ISES and Manhattanville
Host Joint Conference on Long-Term Care Crisis

"Everyone has a plan, but everyone’s second option is always to do nothing," said Stuart Altman to those attending a Conference on Long-Term Care. The event, jointly sponsored by the Institute for SocioEconomic Studies and Manhattanville College, was held on the college campus in Purchase, New York, on April 24th.

In a keynote presentation, Altman, an economist specializing in federal health policy and a Presidential appointee to the Bipartisan Committee on the Future of Medicare, compared America’s impending crisis in long-term care to the debate over the uninsured still playing itself out in Washington, DC.

A former deputy assistant for planning and evaluation at the Department of Health Education and Welfare, Altman retraced the history of Medicare and Medicaid, emphasizing the lack of planning that went into the Medicaid law when it was originally developed. He indicated that many of the problems associated with the program, including the transfer of assets to qualify for benefits, stemmed from its having been created as a footnote to Medicare. No one ever imagined, said Altman, "that almost over night, Medicaid would become long-term care insurance."

Altman described roadblocks to the adoption of policies for long-term care concerns, explaining that policy discussions in Washington typically involve four groups, from among which a majority of each must reach consensus before any plan can be adopted. In terms of this debate, a quarter of the American people believe that individuals should finance their own future long-term care; another quarter feel that Medicaid eligibility requirements should be changed to allow the middle class to qualify without cheating the system; a third quarter who argue that private insurance should be expanded; and the remainder do not see long-term care as a problem to be concerned with.

Altman stressed the importance of compromise on the policy front, suggesting that the best remedy would combine an expansion of private insurance with a merging of government and private financing. "The subject definitely needs to be addressed," he said. "By 2030, the number of people over 65 will have doubled."

Panelists

Catherine DeLorey

Catherine DeLorey, director of the Health Care Management Program at Cambridge College and a former national president of the Gray Panthers, opened the proceedings with a definition of long-term care and an overview of the types of individuals who benefit from these services. She emphasized that although most Americans equate long-term care with the elderly, the program also supports many other groups, including individuals with respiratory diseases and young people injured in serious accidents or with multiple handicaps who can no longer be cared for at home by aging parents.

DeLorey pointed out that long-term care is an issue of particular importance to women. Not only do women make up 60% of the 35 million people over 65, but 75% of all caregivers are women.

Further, DeLorey stressed that "long-term care does not function in isolation," but as a virtual microcosm of the larger healthcare system. She noted that, as a result, the ethics and values of a society are often reflected in the way it responds to the needs of its elderly. "People must open their eyes and look at long-term care from a systems perspective," DeLorey said. She suggested that innovative means of coping with long-term care concerns could be developed if questions involving peripheral issues such as housing and companionship, in addition to healthcare, were examined.

Walter Cadette

Walter Cadette, a senior scholar at the Jerome Levy Economics Institute at Bard College and an adjunct professor at Columbia University, discussed the financing of long-term care, explaining how the lack of a concrete financing structure has led many to rely on Medicaid. Cadette stressed that under the current system, "government is the big payer," footing about 75-80% of the bill for long-term care.

Cadette noted that an unfortunate side effect of reliance upon Medicaid is the diversion of funds away from the indigent population the program was intended to support. At present, only about 50% of those who fall below the poverty line receive Medicaid benefits.

In addition, he indicated that asset ceilings make it incredibly tempting for many middle class elderly to pass the cost of long-term care on to Uncle Sam by transferring assets to their families so as to qualify for Medicaid. He noted that easy access to Medicaid benefits, combined with the high cost of private insurance, has limited the effectiveness of policies designed to shift the burden of long-term care costs away from the government.

Cadette suggests that tightening Medicaid eligibility requirements by lengthening the "look back" period and outlawing estate-planning services that help the elderly to complete asset transfers would go a long way toward reforming the current system.

Thomas M. Cassidy

In a more personal approach to the subject, Thomas Cassidy, a senior fellow at the Institute for SocioEconomic Studies, discussed the importance of elevating the status of many professionals working within the field of elder care. Cassidy, who worked as a New York State health care fraud and patient abuse investigator for 20 years, emphasized that his years of experience have allowed him to conclude that overall "we’re doing a pretty good job in taking care of our elderly." He added that nearly 65% of elder care needs are being met by family and friends.

Despite the need to improve the quality of care provided by a small number of nursing homes, Cassidy applauded the efforts of a vast majority of caregivers, characterizing them as deeply committed to meeting the individual needs of their patients. These "quality, compassionate caregivers are the key to building a strong system of elder care," he said. "We need to build upon some of the lessons that we have already learned and work to increase the prestige and financial resources associated with caregiver positions."

Cassidy also touched on the financing of long-term care, outlining an incentive-based plan being developed by the Institute. Designed to increase the number of persons who pay at least part of their costs for long-term care with private resources, the plan would look to combine the Dollar-for-Dollar model used by Connecticut and several other states with the Total Assets model employed by New York. It would allow consumers to fund long-term care with any combination of private resources and/or long-term care insurance.

 Under the plan, consumers who paid for three years of nursing home care or six years of full time home care would be eligible to protect any remaining assets from the resources counted toward Medicaid eligibility. All seniors, including those with the most limited resources, would be encouraged to participate in this plan, which would have no mandatory physicals or premiums, and would not exclude preexisting conditions. According to Cassidy, the Institute’s plan—by giving consumers an incentive to save for their own long-term care needs and removing the disincentives to saving inherent in the current system—would actually cost less than existing programs, allowing the government to preserve valuable resources.

The Conference was moderated by Richard Berman, president of Manhattanville College, and featured a brief opening address by ISES president Leonard Greene. Both men emphasized the importance of the topic and characterized the Conference as a valuable forum for the discussion of ways to head off the impending crisis.