Recently in Health reform Category

It was a good day for supporters of the CLASS Act, the national long-term care insurance program that has been on the edges of the health reform debate. A version of the measure was included in the House Democratic reform bill introduced today by Speaker Nancy Pelosi. The decison all but assures the long-term care proposal will be included in the final House bill.

However, CLASS is running into new roadblocks in the Senate, where a consensus bill is still being written by Democratic leaders and President Obama. Key Democrats, including Kent Conrad of North Dakota and Ben Nelson of Nebraska, have turned sharply critical of the plan, especially because Congress would count premium revenues as a way to help pay for broader health reform. At the same time, big private long-term care insurance companies are stepping up their efforts to derail CLASS. One strategy: Delay passage by calling for a government study of long-term care financing needs.

The CLASS Act would make government long-care insurance available to all workers over 18. No one could be excluded because of pre-existing conditions. All workers would be automatically enrolled, although they'd have the option to opt-out.

Those with disabilities would receive an average minimum cash benefit of $50-a-day for life once they showed an inability to care for themselves. The premium for this coverage is uncertain. In earlier versions, the proposal set a target of an average premium of $65-a-month. Recent estimates by the Congressional Budget Office assume premiums would average around $120-a-month.    

However, the House version gives broad authority to the Secretary of Health and Human Services to design policies, including flexibility to set both premiums and benefits. For the poor, Medicaid would continue to provide assistance beyond the CLASS benefit. Others could purchase private insurance to supplement the government policies.

In recent weeks, nearly all advocacy groups for seniors and the disabled have lined up behind the measure. They see it as a major step towards giving those who need long-term care, either at home or in nursing homes, important financial resources. But the insurance lobby is hardening its opposition, fearing CLASS coverage would further damage an alrready-weak private market.  

I spent yesterday morning at a Kaiser Family Foundation panel discussion on the CLASS Act, the national long-term care insurance program being considered as part of health reform. The panelists, who included Senate Health Committee aide Connie Garner and a number of advocates for long-term care reform, were upbeat about the possibility that CLASS will be included in a final health bill. However, the idea still faces opposition from big private insurers.

Connie said the proposal continues to evolve, to satisfy both substantive and political concerns. However, its basic form remains unchanged: People would be able to participate as soon as they begin working, enrollment would be automatic, but they could choose to opt-out. Once they need care, they'd be eligible for an average minimum cash benefit of $50-a-day for life. The benefit would increase both with care needs and inflation.

It looks like the premium would now average about $120-a-month, twice what sponsors of the bill had first hoped. However, neither premiums nor benefits would be fixed in the legislation. Instead the Secretary of Health and Human Services would be given broad flexibility to design coverage.

While people would have to be actively working to be eligible for the insurance (a provision actuaries say is important to keep premiums relatively low), employers would not be required to offer a payroll deduction plan. This exemption could make enrollment complex and hold down participation.

We'll know within the next week or so whether CLASS will be included in the combined Senate bill. If it is, it will be a major step forward for the measure, which is already in the House version of health reform.     

In a bit of surprising news, Senate Finance Committee Chair Max Baucus (D-Mont) added some key long-term care amendments to his health reform bill. The provisions, first proposed by senators John Kerry (D-Mass), Maria Cantwell (D-WA), and Chuck Schumer (D-N.Y.) would all make home and community based care more accessible under Medicaid.

Currently, Medicaid is only required to provide long-term care in nursing homes. States provide limited home care services, but in most, the benefits are very limited. The amendments would make more frail seniors and younger people with disabilities eligible for home care, and provide financial incentives for states to expand these benefits.

Baucus also added a separate proposal that would allow hospice patients to receive full Medicare benefits. This three-year demonstration project would make it possible for hospice patients to get both hospice benefits and treatment for their terminal illness. 

Baucus added the changes as the Finance Committee began drafting its version of health reform.  

In recent weeks, we've heard end-of-life counseling compared to government run "death boards."

This rhetoric is beyond irresponsible, but it lays bare a very important problem--too many of us have no idea what living wills and other advance directives do, or how they work.

So, a brief primer: In short, these legal documents allow you to tell doctors and hospitals in advance how you wish to be cared for should you be unable to communicate after suffering an illness or accident. If you are in a coma after a car crash, or are unable to speak or write following a stroke, medical professionals can learn your wishes through your living will. A second document, called a health care proxy or medical power of attorney, designates someone--a spouse, adult child, friend, or lawyer, to act as your advocate to be sure the wishes expressed in your living will are carried out.

It isn't any more complicated than that. But claims that these documents are a way to hasten death are simply wrong. A living will can be used to express any wishes for end-of-life care. If you want no extraordinary measures taken to keep you alive, you may use the living will to say so. But if you want absolutely everything possible done, you may use a living will to request that as well. Had Terri Schiavo made a living will that requested that her feeding tube not be withdrawn, that whole awful legal controversy may have been avoided.

The reality of living wills is far from the alleged euthanasia that critics of health reform are claiming. But deliberately or not, their claims do a terrible disservice to those elders who are thinking about advance directives and those adult children who are caring for their parents.       

The most bizarre episode so far in Washington's health care debate is the persistent rumor that the House version of reform would force Medicare patients to participate in counseling sessions where they would "learn how to end their life sooner."

This is a lie. The House bill would do no such thing. Yet the myth persists, thanks to constant repetition by conservative radio talk show hosts such as Sean Hannity, Rush Limbaugh, and the cast at Fox News. It has successfully distracted attention from bigger issues in health reform. But, most troubling, it has revealed a profound misunderstanding of critical end-of-life matters.

First, though, this is what the bill would do: It merely says that if a patient chooses to consult his doctor about end-of-life issues, Medicare will pay the physician for her time. That's pretty much it. No forced meeting. Nothing about lessons in how to die sooner. Just payment for a once-in-five years discussion about advance directives, living wills, and health care options at the end of life.

Leaving aside for just a moment the rank cynicism in the attacks on this proposal (I'll get back to it though, I promise), think about what its critics are suggesting. They are confusing a foggy notion of libertarian freedom with ignorance. The same people who demand we teach children the fantastical notion that evolution is false imply there is something profoundly wrong with doctors and their adult patients discussing terminal illness and end-of-life. This is not a surprise, of course. The same people have been making the same argument about discussing pregnancy and birth control options for years. When it comes to political correctness, these loonies have left the Modern Language Association in the dust. 

For too long, Americans have had a catastrophic blind spot when it comes to death. We don't want to think about it, talk about it, or plan for it. As a result, too many of us die a death that is needlessly painful and isolated, surrounded by technology and strangers rather than quiet and friends.

The medical ethnologist Frances Norwood spent more than a year studying end-of-life issues in the Netherlands, where euthanasia has been legal for the past quarter-century. There, the kind of candid doctor/patient discussion about end-of-life that so terrifies some American conservatives is quite common. And Norwood reports a remarkable phenomenon: While people talk about euthanasia, they rarely choose it. Indeed, she suggests, the very fact that patients can honestly discuss these tough issues with their families and doctors may actually discourage assisted suicide.

We are not the Dutch, I know, but it is funny how these things work out.        

Now, back to the cynical politics. There is an old story about Lyndon Johnson's first campaign for Congress. LBJ, just learning the ruthless art of Texas politics, was losing badly. To turn the tide, he planned to start a rumor that his opponent, a farmer, was known to have sex with his pigs. A horrified aide tried to warn Johnson that there was no evidence for such a claim. "Well," Johnson was said to reply, "we'll make the SOB deny it."

It is a lesson right-wing radio talkers have learned well.   

The House Energy & Commerce Committee has added Senator Ted Kennedy's national long-term care insurance proposal (the CLASS Act) to its version of health reform legislation. This is another remarkable step forward for the measure although, as I've noted before, the fate of this and other long-term care provisions won't be decided until Congress writes a final health care bill sometime this fall.

The House panel included CLASS in its bill despite a new letter opposing the measure from the American Council of Life Insurers, a major industry lobbying group. ACLI says it opposes the bill because its benefit level, a minimum of $50 per day for life, is insufficient for someone who needs a nursing home level of care.

I suspect ACLI's opposition reflects a major industry split. I'm told that many of the biggest writers of private LTC insurance oppose the CLASS Act while many smaller carriers support it. Although Kennedy has explictly said private insurers could write policies to supplement CLASS Act coverage for many consumers, many of the major writers of private LTC insurance prefer the current environment, where they dominate a small market.

It seems that if I were an insurance company, I'd welcome an opportunity to revive what has been a moribund market. As currently designed, private LTC insurance is too complicated, too expensive, and too far off the radar screen for many consumers. Just as Medigap and Medicare Part D insurance have provided a nice kick for the health insurance business, CLASS has the potential to do the same for private LTC carriers. I think ACLI may be missing the boat here.   

For those interested in long-term care, the House Democrats' consensus health reform bill is pretty disappointing. Unlike the Senate Health, Education, Labor, and Pensions Committee version, it includes no proposal for national long-term care insurance. And it largely ignores efforts to expand access to home care for those on Medicaid, who now often can only get care in nursing facilities, or to better coordinate care for those receiving both Medicaid and Medicare benefits.

Key House Democrats, including Representative Frank Pallone (D-N.J.), are long-time supporters of Sen. Ted Kennedy's plan to provide national long-term care insurance (the CLASS Act). Still, the draft is silent on the issue. Similarly, despite strong Democratic support for efforts to enhance Medicaid home care, the proposal calls for little more than studies. Better than nothing, I suppose, but not by much. 

I expect lawmakers will attempt to add some long-term care provisions to the House draft, which will be considered by three committees over the next few weeks, For those of us looking for help caring for our parents, it will be interesting to see how they fare.   

Nobody wants to see chronically-ill elderly patients making repeated trips to the emergency room. These visits are obviously bad for the patients themselves, who often suffer stress, disorientation, and high risks of infection. They are no good for Medicare, which has to pay the bill: The estimated cost of these readmissions is $17 billion annually. And, despite the common perception, they may not be good for hospitals, which are facing payment cuts for these patients.

Many of the families I met while researching Caring for Our Parents struggled with this problem. Remembering which medicines to take; learning that it is a bad sign when a congestive heart failure patient like my dad gained weight; even something as basic as being able to get to the doctor for a checkup could be the difference between staying at home and ending up in the ER at 3 AM.   

But keeping frail seniors (and others, for that matter) out of the hospital turns out to be hard. One in five Medicare patients is readmitted within 30 days. Although Medicare has been running several demonstration projects aimed at keeping this population out of the  hospital, most have failed. According to a new study by Randall Brown at the highly respected consulting firm Mathematica Policy Research, very few experiments have reduced either hospitalizations or costs.

But the news isn't all bad. Brown identified three models that seem to be working. Two focus on patients who are already in the hospital. In one, advance practice nurses begin to work with patients before they are discharged and then follow them intensively for 4-6 weeks after they go home. In the second, for 4-7 weeks after they are discharged, patients are enrolled in programs that train them to self-manage their care.  

The third model identifes patients at high-risk for hospitalizaton and intensively monitors their symptoms before they get so sick they end up in the ER. These projects, called the Medicare Coordinated Care Demonstration program, have met with mixed success. Only 3 of 15 have reduced hospitalizations and costs. But Brown says they can work if they carefully target patients, if nurses and social workers spend face time with those in their care, if nurses work closely with primary care doctors and carefully tailor services to these patients' needs. Two keys: teaching how to manage medications after discharge and helping arrange for non-medical social assistance, such as transportation and adult day care.

The problem is that setting up these programs is not cheap. Massachusetts General Hospital says it spent as much as $9 million to get its model going, although it says it eventually saved between $7 million and $10 million after covering costs.

With Medicare expected to cut hospital payments for patients it believes could have avoided that round-trip to the emergency room, Brown's lessons will be increasingly important to both hospitals and patients. The trick will be to find ways to not only save money but improve care. If that sounds like a smaller version of the big health reform story, that's because it is.         

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The Democrats on the Senate Health, Education, Labor, and Pensions Committee have, as I expected, included three key long-term care services proposals in their massive 615-page health reform bill. The measure would require states to offer the same access to home and community care as they currently provide for skilled nursing facilities under Medicaid. It would provide new incentives for training both paid and family caregivers. And, the bill includes Senator Ted Kennedy's CLASS Act, which would create a national long-term care insurance program. 

It is hard to overestimate just how far-reaching these changes would be. In my new book, Caring for Our Parents, I discuss each of these ideas. The long-term care training proposal has a good chance of passing this year. The Medicaid changes may be quite costly--as much as $5 billion-a-year--and supporters will have to compete for scarce dollars with dozens of other health reform proposals. The CLASS Act may face the longest odds this year, but at the very least it will focus a tremendous amount of attention on the critical issue of how we pay for long-term care.

Unfortunately, the Democratic leaders of three House committees also laid out their broad blueprint for health reform, but said barely a word about long-term care. Except for worker training incentives, reforms aimed at caring for the disabled as well as the the frail elderly seem to be on the back-burner.

But remember, this is just the first leg in what will be a very long race. Congress will be debating health reform at least through the end of this year.    

I've just started a column for Kaiser Health News, a brand new independent news service. I'll be writing twice a month on long-term care issues, looking at policy, new research, and on-the-ground community ideas for improving long-term supports and services.

My first piece, published this morning, looks at Senate HELP Committee Chairman Ted Kennedy's CLASS Act. While the measure, which would create national long-term care insurance for all, is not perfect, I hope it will start a badly-needed discussion on how we finance the way we care for our parents and those with disabilities. Take a look and let me know what you think.