Meet the new coalitions for long-term care financing: interviews with David Durenberger, Citizens for Long Term Care, and Robert Blancato, Americans for Long-Term Care Security.

Today's long-term care managers can say that they were present at the creation - the creation, that is, of long-term care as a viable issue in national politics. For decades it was a "lip service issue on the national stage. Politicians at least mentioned its "importance," as the field stumbled along toward its eventual configuration as a Medicaid/private-pay mix for nursing home care. The spotlight heated up this past January, though, when President Clinton not only mentioned long-term care in his State of the Union address, but - stunningly - announced a four-point proposal for improvement. Within months, two new coalitions had sprung forth with different strategies, but the same purpose: pressuring long-term care financing further into the national spotlight. The stage is being set for some very lively politicking in the early 21st century.

The new organizations are Citizens for Long Term Care, consisting of a cross-section of senior-related professional associations and groups (see "CLTC Membership"), which has adopted the tactic of raising the issue in the kickoff presidential primary campaigns in New Hampshire and Iowa, hoping to create a national awareness of the need for long-term care financing reform; and Americans for Long-Term Care Security, consisting primarily of insurance-based organizations (see "ALTCS Membership"), which has chosen to focus its initial efforts on getting Congress to adopt private-insurance-friendly legislation. Both, however, have considerably broader plans and goals. Recently, Nursing Homes/Long Term Care Management spoke with the key spokespersons of both groups: CLTC's David Durenberger, former Republican senator from Minnesota and a key player in the healthcare legislative battles of the 1970s and '80s, and ALTCS's Robert Blancato, a former congressional staffer and chair of the 1995 White House Conference on Aging. Questions were posed by Editor Richard L. Peck.

Citizens for Long Term Care

Peck: Senator Durenberger, how did your organization get its start?

Durenberger: I was asked last fall to organize a pair of conferences on long-term care: one for experts in aging and disability, and one for providers and insurers. The attendees of both developed an interest in campaigning to get the next President of the United States to address long-term care financing in the context of reforming Medicare, Social Security and tax policy, which will, of course, be major issues. From that came a commitment to raise $1 million and become involved in the New Hampshire and Iowa primaries and remain active at least through March.

Peck: Isn't this presidential primary approach to generating interest in an issue somewhat unusual?

Durenberger: I don't know that it's ever been done before. I know that, so far, we are clearly the most visible issue group on the scene.

Peck: How will this approach work?

Durenberger: First I'll tell you two things that we won't do. We won't advocate any specific solution to long-term care financing, and we will not support a particular candidate. What we will do is "get in the face" of all the candidates, having people with long-term care experience tell their stories. Groups like the local chapters of the Alzheimer's Association and the American Association for Retired Persons will provide the volunteers to do this and to carry signs and so forth. In the small-town atmosphere of the New Hampshire and Iowa campaigns, they will be pretty difficult to ignore. This fall we might also develop some radio advertising.

Peck: Why the emphasis on informing the candidates first, rather than the general public?

Durenberger: Because we depend on national leaders on this, more than on any other issue, to bring us together; if they talk about it, people will listen. These days many adults have family members or friends who are touched by long-term care, but we relate to this in different ways. We don't have a "name" for it as yet - nothing like "Social Security" that conjures up a monthly check or "Medicare" that, unfortunately, denotes long-term care coverage for many people. That's why it's important for candidates George W. and John and Elizabeth and Al and Bill to identify this as an issue that needs a solution.

Peck: What is the basic message that you are trying to get across to the candidates?

Durenberger: First, that relying on a welfare-based system for elderly and disabled Americans is a demoralizing anachronism. Second, that this should not be viewed as a medical problem, but as a support services problem - not just "another program," but a way for society to share the responsibility of income security.

Peck: Would you explain that last point a little more?

Durenberger: This isn't another big-cost government program. It is a way of replacing the welfare approach to long-term care, which itself costs money, with a different, more sensible and efficient way of using existing resources and subsidies. We can continue to use "donated" caregiving by families, private savings, social insurance (like Medicare) and private insurance, but in a framework that makes more sense.

Peck: What is your view of the role of private insurance?

Durenberger: I remember when I was on the Pepper Commission in 1990 (chaired by then-Senator Claude Pepper, D-Fla.), how clear it was that people could not rely on private savings for long-term care. When we looked at alternatives to get to private insurance, we found that you first have to figure out the role of social insurance. I think that then-Senator George Mitchell (D-Me.) reflected the Commission's views when he introduced two bills to that effect.

Senator Mitchell's thought was that, since most people's experience with long-term care concludes within 18 months, have people be held personally responsible for that 18 months by using private resources and insurance, after which government social insurance, more like Medicare than Medicaid, would cut in. This fixed time period would give private insurers incentive to set competitive rates, which would justify a tax deduction. As it stands now, insurance companies can't set reasonable rates because they can't predict what the overall financing structure will be a few years down the road. In my view, putting a tax subsidy under today's rates would be about as efficient a use of tax subsidies as first-dollar medical coverage by employers. We need a structure with some predictability.

Peck: Does CLTC have any plans for activity beyond March?

Durenberger: We're taking this a day at a time, one candidate appearance at a time. But success begets success, and the success we've had so far in getting candidates' attention in New Hampshire and Iowa suggests there could be a role for us beyond March.

I view this entire process as incremental. For example, once the new President is elected, I would advise not going the Bill Clinton route of trying to solve everything with one legislative solution in the first year. Let's get the American people involved in defining the problem and sorting through a variety of solutions. Maybe we can arrive at a solution during the President's first term and get it in place during the second term. The timing would be right. The year 2011 is when the first Boomers turn 65. In 2001, though, we don't need a solution, we need a leadership commitment to involve all Americans in coming up with one.

Americans for Long-Term Care Security

Peck: How did your organization get its start?

Blancato: I think credit has to go to President Clinton for jump-starting the interest in long-term care with his State of the Union speech. Congress has shown a developing interest in this issue, and as the year has gone on, the need for an advocacy group has become apparent. Our purpose right now is to lobby for legislation to support long-term care and improve the climate for it, both the tax climate and otherwise.

The distinction between our group and Citizens for Long Term Care, as well as the Long Term Care Campaign, which has been around for a while, is that they're focusing on the issue for the presidential campaign, while we're focusing on a congressional session that's been offering several opportunities for meaningful legislative change. The major tax bills of the House and Senate, the managed care bills, perhaps the Older Americans Act renewal - they've all offered opportunities for attaching long-term care insurance legislation. And support for such legislation is bipartisan, too - for example, the tax-deduction legislation we've endorsed is cosponsored by Rep. Nancy Johnson, Republican from Connecticut, and Rep. Karen Thurman, Democrat from Florida.

Peck: So you feel that this bipartisan support enhances the chances for long-term care insurance tax deductibility to be passed this year?

Blancato: I do. The major bills it's been attached to - the tax bills and managed care - have had tremendous political problems having nothing to do with long-term care itself. I think that, no matter what happens with those bills, long-term care legislation will be passed by this Congress.

Peck: Does ALTCS have plans for going beyond tax legislation to address the broader issues of long-term care?

Blancato: If we can make long-term care insurance tax deductibility happen this year, we can use that as a reference point to move on and do more next year. Of course we realize that this is a very broad issue. When I chaired the White House Conference on Aging in 1995, this was considered to be a big issue. The Conference generally acknowledged that we do need a balance of public and private financing and it is important to define what those roles might be. When I worked for the House Committee on Aging during the Pepper Commission hearings, I remember wondering why the people who had defeated the catastrophic health insurance law after only one year had not proposed a broader approach to long-term care that would address more of the needs. Back then, though, it was so difficult to sell the concept of long-term care coverage as an investment worth making. Today, with the aging of the Boomers and the growth of the "Sandwich Generation," the case is getting easier to make.

Peck: How do you think this will play out in the next few years?

Blancato: Look at it this way: long-term care is a seniors issue, a family issue, a Boomers' issue and a women's issue. Put those together in today's political arena, and that's dynamite.

The senior vote has become very important in presidential elections. It went over to the Republicans the last two times and the Democrats want it back. Those voters are conscientious and dependable.

Everyone wants to do something for families, so that has a lot of appeal.

We've got 78 million Boomers coming along, and though they're a bit of an enigma politically, if someone raises the right issue, they could be galvanized - and long-term care might be that issue.

Finally, women's votes and their political activities are very important factors in today's major campaigns.

In short, long-term care has all the ingredients of a central issue in American politics and society. That's why I think that what ALTCS is doing in terms of pushing for long-term care legislation in this Congress is crucial in setting the stage - not only for the 2000 presidential race, but also the 2000 congressional elections, in which the full House and one-third of the Senate are up for re-election. Long-term care is a strong accountability-type issue, and actions taken this year should be evaluated in 2000.

CLTC Membership

Alzheimer's Association American Association of Homes and Services for the Aging (AAHSA) American Association of Retired Persons (AARP) American Health Care Association (AHCA) American Network of Community Options and Resources Arc of the United States Arizona Integrated Residential and Educational Services Assisted Living Federation of America (ALFA) Assisted Living Foundation of America Boomers USA Catholic Health Association Center for Community Class LTD Clearbrook Creative Community Living Services, Inc. Delta Projects, Inc. Evangelical Lutheran Good Samaritan Society Hartford Home Health Services and Staffing Association Home of Guiding Hands Independence Association, Inc. Irwin Siegel Agency, Inc. Lincoln Street, Inc. National Academy of Elder Law Attorneys National Alliance for Caregiving National Association for Home Care National Association of Health Underwriters National Association of Developmental Disabilities Councils National Association of State Long-Term Care Ombudsman Programs National Center for Assisted Living National Council on Aging National Chronic Care Consortium National Multiple Sclerosis Society New Hope Community, Inc. OWL: The Voice of Midlife and Older Women Paralyzed Veterans of America Parc: Peoria Association For Retired Persons Service Employees International Union St. Andrew's Episcopal Presbyterian Foundation T.E.R.I., Inc. Tobosa Developmental Services United Seniors Association Unum Waves, Inc.

ALTCS Membership

American Agri-Women American Council of Life Insurance Assisted Living Federation of America Association of Health Insurance Agents Boomers USA Catalano's National Nurses Registry Citizens for a Sound Economy Council for Affordable Health Insurance Health Insurance Association of America Independent Insurance Agents of America National Association of Health Underwriters National Association of Professional Insurance Agents National Committee to Preserve Social Security and Medicare National Silver Haired Congress Seniors Coalition, The 60 Plus Association, The United Seniors Association