• Heritage LTC ideas via Twitter

    Last week during the conservative victory lap on twitter about the demise of the CLASS provisions, I was asking various folks to focus on the actual policy content of LTC and give their ideas for moving LTC policy ahead. Stuart Butler (@stuartmbutler) of Heritage actually replied with this testimony from Dennis Smith, given before the Senate Finance Committee on the role of LTC in health reform, on March 25, 2009.

    This is mostly standard fare, long on the problems of Medicaid crowding out private options, but shorter on solutions related to moving ahead from where we are, though there are some interesting suggestions about providing more flexibility to Medicaid to allow rebalancing of LTC services toward community based options. However, what really caught my eye in light of the glee over the plug being pulled on CLASS was his response to the question posed to witnesses at this hearing,

    “Are there different policy options for improving long term care for the elderly in comparison to the disabled? His reply:

    There clearly are differences between the elderly and people with disabilities in the use of long-term services and supports when we examine the length of time the two populations use LTSS and the array of services. However, policies for both populations should be the same: they should be person-centered and money should follow the person. (emphasis mine)

    This, of course, is the big idea behind CLASS; providing flexible benefits to be used as those in need see fit. In fairness, CLASS would have to be set up and properly functioning to fulfill this aim, and I agree that the benefit would need to be changed to have a chance of being self sustaining. However, flexible benefits that allow those with disability to decide how to spend them is the idea whose demise is being celebrated by conservatives, leaving us with the default system they do not like, with its central role for Medicaid.

    The worst thing about the entire CLASS episode is the degree to which the discussion of the program has been nearly devoid of LTC policy. If CLASS is only a political scalp, it will be a missed opportunity, and it looks like that is where we are heading. I wonder if our political system is capable of any substantive policy discussion of any difficult topic?

    • You wrote: “I wonder if our political system is capable of any substantive policy discussion of any difficult topic?”

      That is certainly the goal of the Republican Party, and its affiliated PR firms like the Heritage Foundation.

      After all, every single person in GOP-world turned on a dime with regard to the individual mandate– which had been invented by Heritage, supported by Bob Dole, Dick Lugar, Jesse Helms, Strom Thurmond, and by Chuck Grassley, until about a week before the Democrats agreed with them. Then they all said that their proposal was unconstitutional tyranny. At another GOP PR firm, AEI, David Frum was fired merely for suggesting that the GOP should have considered talking about policy instead of ginning up hatred and resentment for policy proposals in an effort to engineer “Waterloo” for the president.

      (To say nothing of the behavior of the GOP on the uncertainty-sparking debt ceiling vote).

      Republicans don’t have policy preferences. They have a preferred team. A muddled, policy-averse, high-emotion public discourse is their optimum scenario.

    • I believe that the GOP actually does have a lot of policy preferences and ideas, just not so much for health care. There are a number of right of center writers who have ideas for health care reform. While I may disagree with them, and have certainly sparred with some over their ideas, I could be wrong. The problem is that, much like writers on the left face, these ideas need to be translated by politicians into policy. For whatever reason, GOP pols have never been that interested in health care issues, except in response to Democratic proposals.

      Don- Almost no one mentions the lawyer mills that help people hide assets so they can have Medicaid pay for their LTC. People are clearly not buying much LTC insurance. This appears to be the default option (or maybe I just happen to get a lot of spam from these people). Seems like there ought to be some way to crack down on these mills even if we cant agree on a LTC plan.


      • @steve
        i have a post on purposeful spend down in the pipeline….mostly I myth I think (that it is a big part of the story). That doesn’t mean that we should allow people to do fraudulent or inappropriate things, but the occurrence of this is fairly low. I think the post will be tomorrow. On Conservative health reform ideas, bottom line is it takes 218, 60 and 1 to do anything so you have to translate wonkery into legislative coalition. Would love to see them prove me wrong and mark up pateints choice act….I really would like to know what CBO thought of it.

      • “I believe that the GOP actually does have a lot of policy preferences and ideas, just not so much for health care.”

        I don’t really think that’s the case.

        As this article points out, Republicans had for years had modestly supportive views on cap-and-trade, on the EITC, on Section 8 housing, on Keynesian stimulus, and of course on the individual health insurance mandate. Then a Democrat became president, so Republicans rejected those policies.

        What’s more, Republicans reject the policies they had created and supported with astonishing venom. You’re correct to note that Republicans don’t care much about health care policy. But once Democrats began to try to pass a plan with the longtime GOP boilerplate idea of an individual mandate, the entirety of the Republican Party didn’t merely oppose it, they turned up the frothing outrage to 11. Roughly every elected Republican official denounced the policy they’d supported up until a few weeks earlier (in Chuck Grassley’s case) as unconstitutional tyranny.

        Republicans care about policy in the same way that Philadelphia Eagles fans care about football. It’s about rooting for a side. It doesn’t occur to Eagles fans/Republicans that one ought to have consistent, principled views on, say, the merits of official review or cap-and-trade. It’s always a question of what the team’s interests demand at the moment.

        (Reagan and Bush Sr. adviser Bruce Bartlett has maintained that Republicans pursue political power “so that they can reward their lobbyist friends with more give-aways from the public purse.” Not sure that counts as a principle, but it’s at least a goal.)

        • @reflectionaephemeral
          The ind mandate flip by Republicans really does seem to suggest that Republican health policies are mostly just ways to argue against policies, and do not represent preferences that they would support politically. I wish they would prove me wrong by marking up the Patients’ Choice Act in commerce and ways and means in the house so that could be compared to the ACA. No evidence that will take place.

    • Ironically, CMS is trying to push Medicaid to adopt more person-centered LTC services, exactly like what Smith and Butler are describing. In fairness to them, they specialize in health care, but my respect for Heritage’s researchers in general has dropped very significantly post health reform.

      • @Weiwen
        one of the links in that post was one I did this past summer looking at rebalancing….Medicaid waivers have lead to a general move toward more community based options. Still not as much patient centered flexibility as cash based benefits would provide.

        • OK, true. But CMS is pushing states to at least adopt agency with choice models in their HCBS programs – this means that while you might not have control of the budget, you at least get to choose who your aide is and at what time they come.

          As an aside, cash benefits aren’t necessarily the be all and end all. I agree that anyone who wants them should have access to them. However, not all Medicaid beneficiaries might want them – Cash and Counseling seems to have had (iirc) higher take up among younger beneficiaries with disabilities than among seniors. It does take a significant amount of effort to manage your own budget, which means you have to take ultimate responsibility for hiring, training and paying your workers, including tax compliance (yes, the fiscal intermediary services often take a lot of that on, but there’s still additional effort on the consumer’s part). Statutory compliance is harder with a budget/cash model – definitely not impossible, but not all states are willing to do this aggressively (poor excuse, imo).

          • @Weiwen
            agree on cash not necessarily best. Basically, a comprehensive dual eligible and LTC reform is needed. Seems hopeless politically.