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Home care provision of Clinton Plan at risk of defeat.

Agreement is growing it won't replace nursing home care

The single major long-term care innovation in President Clinton's Health Security Plan increasingly is viewed as likely to be scrapped as part of any compromise version of the health care reform legislation.

The provision at risk is a proposed revision of Title XV of the Social Security Act that would require government-financed home- and community-based services to be provided to all individuals with severe disabilities, regardless of income or age. The specific services to be provided would include assistance with activities of daily living, plus any other community-based long-term care support that a State may choose to make available. The proposed benefit could be used to provide services in private homes, group and community residential arrangements, or outside the home, but could not be used to fund services provided within a licensed nursing home.

The Nursing Home "Substitute"

Expansion of federal support for home care services for the severely disabled was described early during the health reform process as an approach to controlling the national costs of nursing home care. Advocates claimed that thousands of Americans are forced into licensed care facilities and hospitals by lack of their family's ability to pay for home care aides, With the creation of a new federal benefit forborne care, more elderly spouses and other family members would, in theory, be willing and able to keep disabled patients living at home or in the community. This, in turn, allegedly would reduce the demand for nursing home beds and restrain overall health care costs. The concept of using home care as an alternative to nursing home care in the American Health Security Act is made explicit by the proposed provisions on eligibility. Individuals who are unable to consistently perform at least three of the five activities of daily living or who suffer from significant cognitive impairment would be the only adults who could receive the benefit. This is essentially the same adult population eligible for federally-supported nursing home care. In other words, rather than expanding home care benefits for the type of patients who currently can live in the community, the proposed long-term care benefit would attempt to tap into the patient population that currently seeks admission to nursing homes.

A False Hope

In fact, such diversion of the nursing home patient population is unlikely to occur. The dream of a new federal home care benefit eventually driving down overall health care costs has proven to be one of the weakest arguments in support of the American Health Security Act.

Initial criticism of the home health care benefit was voiced in late summer by representatives of the American Health Care Association (AHCA), one of the two largest national organizations of the nursing home care providers. AHCA released a compilation of findings from neutral studies that concluded expansion of home and community care will not be offset by reductions in nursing home care. Diane Hallfors of the Brandeis University Institute for Health Policy was among several authorities cited by AHCA in the critique of the cost saving argument for the proposed home care benefit:

Increased financing for home and community-based care services may be desirable but will not significantly influence nursing home expenditures...We must seek to justify home and community-based care on grounds other than cost effectiveness or clinical efficacy: the debate should focus on how much community care we are willing to purchase as a society, rather than how much money we can save by purchasing these services.

AHCA argued that nursing homes in the 1990's no longer care primarily for relatively independent elderly patients who need only a small amount of assistance to function effectively. Instead, the nursing home population rapidly is getting older, more frail, and more subject to severe cognitive disability. The overwhelming majority of these patients cannot, in AHCA's view, be cost-effectively maintained through home care or community care.

Consensus Building

AHCA's critique was supported throughout the fall by an increasing number of studies that dismissed the potential cost reductions from the federal home care benefit. Furthermore, State governments that would be required to chip in substantial amounts of tax dollars to support the new benefit also joined the chorus against the home care provision. An analyst for the budget office of North Carolina, for example, recently stated, "With any new benefit of this type, the Feds have a pool of excess funds in the social security system to pay their share, but all we have is the taxpayers' pockets to cover our costs." In fact, Clinton legislation anticipates this problem by allowing States to impose fees for the provision of the mandated home care benefit, even among patients whose income is below 150 percent of federal poverty levels. Last month, a coalition of Republicans and conservative Democrats in the House of Representatives identified the proposed home and community-based care benefit as the single most objectionable portion of the proposed health care package. In a joint release, the provision was described as a new "entitlement" with a potentially unlimited price tag, that was being offered at a time when the President has pledged to attempt to reduce existing entitlements. If the home care provision is sacrificed, long-term care reform will continue to be a part of the total health agenda. The American Health Security Act includes much less controversial provisions designed to reduce abuses in marketing of long-term care insurance and increase the percentage of Americans willing to purchase private nursing home care coverage. It may be that long-term health care will benefit more from these "little" provisions than from the proposed new home care offering now under fire.
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Title Annotation:View From Washington; American Health Security Plan, 1993
Author:Stoil, Michael J.
Publication:Nursing Homes
Date:Jan 1, 1994
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