Long-term-care reform must provide consumer choice while saving money

MOST of us have pretty strong opinions about who we share a bedroom and bathroom with, what time we get up in the morning and what we have for breakfast. Yet, when you find yourself in need of long-term care in this country, there is a good chance someone else will make these decisions for you. Indeed, choosing a nursing home may be the only decision that you can make on your own.

It is precisely because most states do not offer flexible, cost-effective home and community-based services (HCBS) that you may end up having less control over routine activities of daily life. So, as negotiations on health reform extend into the summer, it is vital that this issue — improving long-term care options for older Americans and people with disabilities — not be overlooked.

Recently, I participated in Sen. Maria Cantwell's listening session on health reform. Having dedicated much of my career here in Washington to the issue, I was heartened that the conversation addressed the need for long-term-care options that enable people to stay in their own homes or communities as they age. Cantwell is sponsoring two bills — S. 1256, the Home and Community Balanced Incentives Act, and S. 1257, the Project 2020: Building on the Promise of Home and Community-Based Services Act — that would expand access to HCBS and encourage other states to follow Washington state's lead.

The need is significant. About 11 million adults in the U.S. require long-term-care services — assistance with basic activities such as bathing, dressing, eating and taking medications. Many end up in nursing homes because home and community-based services are unavailable or unaffordable.

Long-term care is challenging from the caregiver's vantage point, as well. An estimated 34 million family caregivers help loved ones live at home at any given point in time. They provide care at great risk to their own health and financial security. Their annual unpaid contributions are valued at more than $375 billion. But they toil on, without sufficient support and resources to help them be better caregivers and take care of themselves.

Part of the problem is that Medicaid — which pays for half of all long-term services and supports in this country — has a strong institutional bias. While Washington has managed this bias by investing in home and community-based services (in 2007, the state spent 55 percent of its Medicaid funds on HCBS), this has not been the case elsewhere. Nationally, 73 percent of Medicaid spending on long-term care for older adults and adults with physical disabilities pays for more expensive nursing-home care while only 27 percent goes to HCBS.

Meanwhile, older Americans who cannot finance long-term care must spend down what resources they do have to qualify for Medicaid. And Medicare is not an option as it provides medical, hospital and prescription-drug coverage for older people but little in the way of long-term-care supports.

The current long-term-care system cannot possibly instill confidence among aging baby boomers. Nor is it working for the states. Medicaid long-term-care services represent an enormous cost for state governments, accounting for roughly one-third of the Medicaid budget. Most states struggle to find adequate revenues. It is not surprising that so many states are looking at reform proposals centering on home and community-based services.

The linchpin of long-term-care reform can be summed up in two words: consumer choice. The good news is that, courtesy of Cantwell and her colleagues, there are bills in the Senate that offer smart, compassionate long-term-care options, as well as incentives for states to build more robust and consumer-oriented long-term-care programs.

It's about time.