A new explainer from The Commonwealth Fund examines how the two presidential candidates will or have approached health issues of prime importance to older adults — Medicare, long-term care and caregiver support.
While it’s a bit like comparing apples and bananas, since only one side can point to any results, this issue brief nevertheless provides a helpful overview of what the U.S. has accomplished under a Trump presidency and how a Biden administration might differ.
The issues that older Americans care about normally get strong support from both parties, but the emphasis is different: Republicans usually seek more private sector and individual responsibility, Democrats tend to want to beef up the social safety net. However, unlike years past, this time, both candidates are older adults themselves—Trump will be 74, and Biden, 78, on Inauguration Day, 2021.
“It’s clear that both candidates really pay attention to the issues that matter to older voters,” said co-author Gretchen Jacobson, vice president, Medicare, for The Commonwealth Fund. “Every older adult’s experience with aging is quite different, and we can even see it in the candidates.”
Under Trump, Medicare Advantage plans have been allowed to cover a greater range of health benefits, including non-health services such as meal assistance. The Bipartisan Budget Act of 2018 also closed the Medicare Part D prescription drug doughnut hole a year ahead of schedule. Biden wants to expand Medicare, to cover additional services like dental, vision and hearing, and lower eligibility to 60 from 65. He’d also allow Medicare to negotiate prescription drug prices.
Long term care only became a key issue under Trump in the wake of the devastating toll the COVID-19 pandemic took (and continues to take) on nursing home residents. CMS Administrator Seema Verma has issued more stringent regulations to improve infection control, additional testing and visitor protocols. She is considering other suggestions based on a report from the independent Coronavirus Commission for Safety and Quality in Nursing Homes. Biden’s plan would put additional emphasis on home- and community-based care, as well as improve nursing home staffing and quality. His plan would boost tax deductions for those paying for long-term care insurance. He also would give states more flexibility and funding to expand and improve home- and community-based services.
“Many questions have been raised during the COVID 19 pandemic — is there a better way for people to receive long-term care and then how would that actually be paid for,” Jacobson said.
About 1.5 million new people go onto Medicare each year, and that figure is expected to remain steady for the next decade, according to the Commonwealth Fund. One year of nursing home care costs more than $80,000. So cost-savings could be significant if care can be provided in a home or community setting. Biden would need help from Congress to implement most of these policies; the proposals would all require finding funding sources somewhere, whether that’s revenue or cuts and other funding which are not specified in his proposal.
“What we’re talking about are middle-income older adults who are really searching for options and getting care, getting help from their children if they can, who are often struggling themselves.
Family caregiving is the backbone of any home-based long-term care; Trump signed the RAISE Family Caregivers Act in 2018, which requires the Secretary of Health and Human Services to determine a national family caregiving strategy. Caregivers of Veterans also got additional support from the MISSION ACT. Biden would provide additional formal and informal support for family caregivers, including tax credits and 12 weeks of paid family leave; he also would offer additional education for performing medical tasks and add more community health workers in underserved communities.
The two greatest challenges ahead are what happens if the Affordable Care Act is overturned, and the fate of the Medicare Trust Fund. Several provisions of the ACA directly impact Medicare and many have already been fully implemented. Some of the major ones, such as closing the doughnut hole, have actually been further modified by legislation that came after the ACA, according to Jacobson. “What is really clear is that it could have a real impact on the Medicare Trust Fund because it could mean repealing the revenue sources that were part of the trust fund.” She said the trust fund is very shaky right now, with economists forecasting only three years left before it doesn’t have enough money to cover all of the costs of hospitalizations and other associated care. Since COVID-19, the situation may be even more dire.
“There’s just a few years left to deal with the solvency problem and it’s likely been further eroded with COVID 19 pandemic and associated funding,” she said.
Biden does not specify how he will pay for any of his proposals, although he has previously discussed repealing the Trump tax break and raising taxes on corporations and those earning above $400,000 annually.
Perhaps the positive aspect of the COVID-19 pandemic occurring in a key election year is that it has brought caring for older adults to the forefront, Jacobson pointed out. “Hopefully it has spurred more discussions about what we ought to do in this country with respect to long-term care.” It’s an area that generally isn’t discussed enough and hasn’t really risen to the top of the policy agenda. “The one bright spot that comes out of those spaces is that it may help to spur more conversations.”
Journalists may want to look into current home- and community-based programs and discuss how a potential Biden plan or current Trump administration policies impact services. How has the pandemic affected community-based care? What’s needed for the future?