Every once in a while, we're struck by a "reality check" that demonstrates the implications of an important public policy decision. Such an event occurred in late October after the Obama administration decided to rescind the Community Living Assistance Services and Support (CLASS) program from the Patient Protection and Affordable Care Act (ACA). As reported Oct. 14 in the New York Times (Pear 2011), CLASS--which was intended to help reform our dysfunctional system of long-term care--died a quiet death whose cause ostensibly reflected its financing realities as well as hostility toward the program from opponents of the ACA.
As some may recall, CLASS was meant to establish a voluntary insurance program for the purchase of non-medical community living assistance services and supports for people with chronic illnesses, functional limitations, or severe disabilities. Although CLASS was proposed to support community living for those with severe disabilities, its financial assistance could also be applied to nursing home care. However, as the Times reported, CLASS never really stood a chance, and the administration decided to refrain from any heroic, life-sustaining efforts.
As if by design, the following Sunday Jane Gross (also writing in the New York Times) provided a poignant reality check that resonated with those mourning the demise of CLASS. Drawing from her own experience caring for her elderly mother, she brought into sharp relief the rather significant flaws inherent in the payment priorities of the current Medicare program. She cited the willingness of Medicare to allocate extensive resources to low-value--and at times painful and intrusive--care in the last stages of life, while noting the scant financial support for the kind of services that would likely be of great value to the elderly and their families, and by implication, available through CLASS. Gross pointed out that Medicare will pay generous amounts for such services as hip replacements for patients with advanced Alzheimer's disease and diagnostic tests, feeding tubes, and surgeries for elders in the last stages of life. She noted that such expenditures not only add to our national debt and deplete the Medicare trust fund, but do little to assist families who must devote significant monetary resources and time to care for frail elders. Citing her own case, she asked rhetorically: How many elders and their families could afford to spend a half-million dollars out of pocket to pay for the medical equipment, skilled home health services, and ultimately, quality institutional care to ensure appropriate care and dignity at the end of life?
Such a reaction points to the fact that as in prior efforts to reform our health care system, support for long-term care (LTC) remains a neglected and costly step-child. Our inability to harness public support for LTC services, either in the context of health reform, as a component of our social insurance system, or via the private insurance market, reflects a number of combined influences: the reliance on our means-tested Medicaid program to finance such care; the problem of adverse selection in insurance markets; and perhaps most seriously, an unwillingness to face the realities of our expected use of long-term care services as we age and as our life span lengthens. At the same time, the costs of financing LTC services, either privately or through the public sector, represent a singular challenge for families and for governments in an era of rising health care costs, stagnant family incomes, and weakened prospects for economic growth and public sector tax revenues. Together with the political discord surrounding the ACA, the demise of CLASS reflects several of these influences.
The Failure of the CLASS Act
As noted, CLASS was intended to fill a specific gap in our system of private and public health insurance: the lack of financial support for community-based LTC services. Structured as a voluntary insurance program, CLASS was to be financed by voluntary payroll deductions. …