The Clinton era: what nursing homes can expect.

When Bill Clinton was elected to the Presidency, it was an historic occasion for the health care industry: He was the first President to have been elected with health care reform at very nearly the top of his agenda. Some voters told exit pollsters that it was number one or two on their agendas. Though acute care access was the specific health care reform most talked about, nursing homes are unlikely to escape the "excitement" of the next few years. Recently NURSING HOMES asked some key observers and participants in long-term care how they thought the Clinton era would shape up for nursing homes.

Sheldon Goldberg, President, the American Association of Homes for the Aging: "I hope that health care reform will not be thought of as just cost cutting, without looking at the implications of those cuts. Nursing homes today are among the most efficient of all health care delivery systems. Also, the dramatic demographic changes in this country must be taken into account, and long-term care moved up on the health care reform agenda. You really can't address health care reform without addressing long-term care or, for that matter, the needs of senior housing. It would be a mistake to focus only on acute care. It is said that there will be a strong emphasis on home and community-based care, and I would support that. But adequacy of reimbursement for long-term care must be addressed, as well, as should regulatory approaches that prove to be inefficient."

Richard Thorpe, Executive Director, the American College of Health Care Administrators: "Neither candidate spoke to long-term care in any depth, and there's nothing fresh on the table that leads me to believe that the Clinton Administration will address long-term care any time soon. I think that acute care and such delivery alternatives as home health care will be addressed first. And this may be a blessing. Perhaps the constraints that will be imposed on other sectors of the health care industry will not be forced on a sector, long-term care, that is already economically deprived. That is why any talk of global budgeting must acknowledge that long-term care is already squeezed down to its most economic format already. The financial mechanisms in this arena have been so austere, and so rigidly enforced, that I don't know how they could get any tighter. I hope some realization of the value that society is getting for the dollars spent will free up more resources for long-term care."

Robert N. Butler, MD, Chairman, Department of Geriatrics, Mount Sinai Medical Center (New York): "In general, I understand that Mr. Clinton's approach in Arkansas was to move toward a wider range of chronic care services for the elderly, such as home health care and community-based services. If this is carried over to the Federal level, there will indeed be an impact on nursing homes - particularly the ones that remain traditionally structured. Assuming that health care dollars will remain constant, I think nursing homes would do well to think in terms of becoming multipurpose and engage in some outreach toward community-based care and some sort of arrangements with home health care. The alternative is that they will be providing the same services they do now, but for less money.

"However, in view of the terrible problem of the uninsured in this country, I think that if President Clinton wants to attack problems A, B, C, and D in health care reform, long-term care will be D, and maybe E."

Leslie S. Libow, MD, Professor of Geriatrics, Mount Sinai Medical Center and the Jewish Home and Hospital for the Aged (New York): "I think the Clinton Administration will be making a mistake if they think they can significantly reduce nursing home costs. The patient population is becoming more burdensome than ever. Nursing homes aren't going to go away - they need to be strengthened to provide patients with a maximum quality of life, as many of the better nursing homes are doing already. What we need is a concept of nursing homes and tome health care collaborating to serve a very needy population.

"I think nursing homes themselves, though, will be serving very different populations in coming years, and will probably have different names - more like geriatric centers, perhaps. Half of more of their beds will be occupied by people now in hospitals. They will be treating sub-acute pneumonias, modest strokes, not-too-difficult-to-treat heart failure, and in general patients who are old and frail but not sick enough for hospital care. And they'll be doing it at one-fourth the cost of hospitals, which will continue to see their beds closed down. Also, another 25% of nursing home beds will be devoted to active rehabilitation.

"If the Clinton Administration doesn't put money into this, it will be a disaster. The patients will be without services, but the needs will still be there."