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Just one more question

January 1, 2010
by Gary Tetz
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Like the great TV detective Columbo, Long-Term Living

columnist Gary Tetz (Funny You Should Ask) always has one more question. In this bimonthly feature, he talks with long-term care leaders about anything that pops into his mind. He's as surprised as you are that they'll speak to him, and apologizes in advance for whatever inanity he might blurt out in the pressure of the moment.

This Month's Victim:

Stephen Moses


Center for Long-Term Care Reform

Seattle, Washington


I don't know if he's part Mayan, but a lot of the scary things Stephen Moses predicts tend to come true. On the bright side, he hasn't said long-term care will end in 2012. Yet.

As president of the Center for Long-Term Care Reform, Moses roams the country promoting universal access to top-quality long-term care by encouraging private financing as an alternative to Medicaid dependency. He's widely considered one of the most influential people in long-term care, a status I have not managed to achieve. Yet.

Since serving as a senior analyst for the Inspector General of the U.S. Department of Health and Human Services in the late 1980s, Moses has played an active role in major legislation aimed at reducing Medicaid planning abuses. A noted speaker and prolific author, he has testified before Congress and most of America's state legislatures, which perhaps explains why he had no difficulty answering my questions.

Where are you this morning?

Providence, Rhode Island.

Remind me where that is. Can you see Russia from your hotel?

Not quite. I can see three states, but not Russia.

You're president of the Center for Long-Term Care Reform. Is that a place facility administrators can go to be rehabilitated and integrated back into society?

Yes, we try to get them on a 12-step process to recovery.

What are you doing in Rhode Island?

I'm working on a study of the state's long-term care financing system and global Medicaid waiver. Rhode Island is attempting to rebalance its Medicaid long-term care program from dominantly nursing home care to more home- and community-based care. This intrigues me, because I'm not at all convinced that it saves money to deinstitutionalize people. It's desirable. We want to do it. But most of the research shows that it doesn't replace nursing home care, it just delays it. And over the lifetime of a population it will end up costing more.

The way I would like to pay for more long-term care for all Americans is to preserve the scarce resources available under Medicaid, which is after all a means-tested*

An examination into the financial state of a person to determine eligibility for public assistance.

public welfare program, and make sure that public money goes to the people most in need. Now, many of the public resources go to the middle class and even the affluent because of the way the generous Medicaid rules work. And even if you don't qualify, there are always attorneys who specialize in impoverishing people artificially.

So I'd like to see if there's a way to use the increased flexibility under Rhode Island's global Medicaid waiver to target welfare benefits primarily to people most in need, and create stronger incentives for those who are still young, healthy, and affluent enough to save, invest, or insure for long-term care. Because Medicaid, for all intents and purposes, is insolvent.

That's essentially the speech you've been giving for more than 25 years.

Yes. And if they'd listened to me 25 years ago, we wouldn't be in the mess we're in now. They didn't, and we are.

You've basically been a roving prophet of doom.

Some people call me the Don Quixote of long-term care, but I've tipped over a few windmills in my time and more are soon to fall.

What has changed, if anything, over that time?

The message has been sent over and over again by the federal government that there is a limit to how much we can pay to cover long-term care for everybody. Unfortunately, they have not successfully restricted it yet. I am now convinced, after 25 years of beating my head against this problem, that it's not going to be fixed through responsible public policy. As a result, the whole entitlement house of cards is going to collapse as we hit a brick wall of fiscal reality.

I think you've called that a long-term care Armageddon.

(Laugh) Ah, you did your homework.

You've also used Niagara Falls to illustrate unfunded liabilities, and the Grand Canyon to show the financial hole this country is digging. Are you going to run out of metaphors at some point?

No, I have a boundless supply.

So what's going to happen?

The public has been totally duped into thinking they aren't at risk. The vast majority never think or worry enough about long-term care even to ask who pays. They don't know if it's Medicaid, Medicare, or Santa Claus-and they don't care. Whether you're poor, middle class, or even affluent, the government continues to pay for the vast majority of all expensive long-term care in this country, and that fact has enabled the public's denial.