Congress’ Epic Fail In Caring For Frail Older Adults

One would have thought that after more than 750,000 Covid-19 related deaths among older adults in the US and more than 200,000 deaths among residents and staffs of long-term care facilities that Congress would act to improve the nation’s long-term care system.

One would have been wrong. Except for including about $12 billion in federal funds to temporarily expand Medicaid’s Home and Community-Based (HCBS) long-term care program in 2021, Congress has done…nothing. In an extraordinary failure of leadership, a partisan, gridlocked US Senate appears to have abandoned any effort to improve a long-term care system that was at least partially responsible for killing hundreds of thousands of people and damaging the lives of countless others.

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

For 18 months, Congress has slowly been whittling away at was initially an extremely ambitious long-term care agenda from President Biden. For example, Biden originally requested $400 billion in additional federal Medicaid HCBS funding. But the Democratically-controlled House, thinking a scaled-backed version would be more acceptable to the Senate, watered his request down to about $150 billion.

The final blow came last week, when conservative Democrat Joe Manchin (D-W VA) announced he would oppose even a slimmed-down version of President Biden’s domestic policy agenda. Because all Senate Republicans oppose that package, it needed support of every Democrat to pass the evenly-divided Senate.

Blocked by Manchin and the GOP, Senate Democrats now appear to be looking at a bill that would include only two major provisions—a measure to allow Medicare to gradually negotiate drug prices and a separate bill to extend certain subsidies for buyers of health insurance on the Affordable Care Act exchanges.

Those changes are important, and reducing Medicare drug prices certainly would help many older adults, but they would do nothing at all to shore up the nation’s failed long-term care system.

Covid-19 exposed the deep flaws in that system. For nursing homes, it amplified severe weaknesses in infection control and staffing, dramatically increased staff shortages, highlighted the problems of social isolation among residents, and accelerated a pre-pandemic trend of moving rehab services out of facilities and into individuals’ homes.

It put many operators under enormous financial pressure and accelerated the trend of non-profit facilities closing or selling out to for-profit owners. And we learned what can go wrong when family and friends are unable to visit loved ones in care facilities, and the resulting dangers of social isolation.

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

Biden did more than propose those now-doomed legislative changes. In February, he announced a package of administrative changes to reform operations at nursing homes. Many can be made by the Department of Health and Human Services (HHS) without approval of Congress.

Those initiatives, some of which are working their way through the cumbersome regulatory process, would crack down on poor-performing nursing homes and improve disclosure of quality and facility ownership. They’d also require facilities to improve infection control, enhance staff training, set minimum staffing levels, and move slowly to end the practice of requiring Medicaid residents to share rooms with strangers.

The problem: Many of these changes would add costs to facilities that already face severe financial stress. And, while HHS can—and should—reform payment models to better reward quality, it cannot on its own put more money into the long-term care pot. Only Congress can do that. But it won’t.

Increased federal Medicaid funding seems off the table. Because of the rise of managed care, Medicare payments are declining. 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 once again missed the opportunity to reform long-term care in the US. The pandemic did raise awareness of the nation’s failed long-term care system. But that window now has closed. And with political gridlock likely to continue or even worsen after the November elections, we may not see new legislative initiatives until after the 2024 campaign.

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

The government estimates that, even now, Covid-19 is killing roughly 20 nursing home staff and up to 250 residents each week. More than 700 older adults in all settings are dying each week from the virus. And, still, Congress does nothing.