Academic journal article Generations

Can Medicare Be a Vehicle for Improving Coverage for Long-Term-Care Services and Supports?

Academic journal article Generations

Can Medicare Be a Vehicle for Improving Coverage for Long-Term-Care Services and Supports?

Article excerpt

Few issues have flummoxed policy makers more than how to address the need to improve coverage of long-term-care services and supports (LTSS). Two leading experts, Sheila Burke, adjunct lecturer and faculty research fellow at the Malcolm Weiner Center for Social Policy at the Harvard Kennedy School, in Cambridge, Massachusetts, and Judith Feder, founding dean and professor at the Georgetown University McCourt School of Public Policy and Institute Fellow at the Urban Institute, both in Washington, D.C., provide their perspectives on the role Medicare can play. Generations Guest Editor Tricia Neuman moderated this discussion.

Generations: Thank you for joining us to talk about long-term care services and supports, both the sad history of efforts to move forward, and the potential opportunities for progress. Let's start with the basics: what is the long-term-care financing challenge?

Sheila Burke (SB): The demographics that we're confronting suggest an increasing number of people over the age of 85 and fewer young people to care for them. The questions that have arisen are how, looking forward, we assist in the financing of those services and the right source of financing. Medicare has, in its history, been a traditional acute care program. We've largely looked to Medicaid or to personal funds as the source of funding for traditional long-term-care services. Today, that continues to be the method of funding and because much of this care is financed out of people's pockets and, in many cases, has impoverished them, there is a growing concern. Looking forward, given the aging of the population, the question is what role do public financing programs play, particularly in the context of Medicare?

Judy Feder (JF): The demographic challenge that Sheila emphasizes is exacerbating a long-standing problem in long-term care. We really have no insurance for long-term care. The need for expensive long-term care stems from an unpredictable catastrophic event. It's unpredictable for the under-65 population with disabilities, which constitutes 40 percent of the current population needing long-term services and supports. It's also unpredictable for people who are now turning age 65. Thirty percent are going to die without needing any services. Among the other 70 percent, there's tremendous variation, with 20 percent likely to need five or more years of care.

With that kind of unpredictability and variation, we typically have insurance. But for long-term care, private insurance doesn't work; health insurance doesn't cover it, and Medicaid provides protection only after financial catastrophe strikes. We have no mechanism that enables us to insure against a need for longterm services and supports. The problem this poses for individuals who need services, and for their families who provide the bulk of long-term care, is enormous.

SB: I want to draw on the reference Judy made regarding the family caregiver, the extent of informal services provided, and the fact that at least a good percentage of what occurs is not what we traditionally consider healthcare services. Support services are what allow people to remain independent and, in many cases, are really more social welfare or supportive services rather than traditional health services.

Frankly, the innovations that have occurred and the introduction of assistive technologies have raised a series of questions about what we need to finance and the best source of that financing. Such a huge percentage of what occurs today is informal family caregiving. To what extent do you want to formalize that in the form of some kind of reimbursement? As Judy points out, private insurance has not been the answer, and is not likely to be the answer, at least as many people believe.

JF: Sheila, let me pick up on a piece you raise, in terms of your overall description. Long-term care is not healthcare; it is not delivered by expensively trained professionals wearing white coats. …

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