| senior Health Therein lies the rub. In actuality, the issue of “the shrinking donut hole” is monumental, said Perry. To put it bluntly, Perry explained: “Basically, the law giveth, and the law taketh away.” “It’s not uncommon to see seniors with $300 to $600 drug bills, so they blow through the initial benefit level,” she said. “Then there’s the donut hole with an amount they have to pay. If they get past the next gap – the out-of-pocket maximum – then catastrophic coverage kicks in; Medicare pays 95 percent.” Even though the concept of the Patient-Centered Medical Home took root in 1967 – a model that provides a primary care provider as a medical home for every American— it didn’t gain significant momentum until Congress passed healthcare reform. “You’d be surprised at the number of seniors who don’t have a coordinated care plan,” said Perry. “It’s quite common for folks to have different doctors for different things. Meanwhile, no one’s looking at the big picture. As a start, you’ll hear more about the model that requires a medical professional to review the panel of medications seniors are taking. They’re living independently and may not want to burden friends or loved ones. Yet someone needs to see if generic medication might lower costs, or if an advantage plan with enhanced coverage might help.” Simply because select populous groups representing the interests of seniors such as the AARP have been convinced that the mandated cuts won’t have a negative impact on their members doesn’t mean they won’t. Even though $400 billion in Medicare reimbursement cuts over the next sev-
eral years were pre-arranged with hospitals regarding care in the emergency room (ER), proponents of the plan reason that money will no longer be paid to hospital ERs when 32 million new recipients are added to the Medicare rolls. Dissention about specific issues such as these continues to escalate among political and bipartisan groups and American seniors in general who continue culling the voluminous healthcare reform law.
Dana B. Perry
“For example, the CLASS (Community Living Assistance Services and Supports) Act provision disappeared from healthcare reform,” noted Perry. The CLASS program would have established a national, voluntary insurance program for funding community living services and supports designed to expand options for people who become functionally disabled and require longterm care (LTC). “The idea was an effort to provide voluntary LTC insurance,” explained Perry. “The issue might be that you shouldn’t have to have some type of LTC insurance, but again and again, people are confused about what Medicare covers for the chronically ill elderly versus what Medicaid covers. If you gathered five people in a room and asked: what would happen to a 90-year-
old living alone who could no longer live alone and needs custodial care? Does Medicare cover that benefit? They’d say, ‘of course!’ But it’s doesn’t. The CLASS program was designed to get more people on board with LTC coverage, yet even at the baby boomer stage, nobody’s buying LTC coverage.” Statistics show a very large percentage of people will need LTC before they pass away, Perry noted. “This notion that people will have a happy life until they’re 95, and then just not wake up one morning, is not borne out,” she said. “If you’re in a profession where you’re dealing with the elderly’s legal, medical or related needs on a regular basis, you know that’s not true. But if it’s not staring you in the face every day, you think it’ll happen to someone else. You might figure your family members have lived a long time so you won’t need LTC coverage. Regardless, Congress pulled the plug on CLASS reform.” The assumption of a safety net isn’t realistic, Perry emphasized. “Many families are shocked there’s no insurance to pay for LTC,” said Perry. “By the time it’s needed, they’re scrambling. Unfortunately, there’s so much misinformation. State and federal rules have changed, making it harder to plan five years or more in advance if you want to get eligible for Medicaid to cover LTC. By the time you need it, you realize there are few available options. Most people don’t want to give away the family home, but you can’t blame the government for basically saying, ‘don’t look to us until you’ve exhausted all your efforts and assets.’ Many middle class people think ‘Mama should be able to keep her house and pass it on to us.’ The situation will get worse as baby boomers age.” HN
Timeline of significant
national healthcare reform efforts: In 1965, President Lyndon Johnson pushed legislators to introduce Medicare to cover hospital and general medical insurance for seniors financed by a federal employment tax; states would manage and co-finance the same services for the poor under Medicaid. In 1985, COBRA (Consolidated Omnibus Budget Reconciliation Act) amended ERISA (Employee Retirement Income Security Act of 1974) to provide some employees the ability to continue health insurance coverage after leaving employment. In 1997, the federal government established SCHIP (State Children’s Health Insurance Program) to provide health insurance to children living in poverty.
In 2010, Congress passed President Barack Obama’s signature Patient Protection and Affordable Care Act (PPACA). The unprecedented legislation included provisions for sweeping change in the way medicine is practiced, moving financial models from volume- to value-based.
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