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Long-Term Care's Lone Realist Rides Again

March 1, 2005
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Interview with Stephen A. Moses, President, Center for Long-Term Care Financing
Long-term care's lone realist rides again
Interview with Stephen A. Moses, President, the Center for Long-Term Care Financing
Remember those thunderous hoofs of yesteryear bearing the mysterious Lone Ranger? Or perhaps you've heard of "the voice crying in the wilderness." Stephen A. Moses might be categorized both ways-or, if you're inclined to disagree with him, as a misguided scout pointing in exactly the wrong direction. There's no disputing one thing: Right or wrong, Steve Moses has for years been the lone voice publicly discussing the macro-issues of long-term care financing. Starting in the early 1980s, when he was an employee of the then Health Care Financing Administration (HCFA) and wondering why Medicaid, a program to pay for the healthcare of the poor, seemed to be turning into a nursing home entitlement program for everyone, Moses has been addressing complicated LTC policy issues head-on. He says he's for expanding private financing of LTC, most particularly through private insurance, not because he's particularly antigovernment or beholden to private interests, but because there is no other way short of a national financial meltdown. In September 2004, his Center for Long-Term Care Financing published The Realist's Guide to Medicaid and Long-Term Care, an impressive review of ten states' approaches to LTC financing. The report concludes that depending on several factors-most notably their Medicaid eligibility rules, estate recovery programs, and encouragement of private financing mechanisms-the states are at various stops along the way to financial disaster. Recently Moses discussed the Center's findings and prescriptions for improvement-and his personal frustrations as a policy advocate-with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: What was your purpose in publishing this ambitious 80-page study?

Moses: The purpose is the same as I've always had, since I worked for HCFA in 1983: to understand and explain why we have this mess, a welfare-financed, institution-based LTC system in a wealthy country where no one wants to go to a nursing home.

Peck: In the public forum, your voice has been virtually alone in discussing the basic issues of long-term care financing. How do you feel about that?

Moses: Very frustrated. I can't seem to wake up the insurance and provider industries to start informing the public about this problem. I've asked the academics to do the research, but they won't. Those who are involved in the public discussion have a stake in the status quo-whether it's Medicaid policymakers, Medicaid planners, or senior advocates, so they fight change. I guess the ones we really need to persuade are those who stand to gain from the system working the way it's supposed to-that is, the poor and those who favor the nonpoor taking personal responsibility for themselves. Right now, though, each interest group huddles inside its own silo-for example, the providers want more money from Medicaid, which is broke, and the insurers try to frighten people into protecting their assets, which people don't believe are at risk for long-term care.

The easy availability of Medicaid LTC benefits enables the public's denial. Although it's true that most people still think that Medicare covers long-term care, insurers look at this and think that the key is to educate the public-but education isn't enough to motivate people when they don't believe they are at risk and government does, in fact, pay for most LTC services through Medicaid. No one is really acknowledging that there is no future in either Medicare or Medicaid for long-term care, and that planning ahead for those who are able to save, invest, or insure is a matter of great urgency.

Peck: Those who have looked at the private financing alternative, long-term care insurance, think it has too many knocks against it: They're saying it's too costly, too out of line with middle-aged people's financial priorities, and too unstable to rely upon over the long term. Your response?

Moses: As we discussed in the Center's Myth of Affordability study published a few years ago, the LTC insurance affordability problem is a myth. The real problem is people's lack of prioritization. Nothing seems affordable that you don't think you need. Consumer advocates tell the public that long-term care insurance is too expensive to purchase unless you have a lot of assets to protect, and that Medicaid is a practical alternative. Leaving aside the questions of Medicaid's financially perilous state and lowered expectations of quality care, this stance ignores the fact that middle-class, middle-aged people can afford private insurance. For the professional couple in their 50s or early 60s with no children to support anymore, the insurance will cost them less than dining out once a week. The family with kids, car payments, and college expenses is indeed in a bind, but would it be unreasonable for their kids, when they come of age, to help with the premiums to protect Mom and Dad and perhaps their inheritance? But right now, they don't have the incentive because they don't see that their inheritance is at risk. Medicaid has in fact become inheritance insurance for baby boomers, anesthetizing them to the risk and cost of long-term care, both for their parents and themselves.