After a year of rancor and wrangling, partisan politics, strident public debate, rallies and protests, back-room deals, and media brawls, the Patient Protection and Affordable Care Act (PPACA) finally passed the House of Representatives in March 2010. It was amended into the final version by the Health Care and Education Reconciliation Act, which was signed into law by President Barack Obama on March 30, 2010.
At first, few had any idea as to what sorts of provisions were included in the 2310 pages of this verbose historic legislation. It was quite the surprise to discover that the PPACA contains several provisions significantly affecting long-term care that will start taking effect over the next four years.
The demographic shift in increased numbers of elderly in our society will cause a shift in focus from acute care to long-term care health services. The present long-term care system, however, is not prepared for the burgeoning elderly population and is in dire need of reform. Weaknesses are many and include: reimbursement-driven and inequitably-distributed services; a fragmented, uncoordinated, and “user-unfriendly” system; a confusing blend of health and social services; multiple entry points; domination by the acute care system; poor public image; and, inadequate support for informal caregivers.
The following summary outlines key provisions of the PPACA for long-term care: 1) introduction of national long-term care insurance; 2) expansion of Medicaid options for community based services and supports; 3) mandating chronic care coordination; 4) more stringent criminal background check requirements for prospective long-term care employees; and, 5) nursing home reforms (the transparency provisions).
The Community Living Assistance Services and Supports (CLASS) Act establishes a new federally administered voluntary long-term care insurance program that will be financed by participating enrollees. This program is an entirely new public-private enterprise to finance and access long-term services and supports in the home or in a facility. Individuals will be automatically enrolled if their employers agree to participate. Premiums will be paid through payroll deductions unless the employee opts out. Many details in the new program have yet to be determined. The CLASS Act may end up crowding out the private long-term care market, which was not that significant in the first place.
The PPACA expands Medicaid and Medicare community-based long-term care pilot and demonstration programs to improve quality and reduce the cost of care, with the ultimate aim of keeping frail elders in their homes longer. These payment and delivery arrangements, if successful, may be expanded nationally. These include community-based prevention and wellness pilot programs, individualized wellness plans, the National Pilot Program on Payment Bundling, the Community First Choice Option, the Programs for All-Inclusive Care of the Elderly (PACE), the Money Follows the Person demonstration, and the Independence at Home demonstration program. The PPACA also introduces a three-pronged structural reform: single point of entry; case management; and standardized eligibility/ need assessments.
The chronic care coordination provisions are a diverse set of new initiatives offered through the PPACA with the goal of better coordinating the care of individuals with multiple chronic conditions. Addressing care coordination is a critical issue in health care payment reform, since many people with multiple chronic illnesses need expensive long-term care services. Presently, care for chronic conditions is poorly coordinated, and the costs of care are increasingly shifted to the client. Care coordination initiatives include: more closely aligning Medicare and Medicaid for dual enrollees; enhancing linkages between health care needs and long term care services; improving primary care provisions for persons with multiple chronic conditions; and, facilitating seamless transitions in care settings across the entire health care continuum. In accordance with these initiatives, the PPACA calls for the establishment of a federal coordinated health care office, Medicare Special Needs Plans, and medical health homes.
The PPACA requires the establishment of a nationwide program for background checks of direct care employees in a wide variety of community and institutional long-term care entities. The new requirements cover employees of nursing facilities, assisted living facilities, intermediate care facilities, and providers of home health, hospice, and adult day care services.
The nursing home transparency provisions are the most sweeping reforms in nursing home quality since the Omnibus Budget Reconciliation Act (OBRA) of 1987. The PPACA provisions require disclosure of ownership, governance, and indirect controlling interests. When fully implemented, the law will provide consumers a substantial amount of new information about individual facilities. The Medicare Nursing Home Compare website will contain staffing data; links with information regarding state surveys, inspection reports, and certification programs; information on accurately interpreting these reports; and, facility responses to these reports. Additionally, the Nursing Home Compare site will include a consumer rights information page.
These reforms are a good start in addressing some of the weaknesses in the present-day system of long-term care. However, they are not the comprehensive overhaul that the long-term care system so desperately needs. The wording for many of these provisions is distant and vague. It is also troubling that many of these mandates, especially the expansion of Medicaid, are unfunded, and risk further bankrupting the states. It will be interesting to see how these reforms unfold over the next few years to decades as the massive baby boomer cohort enter their senior years.
Justice, D. (2010). Long term services and supports and chronic care coordination: Policy advances enacted by the Patient Protection and Affordable Care Act. Portland, ME: National Academy for State Health Policy. Retrieved from http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf
Pratt, J. (2009). Long term care: Managing across the continuum (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc.