On behalf of 18 other Senate Democrats, Sen. Ron Wyden of Oregon has asked for public comments on how to fix the nation’s broken model of long-term care for older adults and younger people with disabilities.

His 81-page request for information raises a broad range of important questions that need to be answered in any reform effort. But it sometimes hints at ideas that are extremely  expensive and unrealistic and sometimes inconsistent with one another.

It is a policy smorgasbord that attempts to satisfy the disparate demands of advocates for people with disabilities and older adults. That’s fine when asking questions but any serious legislation inevitably will have to trim the promises.

Wyden makes his broad goals explicit. He wants:

  • A universal home-based system of long-term services and supports that is flexible, simple, equitable, accessible, and affordable.
  • More support for both paid and family caregivers, including better compensation.
  • Improved nursing home quality and a crackdown on what he sees as corporate abuses in both home-based and facility-based care.

His platform for reform would be some mix of Medicare and Medicaid, the precise formula to be determined.

While Wyden cast a very wide net, he explicitly called two sets of ideas “beyond the scope” of his initiative: public long-term care insurance and expanding care transition models that better integrate long-term care and medical care. Both, he said, could be addressed at some later time.

Wyden is the top Democrat on the Senate Finance Committee and has a long history of supporting better care for older adults. If Democrats win control of the Senate this year, he’d be well-positioned to manage a reform effort, though his real goal seems to be making better, more cost-effective, care a 2028 campaign issue.

Nothing wrong with that. Putting long-term care higher on the political agenda would be a big step toward fixing our deeply-fragmented, inefficient, and often cruel disorder of care.

Wyden deserves great credit for making long-term care a top priority. And his questions are only questions. But some could lead him down policy dead ends.

For example, his intense focus on home and community-based care ignores the reality that, while the vast majority of people say they prefer to receive care at home, there are millions who don’t, or who realistically cannot, once their care needs become severe.

Wyden is right to say that Medicaid LTSS tilts too heavily towards nursing home care. Currently, while states must provide such care to all those who qualify, home based support is optional and requires federal approval. And nursing facilities are the only place where Medicaid pays for room and board. These twin benefits mean hundreds of thousands of those living in nursing homes do not need that level of care.

But he is wrong to focus reform almost entirely on home and community care. Among other things, it could leave people entirely abandoned by any new Medicare benefit once they need facility-based care. (Full disclosure: I am an unpaid board member of a non-profit continuing care organization that operates skilled nursing facilities).

Family Caregivers. Wyden’s request says remarkably little about family caregivers, beyond asking for comments on paying them. While surveys show many would like cash payments, they also may need training, emotional support, and respite care. This will be even more important if more care is provided at home, where family members already are the bedrock of support. He doesn’t ignore those issues, but I wish he had given them more attention.

Ownership. Wyden’s request is highly critical of what it calls “private equity” ownership of both facilities and home services companies. This has been a Democratic trope for years, but true private equity owns less than 10 percent of nursing facilities. Many of the worst operators are mid-sized firms that invest for themselves and not for others.

It is important to not confuse for-profit with private equity. While some of the very worst home care agencies and nursing homes are for profit, so are some of the best.

Nursing homes. Wyden raises some valuable ideas, such as more disclosure about nursing home ownership and more accurate reporting on quality. He’s also asking about curbs on related party transactions where unscrupulous operators sell services to their own facilities at inflated prices.

But other ideas are more problematic. For example, Wyden has been a big supporter of minimum staffing requirements for nursing facilities. But staffing is only a crude proxy for quality. It may be more a symptom of poor care than a cause, says Harvard professor David Grobowski.

Ask yourself if you’d rather your mother live in a facility with relatively few, but highly experienced and compassionate, staff or one that hits the numbers with inexperienced and poorly trained aides.

If Democrats are serious about improving quality of facility-based care, they should create meaningful, enforceable quality standards, rather than imposing a simple check-the-box staffing rule.

Overall, Wyden and colleagues need to be careful that overregulation and financial limits on nursing homes don’t result in their closure. Already many non-profit facilities are shuttering because they can’t find staff or break even financially. More rules could accelerate that trend.

Similarly, direct care workers should make a living wage. However, if Medicaid or Medicare increase their compensation, not only will government costs rise but so will the expenses of those families who must pay for care out-of-pocket. Finding a balance will be hard.

Another issue Wyden will have to resolve: He would mandate HCBS and perhaps universal standards for other benefits and even care worker pay. But if those rules are going to be universal across the country, what is the point of having state-run Medicaid systems?

“Out Of Scope” Rejecting insurance out of hand seems like a curious choice. The RFI notes the success of Europe and other developed countries in creating more efficient care systems but does not say they all have adopted public long-term care insurance programs.

And his goals of flexibility and simplicity, for example, could be far better met with an insurance-based cash benefit than with the highly-complex, rules-based Medicare and Medicaid systems.

Because this is a step towards a political document, it ignores cost. But if Democrats ever want a plan that can become law, they are going to have to pay for it. Inevitably, that will mean some combination of tax increases or, if Medicare is part of the design, perhaps higher premiums. Keeping costs in check will be essential.

Wyden wants to add his long-term care initiative to a broader “affordability” package that would include insurance and pharmaceutical pricing reform as well as a range of other non-health care issues.

But even if Democrats win back the White House in 2028, he’d do well to create a plan that some Republican could support. His RFI includes some of those ideas but he’ll need to scale back its ambition and cost for any reform to have real staying power.