5 LTC commissioners propose alternative LTSS solutions

A compressed timeframe for study and the wide range of views held by members mean that the recommendations approved by a 9‒6 vote and preliminarily issued by the Commission on Long-Term Care Sept. 13 “do not fill its comprehensive charge,” according to a statement from one-third of the commission's members, who jointly have issued separate recommendations. The five commissioners issuing the alternative proposal are among the nine Democratic appointees to the 15-person body.

“We need a broad solution, and our recommendations include a social insurance program for long-term services and supports [LTSS],” says Laphonza Butler, president of the Service Employees International Union‒United Long-Term Care Workers and part of the splinter group. “A[n LTSS] system that does not take into account building and strengthening the direct-care workforce, provide meaningful support for family caregivers and improve current programs will be just another Band-Aid on a system that is increasingly strained as our population ages.”

The social insurance program could provide comprehensive or limited benefits, according to the five commissioners, and it would make “more manageable” the roles of private insurance, family financing and family caregiving, not eliminate them.


In addition to establishing a social insurance program, the dissenting group of commissioners recommend:

  • Ensuring that direct-care workers in all settings are paid a living wage, are well-trained and have opportunities to advance in their careers. (Subsequent to the release of the alternative plan, the U.S. Department of Labor issued a rule to change the “companion exemption” and bring home-care workers under minimum wage requirements.)
  • Addressing the needs of family caregivers and integrating them into a comprehensive LTSS system. Improvements could include reducing barriers to outpatient therapies, home health and skilled nursing facility care for Medicare recipients; the extension and streamlining of existing financial incentives to states for home- and community-based services for Medicaid recipients; the provision of tax-preferred savings accounts for disabled people currently not receiving LTSS through Medicaid—and their families; the expansion of the Medicaid buy-in program for workers with modest incomes; and the pilot-testing of a new program for significantly disabled workers who have higher incomes.

“We are convinced that no real improvements to the current insufficient, disjointed array of LTSS and financing can be expected without committing significant resources, instituting federal requirements and developing social insurance financing,” says Judith Stein, founder and executive director of the Center for Medicare Advocacy and one of the five commission members issuing the separate recommendations. “The people I represent are crying out for a real LTSS system.”

In addition to Butler and Stein, other commissioners issuing the alternative plan include:

  • Henry Claypool, executive vice president of the American Association of People with Disabilities;
  • Judy Feder, PhD, Urban Institute fellow and professor at the Georgetown Public Policy Institute; and
  • Lynnae Ruttledge, co-vice chair of the National Council on Disability.


The 15-member commission’s official approach to LTSS, supported by five of the six Republican appointees and four of the nine Democratic appointees to the body, included adding options for those who prefer to live at home, aligning goals toward person-centered care delivery and improving care coordination among acute care, post-acute care and LTSS, noted the commission’s summary of recommendations. It drew mixed reactions from those in the long-term care industry.

See related: Commission on LTC tackles tough issues but can't agree on financial support system

"While the commission did not advance a solution for financing [LTSS], [it] did call for continued attention to solving this problem," Larry Minnix, president of LeadingAge, said in a statement, adding that studies by the organization suggest that financing solutions exist.

LeadingAge praised the commission members’ support of family caregivers and direct care workers as well as technology. “Their recommendation to create a demonstration project to provide workers with disability coverage for the long-term care services they need to remain employed should be considered and quickly implemented as an initial step,” the statement said.

The commission’s lack of clear direction related to financing was a disappointment to the National Council on Aging (NCOA), according to a statement issued by the organization, but the NCOA blamed Congress rather than the commission. “Congress should establish long-term care subcommittees and create a permanent body…to address long-term care and its financing,” the group said.

The NCOA said it agrees with commission recommendations to promote community-based services, support family caregivers, improve the direct care workforce and enhance quality and will continue its work to devise bipartisan solutions to help those requiring LTSS and their families.

The AARP, in a statement, also said it was pleased that the commission appeared to value family caregivers and said its official report, although “far from perfect,” would “move us in the right direction toward a more person- and family-centered [LTSS] system.” The organization said it would continue to work at the state and federal level to help address the complex issues surrounding long-term care so that the needs of older and disabled citizens can be met.

The American Association for Long-Term Care Insurance said it was not surprised that additional decisions still need to be made related to long-term care, given the commission’s short timeframe to accomplish its goals and the politically charged environment in which it met. “However, the bipartisan support for approval of the report…is evidence that there is clearly no groundswell for another attempt at a government option along the lines of the CLASS Act,” the organization said in a statement emailed to members of the media.

If a commission-recommended advisory committee is formed, all interested parties will be able to discuss a private/public solution to service- and finance-related issues, the group added. “Both public and private entities and private insurers have a role to play, and that is positive news for the long-term care insurance industry.”

The Partnership for Quality Home Healthcare and the National Association for Home Care & Hospice issued statements commending the official commission report for recommending the expansion of home health services for long-term care.

A pre-publication version of the commission’s official report (PDF) is available online. Approving the report were Democratic appointees Javaid Anwar, MD, CEO of Quality Care Consultants and a practicing internal medicine physician; Bruce Chernof, MD (commission chairman), president and CEO of the SCAN Foundation; Carol Raphael, vice chair of the board of the AARP; and George Vradenburg, JD, chairman and co-founder of USAgainstAlzheimer's. Also approving the official report as issued were Republican appointees Judith Brachman, a Jewish Federations of North America board member; Stephen Guillard, president and CEO of Belmont Nursing Center Corp.; Neil Pruitt Jr., chairman and CEO of United Health Services‒Pruitt Corp. and board of governors chairman of the American Health Care Association; Grace-Marie Turner, president of the Galen Institute; and Mark Warshawsky, PhD (commission vice chairman), director of retirement research at Towers Watson. Voting against the report, in addition to Democratic appointees Butler, Claypool, Feder, Ruttledge and Stein, was Republican appointee Chris Jacobs, a senior policy analyst with the Heritage Foundation.

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