Epic failure of Congress in caring for the frail elderly

One would have thought that after more more than 750,000 deaths linked to Covid-19 among the elderly in the United States and over 200,000 deaths among residents and staff of long-term care facilities that Congress would act to improve the nation’s long-term care system.

We would have been wrong. Except to include approximately $12 billion in federal funds to temporarily expand Medicaid’s Home and Community Long-Term Care (HCBS) program in 2021, Congress did…nothing. In an extraordinary failure of leadership, a partisan and deadlocked US Senate appears to have abandoned efforts to improve a long-term care system that was at least partially responsible for the deaths of hundreds of thousands and the lives of countless others. .

It wasn’t entirely a surprise. In effect, you could see cracks in political support for even modest long-term care reform more than a year ago.

For 18 months, Congress has been slowly easing on what was initially a President Biden’s hugely ambitious long-term care agenda. For example, Biden originally requested $400 billion in additional federal Medicaid funding from HCBS. But the Democratic-controlled House, thinking a scaled-down version would be more palatable to the Senate, watered down its request to about $150 billion.

The final blow came last week, when the conservative Democrat Joe Manchin (DW VA) announced he would even oppose a slimmed down version of President Biden’s domestic policy agenda. Because every Senate Republican opposes this package, it took the support of every Democrat to pass the equally divided Senate.

Blocked by Manchin and the GOP, Senate Democrats now appear to be considering a bill that would include only two major provisions – a measure allowing Medicare to phase negotiate drug prices and a separate bill to extend certain subsidies to purchasers of health insurance on the Affordable Care Act exchanges.

These changes are significant, and reducing Medicare drug prices would certainly help many seniors, but they would do nothing to shore up the country’s ailing long-term care system.

Covid-19 has exposed the deep flaws in this system. For nursing homes, this has amplified serious weaknesses in infection control and staffing, staff shortages have increased dramaticallyhighlighted the problems of social isolation among residents and accelerated a pre-pandemic trend of moving rehabilitation services out of institutions to individuals’ homes.

It put many operators under enormous financial pressure and accelerated the trend of closing or selling non-profit facilities to for-profit owners. And we have learned what can go wrong when family and friends cannot visit loved ones in care settings, and the dangers of social isolation that result.

For those living at home, it revealed similar shortages of direct care workers, the burden of rising costs on families and the risks of social isolation.

Biden did more than propose these now doomed legislative changes. In February, he announced a set of administrative changes reform the operation of retirement homes. Many can be made by the Department of Health and Human Services (HHS) without congressional approval.

These initiatives, some of which progress through the cumbersome regulatory process, would crack down on underperforming nursing homes and improve disclosure of facility quality and ownership. They would also need facilities to improve infection control, improve staff training, set minimum staffing levels and move slowly to end the practice of forcing Medicaid residents to share rooms with strangers.

The problem: Many of these changes would result in additional costs for facilities that are already facing serious financial difficulties. And, while HHS can — and should — reform payment models to better reward quality, it alone cannot pour more money into the long-term care pot. Only Congress can do that. But that won’t be the case.

Increasing federal funding for Medicaid seems out of place. Due to the rise of managed care, Medicare payments are falling. And Congress has little interest in even considering a public long-term care insurance program, despite its benefits.

Where do we go from here?

My fear is that we have once again missed the opportunity to reform long-term care in the United States. The pandemic has raised awareness of the failure of the country’s long-term care system. But this window is now closed. And with the political stalemate likely to continue or even worsen after the November election, we may not see new legislative initiatives until the 2024 campaign.

Federal regulators will continue to take some steps that may improve the system, at least at the margin. But remember, despite their intense focus on nursing homes, more than 90% of people in long-term care live at home. And none of Biden’s proposed regulations would help them at all.

The government considers that even now Covid-19 is killing around 20 care home staff and up to 250 residents each week. More than 700 seniors in all settings are dying of the virus every week. And, still, Congress does nothing.