ASA this year is concentrating on health and well-being as a theme. This post is the first of many tackling that topic in a variety of ways.
The deep polarization and narrow balance of power in Washington, DC, may discourage those who want to see greater equity in the health system, and older people struggling with the cost and availability of long-term care services. Health equity and care for older adults are just not hot election issues. Add to that the demise of Build Back Better, with its $150 billion to improve caregiver pay, expand homecare, and make other changes. The prospects for action seem bleak.
But don’t despair. Giant steps are indeed unlikely, given the political situation, but we could see a stream of incremental steps next year in Washington and in the states. Over time, these could add up to a gradual transformation in the care of older adults and significant movement toward greater equity.
An encouraging signal comes from the recent report of a broad-based group of experts and stakeholders for older adult care who were brought together in a year-long bridge-building effort organized by the nonpartisan Convergence Center for Policy Resolution (full disclosure: I helped organize that effort).
Thought leaders and change makers from caregiver organizations, nursing homes, insurers and other aspects of care were able to agree upon a host of administrative steps at the federal, state and local level—in some cases building on current action by federal agencies and states—and some legislative ideas that could gain traction even in today’s poisonous environment. Meanwhile, the momentum is growing for action to overhaul the quality of nursing homes.
Democrats like the idea of community-led change; Republicans call it fostering personal choice and local innovation.
An important element of consensus entails loosening regulations and launching pilots to encourage more home-based care, and to create smaller care facilities that are more integrated in the community. This parallels the pattern in healthcare generally of creating more locally accessible urgent care centers, federally supported clinics in less-resourced neighborhoods and expanded telemedicine. The
Convergence group urged federal agencies and states to overhaul outdated residential facility requirements and “certificate of need” rules to foster more innovative care settings. It also called for more federal pilots and waivers for states to widen the constellation of residential settings.
Interestingly, this approach appeals across the political spectrum. Democrats like the idea of community-led change; Republicans call the same thing fostering personal choice and local innovation. Whatever you call it, creating neighborhood-based institutions that are easily accessible and reflect local culture are an important part of achieving greater equity. And most of the needed actions are administrative (at the state and federal level), avoiding the danger of congressional gridlock.
The Convergence stakeholders see an opportunity to revamp caregiving for older people. They recognize that to create a workforce that is large enough and properly paid and trained will require congressional action of a scale that is likely politically impossible any time soon. Meanwhile, increasing immigration to fill the caregiving gap is controversial.
But there is broad support for growing the pipeline of workers by creating a real career path, improving training (as well as simplifying recruitment procedures), expanding volunteer and apprenticeship programs, and overhauling credentialing to better reflect the skills needed. Fortunately, there is no partisan divide on such steps, nor for improving procedures to create a strong partnership between paid caregivers and the family and friends who are the true bedrock of caregiving.
Like encouraging community-focused facilities, administrative and practice changes can achieve a lot over time—and are less vulnerable to shifts in party control or reflect ideological divides. Over time they can lead to profound change by altering the basic relationship between facilities, caregivers, communities and people needing care.
Still, let’s also not rule out some significant action in the new Congress on care financing and delivery. Medicare Advantage (MA) enjoys solid bipartisan support, and through bipartisan legislation and administrative action, the scope of services and supports that MA plans can cover is significantly expanding, including meals, transportation and in-home supports. Expect more bipartisan support for granting more authority for MA plans to address these “social determinants,” which are major drivers of inequity.
And we may even see some progress toward enacting a universal federal program to limit a person’s out-of-pocket costs due to long-term nursing home care—these costs can be catastrophic and force many older middle-class people to become dependent upon Medicaid. Republican opposition to a new public program will likely ebb as red states financially strapped by rising Medicaid spending calculate their large savings from a federal program.
It is easy to assume that noisy elections and the balance of congressional power are what determine—or doom—policy. But the “long game” is more important for issues like health equity and care for older adults. Administrative actions and a growing consensus on the necessary steps will likely achieve much over the next few years.
Stuart M. Butler is a senior fellow in Economic Studies at the Brookings Institution.