Stop cheering the budget deal. It's a blow to long-term care and the safety net.
This is yet another attempt to extract savings from our most vulnerable to make what looks like a down payment to offset budget irresponsibility.
The new budget deal known as the Bipartisan Budget Act of 2018 included a massive increase in military spending and a comparatively modest domestic spending increase. Both parties claimed victory. Senate Majority Leader Mitch McConnell heralded it as “a significant, bipartisan step forward” while House Minority Leader Nancy Pelosi declared it “a great bill; we got everything.”
The bipartisan jubilation ignored the fact that long-term care was used as a “pay-for” to offset the military spending increase. According to the Congressional Budget Office (CBO), there is a $3.5 billion Medicare cut to home health services, and a $1.9 billion Medicare cut to nursing home care. While the cut will not begin until 2019 for home health, it starts Oct.1 for nursing homes with $140 million slashed from care.
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Long-term care advocates can be excused for fearing this is but the first down payment to accommodate federal budget irresponsibility. After all, according to House Speaker Paul Ryan, “The military is not the reason we’ve got fiscal problems, it is entitlements.” In other words, Medicare and Medicaid.
This familiar conservative refrain from Ryan ignores a tax cut package that the CBO says will add $1.8 trillion to our federal debt. It further ignores a spending deal that adds far more money to the military budget than was even sought by President Trump — he asked for $640 billion for this year and they gave him $700 billion.
A recent audit reportedly found the Defense Logistics Agency, a subset of the Defense Department, couldn’t even account for over $800 million in spending under its current budget, let alone what might happen with more money.
In contrast, the government itself acknowledges that nursing homes lose money caring for government’s clients. An annual report to Congress in March 2017 found nursing homes nationally were only at a 1.6% margin – or actually in the negative (-2%) if Medicare payments were excluded. Matters have worsened since then because Medicaid, the federal-state partnership that covers six in 10 nursing home residents, does such a terrible job in most states of compensating care.
For nursing homes, Medicare has long been the difference between solvency and closing their doors. Now even that safety net is under attack.
By 2030 there will be an estimated 3 million more 85-and-older residents than there were in 2012. But we are doing nothing to prepare for an age wave characterized as a “silver tsunami.” Instead, our elderly population with acute medical needs is looked at as a burden expendable in any state or, now, federal budget debate.
We keep trying to extract more savings from our most vulnerable. A federal commission is even urging Congress to make it even easier for states to offload Medicaid long-term care into the hands of managed care insurers, despite experiments in states like Iowa, where the Des Moines Register has described a “Medicaid nightmare” for providers and Medicaid clients alike. A recent Register investigation found an insurer defending leaving a home care client in a soiled condition: “I would allow him to be a little dirty for a couple of days.”
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Chronic long-term care underfunding might have something to do with the demographics of its work force. The data show that over 90% of nursing assistants in nursing homes are women, for example, and 20% are immigrants. And over two-thirds of those they care for are women. For home health, caregiver characteristics are similar: 88% are women, and over a quarter are immigrants. Many caregivers are single moms, struggling to pursue living wage dreams despite Medicaid underfunding.
Our caregivers, and those they care for, do not enjoy the political clout of defense contractors. No grand parade will be staged in recognition of their sacrifice. Perhaps they are simply easier to marginalize because of their demographics. Whatever their reasons, and whatever the cost to our future, U.S. policymakers have taken us one step further toward dismantling a fragile safety net.
Brendan Williams is the president and CEO of the New Hampshire Health Care Association.