Politicians and news reporters wring their hands over COVID-19 deaths in nursing homes, and the federal government responds with PPE, testing equipment and monetary penalties, all of which malfunction. Washington has allowed bad situations to drift along and worsen—for Social Security, community services and even the quality and cost of medical care. Surely we can do better! We can hope that the new administration will make some substantial improvements quickly and set in motion policies that yield useful reforms over the next few years.
Promises to Implement
Nearly alone among presidential candidates, Joe Biden issued a substantial plan for caregiving. Like many political agendas, this plan may be too rich a mix and need modifications, but his plan would finally put caregiving squarely into federal policy. It would mean more services in community settings, energetic innovations, community health workers and better pay and benefits for direct care workers. The Biden administration is putting knowledgeable and experienced people into leadership positions. We can expect them to address long-standing issues like paying more for continuous and comprehensive care, requiring care plans that reflect patient preferences and enhancing supportive services.
Biden also promised to require drug price negotiation by the Department of Health and Human Services, and to allow purchasing prescription medications from other countries. He has promised to strengthen Medicare and Medicaid, to tax high-earners more to support Social Security and to require a living wage for healthcare workers.
Of course, the most menacing and difficult issues are those arising from COVID-19. The advent of potentially effective vaccines provides renewed faith that we will soon end this particular plague. However, we will have experienced the deaths and prolonged disabilities of so many older adults and their caregivers. We will also have had to make millions more miserable while trying to slow contagion. The public and many politicians are becoming somewhat more aware of the complexity and desperation in much of long-term care, but few news stories or statements from leaders have shown a willingness to examine and reform long-term supportive services in any substantial way.
Before we can tackle those more fundamental issues, we will need to ramp up immunizations to bring COVID-19 under control. This endeavor faces challenges, even beyond the logistics of getting immunization supplies to potential beneficiaries and refuting vaccine misinformation. As of this writing, federal committees are prioritizing populations, and we should all press for caregivers of frail and disabled persons of any age to be among the early groups of those vaccinated. Caregivers are the most common route of virus transmission to their care recipients, and we have fairly good data that immunizing these generally younger persons has good effects and no substantial adverse impacts.
However, reliable data regarding vaccine safety and efficacy for older adults and people with disabilities is missing. As far as we know, only a few dozen people older than age 65 have been included in existing studies, and they did well. But, the first few thousand older people living with advanced illness and disabilities should be studied carefully. We need to generate solid information as to immunity gained and vaccine side effects, so that potential recipients have useful information. With luck, that information will be encouraging; but whatever the facts may be, they should be readily known by physicians, families and older adults.
Policies for an Aging Society
A Biden administration could position U.S. society for its new demographics, with many more older adults, chronic medical conditions and disabilities. This hard work requires building consensus and a will to act to help the beneficiaries of tomorrow. In many cases, the impact of better policies won’t be felt in the current and near-term election cycles. Some important reforms and improvements in eldercare may take a quarter century. Our public life rarely prioritizes future beneficiaries. But improving financing and housing for old age requires a commitment to the well-being of the whole society, over the whole lifespan and into the future.
Some actions should be taken immediately. The new administration could commit to enhancing the Older Americans Act, for example, to ensure that elder justice and food delivery are fully funded. Telemedicine should be extended as it has proven to be useful. The administration should incentivize continuity and team-based care for serious chronic conditions, perhaps building on the PACE (Program of All-Inclusive Care of the Elderly) model.
‘The large and untamed threat is long-term care.'
Requirements for certified medical records could include documentation of functional and cognitive status and identification of caregiver(s) and their roles. Efforts to accomplish interconnectedness among records could be accelerated and include home- and community-based services. Medicare finances most graduate medical education, without any requirement to learn to provide care for older adults—this shortcoming should be corrected.
Housing has become a major impediment to older adults’ welfare. Federally financed or insured housing could require elements of universal design and smaller disability-adapted and affordable units. Programs providing financial support for housing need funding to serve all who qualify, and housing with social services should be broadly available. States and localities could incentivize building and renovating housing stock for older adults.
LTSS direct care jobs, in every setting, must be a path into the middle class. Increased wages, benefits, training, status (respect), career paths and credentials for those currently unlicensed will make the difference and might not cost much.
For the past 50 years, the United States has “kicked down the road” the financing of retirement and disability in old age. Even before the economic setbacks associated with COVID-19, research predicted that by 2030, half of older adults who had been middle class would be unable to afford housing, food and medical care.
With COVID-19, that prediction may be overly optimistic. Younger cohorts are saving even less to prepare for their own retirement and old age. Absent thoughtful reforms, more and more people will have to depend upon Medicaid, and state budgets will be overwhelmed by need and unable to respond effectively. To keep states solvent, Congress will need to enhance the federal match for state outlays (the FMAP).
We must look at U.S. social arrangements in the context of rebuilding a vibrant economy so that working people can afford to save and to pay taxes. Of course, we need to sustain Social Security and Medicare, which President-elect Biden has promised to do. The large and untamed threat is long-term care. From a middle-age working person’s perspective, long-term support costs can be trivial (e.g., due to an early or sudden death) or extreme (due to a disabling condition lasting many years).
One good policy response to this uncertainty is the federal catastrophic long-term care insurance plan. This strategy would make it possible to plan and finance the early front-end costs of old age disability, because most of the costs of longer-term disability would be organized and financed by a national social insurance program.
Adjusting to our future demographics requires another set of more deep-seated changes—reining in medical care costs. Medical care being an entitlement for older adults has allowed those providing and managing it to run up billed costs, often without commensurate gains for elders and their families. And the promise of medical services eclipses the more fundamental claims that all of us first need adequate food and housing. In a constrained economy, we probably need to allow limits on medical expenses in order to secure those basic needs.
And we need to incentivize providers and other stakeholders to monitor and manage eldercare on a local basis on behalf of all who live in the locality, perhaps building on PACE and special needs plans. This entails taking a public health approach to help with monitoring an array of healthcare providers that have formed cottage industries, but not a coherent system of care. We need to know, for example, whether a given county has too many pressure ulcers, or too many elders taking psychotropic medications—or too many families going bankrupt over the costs of long-term care.
And we need entities charged with addressing identified shortcomings, which can marshal a response because they have the ability to allocate some resources. We may have the money and personnel to optimize the performance of local arrangements for eldercare, but they are likely misallocated and unmeasured.
The new Biden administration will have challenges with a divided Congress, a sometimes hostile electorate and a pandemic-weakened economy. They won’t be able to do all that they might want, or even much that is clearly good policy. However, good leaders can accomplish a great deal, even in difficult times and especially if active advocates push a coherent set of agendas. That’s up to those of us who care about our futures and the older adults whom we serve.
Joanne Lynn, , MD, MA, MS, is an analyst in the Program to Improve Eldercare at Altarum in Washington, DC.