Health care reform will not pass our test. . .
* It will not provide basic security. . .
* It will not provide universal coverage. . .
* It will not be comprehensive. . .
* And it will not control costs. . .
Unless it includes real long term care.
Alzheimer's Association, 1994, p. 1
Health insurance has traditionally paid for acute care because employers, the largest payers of private health insurance premiums, have generally only been willing to contribute to the health care of their workers as long as they were employable.
Griss, 1994, p. 8
Social workers watch with guarded optimism as the much-heralded congressional debate on health care reform approaches its prolonged crescendo. As of the Memorial Day recess, with basic issues such as employer mandates and the standard benefit package yet undecided, it seems certain that the final legislation will overlook many critical needs. But given this historic opportunity, one provision in President Clinton's Health Security Act (HSA) bill, on a subject addressed by several of the articles in this issue of Health & Social Work, is of particular significance to social workers in health care: Long-term care will remain in urgent need of national policy attention whether health care reform legislation addresses it or not.
WHERE ARE THE LONG-TERM CARE REFORMS?
The health care needs of disabled people, frail elderly people, developmentally disabled individuals, and people with chronic mental illness are largely social and supportive, not acute and curative. It is estimated that between 9 million and 11 million Americans of all ages--one in 20--suffer severe chronic disabling conditions requiring help with one or more activities of daily living (ADLs) (U.S. Bipartisan Commission on Comprehensive Health Care, 1990). The vast majority receiving care live in the community, but approximately 1.6 million elderly people and 700,000 nonelderly people live in nursing homes and other facilities that provide 24-hour care (White House Task Force on Health Care Reform, 1993). By 2030 these numbers are expected to more than double as our population ages. At least another 7 million Americans--spouses, adult children, other relatives, friends, and neighbors--provide unpaid assistance to noninstitutionalized elders at any given time (Stone & Kemper, 1989). The catastrophic costs of long-term care are the single largest reason for personal bankruptcies, affecting over 1 million persons per year (Halmandaris, 1994). The health care concerns of these Americans involve not only obtaining medical treatment, but also living and coping with diseases and disabling conditions. An insurance approach usually fails to address social and personal needs. The lack of attention to long-term care is embedded in the nature of our discourse about health care and its reform, as well as in the economic paradigm used to analyze its costs.
Long-term care is an afterthought, an add-on, perceived as a costly "benefit" in health care reform considerations. It does not fit the American indemnity model of private insurance and is therefore considered nonessential. One of the persistent symptoms of the acute-care bias in our health care system is that acute and long-term care are separated in most health insurance coverage. Long-term care is of little interest to employers or to physicians, who have financial incentives to over-specialize in acute-care treatments, so both prevention and long-term care are shortchanged (Griss, 1994).
The current policy paradigm assumes that if not by government or insurance, long-term care will be provided by someone; that "someone" is families and, loved ones--80 percent of whom are women--who provide care "for free." Thus, in-home care and community care are usually considered by economic analyses to be "costless." The considerations are full of catch-22s.
Several of the bills now slogging their way through Congress claim to address long-term care, but only the President's Health Security Act bill and the Single Payer bill sponsored by Senator Paul Wellstone (D-MN) and Representative Jim McDermott (D-WA) have detailed these provisions sufficiently to estimate their costs. …