- Changes to Health Coverage Must Include Medicare Improvements
- Policies and “Regulatory Failure” Caused COVID-19 Deaths in Nursing Facilities
- Elder Justice Newsletter – Vol 3, Issue 6 Now Available
- Free May Webinars | Register Now
In his national address before a joint session of Congress last night, President Biden outlined his vision for “rebuilding our nation” in the midst of both “crisis” and “opportunity”. His vision included both health care broadly, and Medicare specifically. President Biden stated:
Let’s give Medicare the power to save hundreds of billions of dollars by negotiating lower prices for prescription drugs.
That won’t just help people on Medicare – it will lower prescription drug costs for everyone.
The money we save can go to strengthen the Affordable Care Act – expand Medicare coverage and benefits – without costing taxpayers one additional penny.
Medicare, often viewed as the country’s flagship health coverage program, serves over 62 million older adults and individuals with disabilities. Although the program is rightly beloved, it is incomplete and in need of repair. As the Administration and Congress work to develop proposals to implement the President’s vision, we urge policymakers to keep the Medicare program and beneficiaries central to the discussion.
It’s important to recognize some differences between Affordable Care Act (ACA) coverage and Medicare – and that Medicare beneficiaries cannot enroll in ACA plans. Unlike coverage available through the ACA, traditional Medicare lacks an out-of-pocket cap on health care expenses. Assistance with premiums and cost-sharing is more generous through the ACA than it is in Medicare. The need for dental, vision and hearing services is great among the Medicare population, but the program largely does not cover these critical services. Prescription drug costs are too high both for Medicare beneficiaries and the Medicare program itself. Medicare coverage for nursing home and long-term care is limited. Further, its home health benefit – which can cover aide services for an unlimited duration if someone is both homebound and also requires skilled care – is not actually being provided as authorized by law – and is ripe for reform as part of an expanded approach to home and community-based services.
Medicare’s private option, Medicare Advantage (MA), is not the answer to these problems. The MA program costs more per beneficiary than traditional Medicare, and such spending is growing faster than previously expected (MedPAC, 2021); Congressional Budget Office, 2020). Further, despite inflated MA payments, enrollees’ health outcomes are decidedly mixed (New England Journal of Medicine, 2018). While MA plans are required to offer an out-of-pocket cap on Part A and B expenses, a larger percentage of MA enrollees report problems getting care due to costs, or paying medical bills, than beneficiaries in traditional Medicare (even after controlling for income and health status) (Kaiser Family Foundation, 2020). In addition, while many MA plans use rebate dollars to offer some vision, hearing and dental services, the scope of these services are limited.
The Center for Medicare Advocacy has outlined our legislative priorities in our Medicare Platform, which include the following goals:
- Oral health benefit, along with hearing and vision care – in traditional Medicare;
- An out-of-pocket cap on beneficiary expenses in traditional Medicare;
- Improved protections for low-income individuals; and
- Other changes, including expanded Medigap rights and reform of the appeals process.
Medicare needs fundamental, structural changes to ensure quality coverage and benefits that accrue to all of its beneficiaries. The Center supported the approach to improving Medicare outlined in the House-passed Elijah E. Cummings Lower Drug Costs Now Act (H.R.3). H.R.3 would have achieved significant drug savings, in part by allowing the Medicare program to negotiate certain drug prices. Importantly, it would have reinvested most of those drug savings into the Medicare program by expanding dental, vision and hearing services, expanding low-income assistance, and improving rights to purchase Medigap policies, among other changes.
As Congress grapples with how to improve our health coverage infrastructure, we urge policymakers to keep traditional Medicare, the country’s foundational health program, front and center. As the nation faces an historic opportunity to strengthen and expand health coverage, Medicare must remain central to the discussion. It’s time to build Medicare back, better.
Professor Challenges the Nursing Home Industry’s “Nursing-Home-As-Victim” Narrative
In an article published in the Georgetown Law Journal, Law Professor Nina A. Kohn challenges the nursing home industry’s narrative that nursing facilities are victims of COVID-19. The industry successfully used this false narrative during the coronavirus pandemic to lobby for billions of dollars in additional federal funding as well as protections from legal liability. In addition to the inadequate public health response to the pandemic, Kohn describes, “deliberate policy choices and regulatory failures that have shaped long-term care in the U.S. and enabled nursing homes to make choices that have long endangered the health and welfare of their residents.” [Nina A. Kohn, “Nursing Homes, COVID-19, and the Consequences of Regulatory Failure,” Georgetown Law Journal, Vol. 110, p. 3 (Spring 2021).]
Professor Kohn describes four key factors:
- Historical regulatory gaps (most significantly, the rules’ failure to require “sufficient nursing staff and an adequate ratio of staff providing resident care to residents receiving care”);
- Under-enforcement of existing regulations (caused by state inspectors’ failure to identify quality of care problems or identifying them “as less severe than they actually are”);
- States’ failure “to penalize violations and to ensure correction” (Most violations do not lead to any monetary fines; the Trump Administration intensified the problem of under-enforcement by shifting to per instance civil money penalties, among other changes); and
- “Medicaid’s preferential treatment of institutional care relative to community-based care.”
Kohn offers several regulatory reform options “that would better align nursing homes’ incentives with quality care:”
- Strengthening enforcement of existing requirements by “improving the quality of the survey process to ensure that deficiencies are accurately identified and categorized,” “imposing monetary fines for a broader range of violations,” and applying enforcement to owners and operators, not individual facilities.
- Linking payment to outcomes, such as enactment of “a robust pay-for-performance system.” Kohn notes that the windfall payments to facilities during the pandemic have been “almost entirely devoid of conditions” for payment and “much of it may not have been spent on patient care.”
- Requiring facilities to provide at least 4.1 hours of direct care staff per resident per day or to adopt minimum staffing ratios or enacting a federal law to require facilities receiving Medicare or Medicaid reimbursement, or both, “to spend a threshold percentage of those funds – or a percentage of their aggregate revenue – on direct resident care (as opposed to spending it on administrative costs or simply pocketing it).”
- Eliminating Medicaid’s preference for institutional care.
Weeks Without a Shower
In the Elder Justice Newsletter, we highlight citations, including deficiencies related to abuse, neglect, and substandard care, that have been identified as not causing any resident harm. The goal of this brief newsletter is to shed light on the issue of so-called “no harm” deficiencies, which typically result in no fine or penalty to the nursing home.
This newsletter focuses on the following “no harm” violations:
- Dental decay: Facility fails to assist resident in obtaining appropriate dental care.
- Out the window: Facility fails to ensure resident safety.
- Resident abuse: Facility fails to protect two residents from sexual abuse by another resident.
- Weeks without a shower: Facility fails to bathe residents.
Do YOU think these deficiencies caused “no harm”? Click here to download and read the full newsletter.
May 5, 2021, 2:00 – 3:15 PM EDT
Geography is not Destiny: Mitigating Harm in SNFs During and After COVID 19
Sponsored by California Health Advocates Senior Medicare Patrol, this presentation will include a discussion of the Center’s recent research into nursing home successes and failures during the COVID pandemic, and what can be done to improve care going forward, as well as updates on residents rights, and fraud awareness and prevention.
- Micki Nozaki, SMP Project Director with California health Advocates
- Toby S. Edelman, Center for Medicare Advocacy Senior Policy Attorney
- Cinnamon St. John, Center for Medicare Advocacy Chiplin Medicare & Health Policy Fellow
Register now at https://attendee.gotowebinar.com/register/7752001593008164109
May 19, 2021, 2:00 – 3:00 PM EDT
Voices of Medicare: Updates from the Field
This presentation will examine real stories of current Medicare Issues told by our advocates, including:
- Home Health Access Issues – Associate Director Kathy Holt
- Medicare Advantage – Senior Attorney Mary Ashkar
- Medicare Appeals – Attorney Paul Grabowski
- Low-Income Beneficiary Issues– Policy Attorney Kata Kertesz
- Oral Health – Senior Attorney Wey-Wey Kwok
Register now at https://attendee.gotowebinar.com/register/6162491503408897803