Experts offer story ideas for covering health reform
Filed under: Health care reform, Health journalism
More than 30 attendees heard local experts sketch the particular challenges and issues presented by the Affordable Care Act in California in the latest “Implementing health reform in the states” panel, hosted by AHCJ’s San Francisco Bay Area chapter on Wednesday night at the San Francisco Chronicle.
The panel, one of a series sponsored by AHCJ, the Alliance for Health Reform and the Robert Wood Johnson Foundation, began with an explanation of exchanges and what’s happening with their implementation (or lack thereof) around the country by Larry Levitt of the Kaiser Family Foundation.
He posed some story ideas, such as: How vigorously will the states promote enrollment through the exchanges? What sort of variations to the ACA might emerge once states have the ability to ask for waivers in 2017?
Kim Belshe, a board member of the California exchange, and Marian Mulkey of the California HealthCare Foundation discussed the California scene, with lots of detail, touching on the state’s large undocumented immigrant population, the challenge of getting people enrolled (since the law of the land is now “performance” – which means maximum participation), new opportunities for medical professions, such as nurses, to fill gaps in care delivery, and how to ensure coordinated care during the transition period to exchanges so no patient is harmed. This is the accountability part of the ACA, and needs thought and new procedures, Belshe stressed.
Belshe noted that Medicaid (Medi-Cal) is the foundation of reform, a subject which reporters sometimes overlook. Both she and Mulkey noted that California is a national pacesetter when it comes to reform implementation - a story idea in itself.
The session was moderated by Ed Howard, executive vice president of the Alliance for Health Reform.
On Tuesday night, a similar briefing was held at the University of Southern California, featuring Walter Zelman, Ph.D., a professor and director of health science at California State University-Los Angeles; Daniel Zingale, senior vice president of the Healthy California program at The California Endowment; Anthony Wright, executive director for Health Access, a California health care consumer advocacy coalition; and Deborah Crowe, the health care and biotechnology industry reporter for the Los Angeles Business Journal. Howard, of the Alliance for Health Reform, moderated the session.
Zelman posed a number of questions about reform, mostly about exchanges. To a reporter from Orange County, he suggested a story about the origin of the individual mandate – an idea championed by Republicans early on, he noted, and opposed by Obama and many Democrats. To a question about accountable care organizations and bundling, he suggested stories about how fee-for-service medicine is anything but dead.
Wright offered a look at what’s happening in Sacramento, including a hearing held just a few hours before the briefing.
Zingale mentioned the importance of prevention, and how the ACA encourages prevention. He too pointed out how nonprofits in the state can team up with reporters to educate people about the ACA. He said that the more people know about the law, the better they like it.
From a reporter’s perspective, Crowe offered several practical story ideas that reporters can start writing about today.
John Gonzales of the California HealthCare Foundation Center for Health Reporting wrote about the panel and Michelle Levander of the California Endowment Health Journalism Fellowships program offers some of the story ideas mentioned by the panelists.
Special thanks to Colleen Paretty, chair of the Bay Area chapter, and Bill Erwin, of the Alliance for Health Reform, for contributing details about the panel discussions for this post.
Investigation delves into Wash.’s prescription drug problem
Filed under: Aging, Children, Europe, Government, Health care reform, Health data, Health policy, Hot Health Headline, Pharmaceuticals, Public health, Public records
Everything time we think prescription drug abuse stories have peaked, something comes along to push the story further. This time, InvestigateWest’s Carol Smith sets herself apart by starting from square one and clearly explaining the origins and dimensions of Washington’s particularly nasty drug issues, tracing back each facet of the problem to its source and spotlighting what makes the Evergreen State unique.
Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.
The backdrop for her work is an epidemic that shows no signs of abating, despite a recently implemented state law Smith calls “a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines.”
Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it. Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.
Why caused it to leap so quickly? Smith tracks down several key tipping points. “There’s plenty of blame to go around for what caused the epidemic,” she writes. “Aggressive marketing of opiates by drug companies, nonexistent tracking of overprescribing, lack of insurance coverage for alternative treatments for pain, and demand by patients for quick fixes, to name a few.”
She drills down into many of those causes, with my personal favorites being two key origin stories:
- How marketing by OxyContin maker Purdue Pharma led to relaxed guidelines for chronic pain treatment and a “1999 law specified ‘No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed,’” both of which helped cause a jump in prescriptions.
- How “the rise in the death rates of Medicaid patients tracks along with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: Methadone.”
See the upper right-hand sidebar for more stories from the six-month investigation.
Article looks at reform concepts put into practice
Filed under: Health care reform, Hot Health Headline
Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.
Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.
“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.
“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.
“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”
The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.
So what are those health reform themes?
Value-based purchasing – loosely translated – is paying for what works.
Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.
Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.
So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.
Share your thoughts on database design for tracking pharma payments to doctors
Filed under: Government, Health care reform, Health data
Curtis Brainard of Columbia Journalism Review reminds reporters that their input is needed on the design of a federal database that will track payments from drug and device makers to doctors.
Investigations and databases, such as Dollars for Docs by Propublica, have revealed payments to doctors who had been accused of professional misconduct, had been disciplined or lacked credentials. Researchers have found evidence that payments can influence doctors’ treatment decisions (PDF).
Provisions in the Affordable Care Act mean that companies will have to report such payments to the Centers for Medicare & Medicaid Services, which will post the data on a public website. CMS has asked for “comments on how to structure this Web site for ultimate usability.”
There are a number of ways to submit your comments, detailed in this Federal Register announcement. Comments must be received by 5 p.m. EST on Feb. 17.
Reuters shows how shell companies hide Medicare fraud in plain sight
Filed under: Government, Health care reform, Health data, Health journalism, Hot Health Headline, Public records
Reporting for Reuters, Brian Grow and Matthew Bigg used an analysis of public data to investigate the practice of using shell companies to defraud Medicare of millions while staying a step or two ahead of federal investigators.
While the specific damage inflicted by shell companies has not been tracked, “Last year, ‘improper payments’ resulted in $48 billion in losses to the Medicare program, nearly 10 percent of the $526 billion in payments the program made, according to a Government Accountability Office report last March.”
“Simply by reviewing the incorporation records of Medicare providers in two buildings” in Miami, they write, “reporters uncovered information that one government official said could prompt “a serious criminal investigation” of some of the companies.”
The fraud rings merge stolen doctor and patient data under the auspices of a shell company and then bill Medicare as rapidly as possible. Other shell companies are often layered on top to camouflage the fraud, law enforcement officials say.
Some of the shells purport to be billing companies; they form a buffer between the sham clinics and Medicare. Others pay kickbacks to doctors and patients who sign off on bogus medical claims or sell their Medicare ID numbers to enable the shell company to bill the government. Still other shells act as fronts to launder the profits.
The key to this kind of fraud, known as a “bust-out” scheme, is for each of the fake companies to bill as much as possible before authorities catch on. Shell companies become a tool that helps keep the crooks ahead of the cops.
The Armenian crime ring whose fraud made headlines last year used 118 shell companies in 25 states and bilked the feds out of at least $100 million. Varying incorporation rules make state-hopping and obfuscation “easy,” they write, especially since states don’t check to see if records are legit before they allow a company to incorporate. The reportes found that even a few simple safeguards would go a long way to detecting the boldest frauds.
In Florida, FBI agents say almost every Medicare fraud scheme involves shell companies. There, Reuters scrutinized incorporation documents for firms located in two buildings near the Miami International Airport. In a building with dimly lit corridors, a rickety elevator and almost no one in sight, a host of companies purport to provide services to Medicare recipients. But telltale signs of fraud abound.
Many of the 26 companies in the buildings had replaced corporate officers at least once in the last four years. Some had changed ownership, or their corporate executives represented more than one medical-related company. Law enforcement officials consider such activities to be red flags for fraud.
For its part, CMS told the reporters it simply didn’t have the resources necessary to conduct the widespread audits needed to catch fraud, though the $350 million allocated to such efforts under the 2010 health reform law should help.
Health journalists who will certainly want to review the “methodology” subheading at the end of the story.
‘Doc fix’ flies in the face of rewarding quality, not quantity, of treatment
One of the last things that Congress did before finally getting out of town a few days before Christmas was the so-called “doc fix” – finding money to stave off a scheduled cut for Medicare physician payments. But they only did it for two months – meaning lawmakers will come back in January and struggle with it all over again.
The uncertainly, coupled with the prospects of what, on paper at least, could be a 27 percent fee cut, raises questions about whether more physicians will start cutting back on the number of Medicare patients they take, or dropping out of the program altogether.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. It’s also worth reflecting on what this Medicare payment system (formally known as the Sustainable Growth Rate or SGR) means – because it reinforces the very heart of fee-for-service medicine at a time when the health reform law, and many large employers and insurers, are supposedly trying to nudge the health care system away from fee-for-service, which encourages volume. The goal is to move toward new models of more coordinated and integrated care that are supposed to promote value. So the irony is that we’re tying ourselves in knots about SGR – which pays doctors for how much they do – when the focus is supposedly on creating a system that rewards doctors for how well they do. Go figure.
The SGR dates back to one of those sprawling congressional budget deals, back in 1997. It is supposed to link Medicare physician costs to larger economic and population trends. But the formula didn’t work. Everyone in Washington has pretty much agreed on that. But they haven’t agreed on how or when to replace it. There’s been a lot of talk about coming up with a “doc fix” for a couple of years to allow time for a transition to a TBD new system. But that’s a tall order, given that all the parties don’t agree on what a new system should look like, or which of the new payment systems and incentives being tested are going to turn out to work well (and how long it may take to get them working.)
Until 2002, payments under the SGR rose modestly. Then in 2002 physician Medicare fees were cut by 4.8 percent. In subsequent years, Congress (heavily lobbied by physician groups) postponed the cuts called for by the SGR formula, or approved modest fee hikes. Now, the cumulative postponements mean that doctors face a 27 percent cut – and erasing it would cost about $300 billion over a decade. payments have grown very modestly for nearly a decade now. On top of the SGR issue, physicians and all other Medicare providers face a 2 percent cut starting in 2013 under last summer’s deficit-reduction agreement.
The Medicare Payment Advisory Commission, or MedPAC, knows a mess when it sees one.
The system … has failed to restrain volume growth and, in fact, may have exacerbated it,” MedPAC wrote to Congress earlier this year, recommending yet again that the formula be jettisoned. To a certain extent, cutting physician payments for specific services only encourages them to offer more services. There isn’t an expert consensus on exactly how much or precisely how the SGR system stimulates more volume. But a recent New England Journal of Medicine article found that doctors in some states were digging the SGR hole much deeper than others (Florida, Texas and New York being among the major culprits). And some specialties’ “excess growth” is much more than others (these include internal medicine, cardiology, diagnostic radiology, and family practice - some of which I would not have guessed.) This doesn’t mean that fees should be slashed in some states and not others, or that family practitioners should get a pay freeze while neurosurgeons make even higher incomes. But it does suggest, as the Harvard health policy experts that wrote the NEJM piece note, that new systems, less blunt and less arbitrary, are required.
The congressional focus on short-term “doc fixes” – a decade’s worth now – blunts the momentum for permanent change. “If you are always doing a fire drill, and finding a perpetual one-year patch, it keeps you from confronting the larger mega-reform that’s needed,” Tom Miller of the American Enterprise Institute observed.
The AMA and other physician groups have warned for years that more and more physicians will stop treating Medicare beneficiaries. On an online AMA survey in 2010, one in five doctors overall, and nearly one-third of primary care doctors, said they are already limiting Medicare patients.
So while Congress struggles for a way out, it’s probably a good time to look at what physicians are doing in your state. (This AMA guide to choices doctors can make about Medicare participation may be useful.) I suspect a lot of doctors don’t quite understand what’s going on in Congress (because as we saw during the pre-Christmas impasse, Congress didn’t seem to quite understand what’s going on in Congress.)
- Do physicians think they will actually get a 27 percent cut? (They won’t - but they may not get an increase or only a modest one.)
- Are they preparing to drop Medicare patients or at least take fewer new ones?
- Have they begun to understand why the system is unsustainable, and become increasingly open to alternatives including ACOs, bundling, medical homes, etc?
- Are they coming up with any creative local solutions? Or are they just assuming that somehow the system can keep muddling through indefinitely?
Growth of for-profit hospices ripe for coverage
Given the recent spate – some good, some pretty muddy, and one I think pretty eye-opening – of articles about the growth of for-profit hospices, it’s probably worth taking a look at the issue, particularly for those of you who live in communities (such as the south and west) where the for-profits are most dominant. I think it’s also important to note some of the context that some of these articles omitted. And, yes, there’s a health reform angle. Several, in fact.
MedPAC started looking into the for-profits several years ago, as the sector started growing very rapidly. It became clear that the Medicare hospice “caps” and penalties meant to discourage too many long stays weren’t working. MedPAC has made a number of payment recommendations, including one that would revamp how all hospices are paid (which would make long stays less profitable) and another focusing more narrowly on creating a separate payment scale for hospice care in nursing homes.
MedPAC advises Congress but doesn’t set policy. And Congress has not acted on the recommendations to date – except that it did include in the 2010 health reform law a requirement that HHS review (and gives it a pathway to revamp) the hospice payment system in 2013. In addition, hospice faces about $7 billion of Medicare payment reductions over a decade under the Affordable Care Act. On top of that is the 2 percent Medicare provider cuts that will be “triggered” next year now that the supercommittee failed to agree on an alternative deficit-reduction steps.
All that being said, the recent Bloomberg piece by Peter Waldman on sales and marketing tactics by the for-profit chains was a hefty piece of reporting. It documents things like “Summer Sizzle” promotions, “Christmas Cash Blitz” and “Fall Frenzy” admission drives. The focus was pretty squarely on the business and sales practices. That is an important issue (and I haven’t seen it as well reported elsewhere ). But for those of you who may want to write about hospice, it’s not the only issue.
If you write about the growth of for-profit hospices – and some communities are now dominated by them – a few things to keep in mind.
- Don’t conflate quality and quantity. A flawed government payment system, and overly aggressive/inappropriate sales tactics (or even outright fraud) by some players isn’t always the same thing as a quality-of-care problem. A nursing home resident who ends up getting hospice care longer than he or she really should isn’t necessarily getting bad care – although they may well be getting care that Medicare shouldn’t be paying for.
- There’s a difference between large publicly-traded, investor-owned hospice chains and smaller, local for-profit hospices, which can be quite mission-driven (and low margin.) A hospice’s tax status doesn’t automatically define whether it provides good or bad patient care. (Remember the ongoing debate about which nonprofit hospitals are really “non” profit).
- Prognosis is really, really hard – particularly for the frail elderly nursing home population. It is hard to know whether a dementia patient is going to die within six months - even when there are some tell-tale danger signs of decline and deterioration. CMS did add some recertification and quality rules two or three years ago that are supposed refine the eligibility criteria - but they still aren’t a crystal ball.
- Long hospice stays may be a poor use of taxpayer/Medicare money but potentially so are very short stays. If people are only in hospice a couple of days, that often means that they got very aggressive care - which usually means very costly care until close to the end. That’s one thing if such care was what the patient/family chose. It’s another if the doctors never explained to the patient/family the likely prognosis, the likely outcome, the relative burdens and benefits of such care (and by “burdens” I don’t mean purely financial burdens). If Medicare paid for all that and then there is a mad dash for hospice to try to get pain and symptoms (physical and emotional) under control in the last few days, it’s neither good for Medicare’s bottom line nor does it give hospice the optimal circumstances for providing really good end-of-life care. Those last few days of life can be intensive for the hospice and a hospice with only very short-stay patients would be hard pressed to survive financially.
- How would small community and rural hospitals survive under some of the new payment models being discussed? Would they close? Get swallowed up by big chains? Both - i.e., first get swallowed up and then be closed because they aren’t as profitable?
- There have been several studies suggesting that patients who receive hospice care may live longer than similar terminally ill patients who do not. There was a whole spate of articles on this phenomenon back when Art Buchwald was dying – or rather when he was not dying. Most of the research I’m familiar with was on hospice care for specific cancers and heart diseases, not necessarily dementia, and not necessarily in the context of for profit hospice care for nursing home patients. But seriously ill people who get expert, interdisciplinary end-of-life care may bounce back, temporarily, and no longer fall in that six-month life expectancy category. If they really rebound, they should leave hospice care, as Buchwald did, with the right to resume it when the time comes.
- When asking whether there’s “too much” hospice care in nursing homes - don’t forget to ask what happens when there is not enough. This is the one area where I thought the Bloomberg story was incomplete – or even slightly misleading – by quoting a physician in Kansas as saying there should “never” be hospice in nursing homes. There is a lot of data – in peer-reviewed journals and medical conferences produced by academics and palliative care experts and nonprofits, not by the “industry” – that pain is poorly controlled in nursing homes, that there is overtreatment (feeding tubes being a prime example) of late-stage dementia patients in nursing homes, and that nursing home patients who could benefit from hospice/palliative care are instead sent repeatedly – often via costly ambulance-to the hospital. I met one doctor who called this care model “Our Lady of Perpetual Hospitalization.” This is a piece of the readmission issue that the health care reform law aims to address. There’s no room here to go into the convoluted mismatched incentives regarding nursing home care, but suffice it to say the revolving door won’t stop without quality end-of-life care in nursing homes – and nursing homes are often surprisingly ill-equipped to provide quality end of life care. Accountable Care Organizations, advanced medical homes, home and community based alternatives to institutional care, all part of health reform, may play a role here in coming years but it’s not going to be an overnight change.
- Hospice was not designed to be a substitute for, or side door to, Medicare-financed long-term care and it’s not the right way to pay for long-term care. Unfortunately, we don’t have a good way of paying for long-term care, nor for helping family caregivers.
- I’ve heard some rumblings – and it’s not a story I’m in a position to chase right now but may be worth looking into locally – that some groups or individuals are starting small nonprofits, specifically to flip them fast in sales to the big chains and make a lot of money. The Bloomberg piece reported on the recent uptick in acquisition of nonprofits.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. Finally, for now at least, remember that most hospice care takes place at home, with family members as caregivers. But not all terminally ill people have family members alive, or living nearby, or hale and hearty enough themselves to provide that care at home. For them, at least for some of them, the nursing home IS “home,” and that’s where they will access hospice.
Update: Just after I finished writing this blog post, Bloomberg and Kaiser Health News wrote about a big fraud case against a hospice chain based in Arkansas, and updated the status of other investigations.
- Bloomberg: AseraCare Hospice Accused by U.S. of Defrauding Medicare
- KHN: Lawsuit Accuses Company Of Fraudulently Cycling Patients Through Nursing Homes, Hospice Care
Tsouderos looks at federal funding of alternative medicine
Filed under: Government, Health care reform, Health policy, Hot Health Headline, Pharmaceuticals, Public health
In her latest series, Chicago Tribune reporter Trine Tsouderos, whose award-winning reporting has brought her hard-nosed approach to investigating less-proven areas of medicine, which will be familiar to many members, to bear upon the federal government.
This time, her target is the National Center for Complementary and Alternative Medicine, which she calls “a small, little-known branch of the National Institutes of Health … launched a dozen years ago to study alternative treatments used by the public but not accepted by mainstream medicine.” According to Tsouderos, the center has spent $1.4 since its inception, some of it on curious projects.
A Tribune examination of hundreds of NCCAM grants, dozens of scientific papers, 12 years of NCCAM documents and advisory council meeting minutes found that the center has spent millions of taxpayer dollars on studies with questionable grounding in science.
You’ll want to read it for yourself, but highlights include sentences such as “The cancer treatment involving coffee enemas was based on an idea from the early 1900s, and patients who chose to undergo the risky regimen lived an average of just four months” and “Thanks to a $374,000 taxpayer-funded grant, we now know that inhaling lemon and lavender scents doesn’t do a lot for our ability to heal a wound.”
It’s not all just cherry-picking wacky studies, of course. Tsouderos also looks deep into the powerful alternative medicine industry as well as the scientific rigor, or lack thereof, that sits at its core.
What do you wish you knew about covering health reform?
You’ll notice today that we have launched our Core Topic pages on health reform to offer helpful reporting resources.
Joanne Kenen is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. One of the features is something called Shared Wisdom, where we tap into the insight of our members on some new ground, on a specific reporting angle or a coverage hurdle.
I will seek out these words of advice from you every so often and also welcome your questions for the brief insights you are seeking.
My first question to you: Tell me – as a fellow reporter: “What’s the one thing you wish someone had told you during your first week on the health reform beat?”
Send your thoughts, preferably in just 100-300 words, directly to me at joanne@healthjournalism.org. I will pick out useful thoughts to highlight on the site. Thanks for your help.
Americans unprepared to pay for long-term care
Filed under: Aging, Government, Health care reform
In the Chicago Tribune, Deborah Shelton examines how unprepared Americans are to pay for their own long-term care needs as they age. Long-term care tends to slip under the radar because, as one of Shelton’s sources told her, “People buy insurance for their life because they know they are going to die, for their car because they know that can get in an accident and for their health because they know they can get sick, but people don’t tend to buy insurance because they think they are going to need someone to help them take a bath.”
Long-term care encompasses everything from nursing home fees to in-home assistance with everyday routines. It all comes with a price tag; Medicare only covers a limited amount and Medicaid programs apply only to those below certain economic thresholds. That leaves the middle class, who can’t afford the services but don’t really qualify for Medicaid, in the lurch, Shelton writes.
Most people assume Medicare will pay the bills, but the program covers long-term care only under certain conditions and for a limited time. While Medicaid covers long-term care, beneficiaries have to be poor or willing to “spend down” their assets to be eligible. Private insurance can be expensive and excludes applicants with serious medical problems.
As a result, many families pay out of pocket until they exhaust their resources and then turn to Medicaid.
The Affordable Care Act attempted to fill in the blanks, but long-term care provisions of that reform plan withered under intense cost pressure.
An initiative that would have incorporated long-term care into the Obama administration’s health reform plan was scrapped in October after actuaries determined that it would not be financially self-sustainable over the long haul. The Community Living Assistance Services and Supports Act would have created a voluntary, self-funded, employer-based insurance option to help people save for long-term care.
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