BY: DAVID DURENBERGER and DALE THOMPSON
Mr. Durenberger is chairman, Citizens For Long Term Care, and a former United
States senator (R-MN, 1978-1995); Mr. Thompson is executive vice president,
Benedictine Health Systems, and vice chair, Citizens For Long Term Care.
To Achieve Significant Change, A Functional National Approach Is Needed
The great debate of the 2000 presidential primary and general election
revolved around candidates' plans to make significant changes to the tax
and Social Security systems that have evolved in America over the last 65 years.
Both the Democratic and Republican presidential candidates committed to an income
tax cut and major reforms of Medicare and Social Security. Reformation of these
two great national entitlement programs is being driven by the increasing cost
of quality of life for a growing number of people with disabilities caused by
age, chronic illness, accident, or development. This situation presents Congress
and the president with an unprecedented opportunity: To commit to reforming
our nation's income and health security policies and closing the gap for
the 38.7 million uninsured individuals and the 94% of Americans without insurance
for long-term care. Many advocates for long-term care financing reform and experts
in health and retirement security see the reform debates surrounding Medicare
and Social Security as important opportunities to interject long-term care financing
reform into the growing health/retirement security debate.
Long-term Care in the Entitlement Reform Debate
Life's most critical hazards are those that unexpectedly reduce sources
of income, significantly strain financial security, or greatly affect health.
What has emerged to help families protect their financial security is a base
of social insurance upon which private insurance and publicly encouraged deferred
compensation arrangements have been built. For most people, financial security
is principally derived from earnings and then Social Security, Medicare, and
employer-provided pensions and benefits, all of which seek to help protect individuals
and families from unexpected risks associated with health or loss of income.
These benefits, as well as other savings mechanisms, are administered through
public programs supported by tax dollars and are, in a sense, social insurance.
Most of this structure is for workers and their dependents; however, a safety
net of public assistance exists, both for those workers who were unable to adequately
save or acquire insurance and for those who did not or could not work. The safety
net of public assistance has become the default financing system for long-term
Long-term care has never been factored into our national social insurance programs
as a possible threat to financial security. When Social Security and Medicare
were established, long-term care as we know it did not exist. People in need
of support often received care from a family member or were institutionalized
in state and local "homes," "schools," "institutes,"
or other large facilities where medical technology did little to enhance the
quality or increase the longevity of their lives. A fortunate few found institutional
care in religious-sponsored institutions. Except among some religious sponsors,
the professional long-term care industry as we know it had not developed, and
the cost of care was significantly lower. As we enter the 21st century, the
continuum of care is significantly different — people live longer, better
lives and have a much wider array of choices of how and where they want to receive
care. Unfortunately, financing mechanisms have not kept pace with the progress
The emerging debate on entitlement reform presents the greatest opportunity
to address long-term care financing since the Clinton administration undertook
comprehensive health care reform in 1992. By including this issue, policymakers
have a golden opportunity to do several beneficial things:
- Enhance the economic and health security of all Americans
- Restore function to a system that has become increasingly dysfunctional
- End the politics of Medicare, Medicare reimbursements, and Medicaid long-term
- Deal with the "new uninsured"
Why does long-term care financing belong in the Medicare and Social Security
debates? Think about Medicare, Medicaid, and Social Security. Medicare and Medicaid
are not health programs. They simply provide financial access to health and
medical services. They appear to be health programs because of the administered
pricing system the government has chosen to use. This system has dictated practice,
terms of access, and provider behavior since the inception of these programs.
Medicare is an insurance program that finances care and in doing so helps preserve
the economic security of our nation's elderly.
Is Social Security or Social Security disability insurance a health program?
No. But people have used income from these programs to purchase prescription
drugs, supplemental insurance, and long-term care services. As people get older
and their needs evolve, Social Security and Medicare achieve the dual purpose
of providing the resources to pay for health care needs and thereby helping
to ensure their financial security. By providing a defined health benefit under
Medicare and a defined contribution through Social Security, people have the
ability to survey their needs and purchase additional protection if they believe
such protections are warranted. Additionally, private insurance companies have
the ability — based on the knowledge that the Medicare benefit is constant — to
develop private financing mechanisms that supplement current benefits and are
However, Medicaid, which finances a majority of all long-term care, does not
act as an insurance program for long-term care. Rather, it is a financing program
only after a certain economic floor has been breached. Neither a defined benefit
nor a defined contribution exists upon which people can build to protect themselves.
People must turn to the private insurance market early in life — most often
before they are aware of the potential risk — to purchase a product most
deny they will ever need. And although last two Congresses have debated the
issue, currently no tax incentive exists for the purchase of long-term care
Private insurance, however, is not the right product for everyone, and not
everyone is capable of qualifying for long-term care. As a result, we must begin
to look at additional financing mechanisms to assist individuals and families
who help care for loved ones.
The Framework for Reform
In July 2000, Citizens For Long Term Care began a process of deliberation among
nine large long-term care groups to try to establish a framework for long-term
care financing reform that would be incorporated into our national economic
security system through a program of private and social insurance. The groups
involved represented providers, insurers, consumer advocates for the elderly
and disabled, and unionized workers — all of whom were committed to finding
a better financing system.
In April 2001, Citizens For Long Term Care released a paper developed through
this process of deliberation. Defining Common Ground: Long Term Care Financing
in 2001 built on the conclusions of the Pepper Commission and developed
a framework that the diverse organizations in Citizens For Long Term Care could
support. The major conclusions of the paper stated:
Citizens For Long Term Care agrees that there must be a new social insurance
benefit that finances a minimum floor of financial protection combined with
a program of incentives for the early acquisition of private insurance. The
social insurance component would provide a new floor of protection for all
based on functional need with appropriate eligibility and benefit level standards
and requirements. Public assistance must be available to ensure that those
whose needs exceed all other public and private resources are helped.
Building on these statements, Citizens For Long Term Care made a variety of
conclusions that reinforce why financing reform needs to be included in the
entitlement reform debate. Citizens statements include the following:
A new social insurance cash payment benefit, with appropriate eligibility
and benefit level standards and requirements, must be based on the level of
functional need and provide a minimum floor of protection in a way that is
sufficiently flexible to best help disabled individuals and families meet
their unique circumstances.
Citizens believes that such a benefit system could be built on the existing
structures of either our Social Security or Medicare programs, thus avoiding
the need to develop an entirely new program or infrastructure. The current Social
Security disability insurance program is an example of a cash benefit program,
which provides resources to people to help maintain economic security in times
of disability. Citizens proposes a cash benefit based on functional disability
so that individuals will receive assistance commensurate with their level of
disability — in an effort to avoid the permanent impoverishment that often
besets people born with developmental disabilities. Citizens also believes that
a system that is as flexible as possible will help meet the different and changing
needs of individuals and will also ensure appropriate consumer choice in settings
across the continuum of care. Two people with the same level of functional need
should receive the same level of assistance but be able to use that assistance
To commit to developing a cash benefit system for long-term care financing
that most logically fits within the social insurance system, Citizens recognized
that portraying the size and scope of the long-term need is important so that
we can estimate the cost of the issue. To do this, the Medicare system must
first be reformed to more adequately cover chronic illness. Citizens states
Medicare must also be reformed in ways that ensure more beneficiaries are
able to either avoid or delay the onset of chronic and disabling conditions.
In addition, Medicare must better define the difference between chronic health
care and long-term care services so that the health needs of those with chronic
conditions are better met.
By reforming Medicare to better address, manage, and avoid chronic illnesses,
Citizens believes the possibility exists for a decreased utilization of expensive
skilled nursing care. Moreover, because it currently does not adequately address
chronic illness, Medicare forces many people into the long-term care system
who otherwise do not belong there. This occurrence causes unnecessary use of
limited long-term care services and dollars and inflates the cost of a solution.
A Medicare system that treats chronic illnesses will reduce the strain on the
long-term care system and will present an accurate snapshot of what a limited
cash payment benefit will cost the federal government.
The Role of Values in Financing Reform
To truly overhaul long-term care financing, we will need to expand on and reinforce
those values that the Catholic Health Association has long advanced. Among the
defining values of Catholic health care are:
- Commitment to promote and defend the dignity of every human life
- Preference for poor or marginalized
- Health care that is holistic, including attention to the spiritual needs
of the person
- Commitment to the common good
- Commitment to be responsible stewards of resources
- Commitment to offer health care as a service to those in need
By transforming our current system to one that recognizes long-term care as
an integral part of economic security, we will avoid marginalizing people when
policy forces them to impoverish themselves and their families. A financing
system that is integrated into our economic security system will help provide
the resources that allow people to access the necessary services where and when
they need them, thus assisting people to serve mind, body, and spirit.
Finally, transforming our financing system will further Catholic health care's
commitment to the common good. It will help providers and caregivers continue
to deliver quality health care. It will help those in need access services without
impoverishing themselves, and it will help society develop and deploy the resources
to ensure the necessary care of our most fragile citizens.
No easy or inexpensive solution exists. Many people would like to ignore the
problem and hope it goes away; unfortunately that will not happen. We can hope
that advances or possible cures for chronic illnesses such as Alzheimer's
or Parkinson's will dramatically reduce future long-term care needs, but
people will always need long-term care for accidents or developmental and age-related
disabilities. By recognizing the need to discuss long-term care in the context
of the developing entitlement reform debates, we hope to make Medicare more
responsive to chronic illnesses to better define the long-term care system and
give policymakers a better defined need that must be filled.
With a better defined long-term care system, policymakers can develop a limited
social insurance benefit that will work in conjunction with tax incentives for
private financing mechanisms to provide the necessary coverage. When and if
this occurs, long-term care financing will be fully integrated into our national
economic and retirement security system.
Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.