The governors take long-term care seriously.

In August, Idaho Governor Dirk Kempthorne became chair of the National Governors Association (NGA), a bipartisan organization that provides policy support to the chief executives of state and territorial governments. Kempthorne, a 51-year-old California native, has had a public affairs career as a pragmatic conservative, including two terms as mayor of Boise, Idaho's largest city, and a single term in the U.S. Senate. Kempthorne surprised many observers by announcing that he wanted his term as NGA chair to be marked by a year of discussion and innovation concerning the challenges posed by long-term care.

Addressing the annual NGA meeting on August 19, Kempthorne explained:

In essence, this country is a victim of its own medical success. Thanks to better research, medicines, and techniques, Americans are living longer. Life expectancy is increasing, but to what end? To what quality of life?

Sure, we know the problem because of what it does to our budgets. But it is more than budgets. It is more than legislation. It is people. It is dignity, And we need commonsense solutions to truly provide long-term care that addresses the needs of an aging population.

Convinced that states rather than the federal government should continue to be the primary source of regulation and reform of nursing homes and their financing, Kempthorne called upon the NGA to become the preeminent resource for communicating best practices related to long-term care. Nursing Homes/Long Term Care Management Washington Editor Michael J. Stoil interviewed Gov. Kempthorne at his office in Idaho to learn why he selected long-term care as the focus for his initiative as NGA chair, as well as details on what he hopes to accomplish.

Stoil: Have your views on long-term care been shaped by personal or family experiences?

Kemptnorne: My views nave been reinforced by personal experiences with my parents; I've seen [long-term care financing] affect untold numbers of families. I've seen this for some years now, and it's interesting that every reporter that I've talked with since I began the initiative has been able to put down the pencil and say, "Now, let me tell you what I've been experiencing."

There's a couple whom I know personally who are taking care of two of their aged parents--she's cooking and delivering meals for them--while at the same time they're taking care of their own grandchildren. I've seen families wrestling with these situations, and they're not sure what the solution is. I've seen them selling assets and rearranging their lifestyles so that they can provide long-term care.

There's a lot of courage involved in the decisions that are being made by a lot of people as they deal with this. It's real life.

Stoil: Not long after you took office as governor, states began struggling with a real fiscal crisis that has cut into their ability to fund long-term care and Medicaid. Has this been the case in Idaho? Did it influence your decision to call for an initiative?

Kempthorne: All states are experiencing skyrocketing costs in Medicaid: anywhere from 12 to 24% increases on an annual basis. In Idaho, 65% of our state budget goes to education; 20% goes to healthcare, including the Medicaid components; and 10% goes to public safety, including corrections. Those three categories comprise 95% of our budget; I think these percentages also are in the ballpark for most states. As you see a continuing increase in healthcare costs, I think it puts you on a collision course with state funding for education. So we have to find solutions.

Stoil: Have you done anything specific in Idaho to address the funding problem?

Kempthorne: We've been aggressive in expanding home- and community-based waivers, so that individuals can remain in their homes longer rather than receiving services in a residential institution. This practice is financially efficient and also affects human dignity. People have worked lifetimes to retire a 30-year home mortgage. They'd like to then stay in their homes with the memories that surround them, as opposed to suddenly finding themselves uprooted and never able to return to their homes.

Stoil: Is state-assisted nursing home care a necessary part of the public agenda?

Kempthorne: Yes, because the elderly are an important segment of our society. Our seniors have spent their entire adult lives paying taxes. It may now be that they will have some return on that expenditure that they've made over a lifetime.

We'll be looking for both public- and private-sector solutions and innovations to the funding problem. I'll give you one thought--young families now have incentives through state programs to begin an education fund for their children, so when the children graduate from high school, they have a college fund. I think it's very wise for parents to do this, but maybe they should consider that after the last payment is made on the college account, some of their income should then go to long-term care.

Stoil: Do you see private-sector long-term care insurance as a possible solution?

Kempthorne: It has to be part of the solution; it's certainly not the total solution. Through dialogue and through forums, I intend to have spokesmen for the insurance industry come forward to discuss what they currently provide. We'll learn the challenges and obstacles they face in providing more expansive--not more expensive--programs that can provide for long-term care needs.

I'd also like to hear from consumer groups. They have views on some of these financial instruments: Are the instruments viable, are they working, and what are their shortfalls? We need a thorough examination.

Stoil: One policy initiative that you discussed at the NGA conference was establishment of a "best practices" clearinghouse for long term care. What is a "best practice" in long-term care?

Kempthorne: "Best practices" are initiatives showing proven success. Another term can be "positive practice," defined as something that's working and is worthy of consideration as a model. One state could identify a practice and say, "This has been working for us. It might not work identically in your region, but it has been successful for us; therefore, it is worthy of consideration as a best practice." These practices include development of financial instruments, encouraging and preparing families for long-term care of a loved one, or examining the policy of waiting until a person is absolutely eligible for nursing home admission before supplying some assistance, so that they may not have to leave the home. I would like these things categorized by topic so ally individual and any state can access the Center of Best Practices to see what is on the books, what the expectations and experiences have been, and what innovations emerged.

I'm just as interested in measures taken that are not successful. It's not a failure when somebody, to his or her credit, tried something with a positive motivation. Even if it did not achieve what he or she set out to do, we can learn from that.

Stoil: Government has shown increased interest in the role of faith-based institutions in providing social and healthcare services. In long-term care, where faith-based institutions have been providers for decades, there often is a feeling that nursing homes are subjected to increasingly burdensome regulation. How do you balance encouraging faith-based and private-sector innovations in long-term care with a highly regulated environment?

Kempthorne: Government must not seek an environment that says, "We'll now turn over this portion of long-term care to a faith-based institution or simply to a private-sector institution, but we'll put additional requirements on it." I believe in incentives. Incentives in different instances can and should be offered. With incentives, you shouldn't encourage faith-based and private institutions to provide long-term care, and then take the incentive away with regulations that increase the cost. There's a cost-benefit equation that we all need to be cognizant of.

Stoil: At the end of your term as chair, what should people remember that you accomplished through the long-term care initiative at the NGA?

Kempthorne: A thorough national discussion on long-term care that brought forward a variety of policy questions that needed to be asked and answered. Also, a variety of innovations brought forward for review.

This is a problem that, at this point, does not have a long term solution. As a result of this national debate, we will see state executive branches and legislative branches step forward, knowing that solutions put in place today will help us with the future. We're going to begin the national discussion, and long-term care will become a topic that people are much more conversant in. And we will be able to have an entire array of options that policymakers can examine to determine which way they'd like to proceed.

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