Long-Term Care: A Managed Care Nightmare Few Will Discuss, NEJM Reports

Long-term care, whose costs burden both Medicaid and millions of unpaid family members, is the silent policy bomb waiting to explode, John K. Iglehart, national correspondent for the New England Journal of Medicine reports.

States are increasingly turning to managed care to keep in check the costs of long-term services and supports, or LTSS, the trade term for the blend of medical and personal care needed by the estimated 12 million people whose needs are sufficiently complex that they need help with such basic activities as eating, dressing, toileting, and moving from one place to another.

An attempt to address this issue in the Affordable Care Act fell short when former HHS Secretary Kathleen Sebelius said she could not certify the financial solvency of a proposed insurance plan, which would have let Americans self-select their way into coverage for long-term costs. But that doesn't mean the problem is going away.

As Iglehart writes, changing demographics and lack of insurance coverage for LTSS means that this is a need that will explode in the coming decades: Only 3% of Americans have coverage for such needs, few have resources to pay for such care, and few policies are still sold.

With the oldest baby boomers set to enter the years when such care is needed, the generation that needs this care may be larger than the one behind it that traditionally provides the heavy lifting: there are simply fewer 45 to 64 year olds in the upcoming caregiver generation than the current one, and more women now have careers (it’s been adult daughters who have traditionally provided much of the care.)

As much as LTSS costs Medicaid, after assets have been spent down, the value of LTSS provided by family members has been huge—Iglehart reports AARP estimates that 37 billion hours were provided by 40 million caregivers in 2013.

As the NEJM article reports, managed care is growing across the land, in major states like New York, California and Florida. As reported over the past year by The American Journal of Managed Care, mandatory assignments have not always be smooth or easily accepted, given the relative lack of experience that many of these private plans have with handling complex cases.

So why hasn’t more been done, in either the financing or policy arena? One reason, Iglehart writes, is that a government solution would discourage the free labor now provided.

“One argument that policymakers make to explain the failure to address the financing quandary is that any remedy calling for greater federal funding could supplant, rather than supplement, informal caregiving, thus increasing federal expenditures in an era of looming battles over the growth of Medicaid, Medicare, and Social Security,” he writes.

Perhaps it not a coincidence that the one candidate who addressed LTSS in the 2008 presidential cycle was then Sen. Hillary Clinton, D-NY, since most of the lost work opportunities fall on women. Thus far in the 2016 cycle, Iglehart writes, the issue has received almost no attention. “Nevertheless,” he writes, “a major societal challenge looms without a policy roadmap to guide it.”