Single-Payer Long Term Health Care: A Reality or Pipe Dream?

Single-Payer Long Term Health Care: A Reality or Pipe Dream? By Paul Lang (Note: I am graduating this May.) “Despite pressing problems inherent in all facets of long-term care, we are in the lull before the storm. We are missing the opportunity for structural reform.” 1 -Charles J. Fahey Long-term health care can be enormously expensive. The costs of long-term health care can increase exponentially given the indefinite period a chronically ill or functionally impaired person can remain under long-term care. Currently, the United States enjoys relative affluence compared to its global counterparts. If, however, longterm care is not addressed as a national priority and civic dialogue does not develop regarding its importance, the country will face a crisis with our elderly. In this paper, the current system of long-term care will be explained. Then, the idea of single-payer health care2 will be discussed and examples of other nations using single-payer plans will be highlighted. Finally, the political reality of a single-payer system will be examined. The author of this paper will then explain the current weaknesses in the system and show that a single-payer system provides significant cost benefits over the current system. In addition, after evaluating the drastic measures individuals must take in their twilight years, the author hopes that readers will see the responsibility this nation of largesse has to care for and provide dignity to individuals in their final years. Long-term 1 David Blumenthal, Can We Improve the Continuity of Care?, National Academy of Social Insurance (2002). 2 In this paper, the terms “national” and “universal” will be used interchangeably with “single payer” health care. health care is a moral issue and, in the author‟s opinion, the next issue on the scale of individual and personal rights in the maturation of the nation. National Condition of Long-term Health Care: Costs and Use Many seniors are facing a future that involves long-term healthcare. The United States‟ long-term health care system has been described as “a before-and-after system of cost sharing: Those in need of long-term care pay for everything –in effect 100 percent co-payment –until they have exhausted their resources. Then, after they have impoverished themselves, the government steps in.” 3 According to the Brookings Institute, “long-term care in nursing homes costs around $150 a day on average” and “for people staying a year in a nursing home (the average stay is 2.6 years), the annual cost of care is greater than $50,000, and those costs are expected to increase over time at a rate greater than inflation.” 4 In a 2006 study in the Inquiry: Journal of Health Care Organization, Provision, and Financing, the journal stated, “Individuals currently turning age 65 face an average of three years of need for LTC some time before they die, with one in five expected to need five years of care or more. Much of the care will be provided by family members. Though half of today's retirees will incur no outof-pocket expenses for LTC, 1 percent will need more than $250,000 of their own money set aside and invested at age 65 to pay for their future care.” 5 The study shows that an astounding 35 percent of people age 65 will use nursing home care with 5 percent of 65-year-olds spending more than five years in nursing facilities. 6 The study concludes, that “the amount of money in today's dollars that would have to be set aside and invested at age 65 to cover future LTC expenditures is estimated to be 3 Supra note 1. Alexis Ahlstrom & Anne Tumlinson, Linking Reverse Mortgages and Long-Term Care Insurance, The Brookings Institution (2004). 5 Peter Kemper & Harriet L. Komisar, Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect?, Inquiry Journal (Winter 2005-06). 6 Id. 4 $47,000. Government programs will cover 53 percent of these total LTC expenses, but private LTC insurance is projected to cover only 2 percent. Thus, 45 percent of LTC bills will be paid out of pocket.” 7 With 45 percent of LTC bills coming from personal savings, the financial impact on individuals can be astounding. The variability of time and need for a person entering a long-term care program creates a risky financial situation. As the Inquiry study concluded, “Long-term care risk is substantial, and under current Medicare and Medicaid policy, much of it is the uninsured private responsibility of individuals who pay for care and of families who care for their relatives."8 Long-term Options For someone who needs long-term health care in the United States, there are multiple options. Other than personal savings, they include family support and caregiving, private insurance, veteran‟s benefits, viatical settlement, reverse mortgages9, Continuing Care Retirement Communities (CCRCs), Programs of All-inclusive Care for the Elderly (PACE), Medicare, and Medicaid.10 Family Support and Caregiving Many families have contributed greatly to the long-term care of their relatives. According to the 1994 National Long-Term Care Survey, “more than seven million Americans––mostly family members––provide 120 million hours of unpaid care to elders 7 8 Id. Id. 9 “Reverse mortgages are home loans that require no repayment until the home is sold.” Richard W. Johnson & Cori E. Uccello, Is Private Long-Term Care Insurance the Answer?, Center for Retirement Research at Boston College (March 2005). 10 Medicare Long-Term Health Care Payments, http://www.medicare.gov/LongTermCare/Static/PayingOverview.asp (last visited April 14, 2006). with functional disabilities living in the community.” 11 The overwhelming majority of noninstitutionalized elders with disabilities (around 95 percent) receive at least some assistance from relatives, friends, and neighbors. 12 Almost 67 percent rely solely on unpaid help, primarily from wives or daughters. 13 Furthermore, “Eighty-six percent of elders at greatest risk for nursing home placement [those with three or more Activity of Daily Living limitations] live with others and receive about 60 hours of informal care per week, supplemented by a little over 14 hours of paid assistance.”14 In addition to this serious burden on families, the average age of the informal caregiver is 60. 15 With the increasing senior population and the increasing life-span of citizens, the strain of longterm care on family and friends is sure to increase. Private Insurance Long-term care insurance coverage can vary widely. Some policies may cover only nursing home care. Others may include coverage for a whole range of services like care in an adult day-care center, assisted living, medical equipment, and formal and informal home care. 16 Long-term care insurance premiums also vary, depending on one‟s age and health status when they buy the long-term care insurance policy and how much coverage they want.17 In 1995, approximately $106.5 billion was spent on long-term care.18 Private insurance accounted for only 5.5 percent of the expenditures, with one out 11 National Long-Term Care Survey, Duke University, Center for Demographic Studies, National Institute on Aging (1994). 12 Id. 13 Id. 14 Id. 15 Robin I. Stone, Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-First Century (2000). 16 Medicare Long-Term Health Care, http://www.medicare.gov/LongTermCare/Static/PayingOverview.asp (last visited April 11, 2006). 17 Id. 18 National Academy on an Aging Society, Public Policy and Aging Report (1997). of three of those dollars attributable to out-of-pocket expenses. 19 Many states offer tax deductions or credits for long-term care insurance. 20 Despite the increase in long-term care insurance, 94 percent of all Americans are without long-term care insurance. 21 Veteran Benefits The VA provides care in VA nursing homes and some at-home care but the patient must be eligible for VA benefits and can only receive care in VA facilities.22 Currently, there is a long wait time to enter a VA long-term facilities and “it [the VA] is discharging them [veterans] after much shorter stays that may not satisfy their need for ongoing care.”23 Viatical Settlement For a viatical settlement, it “allows you to invest in another person's life insurance policy. With a viatical settlement, you purchase the policy (or part of it) at a price that is less than the death benefit of the policy. When the seller dies, you collect the death benefit.” 24 Weaknesses of a viatical settlement to fund long-term health care include the concern that “most people can‟t get these types of settlements because their life expectancy is considered to be more than five years.” 25 Morally, it is a concern that a 19 20 Id. States Offering Tax Incentives for Long-Term Care Insurance, AARP‟s Public Policy Institute (2005). 21 Supra note 1. 22 Medicare‟s Long-Term Care Veteran‟s Benefits, http://www.medicare.gov/LongTermCare/Static/VeteransBenefits.asp (last visited April 14, 2006). 23 Veterans’ Millennium Health Care Act, 106th Cong. (1999) (statement of Lane Evans, Congressman DIL). 24 Securities and Exchange Commission Answers, http://www.sec.gov/answers/viaticalsettle.htm (last visited April 14, 2006). 25 Medicare‟s Long-Term Health Care Viatical Settlements, http://www.medicare.gov/LongTermCare/Static/ViaticalSettlements.asp (last visited April 13, 2006). person who invests in a person‟s life insurance policy “hopes” that the person dies earlier rather than later in order to collect more money. Reverse Mortgages In 2000, federal law allowed participants in a government-backed reverse mortgage program to avoid the upfront mortgage premium, which typically amounts to 2 percent of the value of the home, by devoting all proceeds to a qualified long-term care policy.26 The rationale behind using a reverse mortgage to pay for long-term health care is “it allows seniors to tap into the value in their homes while protecting their retirement income and other assets from the potentially catastrophic costs of long-term care.” 27 The public policy behind reverse mortgages is that “reduc[es] the number of people who “spend down” to Medicaid [which] could help relieve the strain on state and federal budgets.” 28 One serious concern when using reverse mortgages for long-term health care is that “you may outlive the length of a reverse mortgage. If this happens, you may have to sell your home to repay back the reverse mortgage loan.” 29 There is also evidence that the target populations for long-term health insurance and reverse mortgages are not the same. As the Brookings Institute explains, “Currently, the average age of a person getting a reverse mortgage is 75 years old, while the average age at time of purchase of a LTC insurance policy is 64 years old. People cannot even qualify for a HECM until they are 62 years old. LTC insurance is the least expensive for people who are relatively young, in their fifties and younger. People who wait to purchase a LTC policy until their 70‟s may 26 Richard W. Johnson & Cori E. Uccello, Long-Term Care, Center for Retirement Research at Boston College (March 2005). 27 Supra note 4. 28 Id. 29 Medicare Paying for Long Term Care, http://www.medicare.gov/LongTermCare/Static/HomeEquityConv.asp (last visited April 13, 2006). find that they are no longer medically-eligible. The optimal time to buy a LTC insurance policy is not necessarily the optimal time to take out a reverse mortgage, and vice versa.”30 Furthermore, “the money you get from a reverse mortgage counts towards your income [which] may affect your eligibility for Medicaid or other state assistance programs.” 31 Thus, despite potential financial advantages to using a reverse mortgage, there are also concerns that could hurt the individual. Finally, there is the overall moral argument that a homeowner should not have to “lose their home” in order to provide for their long-term healthcare. Continuing Care Retirement Communities (CCRCs) Continuing Care Retirement Communities (CCRCs) provide housing, health care, and social services. 32 In the same community, there may be individual homes or apartments, an assisted living facility, and a nursing home. 33 Continuing Care Retirement Communities contract with a resident in advance for a lifetime commitment from the Continuing Care Retirement Community to care for them, regardless of their future needs.34 Because of this long-term contract, CCRC‟s “are the most expensive long-termcare solution….[where] monthly maintenance fees usually range from $650 to $3,500 and may be increased from year to year as inflation dictates [and] buy-in, or entrance, fees that range from $38,000 to $400,000.”35 30 31 Supra note 4. Medicare Home Equity Long-Term Health Care, http://www.medicare.gov/LongTermCare/Static/HomeEquityConv.asp (last visited April 13, 2006). 32 S. Preston & S. Roderick, Assisted Living and Nursing Unit Use among Continuing Care Retirement Community Residents, Research on Aging (1995). 33 Supra note 10. 34 Helpguide Aging Issues, http://www.helpguide.org/elder/continuing_care_retirement_communities.htm (last visited April 13, 2006). 35 Medicare Long-Term Health Care Continuing Care Retirement Center, http://www.medicare.gov/LongTermCare/Static/ContinuingCare.asp (last visited April 13, 2006). Medicare Medicare spending for home health services increased nearly tenfold between 1987 and 1995.36 However, Medicare was not designed to cover activities of daily living. Rather, “it was designed to cover acute care or skilled care such as that provided during a short hospital stay” and not “custodial care”. 37 The specific cases where Medicare will cover nursing home or home healthcare, is “only after a three-day stay in the hospital, and only for services provided by „skilled medical professionals‟, such as registered nurses and physical therapists.” 38 Medicaid In 2001, total U.S. spending on Medicaid was over $214 billion. 39 The Medicaid program is the largest single-payer for long-term care services. 40 The share of total Medicaid spending devoted to long-term care averaged 35 percent across the states in 2001.41 This equates to per capita spending of $264 per person in the U.S. 42 The Medicaid system is state run with some federal involvement.43 The Medicaid program is a federal “grant-in-aid” program where the “federal share of service costs is inversely related to a state‟s per capita income.” 44 The patient must meet low income and limited asset tests in their state and are limited to a Medicaid licensed facility with an 36 37 Supra note 15. Supra note 10. 38 Id. 39 Across the States: Profiles of Long Term Care, AARP Public Policy Institute, 2002. 40 Nancy Eustis, Jay Greenberg, Sharon Patten, Long-Term Care for Older Persons: A Policy Perspective 119 (1988). 41 Supra note 20. 42 Id. 43 Supra note 10. 44 Supra note 40 at 121. available Medicaid bed. 45 Often times, individuals “spend-down” to become eligible for Medicaid benefits. About one-third of discharged nursing-home residents and one-half of current nursing-home residents entered as private-pay residents but spent down to become eligible for Medicaid. 46 From those individuals spending down to become eligible for Medicaid, the average out-of-pocket payment for nursing home care prior to their Medicaid eligibility is $40,000.47 In addition to the voluntary impoverishment problems with Medicaid, another weakness of the Medicaid system is the differing eligibility and care standards in various states. In addition to the various standards in states, nursing homes have been found to discriminate against Medicaid patient. In one prominent study, nearly 80 percent of nursing homes discriminated against Medicaid patients in their admission policies, where patients were often “forced to wait two to three times as many days for admission as Medicare or private-pay patients.” 48 PACE PACE is a permanent entity within the Medicare program and enables states to provide PACE services to Medicaid beneficiaries as a state option. 49 The state plan must include PACE as an optional Medicaid benefit before the State and the Secretary of the Department of Health and Human Services (DHHS) can enter into program agreements 45 46 Supra note 10. J.M. Wiener, Can Medicaid Long-Term Care Expenditures for the Elderly Be Reduced?, Gerontologist Vol. 36 (1996). 47 Lewis Gruenberg & Brian Burwell. An Analysis of the Impact of Spenddown on Medical Expenditures, U.S. Department of Health and Human Services (1992). 48 Madonna Harrington Meyer & Michelle Kesterke Sorbakken, Shifting the Burden Back to Families 219 (2000). 49 Centers for Medicare and Medicaid Services for the U.S. Department of Health and Human Services, http://www.cms.hhs.gov/pace/. with PACE providers. 50 Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate State agency.51 Weakness of the PACE program is that the program must be available in the state where the patient is living, the patient must pay a monthly premium, and it has narrow eligibility.52 Why Single-Payer Long-Term Health Care? Single-payer or national long-term health care provides significant benefits over the current system. The cost savings in administrative reductions would be astounding. 53 In California, for example, administrative costs account for 25 percent of health care spending.54 The Lewin Group, an independent accounting firm, found a savings of 10.8% of total health care costs (administrative costs of insurers, hospitals, physicians) with universal single-payer health care in the California bill. 55 Dr. Benjamin Brewer, in his online column “The Doctor‟s Office” in the Wall Street Journal, states that his views for a national health care system have changed when considering the elimination of 301 different health care plans he handles and the complexities he faces with each one. 56 He states, 50 51 Id. Id. 52 Supra note 10. 53 Most studies concerning the administrative cost savings involve broader universal health care schemes. 54 James G. Kahn, Richard Kronick, Mary Kreger, & David N. Gans, The Cost of Health Insurance Administration in California: Estimates For Insurers, Physicians, and Hospitals, 24 Health Affairs 27, 30, (2005). 55 The Health Care for All Californians Act: Cost and Economic Analysis, The Lewin Group, January 19, 2005. 56 Benjamin Brewer, M.D., “The Doctor‟s Office: Government Funded Care is the Best Health Solution.”, Wall Street Journal Online, April 18, 2006, http://online.wsj.com/article_print/SB114528925682927634.htmlk. “The amount of time, staff costs and IT overhead associated with keeping track of all those plans eats up most of the money we make above Medicare rates. As it is now, I see patients and wait between 30 and 90 days to get paid. My practice requires two full-time staff members for billing. My two secretaries spend about half their time collecting insurance information. Plus, there's $9,000 in computer expenses yearly to handle the insurance information and billing follow up. I suspect I could go from four people in the paper chase to one with a single-payer system.” Dr. Brewer continues to state that the elimination of multiple state Medicaid systems under a universal system will save costs and improve quality. Dr. Benjamin explains, “A single-payer system would increase access to care for the uninsured and the underinsured, including the working poor. It would lower total health costs, in part by replacing 50 different state Medicaid programs and umpteen insurers with one system. This approach has the potential to improve quality and lower costs by improving care for chronic illnesses such as diabetes, high blood pressure and heart disease. Such a system of care would rely on evidenced-based interventions, that is, providing the right care.” Many opponents of a single-payer system believe that advocates for such a universal program are pushing “socialized medicine”. The quality of care under a singlepayer system should not deteriorate as most plans include using existing facilities and nursing homes. In this case, the only difference in the use of treatment for long-term care for patients would be “below the surface” in back-end administrative and billing changes. Under a single-payer system, the “government collects and allocates money for health care but has little to no involvement in the actual delivery of services. Care is provided privately at hospitals and clinics but paid for publicly.” 57 Furthermore, federal oversight will create better standard care. Most importantly, citizens facing long-term health care 57 National Health Care for the Homeless Council, http://www.nhchc.org/singlepayer.html needs will not face the troubling possibility that they may not qualify for various state and federal programs. In addition, citizens can avoid the precipitous decline in their retirement savings by avoiding steep long-term health care bills. Finally, as developed as the United States has become, there is a moral argument that the measure of a country‟s greatness is the extent to which they protect and help their most helpless. In this instance, where a senior citizen or a person with a disability is looking to the final step in their lives with long-term care options, the dignity and respect a single-payer program can provide to all individuals is invaluable to making America great. Examples of single-payer/universal health care In 1994, Germany instituted a universal or single-payer system for long-term care. The German LTC program consists of a mandatory system in which employees and their employers make equal contributions to the LTC insurance program. 58 In Germany, “The program has achieved many of its stated policy goals: shifting the financial burden of long-term care off the Länder (states) and municipalities; expanding home and community-based services; increasing the supply of longtermcare services; lessening dependence on means-tested welfare; and increasing support of informal caregivers. To the surprise of some outside observers, the new program has met many of its policy goals without exploding caseloads or uncontrolled expenditures.” 59 58 Charlene Harrington & Max Geraedts, Germany's long term care insurance model: Lessons for the United States, Journal of Public Health Policy (2002). 59 Alison Evans Cuellar & Joshua M. Wiener, Can Social Insurance For Long-Term Care Work? The Experience Of Germany, Health Affairs, V o l. 1 9 , No. 3 (2000). Currently, in Germany, the program is paid for by fixed-rate payroll and pension taxes. 60 The German long-term care system is “often criticized for being too expensive and a major strain for the economy.” 61 In Japan in 2000, the government embarked on a plan “designed to cover the growing expenses of long-term care by reimbursing expenses for facility services and home care services to older persons who are in need of care. ”62 Close to “15 percent of persons 65 years and older have been certified as eligible in 2005” where “this ratio has grown from 10 percent when the program started.”63 LTCI in Japan is currently financed in several ways. Citizens pay ten percent out of pocket for most services, with taxes and insurance covering half of the remaining 90 percent. 64 As Professor Ikegami explains, the government has attempted to reduce the cost of the program, Expenditures have increased commensurately, from 3.7 billion yen (0.7 percent of GDP) in 2000 to 6.7 billion yen (1.3 percent) in 2005, which is greater than the original government‟s projection of 5.5 billion yen. In an effort to contain costs, the government has made revisions in 2005 that consisted of levying modest hotel costs for institutional care (additional $300 per month on average, more for those in single rooms, less for those with low incomes), and restricting the provision of home-making services in the two lightest eligibility levels. For the latter, a new package of “preventative” service has been introduced that include exercise training, oral health and nutritional counseling. Whether these measures would succeed in containing costs remain doubtful but there has not been any demand to tighten the eligibility criteria or reduce the benefit amount. This may be due to the fact that the program has been 60 61 Supra note 1. Dr. Joachim Wilbers, Long-Term Care Insurance in Germany, International Longevity Center (2004). 62 Kazuhito Ihara, Japan's Policies on Long-Term Care for the Aged : The Gold Plan and the Long-Term Care Insurance Program, International Longevity Center (2003). 63 Naoki Ikegami, Design and Impact of Public Long-Term Care Insurance in Japan, AARP‟s Public Policy Institute (2005). 64 Andrew M. Saidel, Japan's Long-term Care Insurance System Faces Overhaul: Straining to Meet Demand, Lawmakers Set to Make Changes, AARP Policy Research (2004). popular with the public, perhaps more so than health insurance, because the benefits are more tangible and have been newly introduced. 65 In the end, Japan‟s long-term health care program is still only 6 years old and many issues must still be worked out. The biggest problem encountered in Japan‟s long-term health care plan is the concern for the sustainability of the program with regards to Japan‟s growing aging population and the budgetary constraints on the government and the public.66 In Canada, the long-term health care financing is bifurcated, where some longterm care does fall under a national health care plan while other aspects are administered in the various provinces. 67 The country has a five-level classification system68 where acute hospital, rehabilitation, and chronic hospital are covered under the universal health care plan and extended and resident care 69 is administered by provinces. There is a partial payment system in most provinces for long-term care, but the “consumer payment is fixed so the poorest resident can afford it and be left with a rather generous allowance for personal spending” where the personal allowance “is more than twice the comfort allowance permitted nursing home residents by even the most generous states in the U.S. Medicaid system.” 70 65 Supra note 64. Kikuchi & Suzuki, Evaluation on the Financial Management of Long-term Care Insurance System, Japan Center for Economic Research (2005). 67 Looking North for Health, Edited by Arnold Bennett and Orvill Adams, 1998, p. 90, 68 “Level 1 is residential, Level 2 is extended care, Level 3 is chronic hospital, Level 4 is rehabilitation, and Level 5 is acute hospital.” Id. at 90. 69 “Extended care in Canada is analogous to skilled and intermediate nursing home care in the United States, and residential care is analogous to board and care.” Id. at 90. 70 Id. at 92. 66 In 1999, health administration costs totaled at least $294.3 billion in the United States, or $1,059 per capita, as compared with $307 per capita in Canada. 71 After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. 72 In British Columbia, for example, the savings in the Canadian system compared to the United States private pay system is stunning with respect to administrative costs. In 1998, administrative costs for health care in the United States amounted to $95 per person per year.73 In British Columbia, “they don‟t spend all that much [$95] more to fund their entire long term care program than Americans spend to cover just the administrative costs alone in their health care system.” 74 Weaknesses in the plan surround the inequality of care in different provinces 75 and “difficulty staffing remote rural areas.” 76 In addition, the problems in the system appear to be the same as in the U.S., where recruitment and retention of employees is difficult and specialists in geriatric medicine are in a shortage. 77 Why is Single-Payer Care Not a Reality in the United States? There is strong support for a comprehensive, national long-term care program. In 1988, the AARP conducted a poll and found that more than 75 percent of people age 45 71 Steffie Woolhandler, Terry Campbell, & David U. Himmelstein, “Costs of Health Care Administration in the United States and Canada”, New England Journal of Medicine (2004). 72 Id. 73 Supra note 68 at 109. 74 Id. 75 Robin Stadnyk, The Status of Canadian Nursing Home Care: Universality, Accessibility, and Comprehensiveness, Atlantic Centre of Excellence for Women‟s Health (2002). 76 Supra note 68 at 101. 77 Supra note 68 at 111. and older supported a national long-term care program similar to Social Security. 78 An ABCNEWS/Washington Post poll reported that Americans by a 2-1 margin, 62-32 percent, prefer a universal health insurance program over the current employer-based system.79 Despite the popularity, obstacles to a national long-term care program exist. According to Rosalie and Robert Kane, two researchers in the field of elder care, reform of the long-term care system is difficult for the following reasons:      The system is largely proprietary. The system is very much institutionally based. It is built on a welfare rather than an entitlement (insurance) model. It is constructed as a health program rather than as a social service program with health components. It is primarily a closed-ended system, that is, once a patient enters, he is not likely to be released before death. 80 In addition, David Durenberger, former Senator from Minnesota states that our leaders have not given an “adequate voice to the millions experiencing long-term care” because long-term care is “thought to be too close to issues concerning the end of life.” 81 The political reality of states or the federal government taking the burden of longterm care, however, is highlighted in Congressman Claude Pepper‟s battle. 82 The private insurance industry fiercely battled with Congressman Pepper‟s various proposals to federally fund portions of the health care system. 83 In 1987, after initially having his bill to expand Medicare to cover home care services for disabled persons of all ages stopped 78 Insurance for Elderly Increasing, Washington Post, March 18, 1988, Box 60 File 5. Gary Langer, Health Care Pains Growing Health Care Concerns Fuel Cautious Support for Change, at http://abcnews.go.com/sections/living/US/healthcare031020_poll.html, October 6, 2003 80 Robert Kane & Rosalie Kane, Assessing the elderly: A practical guide to measurement 20 (1981). 81 Supra note 1. 82 Representative Claude Pepper (D-FL) was also a Senator in the 1940‟s. He served as a Congressman from 1962 to 1989. He was known as a champion of the elderly and he passed away in his 90‟s. The author of this paper was fortunate enough to meet Congressman Pepper in the Congressional Members Dining Room when he was 12 years old. 83 Jill Quadagno, One Nation, Uninsured: Why the U.S. Has No National Health Insurance 175 (2005). 79 before reaching the floor in June, Pepper reintroduced his bill in November. 84 The health care industry moved quickly, operating under the lobbying group the Health Insurance Association of America, by stating that the bill was a “direct threat to the developing long-term care market.” 85 The group sent a letter to every member of Congress declaring that “this bill is the wrong medicine for our country.” 86 President Reagan voiced his opposition to the bill and promised to veto the bill while the Wall Street Journal called the bill “the welfare state on cocaine.” 87 In 1988, the bill was defeated. Congress, in 1990, established rules to regulate long-term care insurance, where the outlined regulations for timely payment of claims, prohibited insurers from offering coverage that duplicated what Medicare already provided, and required insurance companies to adopt the National Association of Insurance Commissioners model policy.88 During the Congressional formulation of these rules, the Health Insurance Association of America “objected that federal regulation was unnecessary and that insurers needed protection in this new and risky market.” 89 Promise on the Horizon There is a strong movement to create a single-payer health care system for the United States. Many of these proposals include components for long-term health care. The groundswell of support for universal health care in the United States is growing. The Center for American Progress and the Service Employees International Union published 84 85 Id. at 176. Id. at 176. 86 Id. at 176. 87 Id. at 177. 88 Justin Keen, Donald Light, & Nicholas May, Public-Private Relations in Health Care 120 (2001). 89 Supra note 84. a report in January 2006 which found that nearly nine out of 10 Americans think the current system is broken. 90 Recently, the state of Massachusetts passed a law that requires that all of the state's population of about 6.3 million people have medical insurance by July 1, 2007. For the plan, “no new taxes are planned but employers with more than 10 staff -- who do not provide health insurance -- will have to make a contribution of about 295 dollars per worker. The plan will cost about 1.2 billion dollars over three years.” 91 The law, in essence, does not provide universal coverage for the state‟s residents, but “require[s] all residents to purchase health insurance or face legal penalties.” 92 The law does not require long-term care insurance. Earlier this month the Kentucky House Health and Welfare Committee voted to urge Congress to pass a bill that would expand Medicare to cover all Americans. 93 The bill, introduced in the U.S. House of Representatives by John Conyers (D-MI), would bill “would create a "single-payer" health-care system, publicly financed and privately delivered.” Conyers‟ bill, the “United States National Health Insurance Act” H.R. 676, covers long-term care and specifically provides for nursing home care. The Conyers bill currently has 68 co-sponsors.94 The federal government would pay for the Conyers plan by using “a modest payroll tax on all employers and employees of 3.3% each, a 5% health tax on the top 5% of income earners, a small tax on stock and bond transfers, 90 Laura Unger, Support Swells for Universal Health Care, Jan. 30, 2006, The Courier-Journal, at http://www.courierjournal.com/apps/pbcs.dll/article?AID=/20060130/NEWS0101/601300362/1008/NEWS 01 91 Massachusetts becomes first US state with universal health insurance, Associated Press, April 5, 2006, at http://news.yahoo.com/s/afp/20060405/hl_afp/ushealthinsurance;_ylt=Al1uhyHE3unqYxuX3ZG4c6QDW 7of 92 David A. Fahrenthold, Mass. Bill Requires Health Coverage, Washington Post, April 5, 2006 at A1. 93 Supra note 91. 94 H.R. 676, 109th Cong. §2 (2005). closing corporate tax loop-holes, and repealing the Bush tax cut for the highest 1% of income earners.” 95 At the least, a national dialogue is occurring with respect to single-payer health care. Couched in some plans is a long-term care component. Given the lobbying influence of senior organizations like the AARP, long-term health care can become a sound plank in a single-payer platform. The concern over where the funds will come from for single-payer long-term care is a valid one. Although no specific payment plan has been advocated for in this paper, it is realist to assume that there will be “losers” (insurance companies, high net-worth individuals) who do not economically benefit from the program. Despite such concerns, the overall benefit to the country that long-term care provides in dignity, respect, and administrative cost-savings will surely counterbalance any ill-gotten burdens on some individuals or corporations. Finally, when the economic plight of millions of seniors is brought to the table, it appears that single-payer long-term health care will also enjoy the high polling of universal comprehensive coverage. 95 Conyers Fact Sheet for California Nurses Association, http://www.calnurses.org/healthcare/hr676summary.html.