Filed Under:Health Insurance, Ltci

Real gridlock: The LTC commission

A post mortem

(NLM History of Medicine image)
(NLM History of Medicine image)

By now we are all familiar with the origins of the federal Commission on Long-Term Care (LTC).

Established by Congress as part of its Jan. 2 "fiscal cliff" deal, the commission arose literally as CLASS was being repealed. Tasked with advising Congress how to reform our nation's access to, delivery of, and funding for long-term care, the 15-member bipartisan panel just released its findings last month.

The precious balloon which had been afloat all summer did not so much "pop" with excitement at the news, as deflate with a "pffft."

No one held the commission to high expectations-- strapped as it was by a six-month deadline and $500,000 budget -- but it still managed to attract sustained coverage in the press even as Syria and our government shutdown threatened the steal the spotlight.

I disagree with the suggestion from my colleague Tom Koziol that revolutionary legislation may emerge.

“We didn’t have the resources or time to get that done,” admitted Commissioner Grace-Marie Turner (president of the Galen Institute, a Speaker Boehner appointee).

Had commission members gotten that done, the proposal would have had to be introduced in the U.S. House and Senate.

On the other hand, it was easy to reach consensus on softball topics such as eliminating Medicare's onerous three-day prior hospital stay requirement (which private long-term care insurance (LTCI) eliminated over 15 years ago), calling for background checks on LTC workers, ensuring that family caregivers are included in the planning process, or grandstanding for increased use of technology.

In fact, one of the commissioners has just released a statement optimistically predicting that the panel's budget-neutral recommendations will be adopted by Congress within a year.

But any casual observer could see the commission was doomed.

The witness list
If we agree that the road ahead will rely upon a partnership of public and private funding sources, why was no one from private LTCI invited to testify before the commission?

One can't very well talk about questions of "access" without eventually, recursively, talking about money to pay for services.

No one has a better track record -- not Medicaid, not Medicare, not the VA -- than private insurance. No one knows more about claims and utilization than private insurance.

So why were private insurance company representatives not allowed to speak and respond to questions from the 15 members of the commission?

Some were permitted to submit written statements, but on the list of the 36 participants invited to testify before the panel over four all-day sessions, private insurance industry participants were glaringly absent -- even from the session entitled "Strengthening Private Long-term Care Insurance."

Vocabulary
As I've written in the past, words are powerful framing instruments.

The fact that a "Long-term Care" Commission could not bring itself to discuss "long-term care," but instead resorted to the cumbersome "long-term services and supports" (LTSS) throughout its hundreds of pages of documents, speaks volumes.

No one outside of academia, think tanks, research institutions and the occasional government office uses the term LTSS.

This is such a truism that Google won't even allow you to run an ad using the terms 'LTSS' or 'long-term services and supports' since no one in America is familiar with these words.

So what we have is a divide: A handful of academics who insist on writing about 'LTSS' vs. 330 million Americans who are comfortable with the term LTC, and the insurance company marketers who smartly cater to them.

Two reports
Could there be anything more emblematic of our intransigent government, so full of brinksmanship that it would shut down, than a 15-member panel of appointees who felt the need to issue two rival reports?

First came the original recipe, rejected by Democrats (and one Republican) on grounds that the process was not transparent since the public was largely excluded from deliberations.

Then the five Democrats issued their own report, which calls for -- besides increased training and pay for caregivers -- the establishment of a national social insurance program.

This has been described alternatively as a new Medicare Part A benefit (financed through taxes), or a public program to insure against only catastrophic risk.

This was followed by the six Republicans on the commission sending a letter to President Obama and other congressional leaders urging that taxes not be raised for new programs, but rather that private LTCI should be leveraged as the tool to "alleviate pressure" on Medicare and Medicaid.

And around we go.

What's likely to emerge are a few enduring takeaways.

First, the commission itself recommended to Congress the creation of a new national advisory committee in order to continue their truncated work.

Second, the panel reinforced an emerging science we've noted wherein the needs of the young disabled or working disabled must be treated differently than those of the senior population. Although obvious on its surface, the fact that our system doesn't account for such distinctions shows how much work is left to do.

Finally, as LTCI producers we are left with this gem from the alternative report: "Given the unpredictable, catastrophic nature of extensive LTSS costs, insurance -- not savings -- is the most efficient and effective means of preparing for their possible occurrence."

Here here!

What do you think? Was the commission doomed from the start by partisanship? How lasting of an impact do you think it will leave? Do you agree or disagree with its conclusions? And what has become of the other committee working behind the scenes on the same issues?

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