Warning signs for the White House: LTC leaders sound off on the forthcoming 2005 White House Conference on Aging.

It happens every ten years--the presidential administration occupying the White House summons deep thinkers, experienced practitioners, association executives, advocates, and activists of every stripe to assemble in Washington, D.C., to hash out policy for dealing with the aging of America. This has produced eloquent pronouncements, penetrating observations, and reams of research data, all receiving national exposure in unusually concentrated form. No doubt each conference has influenced legislation and policy making during the subsequent decade in hundreds of ways. But no dramatic policy measure or law has yet to emerge from one.

This December the fifth such conference will occur. In terms of inspiring definitive action, will this one be different?

On the plus side is a slowly growing consensus in Washington that the aging of America is truly becoming a front-burner issue. Aside from the fact that the oldest baby boomers, born in 1946, are about to enter their 60s, there is the phenomenon of the boomers' parents requiring long-term care services in rapidly growing numbers. It seems safe to say that everyone "knows someone" having direct contact with long-term care. Each person has a story to tell, and it's often not a happy one. In short, the public imperative for action is almost upon us.

On the negative side is a political system distracted by war, budgetary deficits, strongly competing needs within healthcare and education, and powerful, often bitter, partisanship. This can frustrate good intentions, well-thought-out recommendations, and all but the most powerful of political upswells. Despite the demographic--and increasingly political--imperative, the fifth White House Conference on Aging could conceivably go the moderately influential way of the others.

If so, it won't be for lack of long-term care leaders speaking out. In April, a large cross section of them from all walks of life--providers, planners, insurers, and government and corporate officials--convened for what was billed as a "mini-conference" in preparation for the 2005 White House Conference on Aging. Three workgroups hammered out a set of specific recommendations for what all agreed was a national crisis (see "Recommendations at a Glance," p. 30). Subsequent to the release of the miniconference's recommendations in August, several attendees offered further thoughts as they and others prepare for the official "march on Washington" in December.

Do you believe long-term care faces a crisis? Why or why not?

Carol Regan, Director, Health Care for Health Care Workers Institute, Paraprofessional Healthcare Institute, Bronx, New York: Yes, in many ways, but particularly regarding the workforce, a largely "invisible" issue that policy makers, employers, consumers, and worker advocates are beginning to address. There is a huge "care gap": Between 2000 and 2030, our elderly population (age 65 and older) will more than double, increasing by 104%. In the current decade alone, the U.S. Bureau of Labor Statistics projects that the demand for direct-care workers serving long-term care clients will increase by more than 40%--requiring an additional 800,000 direct-care workers.

Less understood is that the growth in the traditional supply of direct-care workers--women aged 25 to 44--will slow dramatically. Between 2000 and 2030, the number of women in this age group will increase by only 7%. In fact, during the current decade, the number of women aged 25 to 44 in the entire civilian workforce will increase by only 400,000 workers.

Stephen McConnell, Senior Vice-President for Advocacy and Public Policy, Alzheimer's Association, Chicago: It is a serious crisis. We have the absence of a coherent financing system, the aging of the baby boomers, demand pressures on Medicaid, worker shortages, and a head-in-the-sand attitude of national leaders.

Todd Smith, Director of Legislative Policy and Analysis, American Health Care Association/National Center for Assisted Living (AHCA/NCAL), Washington, D.C.: Medicaid is in crisis, and this has serious implications for long-term care. Proof is in the rising costs of Medicaid, which pays the bills for two out of three individuals needing nursing facility care. According to a 2005 BDO Seidmanstudy, (1) government (state and federal) does not fund the full costs of care, thus:

* the average shortfall in Medicaid nursing home reimbursement was $12.58 per Medicaid patient day;

* the daily reimbursement shortfall increased by approximately 9% from 2001 to 2002 (about 39% in the four years from 1999 to 2002); and

* unreimbursed Medicaid allowable costs were estimated at $4.5 billion nationally.

This situation will only get worse in the future because of our nation's rapidly aging population. Even with steep underpayment for services by Medicaid, several government reports (2) have noted that long-term care quality is on the rise--yet these gains will be hard to maintain if shortfalls persist.

How might financing of long-term care be improved?

Regan: To address this workforce crisis, adequate funds need to be invested to guarantee a living wage for the millions of mostly women workers, as well as health benefits, training, and career ladder opportunities.

McConnell: A comprehensive approach is needed that draws on both the public and private sectors. The government must step up to its role to cover those who can't afford care or insurance and to provide a stable environment, perhaps through a basic social insurance benefit within which private coverage can flourish. The private sector must find ways to encourage those who can afford it to plan for LTC needs and make sure that their products are high-quality, reliable, and affordable.

Smith: There must be a public/private approach to long-term care financing. Retired individuals must accept greater responsibility through various means, such as LTC insurance, reverse mortgages, savings, or other financial mechanisms that can pay for long-term care services if needed. Government's role is to provide for funding stability in public programs and encourage greater public responsibility for long-term care planning through tax incentives, education, etc., and to maintain a "safety net" for those citizens who truly cannot afford extended care. AHCA/NCAL supports the Long Term Care Insurance Partnership Program Act of 2005 that encourages self-reliance through long-term care insurance and helps families through asset protection, while alleviating pressure on long-term care financing and, in particular, Medicaid.

How should long-term care's staffing concerns be addressed?

Smith: Currently, there are almost 100,000 nursing staff vacancies in long-term care. (3) Government must assist the private sector in building a pipeline to produce an adequate supply of caregivers who can serve in all settings. This includes investing in the expansion of nursing programs at colleges and community colleges so that there will be adequate faculty and facilities to accommodate interest in nursing. Today, nursing schools are turning folks away, especially because of a lack of faculty. In the nursing assistant area, government must help and work with the LTC profession to enhance recruitment, training, and retention of those caregivers who now provide about 80% of direct bedside care.

McConnell: We must create a culture that values LTC staff and ensure proper training, work environment, pay, and benefits commensurate with the critical importance of their work.

What are your thoughts on creating a specific federal agency for long-term care, as two of the three mini-conference workgroups recommend?

Regan: We can learn a lot about developing good systems of long-term care by looking at the states. States that have been successful in developing the right balance of institutional and home- and community-based services have eliminated the multiple bureaucratic silos that make the coordination and continuity of care so difficult to achieve. Also, financing, quality oversight, and workforce standards need to be integrated in an effective long-term care system.

McConnell: If such an agency reflects a strong commitment by Congress and the President to really address LTC, then it is a good idea. If it's, in effect, window dressing, save the expense.

Smith: In the current political environment in which the focus is on acute care, long-term care is always the stepchild. There must be a seamless system of acute and long-term care. A federal agency or a public/private government-chartered and -funded body (such as MedPAC) must be created to help level the playing field between acute care and long-term care. In either case, the entity must have the authority to make this happen.

What do you think will be the real political drivers influencing this issue, post-White House Conference?

Regan: Consumers, workers, and employers and their organizations--those folks at the front lines of the system--are the key voices for reform at both the state and national levels. And as elected officials themselves age and long-term care becomes a personal and not just a policy issue, change will occur.

McConnell: Unfortunately, it appears that budget deficit politics will drive our politics until the baby boomers finally realize that this isn't just about someone else's parents--it's about our parents, our children, and ourselves, and time is running out!

Smith: One driver will be the public outcry as more and more Americans are impacted by the consequences of not planning for long-term care. This political discord will accelerate as access to quality long-term care becomes problematic thanks to funding cuts, particularly as they pertain to Medicaid, and advance transfers of assets become more and more difficult. However, for now, although policy makers are aware of the growing crisis in long-term care, without a public outcry, they feel the issue can be put off.

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References

1. A Report on Shortfalls in Medicaid Funding for Nursing Home Care. Prepared by BDO Seidman, LLP, for the American Health Care Association, April 2005. Available at: www.ahca.org/brief/bdo_seidman_study.pdf.

2. Three Leading Government Reports Cite Marked Quality Improvements in Nation's Nursing Homes. Washington, D.C.: American Health Care Association; April 12, 2005. Available at: www.ahca.org/news/nr050412.htm.

3. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes. Washington, D.C.: Health Services Research and Evaluation, American Health Care Association; February 12, 2003. Available at: www.ahca.org/research/rpt_vts2002_final.pdf.

RELATED ARTICLE: Recommendations of the LTC Mini-Conference at a Glance (with explanatory excerpts)

Economic Security & Long-Term Care Financing

Coverage for all Americans through public and private mechanisms

With respect to expanding public risk pools ... Congress must establish a new public program that provides basic services for chronic care to all Americans. With respect to expanding private risk pools ... Congress must enact laws to encourage private participation by individuals and families ... such as tax incentives for the purchase of long-term care insurance and/or other private options for financing long-term care.

Use current public dollars more efficiently, intelligently

Launch a national long-term care education campaign

Health and Independence

Federal and state policymakers should create financial incentives and otherwise provide for workforce training and service delivery that reflect the following priorities:

* Maximizing consumer self-direction, independence, and health in homes and communities;

* Promoting models of coordinated, multidisciplinary, continuous care and support across all settings and throughout the life spans....

* Emphasizing secondary and tertiary prevention....

Establish a unified quality agenda for long-term care

... including unified measurement and reporting across the continuum of services and settings; performance-based payment; consumer satisfaction and expectations; addressing health literacy and cultural disparities.

Fund a broad initiative to incentivize, support self-directed consumers

Reform public, private funding programs to remove institutional biases

... integrating acute and long-term care and maximizing health and independence in homes and communities; and specifically balancing the Medicaid entitlement to cover home- and community-based services.

Establish federal office to address long-term care workforce issues

... to improve the recruitment, training, retention, and practice of a strong long-term care workforce.

Supportive Services

Fund and prioritize recruitment, training, and retention of long-term care workforce

... to effect policy changes [to] include policy changes that will ensure:

* The infrastructure for educating nurses, doctors, therapists, nursing assistants, and other healthcare professionals is strongly supported and adequate financing is available to resolve the shortage....

* Government reimbursements ... will cover the costs of care so that providers in all settings are able to provide higher salaries, benefits, and a valued career path.

* Government will elevate the status of family caregivers by providing financial resources [for] training and financial supports to family caregivers.

Establish a new agency within HHS to focus solely on long-term care

This agency and its director ... would be tasked with defining realistic strategies the Administration and Congress can use to accomplish goals that include....

* Creating a seamless long-term care continuum from acute to chronic care.

* Removing Medicaid institutional biases ... and removing the silo mentality in the delivery of care and services.

* Creating a basic-level long-term care benefit under Medicare (e.g., a Part E).

* Ending middle-class Medicaid manipulation to better preserve this resource for the truly impoverished.

* Creating incentives to encourage individuals to take planning responsibility for their own long-term care needs.

* Redesigning Medicaid to allow dollars to follow the person across all settings....

* Increasing utilization of technology (telehealth, home modifications, monitoring devices, electronic medical records, etc.) in all care settings--particularly in rural settings.

* Supporting consumer and caregiver needs as related to transportation, housing, services like meals-on-wheels and other volunteer programs.

RELATED ARTICLE

General Comment: Robyn Stone, DrPH, Executive Director, Institute for the Future of Aging Services, Washington, D.C. (from remarks at the mini-conference): I have been through several of these conferences, and I'm a little cynical. Can we make recommendations that are concrete, with teeth in them? We will be indulging in platitudes otherwise. The rebalancing this system needs can't be done through the current system. We need genuine long-term care financing, and the public has to understand the need for change. Right now the people needing assistance are not on the public's radar until people's own family members are involved. Meanwhile, the long-term care workforce has never been addressed on the agenda as seriously as we recommend now; it has tended to get lost in general healthcare workforce discussions. Creating a separate agency for long-term care will be a travesty unless real dollars and real appropriations are devoted to it.