Medicare-for-All

Stepchild of Health Care Now Getting Overdue Attention

People are living longer and the population of older adults is growing, but long-term care remains a stepchild in debates over health care. That is beginning to change as presidential candidates offer options for expanding long-term benefits for older adults and people with disabilities. With only a small percentage of older adults who have private long-term care insurance, the challenge and costs of expanded benefits are daunting.

People are living longer and the population of older adults is growing, but long-term care remains a stepchild in debates over health care. That is beginning to change as presidential candidates offer options for expanding long-term benefits for older adults and people with disabilities. With only a small percentage of older adults who have private long-term care insurance, the challenge and costs of expanded benefits are daunting.

Long-term care has been the missing link in health care reform debates, but that is changing as 2020 Democratic presidential candidates offer options for addressing the arguably biggest gap in the US health care system.

The Medicare-for-All plan introduced by Vermont Senator Bernie Sanders and supported by several Democratic presidential candidates adds long-term care benefits to Medicare. Independent estimates place the cost for expanded benefits at $25 trillion over 10 years.

A House version of Medicare-for-All, cosponsored by Washington Congresswoman Pramila Jayapal and Michigan Congresswoman Debbie Dingell, which emphasizes policies that allow older adults to remain in their homes. "Instead of saying institutional care is the default, we say you should be able to get care at home, in your community," Jayapal says.

New Jersey Senator Cory Booker recently unveiled a proposal to expand eligibility for long-term care services for older adults and disabled persons under Medicaid. Roughly 20 percent of Medicaid spending goes toward long-term care. About 65 percent of nursing home residents are supported primarily by Medicaid.

Minnesota Senator Amy Klobuchar has a “Plan for Seniors” that seeks to expand long-term care facilities, add hearing, vision and dental care to Medicare and support training for long-term caregivers. Klobuchar wants to bolster Social Security by lifting the payroll tax from the current $133,000 income cutoff to wages up to $250,000. 

Political dialogue about long-term care has been sparked by data showing projected growth in the number of older adults in the US population. By 2035, there are expected to be 78 million people 65 years and older compared to 76.7 million people under the age of 18. As few as 8 million Americans have some form of private long-term care insurance. There also has been a strong push by disabled Americans to strengthen long-term care.

Older Americans make up one of the most consistent voting blocs and they tend to be more conservative than younger voters. Democrats sniff an opportunity to eat into a bedrock conservative cohort by advancing long-term care initiatives.

AGE+,  a new nonprofit, has formed to address long-term care issues holistically in Oregon with an emphasis on aging in place and addressing equity for underserved older adults in rural areas and minority communities.

AGE+, a new nonprofit, has formed to address long-term care issues holistically in Oregon with an emphasis on aging in place and addressing equity for underserved older adults in rural areas and minority communities.

Providing long-term care benefits under Medicare or Medicaid will be expensive. The dimensions of the problem go beyond money. There aren’t enough long-term care beds available, there are too few single-story homes where disabled and older adults could age in place and there is already a shortage of trained caregivers. Add to that isolation that can occur, especially in rural areas, and inequities in available long-term care options. Low pay is a barrier to recruiting more caregivers.

Gerontology researched Marc Cohen describes long-term care as the stepchild in the broader health care reform discussion. Nicole Jorwic, policy director for The Arc that serves people with disabilities, says, “If you don't include long-term supports and services, it cannot be considered a bill that is for all people because it leaves out huge portions of the population, including people with disabilities and aging Americans."

 


Medicare-for-All Debate Reflects Voter Interest in Health Care

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Medicare-for-All has become a campaign battle cry, even though what it actually means is far from clear.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

First off, the Medicare-for-All version espoused by Vermont Senator Bernie Sanders isn’t actually an extension of Medicare, which now covers 50 million Americans, but would be phased out over four years. His bill contains provisions, such as coverage for long-term care, that aren’t covered now by the landmark health insurance plan created in 1965. Sanders is short on details of how to pay for more robust and costly benefits.

Most advocates of “Medicare-for-All” are expressing support for a single-payer system under which the federal government would assume the role of a giant, publicly funded health insurer. Sanders and others want to see expanded coverage for current Medicare enrollees as well as universal coverage. An enlarged pool of patients under a Medicare-for-All system would give government officials even more leverage to negotiate lower and more consistent pricing for medical services and prescription drugs.

Elimination of all private insurance, including insurance policies provided through employers, has been branded as “socialism” by Medicare-for-All opponents. For context, opponents said the same thing about Medicare.

Some Medicare-for-All proponents would like to see an expansion of Medicare eligibility and benefits, but not necessarily elimination of all private insurance, which provides coverage for 150 million American workers and their families.

Democrats who pushed through the Affordable Care Act (ACA) in 2010 made a similar political calculation, though they stopped short of including a “public option” that would have provided a government-sponsored health insurance plan. Instead, they opted for expanding Medicaid eligibility on a cost-sharing basis with states.

Some present-day Democrats, including House Speaker Nancy Pelosi who steered the ACA through Congress earlier this decade, still prefer an incremental approach as the logical and politically achievable next step towards universal health insurance. That might involve increased federal funding for Medicaid expansion, restoration of the mandate for everyone to have health insurance coverage or creation of some form of reinsurance pool to smooth out the cost of high-cost patients.

These variations, combined with 23 Democratic presidential candidates running around the country talking about health care while attempting to differentiate themselves from the herd, have created understandable confusion among voters. That confusion is compounded by continuing efforts by the Trump administration to take the ACA (Obamacare) off the books.

What’s clear is that some provisions of the ACA are very popular, notably preventing people with pre-existing conditions, often chronic illnesses or cancer survivors, from being denied affordable health insurance coverage. That has created a conundrum for congressional Republicans who tried unsuccessfully to repeal and replace Obamacare. Republicans express support for retain the pre-existing condition provision, yet they haven’t successfully landed on a larger platform to address health insurance access – and rising health care costs.

Beyond the debate over Medicare-for-All, health care in America is confusing. There are multiple public players (Medicare, Medicaid, Veterans Health Care, Indian Health Service, public health clinics, hospitals affiliated with public universities, public mental health clinics and public school clinics) and private players (for-profit corporations, nonprofit organizations, medical practices, medical laboratories, hospitals affiliated with private universities and integrated health care systems). 

The divide between health insurance and health care delivery is a blurred line. Many private health insurance policies come with their own networks that limit choice of medical providers.

Adding to this dizzying picture are soaring drug prices, with their own cast of characters that include pharmaceutical companies, pharmacy benefit managers, self-insured corporations, foreign-based internet retail outlets and prescription drug patent attorneys.

The end result is a health care system that is costly, suffers from a lack of coordination and isn’t equitable. One report concluded, “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.” 

Oregon has pioneered approaches to health care that respond to broader criticisms of the US system, or lack of a “system.” Under a federal waiver, Oregon has promoted increased in-home care for older adults and physically disabled persons that enables independent living and avoids more expensive institutional care. Oregon was among the first states to expand Medicaid eligibility, as permitted under the ACA, and has steadfastly defended that expansion despite rising costs.

Former Governor John Kitzhaber implemented coordinated care organizations serving low-income Oregonians to “bend the cost curve” through innovation and coordination. Since leaving office, Kitzhaber has pushed for investing to redress “social determinants” of health such as a lack of proper nutrition and early childhood education. Health care systems are striving to integrate physical and behavioral care to improve outcomes.

The Washington Legislature enacted this year a first-in-the-nation state-sponsored long-term care social insurance program. Under the program, Washington residents will pay 58 cents on every $100 of income, with the revenue flowing into a Long-Term Care Trust. Residents who pay into the fund for 10 years (three if a catastrophic disabling event) will be entitled to receive $100 a day up to a lifetime cap of $36,500. The money can be used for in-home care, installation of accessibility ramps, home food deliveries or transportation. The payroll tax is projected to generate $1 billion per year.

For many health care observers, actions such as Oregon’s and Washington’s are akin to bailing water out of a sinking boat. They call for a broader, more holistic approach to reform. That isn’t the same as calling for Medicare-for-All, which remains somewhere on the political spectrum between an aspiration and an abstraction.

What seems inevitable is that Americans have grown restive with gridlock as health care out-of-pocket costs and drug prices continue to rise much faster than inflation or wages. The 2018 mid-term election, which saw Democrats unseat GOP congressional incumbents and capture Republican-dominated seats, could be a bellwether of growing voter interest in tangible action on health care. Most prominent Democratic 2020 presidential candidates have apparently heard that message, which accounts for their support for Medicare-for-All or something like it that is significant and meaningful.