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.
"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.