Why nothing gets done.

Congress is taking a great deal of heat these days for the poor quality of its policy-making process in long-term care. For example, on the financial side, many commentators have blamed Congress for three consecutive failures to enact the annual appropriations bill for health and human services. Even the White House suggested that it was the failure of congressional representatives to reach agreement that resulted in all nonmilitary domestic spending being authorized by an omnibus "emergency" bill in 2002, 2003, and 2004. Hardly anyone mentions the annual inability of the Bush administration to draft an appropriations bill until eight weeks before the end of the fiscal year (roughly three months after the normal deadline for the annual appropriations legislation. See View on Washington, November, p. 10.).

Similarly, Congress in general often is blamed for the slow pace of initiatives to improve the quality of care among the elderly (see, for example, "NH Scorecard," Nursing Homes/Long Term Care Management, October 2004, p. 22). But is it fair to assign responsibility to all of Capitol Hill for the sluggish pace of reforms in federal support for long-term care services and research? Or is it more accurate to identify a few committee chairs as the culprits?

Let's consider the case of two bills affecting healthcare among older Americans: the Positive Aging Act (HR 2241) and the Elder Fall Prevention Act (S 1217).

Congressman Patrick Kennedy of Rhode Island, the son of Massachusetts Sen. Edward Kennedy, introduced HR 2241 in Congress in May 2003. Patrick Kennedy was the youngest member of his family ever elected to public office, winning a seat in the Rhode Island State House at age 21. As a congressman, he is best known as an advocate for mental health concerns.

The Positive Aging Act is part of Kennedy's focus on mental health. In its original format, it called for establishing an Office of Older Adult Mental Health Services within the Administration on Aging of the Department of Health and Human Services (HHS). In addition, it directed HHS to make grants to states for systems to deliver mental health screening and treatment to older individuals lacking access to such services, and for programs to increase public awareness of the benefits of preventing and treating mental disorders. It also called for federally funded demonstration projects that would:

* provide mental health screening and treatment services to older individuals residing in rural areas or in "naturally occurring retirement communities" (NORCs) in urban areas;

* integrate mental health services for older patients into primary care settings; and

* operate multidisciplinary geriatric mental health community outreach teams.

Conspicuously missing from the Positive Aging Act were any provisions that would be helpful to older residents of assisted living facilities or skilled nursing facilities.

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Congressman Kennedy's failure to identify a role for long-term care facilities in improving mental healthcare among the elderly is not unusual among Democratic healthcare proposals. Many of these legislative initiatives also ignore the potential of SNFs and assisted living programs as well-run "laboratories" for innovative care. Instead, they propose helping community mental health centers, hospitals, nonprofit storefront clinics, and other beneficiaries of the Great Society largesse of the 1960s. This is a particularly strange position for Kennedy to adopt in his chosen area of expertise, especially after the Center for Health Policy and Research (CHPR) in collaboration with the Division of Medical Assistance in neighboring Massachusetts issued its 2003 report on "Depression in Nursing Facility Seniors." The report acknowledged that "nursing facilities have made great strides in identifying, diagnosing, and treating depression in seniors," although it noted there was room for improvement,

Kennedy's indifference to institutional long-term care--which congressional critics say is characteristic of that body--in the long run made little or no difference to the outcome of the bill. The Positive Aging Act was referred to a subcommittee of the House of Representatives whose chairman refused to schedule either hearing or a vote on the measure. Kennedy introduced the bill a second time in 2004, and it suffered an identical fate.

In comparison with Kennedy's legislation, the Elder Fall Prevention Act is much more long-term care-aware. It was first introduced in a previous congressional session and reintroduced in June 2003 by Sen. Michael Enzi (R-Wy.). He immediately attracted a cosponsor, former social worker Sen. Barbara Mikulski (D-Md.). Three more Democrat and four more Republican senators eventually signed onto the bill as cosponsors.

Enzi relied on personal experience with a 90-year-old father to explain to colleagues why he introduced the bill:

    Anyone who has an elderly parent, relative, or friend who lives
  alone knows the concern that is often raised when a phone call placed
  to them goes unanswered. Our first and immediate reaction is often
  worry because we know that for many of our nation's elderly, a fall
  can produce a very serious injury. As the phone continues to ring, we
  wonder if Mom is upstairs and can't hear the phone, or Dad is in his
  workshop, or our friend has just stepped outside to catch a breath of
  fresh air.
    We hang up, wait a few minutes, and place our call again, often with
  a greater sense of urgency. This time, our concern becomes worry as we
  picture our loved one suffering from the effects of a fall, alone,
  with no one to help them. Then, when the phone is answered, a huge
  rush of relief overcomes us as we realize our fears were misplaced.
    Would that every story like that had such a happy ending. For too
  many of our nation's elderly, however, it sometimes ends tragically,
  as brittle bones and a reduction in our sense of balance become a
  formula for serious injury and a dramatic reduction in one's quality
  of life.

Not wishing to rely on sentiment and human interest alone, however, Enzi also explained to the Senate that avoidable falls among the elderly often lead to costly Medicare and Medicaid expenses, leaving less money available for conditions that may not be as easily prevented.

Enzi's legislation proposed that HHS respond to this problem by developing public education on fall prevention for the elderly and their caregivers. It also called for an investment of federal research funds on effective approaches to fall prevention and treatment. Finally, the legislation called for an evaluation of the effect of falls on the costs of Medicare and Medicaid, as well as the potential for reducing those costs through education, prevention, and early intervention. Enzi specifically proposed that the research evaluate the effectiveness of community programs to prevent falls among residents of assisted living and skilled nursing facilities.

A wide variety of groups supported this legislation, including the National Safety Council, the Assisted Living Federation of America, the American Geriatrics Society, and the American Health Care Association. Enzi's staff specifically recruited many of these groups with the expectation that they would become "partners in this comprehensive effort to address one of the leading causes of death and disability in the elderly."

By any standard, the Elder Fall Prevention Act should have been a legislative winner. It had bipartisan support from legislators throughout the political spectrum, it promised to save federal funds in the long-term, it offered a private-public approach to a real problem that affects a wide range of older Americans, and it recruited support from both industry and nonprofit groups. Its cost was low, its potential benefits high: The Congressional Budget Office estimated that the legislation would cost taxpayers no more than $11 million over a five-year period and potentially save that much money in Medicare payments during less than a single year.

In September 2004, the Senate Committee on Health, Education, Labor, and Pensions unanimously passed a version of S 1217, now entitled the Keeping Seniors Safe From Falls Act. The full Senate then passed Enzi's bill by a respectable margin. On December 1, 2004, the House of Representatives referred the Senate-approved measure to the same House subcommittee on health that declined to hold hearings on Patrick Kennedy's legislative proposals--and to similar effect. The House subcommittee on health scheduled no hearings for Enzi's bill.

Enzi's staff plans to reintroduce the legislation a third time in 2005. But for now, the moral is: Even when legislators do everything right, they cannot overcome an apparent determination by today's House leadership to stifle debate and innovation regarding matters of social concern--like long-term care.

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