green Houses, reimagined assisted living, or some new alternatives.

This roundtable did not resolve LTSS challenges, but it highlighted many possible solutions. And it began what should be an intense national discussion on how to fix our badly broken system of long-term care.