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Health Care Reform and Family Caregivers

President Obama made history when he signed health care reform legislation into law on
March 23, 2010. Th e new law, which will expand health insurance coverage to nearly every
citizen, is packed with provisions that will impact all Americans. Some of the changes are
happening now, while many larger pieces of the law will be implemented in the months and
years to come. Th ese changes have promise to impact family caregivers� lives directly, both as
consumers of their own health care and as advocates, care coordinators and care providers for
relatives and friends. The law makes health care more aff ordable and accessible, expands access
to long-term care services, works to improve the quality of care and care coordination provided
to patients�including those suff ering from chronic or disabling conditions, and focuses on
unmet needs within the health care workforce. Below is an overview of the provisions in health
care reform that will have the most direct impact on family caregivers.

Long-Term Care

With the aging of the population, the prevalence of adults with long-term care needs is rising.
Th e number of adults in the U.S. who need long-term care services�over half of whom are
65 years or older�is expected to increase by over 100% between 2000 and 2050.1 Most adults
with long-term care needs want to remain at home or in the community, rather than go into a
nursing home. And while family members are by far the main source of long-term care, they
often rely on additional help from in-home care providers, visiting nurses, adult day centers
and other home and community-based services. Yet, these services are expensive and are
covered by Medicare under very limited and specifi c circumstances.
T
his law recognizes the need for home and community-based care and provides incentives and
more fl exibility for states to provide these services�at least for low-income adults�through
Medicaid.

For example, the health care reform law:

 Provides states with new options for off ering home and community-based servicesto individuals with incomes up to 300% of the maximum SSI payment through aMedicaid state plan. Currently, states must apply for and receive waivers from the
Centers for Medicare and Medicaid Services (CMS) in order to off er those services.

This provision goes into eff ect October 1, 2010.

 Establishes a new Community First Choice Option in Medicaid to providecommunity-based attendant supports and services to individuals with disabilities who require an institutional level of care. States would receive enhanced federal matching
rates for this program.

This provision goes into eff ect October 1, 2011 and sunsets after five years.

 Extends Money Follows the Person demonstration programs through September 2016. Th is Medicaid program helps people move out of institutional care by providing financial support for home and community-based services.

 Provides protection for recipients of Medicaid home and community-based services against spousal impoverishment.

 Authorizes $10 million per year for fi ve years, starting in 2010, to continue the Aging and Disability Resource Center (ADRC) initiatives. ADRCs are single points of entry into the long-term care system for older adults and people with disabilities
CLASS Act: Considering the ongoing and growing need for long-term care, the law takes a more comprehensive approach to reform by establishing a new national long-term care insurance program. Financed by voluntary payroll deductions, this program�known as the CLASS Act�will allow adults who contribute to the program for at least fi ve years and who become functionally impaired to purchase community living assistance services and supports.

Individuals must be 18 years old in order to qualify to receive benefi ts of between $50 and $100 a day, depending on the level of disability or cognitive impairment. Beneficiaries will be able to use those benefits to purchase services that assist them with daily activities, such as bathing and eating, as well as tasks related to communicating, managing money, housekeeping and taking medications. The government has until October 2012 to present the full rules, and experts expect enrollment to begin in 2013.

Care Quality and Coordination

Millions of patients and their caregivers suff er needlessly because our health care system fails
to provide the care and support they need. Nine in 10 Americans age 65 and older have at least one chronic health condition and 77% have multiple chronic conditions.2 Our health care system remains best equipped to deal with acute, episodic care,3 while older adults�and their caregivers�also need a system that can handle an increasing incidence and prevalence of chronic conditions. Older adults with multiple chronic health conditions have numerous medical visits a year with any number of diff erent doctors; often report duplicate tests and procedures, confl icting diagnoses for the same set of symptoms, and contradictory medical
information; and are more likely than others to experience avoidable hospitalizations.4 At the
same time, their family caregivers are often responsible for coordinating all this health care,
managing medications, dealing with transitions in and out of the hospital, and providing care
at home�all with very little assistance or training.
Th e new law addresses those concerns by making a number of changes to the current health care system which promote higher quality and better coordinated care and focus more on patient outcomes, patient-centeredness, and care coordination. Some of these changes include:

 Realigning our payment system and changing the way physicians and hospitals are
paid in order to incentivize health care professionals to provide services critically needed.

Making the Case: Saving Your State�s Caregiver Support Programs important to patients with chronic conditions, to reduce excess hospital readmissions,
and to focus on quality improvement. These changes will go into eff ect over the next
few years.

 Creating a new Independence at Home Medical Practice Pilot Program providing Medicare benefi ciaries who have multiple chronic conditions with coordinated, primary care services in their homes from a team of health care professionals.
This
program is set to begin January 2012.

 Creating a new Community Care Transitions Program to provide transition services to high-risk Medicare benefi ciaries following hospital discharge. This program is set to begin January 2011.
 Requiring federally-funded geriatric education centers to off er free or low-cost training to family caregivers.
 Establishing a new offi ce within CMS charged with improving coordination between Medicare and Medicaid for dually eligible benefi ciaries in order for these federal and state programs to work better together to meet patients� needs.
 Establishing a Center for Medicare and Medicaid Innovation within CMS to test innovative payment and service delivery models and to replicate and expand those that reduce health care costs and enhance care quality and care coordination.
Health Insurance Coverage

Millions of Americans lack health insurance, including thousands of family caregivers. In many
cases, people decide to leave their paid jobs to provide full-time care to a family member or
friend. As a result, not only do they lose their income, but they often lose their health insurance
as well. Over time, this new law will provide uninsured individuals who aren�t eligible for
Medicare with access to aff ordable health insurance. Family caregivers will benefi t greatly from these provisions.

In the short-term:

A person who has a preexisting condition and has been uninsured at least six months, they will
be eligible to buy coverage through a temporary high-risk program�which limits what they
will be charged for out-of-pocket costs. Th is program starts in July 2010 and ends in 2014 when
a new requirement will forbid insurance companies from denying anyone coverage because of a pre-existing condition.

Starting in September 2010, adult children up to age 26 will be allowed to maintain coverage on their parent�s insurance plan. This could greatly benefi t to young adult children who are unable to work because they are caring for a sick parent.

Staring in 2014:

Starting in 2014, everyone will be required to have health insurance. For those who don�t get health insurance through their employer or purchase it on their own and who earn between 133-400% of the federal poverty level, they will be able to purchase coverage from private insurers through state-run exchanges. Purchasing through an exchange should promote group rates, which tend to be lower. For those who still can�t afford coverage on their own, the new law will provide subsidies or tax credits to reduce the cost of buying insurance through a state exchange. Th is help will be provided on a sliding scale to those whose income is below a certain level. In addition, the law will limit annual out-of-pocket costs�deductibles and copayments�bought through an exchange for people with moderate incomes.

Finally, for very low-income people, the law expands Medicaid to cover all non-Medicare
eligible individuals under 65 who are legal residents earning up to 133% of the federal poverty line. Currently, Medicaid tends to be limited to low-income children, adults with disabilities, pregnant women and older adults. Health Care Workforce Development As many patients and caregivers know, fi nding the right doctor or a well-trained home
care worker can be extremely diffi cult. And as the population ages�and more Americans become insured due to health care reform�the need for primary care doctors, health care professionals who specialize in geriatrics, and well-trained direct-care workers is only going to grow. However, physicians who practice in primary care or geriatrics earn far less than those who choose to specialize, creating adverse incentives steering students away from becoming the very types of doctors we need more of. Th e new law takes a number of steps to address
those concerns:
 Provides grants and other fi nancial incentives to encourage students and health professionals to enter the fi eld of and receive training in geriatrics, chronic care management and long-term care
 Increases training opportunities and fi nancial support to encourage medical students and nurse practitioners to go into primary care. In addition, it provides increased Medicare reimbursements for primary care practitioners
 Provides funding for training direct care workers.
 Establishes a National Health Care Workforce Commission to provide objective recommendations for how to meet our unmet health care workforce needs.
 Establishes a Personal Care Attendants Workforce Advisory Panel to examine and advise on direct care workforce issues, including salaries, wages, benefi ts, and overall numbers of direct care workers, as well as on access to their services.
References
Campaign for Better Care: �Summary of Key CBC Priorities in Health Care Reform Law�
http://www.campaignforbettercare.org
Kaiser Family Foundation: �Focus on Health Reform: Summary of New Health Reform Law�
http://healthreform.kff .org/
PHI: �Direct Care Workforce and Long-Term Care Provisions�
http://phinational.org/policy/
White House: �Implementation Timeline: Refl ecting the Aff ordable Care Act�
http://www.whitehouse.gov/healthreform/timeline
Prepared by Family Caregiver Alliance and funded by Th e Retirement Research Foundation.
� 2010 Family Caregiver Alliance. All rights reserved.
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