Let’s start familiarizing policymakers about more difficult, more fundamental reforms
Most eldercare advocates in the United States are fully occupied pushing for effective allocations in the current reconciliation bill. This activity offers the opportunity to plant the seeds of Long-Term Services and Supports (LTSS) reforms that are not yet likely – but are worthy and important. So, yes, we need to argue strongly for Medicaid funds to increase pay and require benefits for direct care workers, and maybe we’ll even get a little funding for information infrastructure and some public education about long-term supports and services. In addition, let’s start familiarizing policymakers about more difficult, more fundamental LTSS reforms – just to start getting these included in the policy discussions. It’s said that an adult has to hear a new idea a dozen times before they start to make it their own!
What seeds should we be planting? I’d recommend serious work on financing for the long term, like the WISH Act. I’d recommend serious work on housing – let’s get affordable, disability-adapted, and services-connected housing widely available. This will require tackling restrictive housing regulations, building back better after catastrophes, and integrating supported senior housing into communities. I’d go for reforming congregate facilities of all sorts to be more home-like, smaller, and more often integrated into communities.
The categories that the United States uses for LTSS issues have created thoroughly dysfunctional silos, from the perspective of eldercare — medical care, behavioral care, custodial care, rehabilitation, community-based services, nursing homes, assisted living facilities, family care, personal care, homemakers, and so on. What we need is to live in communities where eldercare has been anticipated and planned, since most older adults end up needing most of the services now in silos. So, we could be planting the seed of the idea of generating a local entity that has data, authority, and some finances to set priorities for improvement, implement improvements, and monitor the performance of eldercare locally. At least, CMMI could sponsor a multi-year LTSS improvement trial in a couple dozen communities. Let’s see just how much better eldercare could be – more reliable, more equitable, more supportive of older adults and their families!
All members of ASA know that the United States has a wholly inadequate set of “arrangements” for supporting people who need long-term supports and services (LTSS), about half of whom are past retirement age. And they know the situation is on course to become dire within a decade, when so many in the Baby Boomer generation encounter the disabilities associated with aging.
Potential reforms abound—better pay and benefits for care workers, single point of entry to services, skilled physicians, integrated teams, comprehensive care planning and so on. But all of these reforms will be stymied if there’s no money, and the funding has to be sustained into the future—not just as a short-term fix.
To address this situation, Rep. Tom Suozzi (D-NY) has introduced a remarkable bill, the Well-Being Insurance for Seniors to be at Home (WISH) Act, which would create a social insurance trust fund to cover long periods of LTSS needs, thus making it possible for workers to plan responsibly for the risks of disability in old age.
How the WISH Act Would Benefit Everyone
The WISH Act has a great many good effects: reviving the long-term care insurance industry, reducing the need to spend down to Medicaid, saving state and federal Medicaid programs from dire financial consequences, providing a targeted supplement to Social Security at just the time the beneficiary needs it most, educating Americans about the need to plan for LTSS risks in old age, improving pay and benefits for caregivers, and more.
And it does all of this with a truly modest mandatory insurance contribution from wages—0.3 percent from workers, 0.3 percent from employers. Someone making $50,000 per year, about the median income in the country, would be paying $150 per year, or less than 50 cents per day.
THE WISH ACT REQUIRES A MODEST MANDATORY INSURANCE CONTRIBUTION FROM WAGES—0.3 PERCENT FROM WORKERS, 0.3 PERCENT FROM EMPLOYERS.
The trust fund would be separate from other trust funds and would require 40 quarters (10 years) of having earned the current equivalent of $5,600 per year to qualify for full benefits. Pro-rated benefits start at six quarters. The benefit would be enough to pay for a national average of about six hours of paid caregiving, or about $3,600 per month, paid in cash like Social Security.
To qualify for benefits, the worker must be older than full retirement age and either dependent in two or more Activities of Daily Living or sufficiently cognitively impaired to require nearly full-time supervision and assistance. This is the standard that most long-term care insurance plans use and is ensconced in the HIPAA regulations.
In addition, the person must have had this level of disability for a waiting period that depends upon their earnings record, while contributing to the WISH Trust Fund. Low-wage earners in the lower 40 percent of earnings would only wait one year, and those with higher earnings would add one month for each 1.25 percentiles above the 40th percentile.
For example, the median wage earner would wait 20 months, the 70th percentile person would wait three years, and the highest earners would wait five years. Once begun, the benefit is life-long. This strategy rests on two observations: first, the definition of catastrophic financial burden differs for workers with different opportunities to save, own homes, invest in insurance, and raise families to help; and second, the cost of LTSS does not differ much for poor or wealthy people.
IT IS REALLY THE LONG-RANGE PLAN FOR ELDERCARE FOR US ALL.
The upshot when fully operational is that LTSS would have an infusion of payouts that total around $100 billion per year (in current dollars). The bill includes substantial education about LTSS risks and costs, in addition to the obvious education of having money taken from your paycheck each payday. Many people would learn to plan ahead to protect their ability to manage during disability in old age, without bankrupting their families. Long-term care insurance providers will fill in the waiting period and the additional costs of LTSS beyond the WISH benefit with much more affordable and flexible offerings.
Let’s Not Repeat History, and Instead Take Action on the WISH Act
Many ASA members will remember the push for the CLASS Act, which was part of the Affordable Care Act but could not be implemented because the finances could not work with a voluntary enrollment. The need for something to address LTSS costs has persisted, and WISH is a thoroughly responsible response!
It does not address the urgent needs or the short-term reforms we need in eldercare, and it does not help current retirees or younger people living with disabilities (until their own old age, provided they’ve worked a little over some years, which is true of most persons living with disabilities in working age). It is really the long-range plan for eldercare for us all. If it had been enacted in 1990, we would not be looking at having enormous numbers of elders unable to afford housing, food and medical care within a decade.
Admittedly, we are late to act, but it’s time to stop pretending that we mostly won’t live into old age, or that most of us won’t need LTSS. The opportunity to grow old was still uncommon in the middle of the last century, when Medicare and Medicaid came into being. Having that longevity opportunity now, for most Americans, is a remarkable achievement. But it requires some changes in how we manage to pay for our needs, and the WISH Act would be a major part of that reform.
To get the WISH Act passed will require substantial public interest and support. Call your Congressman and Senator. Explain the importance of this Act. Ask them to co-sponsor. Let’s stop kicking that cursed can down the road!
The Ways & Means Committee of the U.S. House of Representatives heard testimony on “Caring for Aging Americans” on November 14. Dr. Joanne Lynn participated as an expert witness. A video of the hearing can be viewed at https://www.youtube.com/watch?v=20GgbnOMIn4.
Read Dr. Lynn’s comprehensive written testimony by clicking below.