The CLASS Act and Long-Term Care

TO: Senator Kay Hagan (D-NC)
FROM: Robert Swendiman, MD MPP
DATE: October 26, 2012
RE: Demise of the Community Living Assistance Services and Supports (CLASS) Act

The CLASS Act program was an effort within the Affordable Care Act (ACA) to address the rising costs of long term care (LTC) for seniors and young workers with disabilities. Ultimately, the Obama Administration halted its implementation due to concerns regarding its fiscal sustainability. Unfortunately, in this political climate, new federal efforts to address LTC spending are likely to meet a similar end.

Financing Long-Term Care. As the cost of long-term medical care rises, both for public programs and individuals, lawmakers have sought ways to alleviate this financial burden. Medicaid now finances over 60% of this $208 billion annual price tag, and individuals pay about one-fifth of costs out-of-pocket. Approximately two-thirds of seniors will need some type of LTC in their lifetime, with services ranging from intermittent care in one’s private residence, to full-time observation in a nursing home or skilled facility. Given that fewer than 10% of all individuals 55 and older have private insurance policies for LTC, the CLASS Act was meant to serve as a voluntary, national insurance program that could attend to this growing financial risk.

With the goal of ensuring financial and personal independence for those with functional limitations in their daily activities, the CLASS program would offer all working individuals 18 and older the opportunity to purchase the LTC insurance, given a minimum yearly income of $1,200. Enrollees could collect a minimum of $50 as a daily benefit for LTC, which is about one-third the average daily benefit provided by similar insurance programs today. Premiums would be set based on 75-year cost projections to ensure solvency, and advocacy/counseling services would be established to aid individuals in LTC decision-making.

CLASS Program Limitations and its Demise. Due to a five-year vesting period, Congressional Budget Office (CBO) and the Centers for Medicare and Medicaid Services estimated that initial 10-year deficit savings would be $70 billion and $38 billion, respectively, though this trend would reverse in the ensuing years. However, the program’s sustainability was ultimately called into question, mainly due to the guarantee issue requirement and voluntary nature of the program. The concern was that patients who most needed the benefits would opt-in, and healthier patients would opt-out, also known as “adverse selection.” This, combined with the perceived modest benefit of the program, led the Secretary of Health and Human Services to send a letter to Congress, stating that the Administration did not see a viable path forward for implementation of the CLASS program at this time, and that implementation efforts would be halted.

“Fixing” CLASS. Thus, in addressing the question of paying for LTC through a federal program, the flaws that buried the CLASS program would have to be addressed:

• Adverse Selection – It is vital to the program that those with pre-existing medical conditions are included, but is it possible to ensure that enough young and healthy individuals enroll to spread the risk? While some have suggested a universal mandate to purchase LTC insurance, this produces obvious political challenges.
• Incentivizing Enrollment – Designing the program to require employees to “opt-out” would increase enrollment, but how would employers be incentivized to purchase this insurance? Without employer buy-in enrollment would remain low, as CBO already projects, estimating a 3% national participation rate.
• Financing and Modest Benefits – The Secretary estimated that monthly premiums would rise to just under $400 a month, a figure that is unaffordable, especially given such a meager daily benefit ($50).

There have been a number of small tweaks proffered in order to revive the CLASS program, though implementation would be extremely difficult given the current political climate. Despite the President’s reelection, 51% of Americans still desire repeal of the ACA, with the individual mandate remaining exceedingly controversial. A mandate for LTC insurance has been proposed to account for adverse selection, but cost and popularity would likely hinder enactment. The income requirement could be raised to $12,000 in order to lower premiums; however, this would likely exclude many of the working-disabled, a key demographic target of the CLASS program, thus limiting access. The daily payout could be increased, while the duration of eligible benefits limited, but this poses similar concerns. Without a mandate, CLASS is unlikely to seriously address the LTC issues this country faces.

Next Steps. Given barriers to implementing a program like CLASS, one must seek other viable options to improve access to LTC. Two such solutions to consider would be 1) creating a private insurance market for LTC under the Medicare program, much like Medicare Part D for prescription drug coverage. This again would be a voluntary system, but one that could potentially obtain more visibility and better buy-in, especially with seniors. 2) Allow individuals to use a small portion of their Social Security benefits to purchase LTC insurance in the private market. Coupling LTC insurance with Social Security may allow better planning for future health needs. However, cost and access remain unknown considerations in both of these proposals.


References

• U.S. Congressional Research Service. Community Living Assistance Services and Supports Provisions in the Patient Protection and Affordable Care Act (R40842; February 15, 2012), by Janemarie Mulvey and Kristen J. Colello. Text in: LexisNexis® Congressional Research Digital Collection. Accessed: November 5, 2012.
• H. Stephen Kaye, Charlene Harrington, and Michell P. LaPlante. Long-Term Care: Who Gets It, Who Provides It, Who Pays, and How Much? Health Affairs, 29, no.1 (2010):11-21.
• Terence Ng, Charlene Harrington, and Martin Kitchener. Medicare and Medicaid In Long-Term Care. Health Affairs, no. 1 (2010):22-28.
• Howard Gleckman. Requiem for the CLASS Act. Health Affairs, 30, no. 12 (2011):2231-4.

Lifting Weights 101 - Get It Together, Harvard

I'm taking up a new cause. I've decided to petition all the schools here at Harvard to require "Lifting Weights 101: How to not look like a weightlifting virgin." Inspired by the upcoming election, I have decided to make phone calls, canvass local businesses, yell and scream in the Quad, and run my own TV ads. The amount of idiocy and general douchebaggery in the weight rooms here has been absolutely atrocious. First of all, the student gyms here are abysmally tiny (of course no one knows about the Business school gym - us "normies" aren't allowed). Sure, there are 100 ellipticals lining the walls, but if you can work out your Differential Equations homework while "faux-running," you aren't working out. Where are the squat racks? Why do I have to weight an hour to bench press (pun intended)?! I would love to say that I'm going to raise enough money to build new facilities here, but I can't. However, in the meantime I will require all undergrads and graduate students to learn a few basic lessons about gym etiquette.

Here are the Top 10 lessons Harvard students should take away. People who lift at the law school gym and the MAC, this is for you:

1. The weights should be EQUAL on BOTH SIDES of the bar. I'm leading with a very crucial learning point here, so pay attention. I recently watched someone bench pressing (if you can call it that) with a 35 lbs. plate on one side, and a five and a 25 lbs. plate on the other. 35 does not equal 30, people. Where do I start with how piss poor this is? First of all, it immediately proves that Harvard is not accepting the "best and brightest." Admissions committees here must be sure to screen out such individuals, perhaps on the campus tour through the gym facilities (as Kelly knows, I use lifting knowledge as part of my screening test for women... Harvard could learning something from this). Anything less is a disgrace to the institution. Furthermore, be advised that a 45 plate on one side, and a 25, 10, and a 10 on the other is ALSO NOT THE SAME! PUT EQUAL WEIGHTS ON BOTH SIDES. Goodness gracious.
2. Don't wear a hat on the premises. You look like a douche.
3. Rack your daggum weights! Okay, I shouldn't have to spend half my time scouting machines and racks that aren't in use. You put weights on when you start, then you take them off when you're done. If you just leave them there, other people think you are still doing that exercise. Don't be that guy (or girl). Rack 'em and stack 'em, like Willie. No one wants to be the one who has to take off your two and a halves from the bar. It's just annoying.
4. Couples lifting is sketchy at best; holding hands makes patrons vomit. Working out is sacred time. Throw on your music, get lean, and get mean. The gym is not a movie theater, a hotel room, or the back of a Chevy, i.e. no hanky-panky. Twice I have spotted couples canoodling (sp?) between sets, and that is not okay. And, "I don't use tongue" is not an excuse. If I have to say this again, someone is getting slapped.
5. Headbands are for people who can pro-bench ONLY. If you don't know what pro-benching is, don't even think about throwing on your LeBron band. At the NFL Scouting Combine, they have the athletes see how many times they can bench 225 lbs. That's the bar with two 45 lbs. plates on either side. If you can't lift this (let along a 45 lbs. plate by itself), again, please don't try to make any fashion statements.
6. You don't need anything to make the bar "softer" when you squat. No towels, no other contraptions. Squatting with the bar on your shoulders doesn't hurt. If it does, you either squat with Ray Lewis weight or (more likely) you just need to suck it up.
7. I'm 6'5'' 200 lbs., I SHOULD NOT LOOK LIKE A WEIGHTLIFTING GOD. At Carolina, I'm puny. At Harvard, I'm Arnold Schwarzenegger. Milk is for babies. When you grow up, you have to drink beer. Just saying that I shouldn't be the one writing this blog.
8. Don't ever tell me you don't know how to "spot." I know you have your iPhone on you, because God forbid you would miss a journal publication whilst working out. Ask Siri what it means to "spot."
9. Never lift in a button-down dress shirt. Really?! #PaulRyanWearsUnderArmor #SoShouldYou
10. If you don't know what you are doing, hire a personal trainer. There's an awesome dude whom I see all the time in the weight room who looks like Leonard from the Big Bang Theory. He doesn't know what he's doing, but instead of making the many egregious mistakes above, he is using the available athletic trainers to help him beef up and win over the lady-folk. Every time I see him, it brings tears of joy to my eyes. This is the kind of common sense that is needed in these dark times.

Heed my wrath. Now go and prosper.

Early Liver Transplantation in Acute Alcoholic Hepatitis

More than 16,000 Americans are waiting for a liver transplant, according to federal data from the Organ Procurement and Transplant Network. Only 6,000 organs are available a year and nearly 2,000 people will die waiting for one to become available. Should an alcoholic who is likely to die from liver cirrhosis in the immediate future be allowed an early transplant (i.e. prior to the required six months of abstinence), if she is commits to abstinence from alcohol and has family support to help keep her promise, even as thousands of others who have not abused their bodies with alcohol or drugs await a new liver?

We first must agree that there are circumstances in which human beings deserve a second chance. Mistakes are made, and we ought to have the opportunity to learn from them. If the mistake is egregious enough, we, as a society, invoke laws requiring restitution and punishment. When found guilty in a court of law, a criminal may pay a fine, provide community service, or spend time in prison (or sometimes a combination of all three). Only then can the person return to society as a free citizen. A former criminal may also be subject to a period of probation, during which the individual must prove she can adhere to the rules of society without recidivism.

There are also circumstances in which society determines that a criminal does not deserve a second chance to be a free citizen. In these cases, the criminal may be banished from society permanently, sentenced to prison for life or put to death. These offenses almost always involve intense violation of someone else’s bodily integrity, not one’s own. Applying this dichotomy, if one views alcoholism as a “crime” that involves “fault,” it is certainly not worthy of complete condemnation; alcoholics deserve a second chance.

Sometimes, that second chance at life is a liver transplant. If so, should all alcoholics not abide by some form of "penance," i.e., evidence of abstinence from alcohol, in order to be eligible for a transplant? In fact, the United States transplant system already includes this requirement. Patients must abstain for at least six months before they can receive a new liver. These six months are the required justification to become a "free citizen" again, and be accorded the same rights as other persons to "life, liberty, and the pursuit of happiness." Some will argue that despite this six month penance, despite the probation, reformed alcoholics still deserve to be treated as second class citizens in terms of priority for liver transplantation. It is their fault, so they should wait behind those who have not ravaged their bodies with alcohol.

While this argument may “comport with basic intuitions about fairness” (Wikler, 110), society generally discards the notion that personal fault should play a role in medical treatment. The medical community, in particular, has rejected this idea of “priority” based on fault entirely, believing that all patients deserve medical treatment regardless of whether or not they may have caused their own illness. Imagine an Emergency Room where physicians prioritize patient care in terms of “fault” instead of “need.” A doctor would be obligated to treat a patient with warts before an individual who is bleeding to death from a skiing accident. While the latter person had arguably knowingly engaged in a dangerous sport, can a lack of immediate treatment truly be justified? Few would argue so.

Some scholars also argue that social injustices account for many health injustices, and thus society cannot be completely exculpated. Daniel Wikler presents this view eloquently in Personal and Social Responsibility for Health, and it is worth noting that the belief that alcoholics are completely at fault for their illness is shaky at best. There are too many genetic and societal factors that contribute to this disease. Without a clear concept of “fault,” it follows that “need” is the only justifiable means of priority, despite limited resources.

Unfortunately with liver disease, sometimes six months of abstinence is a death sentence in itself. Patients with severe alcoholic hepatitis may deteriorate over days and weeks, not months. So if we agree that these patients are morally justified in obtaining a new liver after six months of abstinence, what of their dire prognosis? I believe there are two requirements for providing a new liver without strict adherence to the six month rule. The first deals with “intent.” The patient must state her intention to become or remain abstinent. If the opposite were true, the patient would never actually have completed the required penance in the first place. Therefore, a new liver would not have been transplanted, and would not be justified.

I would further argue that this patient population (those who are alcoholics, have less than six months to live, and swear abstinence) should be studied in terms of rates of recidivism. If 100% of these patients typically fall back into alcoholism post-surgery, then one could argue that early transplantation is not morally justified. However, if patients who meet these criteria are found to have similar rates of recidivism to those who were able to abstain for six months, there is no question that early transplantation would be moral justifiable. There is current evidence to support this argument. Thus, with the caveats of “intent” and that it would be prudent to study the population at hand, our patient with acute alcoholic hepatitis deserves a new liver.


References

• Wikler, Daniel. “Personal and Social Responsibility for Health.” Public Health, Ethics, and Equity. Eds: Sudhir Anand, Fabienne Peter, Amartya Sen. New York: Oxford University Press, 2004. 109-134.
• Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365(19):1790-800.
• Brown RS Jr. Transplantation for alcoholic hepatitis—time to rethink the 6-month “rule.” N Engl J Med. 2011; 365(19):1836-8.

Story of Self

Tonight at our leadership workshop I was asked, "Why are you here?" It's the theme of this year, repeated over and over, because it is so easy to forget. I could get lost studying statistics and economics, going out in the city, and doing what some people refer to as "the n-word" (aka "networking" - the dirty word you should never use when talking about what you are doing here at Harvard...). But tonight I was pushed further. It is not enough to say, "I am here to learn how I can be an effective public servant. I'm here to learn, and I'm here to lead." Well, why? Why do you want to be a public servant? And why do you want to lead? In response, I often refer to the quote that I leave at the bottom of my emails:

The moral test of government is how it treats its people in the dawn of life, the children, in the twilight of life, the aged, and in the shadows of life, the sick the needy and the handicapped.

Is that not enough? Can't I tell you story after story about patients I've met and how they have affected how I view the world? It's not. It's not because I could've had these experiences, developed these relationships, viewed the world differently, and still not thought that we need to do more. Still not thought that policy changes can be made for the greater good, and I have a responsibility to be part of that change. So again, I am asked, why am I here? Why did I go to medical school, and why am I interested in public service?

After I got home, the first thing I did was call my parents. I needed a debrief. Why am I here?! Someone please tell me a story from my childhood that in some way embodies the values that I believe in today. Where was my life changed? As my parents sit on speakerphone listening to me babble and push back, I keep thinking that I don't have a story. I didn't grow up in poverty, work my way out, and feel like I needed to go back and make a difference in my community. I didn't struggle most of my life with being gay, growing up in a society that doesn't accept me for who I am. I didn't have to learn English as a second language. I'm a white male from the suburbs who went to a high school with a golf course on campus.

I got off the phone with my parents and looked at the screen. We talked for over 43 minutes. My first thought was, "Those are the only two people in the world who would drop everything and listen to my quarter-life crisis." My grandmother would as well, but unfortunately she is no longer with us. And as I was thinking about these three individuals, what they have (and would) sacrifice for me, I realized I had a story.

When I was 17 years old, I had an opportunity that I wish every child could have as well. During a high school retreat, I received a packet of letters. These letters were from the people who cared about me in my life. Some were from friends and mentors, some from distant relatives, but there were a few that meant much more. A few letters that still bring tears to my eyes, even just thinking about them. Three letters in particular, all of which have had a lasting impact.

Tonight I reread those letters. It has been a number of years since I have gone back and poured over them, but I always remember the kindness, love, and hope they embody. Much in these letters is private, but there are a few quotes that I do want to share. So again I ask myself...

Why am I here? My mother writes, "We hope in our hearts that you will come to know certain things when you become a man: that you will know in order to gain respect from others, you must give them respect; that you will realize it is not whether you control others that matters, but whether they choose to follow your leadership... that you know all the money in the world can never buy back your good name if you have disgraced it; and that you will understand you can expect many people to treat you worse than you treat them, but you can never expect anyone to treat you better than you treat them."

Why am I here? My father writes, "Now we wish we could prepare the world for you, but we can't, so we have to prepare you for the world. We want to provide you with the tools you will need to cope with the challenges of the fast-paced, demanding, and all too amoral world waiting for you. When you think about it, your appearance came near the end of a century that saw immeasurable evil and cruelty. It was a century that ended any illusion that there is a limit to the atrocities of which human beings are capable. But that wasn't your century; your century is that of the twenty-first... To your generation comes the burden of the past, but also in your generation lies the hope of the future. And the future will depend in large measure on the character of the men and women growing up now, as you are."

Why am I here? My grandmother writes on a theme that I will never forget. It is the one quote in life that I will hold with me until I die. I can literally hear her words, both spoken and written. "Rob, with great power comes great responsibility. 'To whom much is given, of him much shall be required' - Luke 12:48."

There is so much more I could share, and in so many ways I have failed these letters. But I, like my parents, haven't given up hope. So what is my story? My story is built on the values my parents taught me. They are the values that are at the core of the passages above. Hope. Love. Respect. Sacrifice. Courage. There are many ideologies in this world, but when I see patients who are disabled, poor, marginalized, or silenced in a world that does not allow them to speak, for me I hear their story. How I intertwine my story into their narrative is with the values that my family have tried to instill in me.

My story is to hope. To hope that our generation can overcome the poverty and hate that holds humankind back. My story is to love. To love every person like they are my mother, my father, my grandmother. My story is to respect. To respect those without a voice, and to be their voice when the time comes. My story must be to sacrifice. To sacrifice my time and energy for something greater than myself. My story is to have courage. The courage to accept the things I cannot change, change the things I can, and the wisdom to know the difference.

That is my story. That is why I am here.