Stephen A. Moses likens the current status of long-term care to the blind men and the elephant allegory. Each blind man felt different parts of the elephant without “seeing” the whole animal. Without seeing the whole, the beast was described as everything from a wall to a spear, depending on where each man touched the creature.

“How can anyone describe the whole until they have learned the total of its parts?” Moses asks rhetorically. And therein lies the mandate Moses has given himself for educating everyone who is a long-term care (LTC) stakeholder from politicians to the public through his Center for Long-Term Care Reform’s National Long-Term Care Consciousness Tour (LTCCT)—a one-year, 35,000 mile sojourn across the United States in a 16-ft. Airstream trailer (dubbed “The Silver Bullet” and sporting the tour’s sponsors’ logos). He is proselytizing on the need to save Medicaid as a long-term care safety net for the neediest in the country, restrain its rising tax burden, and improve the program in the process. The key to accomplishing this, Moses says, is long-term care insurance for people not requiring public assistance.

“In order to avoid the catastrophic risk of a long-term stay without adequate funding, the public needs to look through the windshield, rather than the rearview mirror,” Moses says. “In the rearview mirror is government-financed nursing home care. Through the windshield is the brick wall of fiscal reality that will end government long-term care financing and force personal responsibility.”

The LTCCT began in Florida in January. Moses, a modern-day crusader for social change, has been in the Southwest, Southeast, Central, East, Mid-Atlantic, and was scheduled to be in the Northeast and Midwest in September and October, and work his way back toward his home base in Seattle during November and December. Moses speaks to anyone who will listen. He has been interviewed by countless local television stations, newspaper reporters, magazine editors, and radio talk show hosts; done podcasts; and appeared as a speaker at state capitols and for insurance groups, financial professionals, national associations such as the American Medical Association, and the general public. He chronicles his travels with a daily “LTC Bullet: Livin’ in Aluminum” e-mailed to his supporters.

Why would anyone subject himself to life on the road for a year, spending much of his own money, enduring the rigors of road rage, traffic congestion, malfunctioning GPS equipment, campground living, and meeting after meeting explaining the same thing? One word: passion. And Steve Moses has it in spades.

How it began

From the late ′70s through the late ′80s, Moses worked for the U.S. Department of Health and Human Services (HHS) as a Medicaid state representative for the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services [CMS]), and a senior analyst for the Office of Inspector General of the HHS. It was during this time that he was exposed to the scams involved in getting Medicaid. “Here I was, a government employee in a little regional office in Seattle and I came across a report that showed the state of Oregon recovered $5 million a year out of the estates of deceased Medicaid recipients who lived in nursing homes! I thought Medicaid was welfare! How do you qualify for public welfare, spend years in a nursing home at enormous cost to the state and federal government, and you die, and a state like Oregon collects $5 million a year?”

Moses explains the conventional wisdom says the only way to get Medicaid is if you have no or a low income, have assets less than $2,000, and need nursing home care. “The idea you have to be low income to qualify for Medicaid long-term care is preposterous. Why this doesn’t sink into the minds of the academics and policymakers is beyond me. If you’re over age 65 and have a nursing home-level of medical need, practically everyone qualifies for Medicaid,” he says. (Moses now specializes in correcting problems associated with “Medicaid estate planning,” a practice of artificially impoverishing affluent people to qualify them for public assistance. He has had an impact on passage of several national statutes, including the Deficit Reduction Act of 2005, which discouraged Medicaid planning abuses and supported the LTC Partnership programs involving state governments and private insurors.)

After doing some studies for the Health Care Financing Administration to confirm his original analyses of the scope of the problem, the studies were picked up by the General Accounting Office. That resulted in legislation being passed to make transfer of assets penalties longer and to make estate recovery mandatory, Moses says. “The principle was, Medicaid should not be free long-term care insurance,” he explains, “but should be a loan. Either pay for your LTC up front, or, if you expect the government to pay for it and (you) shelter all your assets and wealth, then you pay for it out of your estate. These types of abuses were even more egregious 20 years ago,” Moses says. “Subsequently, there has been no incentive for a privately financed home services infrastructure to develop. This explains why we’re in the mess we’re in. The United States has a nursing home-based, welfare-financed long-term care system.”

Flying solo

Moses’ work was starting to draw national attention and his federal agency superiors didn’t think it was appropriate for a regional office employee out in Seattle to be talking about national public policy. “I was rocking the boat. I was threatened with negative personnel action, so I left in 1989.” He then worked for nine years for LTC, Incorporated, a small company that designed LTC insurance, as a director of research. LTC, Incorporated was purchased by General Electric in 1997.

“I made a decision then that I couldn’t do what I do, which is research and advocacy, and have it appear as objective while working for an insurance carrier,” Moses says. “General Electric helped me financially to set up the Center for Long-Term Care Reform Financing (CLTCRF) in 1998, cofounded by David Rosenfeld, a lawyer, and me.” While their goal was simple (preserve Medicaid as a safety net for the poor), there wasn’t a groundswell of support from private financing sources. In 2005, the CLTCRF closed its doors and was reborn as the Center for Long-Term Care Reform. The staff now consists of Moses, his wife, and their son. It is financed through donations from sponsors such as CareOptions Online, https://LTCMonth.com, MetLife, OneAmerica, Prudential, GoldenCare, and Bankers Life.

Not hawking LTC insurance

What Moses says he doesn’t think LTC providers understand is how soon Medicaid is going to collapse as a financing source. “There are two things currently supporting Medicaid that are going to rapidly disappear. One is Social Security. Thirteen percent of the revenue that goes to nursing homes comes through Social Security. People in nursing homes on Medicaid have to contribute their income. Since Social Security is the primary source of income for the elderly, I call this Social Security spend-through instead of spend-down.”

Moses says half of the 26% of nursing home costs that are attributed to out-of-pocket expenditures by the CMS is nothing more than Social Security spend-through. “The reason that is so critical is that once somebody is on Medicaid, even if they’re paying all but $1 of the bill, the damage is done for the nursing home because the nursing home gets the lower reimbursement from Medicaid.”

Another brick wall for LTC providers is Medicare’s $85 trillion unfunded liability. Moses says Medicare can’t go on propping up Medicaid to fund long-term care. “Medicare is critical to long-term care not because it funds it, but because it pays nursing homes very generously, to the tune of 17% of their revenue. That won’t continue.” Moses estimates the Medicare meltdown to happen within the next five to 20 years.

His message to insurers: Enhance the market for your product. “I’m not marketing long-term care insurance,” Moses says, “but it’s the only solution I’ve got for this problem. The boomers either have to buy insurance or they’ll end up using home equity (to finance their long-term care).” Moses quoted figures of 83% of boomers own homes; 73% of them free and clear. That translates to $4.2 trillion in home equity being held by people over 62.

“Everything is upside down,” Moses says of the LTC funding situation. “What I’m trying to do with this tour is to put it right side up for the people—to tell policy-makers what they can do to save money on Medicaid and improve it; to show providers how to attract more private financing; to try to find a way to save Medicaid as a safety net for the poor, which is my principal motivation. The time is passed for trying to solve the long-term care funding catastrophe through public policy. People need to wake up to the reality they’re being confronted with.” n