For most of the past decade, politicians studiously have avoided any serious discussion of long-term care.
That’s shortsighted and President Clinton deserves credit for realizing it. But his recently announced long-term care plan doesn’t go nearly far enough.
Long-term care is an anxiety-producing subject. Consider the images associated with older people who need long-term assistance. Dependency. Debilitation. Disability. Consignment to a nursing home.
Politicians have especially strong reasons to shy away from the topic. By far the bulk of long-term care–helping people with essential activities such as bathing, dressing, eating, taking medications or going to the bathroom–is performed free by family members, friends and neighbors.
The economic value of services provided by this huge caregiving network of more than 25 million Americans is close to $200 billion a year, according to a major study last year by the United Hospital Fund of New York. That’s double the nearly $100 billion the government presently spends annually on nursing homes and home health care through its two huge health programs, Medicare (for the elderly and disabled) and Medicaid (for the poor).
The last thing politicians want to do is to substitute paid government services for the services caregivers currently provide, especially in light of the huge tide of Baby Boomers who will be aging over the next several decades. It’s a potentially budget-breaking proposition, and one for which no substantial political will exists in Washington.
But supporting caregivers is another thing altogether: sensible, far less costly and politically almost sure to win substantial support from Republicans and Democrats.
That’s where Clinton’s new five-year, $6.2 billion long-term care program, proposed just after the new year, comes in. The president’s plan has four key planks: a $1,000 tax credit for people who need long-term care, funding for community-based services, a Medicare education campaign and incentives to spur the private long-term care insurance market.
The $1,000 annual tax credit for people who need long-term care or the caregivers who look after them is by far the most important component. It’s estimated that three-quarters of the $5.5 billion in credits will go to spouses or family caregivers. People who have severe dementia or adults who need assistance with three activities of daily living (such as bathing, eating and toileting) and who live with caregivers at least six months out of the year will qualify. There are also income eligibility standards.
It’s the first major government recognition of the substantial strains–economic, social and emotional–associated with caregiving, and groups representing caregivers quickly expressed approval, with some reservations.
“This puts long-term care back on the public screen after a long absence . . . it’s a very positive first step,” said Gail Hunt, executive director of the National Alliance for Caregiving. But she cautioned that people shouldn’t get their hopes up too high because only the most feeble– people who need nursing home-level care–are targeted by the program. According to the government, 1.2 million older Americans, 250,000 children and more than 500,000 disabled adults will qualify.
What will the $1,000 tax credit buy them in the Chicago area? The unfortunate reality is, not much, according to Pam Steinbach, administrator of Resurrection Home Care, an agency that serves about 150,000 people in the metropolitan area.
For an elderly person on Medicare, for instance, an hourlong home health care visit by a nurse costs $100 to $110; 10 visits will eat up the entire credit. Nurses aides or certified nurse assistants operating under a nurse’s occasional supervision bill at $50 to $70 an hour; at those rates, the credit will pay for 20 or fewer visits.
Private duty aides operating without supervision go for $20 to $25 an hour. The going rate for companions is $15 to $18, an amount that would allow slightly more than one visit a week under the credit. About 22 adult day-care visits, costing about $45 a day, would be covered. The $1,000 also could be used to add a wheelchair-accessible ramp to an apartment entrance, for instance, or to make home modifications such as installing handrails in bathrooms or to reimburse a friend or family member providing care.
For families that currently receive little if any help from the government, these contributions, however modest, will surely be welcome.
A 1996 Commonwealth Fund report on long-term care shows that 53 percent of frail older people, who need substantial assistance with daily activities, receive only unpaid help from caregivers. Another 40 percent receive a combination of paid and unpaid help. To the extent the tax credit allows their caregivers a much-needed break, if only occasionally, it’s important.
But it’s a drop in the bucket. Many needy people live alone and won’t qualify for the credit because they don’t pay taxes, according to Joshua Wiener, a long-term care specialist at the Urban Institute. And many people who are feeble enough to qualify for the credit need far more care than $1,000 could buy. Someone with Alzheimer’s disease, for instance, may need constant supervision. Someone recovering from a stroke may need help getting up in the morning and eating three times a day. Someone who is paralyzed may need to be turned at regular intervals to prevent bedsores.
A 1997 national survey by the American Association of Retired Persons and the National Alliance for Caregiving suggests that caregivers attending to people with significant needs spend 27 to 56 hours a week on caregiving tasks. Nearly 1 in 5 caregivers contributes at least 40 hours a week of their time. The $1,000 won’t be enough to let them return to work or to hold on to a job they’re in danger of losing. It may, however, spur states such as Illinois to also contribute to caregivers.
The second plank of the president’s plan addresses a much broader audience. It would give $625 million over five years to local Area Agencies on Aging, which effectively function as one-stop shops on long-term care, supplying information, referrals and direct services. Most of the funding would pay for respite care: short-term relief for caregivers provided either in the home or through a center. Training for caregivers–What exercises can help improve mobility? What’s the best way to change a catheter?–would be funded.
Much-needed connections between the fragmented community organizations providing services, everything from churches to hospitals, could be strengthened. Anyone needing information could benefit. The president’s plan suggests that 250,000 families would get some type of services.
The proposal is welcome, in light of flat funding for aging agencies in recent years. But officials with those programs also sound a warning. “What we really need to do is make sure services are available and affordable to people who need them,” said Jonathan Lavin, executive director of the Suburban (Cook County) Area Agency on Agency. “We’re still a very long way from that.”
Robert Kane, a professor at the University of Minnesota School of Public Health and author of a new book on long-term care, agrees. The problem lies in an essential disconnect: the present system is strongly biased toward nursing home care (three of every four long-term care dollars spent by the government are for nursing homes), but consumers overwhelmingly want long-term care at home, he argues. To build the infrastructure needed to support a community-based system of long-term care would take “billions and billions” of dollars, spent on everything from new housing options for the elderly and disabled to enhanced home health care services.
Can it be done? Absolutely, Kane insists, noting that the Scandinavian nations serve as an example of what can be done. Is it affordable? Yes, insists Robert Friedland, director of the Washington-based National Academy on an Aging Society, which last week issued a major report arguing that society can afford to meet the needs of the elderly if current levels of economic growth are sustained in the future. Is it politically feasible? Perhaps not, given the current emphasis on curbing the growth in entitlement programs such as Medicare, which recently cut funding for its home health benefit.
Clearly, the private market has a role to play in funding long-term care. The debate is over what is reasonable to expect. Kane and Wiener of the Urban Institute argue that private long-term care insurance will never solve the nation’s current long-term care problem, which is that services cost too much and too few people have means to pay. Long-term care insurance is expensive for older people, they note, and those of middle age are occupied with other concerns such as raising children, paying mortgages and, increasingly, supporting elderly parents.
Insurance industry experts are far more optimistic. Nearly 6 million people have some type of long-term care insurance and growth rates are strong, with more companies offering the product to their workers. Increasing attention to the long-term care issue and the Baby Boomers’ experiences with their parents may stimulate demand.
The president’s plan might make a difference in the market by adding long-term care insurance as a benefit for federal workers and their families. The federal plan is a gold standard for benefits and may spur other companies or state employee insurance programs to follow the government’s example. Perhaps companies will band together to buy long-term care insurance at discounted rates, a strategy they’ve pursued in the health insurance market. The federal plan hopes to achieve savings of 15 percent to 20 percent through its plan, which may be possible because of the large numbers of potential enrollees.
Many details are still uncertain. But one thing is very clear: The long-term care problem begs to be addressed, through plans like the president’s and many other measures. It’s only going to become bigger, and more significant, over time.
