Medicaid (MassHealth in Massachusetts) is our nation’s safety-net health care program for the poor and near poor. The estimated $1 trillion cut in Medicaid funding in the “big beautiful bill” will mostly hit those least able to afford it. But it won’t just affect them.
In a recent article in The New York Times, their “Your Money” columnist, Ron Lieber, explains how Medicaid also covers the middle class in the United States, including coverage of nursing home care when residents have run through their savings. In the absence of universal long-term care coverage, Medicaid has become the long-term care insurance of the middle class.
In addition, while the Affordable Care Act requires that children through age 25 continue to be carried on their parents’ health insurance plans, they lose that coverage on their 26th birthdays. Many are not covered by their employers and cannot afford to purchase private health insurance. Depending on their state, many qualify for Medicaid coverage.
For Americans with disabilities, Medicaid is often the program that allows them to live independently in large part because, unlike other health insurance, it pays for personal care attendants.
All of these protections are at risk with the coming cuts.
A Better Alternative: The Netherlands
The reason that Medicaid is so vital is in large part due to the convoluted way we do things in the United States. Rather than providing comprehensive health and long-term care coverage to everyone, we say “pay your own way” until you’re broke, and then we provide assistance. One result, especially in the area of long-term care, is that we have a patchwork uncoordinated system of private and not-for-profit providers that is inefficient and often provides substandard care.
Benjamin Veghte, the director of the Washington Cares Fund, a new initiative to provide basic long-term care coverage to all residents of Washington state, has authored a report about how long-term care is provided in the Netherlands, “Promising Policy Innovations to Make Aging in the Community Affordable for All: Lessons from the Netherlands.” He describes a system based on affordable housing and joint planning by all providers of services that provides seniors with the support they need to age in community. They are able to do this at a much lower cost than what we spend in the United States.
The history of housing and health care funding in the Netherlands supports its approach. This includes a tradition of older people moving to senior housing, in large part to make housing available to younger families, and comprehensive insurance that covers long-term care. But it’s also the result of more recent changes to the system which were implemented in recognition of the growing number of seniors and the growing cost of a system that had been based in large part on institutional care.
In response, the Netherlands adopted a system of “tailor-made” care “wherein care is adapted to the
totality of a person’s physical and social context. This results in each person being treated
differently.” This was aimed at taking advantage of each individual’s informal and community support networks. The Dutch system also transferred control of the long-term care funding from the national to local governments so each could figure out the best way to provide care in their communities.
But at root, these reforms were able to take place because long-term care in the Netherlands is seen as a community-wide responsibility rather than an individual one. Since there’s a funding source, communities are able to determine how best to use the funds to provide care rather than various and disparate care providers seeking payment from individuals or the Medicaid program, and the Medicaid program trying to limit costs either by restricting eligibility or keeping reimbursement rates low.
A Better Alternative: Massachusetts
On my Risking Old Age in America podcast, I recently interviewed Lizbeth Heyer, President of 2Life Communities, a non-profit organization that provides supported senior housing in greater Boston. She described how they have been able to cobble together donations and housing subsidies to keep costs low and how by having social workers in each of their communities they are able to help their residents stay in their apartments as their needs develop. They also help residents qualify for MassHealth and other programs that help pay for the care they need.
Further, Heyer explained that the cost of care in their communities is much lower than such costs for individuals living in single-family homes scattered around various towns. Many home health agencies require that care be purchased in four-hour chunks even if the need is simply for someone to visit briefly to assist in dressing and taking medications. The same home health aide can take care of many residents in the 2Life communities during the same four-hour shift.
In addition, it’s a better job for the home health aide. They are working with others in a community rather than in the isolated setting of a single-family home.
The lesson from both the Netherlands and 2Life Communities is that we need to be thinking comprehensively about how best to provide care rather than the piecemeal, Medicaid-based approach we have today.