Douglas Wolf is a demographer, policy analyst, program evaluator, and gerontological researcher with many years of experience studying the economic, demographic, and social aspects of aging and long-term care. He co-edited RSF's free e-book, Universal Coverage in Long-Term Care in the United States.
Q: As its title suggests, Universal Long-Term Care Coverage concerns itself with America’s long-term care sector – an area usually relegated, you write, policy wilderness. Why don’t we talk more about long-term care? Why isn’t it higher on the national agenda?
A: Actually, I think we do talk about long-term care quite a bit. As our chapter points out, scholars have been writing about a "long-term care crisis" for decades, and more-or-less sweeping proposals for a comprehensive public long-term care program have been put forward periodically for decades as well. And the mass media is full of stories about the difficulties faced by those in need of care as well as by the family members engaged in providing care.
What is surprising is that the widely-reported (and widely-experienced) problems of coping with long-term care needs don’t seem to get connected to the ideas about comprehensive programs, producing pressure to actually do something. Part of the reason must be that it will cost something—a lot, actually—to provide the services that people want, and that implies a need to raise funds, and that, in turn, comes up against a stubborn unwillingness to raise taxes, even when the taxes would be earmarked for services that people want. So a large minority of the population ends up paying a lot—including off-the-books payments in the form of uncompensated care hours and psychological stresses—for care received or given, while the population at large doesn't have to pay the much smaller costs of supporting a universal, actuarially-fair long-term care insurance program. Another part of the reason may be (as many people have speculated) that people think that Medicare covers those services, when in fact it doesn’t. I suspect that many people are surprised to discover just what it takes to get Medicaid-funded long-term care services, despite the many advertisements for "estate planning" and "elder law" services.
Q: In the concluding chapter of the volume, you and your co-author Nancy Folbre write: "Our current system of long-term care is fragmented, inadequate, and inequitable…" What are some of the glaring problems you think we need to face and reform about long-term care – Is it affordability? Access? Or something else?
A: The "fragmented" and "inequitable" parts of that statement can be tied most closely to the huge geographic variation in patterns of long-term care eligibility and service use. People’s care needs are met in a wide variety of ways, including: by themselves (i.e., self-care); by family, friends, or neighbors; by paying for private services (with or without private insurance coverage); by in-home Medicaid-financed care; by institutional Medicaid-financed care; and often by combinations of these various care modes. And, of course, some of the needs aren’t met. This "fragmentation" of care arrangements isn’t, by itself, evidence of inadequacies of the system (it could reflect different preferences, for example). But the fact that the opportunities for care that people face differ so much from state to state is a problem. For example, for those with relatively modest care needs, in-home care may be sufficient; however, according to a June 2012 factsheet produced by the Kaiser Family Foundation, the percentage of long-term care spending going to home-based services ranges from 16% (in Mississippi) to over 90% (in New Mexico). Differences this great are probably not due just to differences in preferences. Medicaid-funded services are limited to the poor, and means testing takes both assets and income into account; however, there are large differences across states in the restrictiveness of income-eligibility standards. There is evidence that attempts to control Medicaid costs through the setting of reimbursement rates (e.g., payments to nursing homes)—another feature that varies a lot across states—can lead to reduced access to services among those eligible for them. A good indication of “inadequacy” is the existence of long waiting lists (for example, the same KFF report says that in 2010 there were over 400,000 people on waiting lists for home-based care, in 39 states).
Q: One major victory for long-term care activists came with the passage of the CLASS Act, which calls for a public, voluntary long-term care insurance program. Its implementation was suspended in 2011, however, after the Obama Administration called it unviable. What went wrong?
A: The chapters by Howard Gleckman and Robert Hudson have a lot to say about this. There are many answers to the question, and much room for disagreement about what is the “right” answer. A simple answer is that the legislation specified a number of mandatory program features that, taken together, created mutually incompatible requirements. So, you could say that requiring uniform premiums was the problem; or, you could say that allowing those already eligible (with respect to need for care) to obtain services after a relatively short vesting period was the problem. Press coverage of the Administration’s decision to suspend the implementation of CLASS suggested that there was internal dissent – it seems that some of those engaged in the implementation process felt that the problems of CLASS could be “fixed” within the constraints imposed by the legislation; we may have to wait for some memoirs or investigative journalism to clarify that. Our chapter basically argues that making the program voluntary rather than mandatory (i.e. universal) was the problem.
Q: Going forward, do you think there are ways to improve upon the CLASS Act? Or do you feel that, because it is based on a voluntary system, that it would be better to look to other models for future policies?
A: Our chapter does suggest several ways to tinker with CLASS, while retaining its voluntariness. But I think it is fair to say that these suggestions represent ways to get around voluntariness – for example, broadening the set of employees that would have to actively opt out of paying the premium (and hoping that they won’t expend the effort that it takes to opt out). I would certainly prefer to see a successful campaign of leadership intended to (1) get people to realize the substantial risks they face with respect to long-term care needs, (2) get people to accept the fact that the sorts of services (and service settings) they would want, if they ended up needing them, cost money and therefore must be paid for, and (3) bring people around to a shared view (or at least a majority view) that a broad-based taxpayer-supported program is the best way – probably the only way – to get there. There certainly are models for that (see Mary Jo Gibson’s chapter about Germany and Japan).
Q: Your volume ends with a brief defense of the benefits of universal coverage. Do you think universal long-term coverage will have to be driven by a public program, like an extension of Medicare? Is there room for private insurance in your ideal scenario?
A: In principle, universal coverage can be achieved using private insurance; the Patient Protection and Affordable Care Act does that through its purchase mandate. To me one of the most striking things about CLASS is that it contained ONLY a "public option" – a government-operated insurance company – despite the fact that CLASS was passed along with PPACA, where a public option was so strongly opposed that its inclusion wasn’t really even attempted. I don’t have my own fully worked-out “ideal scenario” plan, but I think I’d lean towards a plan in which a great majority of long-term care needs are met through a mandatory public plan, but that private insurance is available to those who want (and can afford) it, to cover the rest (this would be analogous to "Medigap" coverage). For me the real trick is to figure out a long-term care program that somehow preserves the family role in care provision, without penalizing recipients of informal care (or providers of informal care) by, in effect, making them pay twice—once through their premium payments (aka “taxes”) and once through their private efforts. One program feature that could be incorporated into the universal-coverage ideal scenario is “cash and counseling” (in Europe, “cash for care”), which turns an in-kind benefit into cash that can be used at the beneficiaries’ discretion, for example to pay informal caregivers.
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