In This Issue: Tax bills’ rush to judgment | potential Medicare cuts | bundled payments’ demise | “essential health benefits” | HRRP concerns | long-term care patients’ rights | “no harm” deficiencies | primary care physicians’ primacy | CBT | robotics | Medicaid waivers | caregiving in the “sharing economy” | end-of-life high tech v. palliative care | and “skinny” health plans.

As Caregiving Policy Digest was nearing publication, news came of a House-Senate

conference committee agreement on tax legislation. We will send an update next week covering pertinent aspects of the merged bill.

Tax Bills and the Impact on Social Programs

Two tax bills careening towards a conference committee merger process and on to a White House signing ceremony held center stage as 2017 drew to a close. For the health care policy and advocacy communities—concerned with the fate of health care coverage under Obamacare, Medicare, and Medicaid—the short term implications of the final outcome lay primarily in the fate of the ACA’s individual mandate, possible cuts to Medicare mandated by budgetary pay-as-you-go requirements, and the ability of taxpayers to deduct high medical expenses often incurred because of family caregiving needs. Longer term, the passage of a deficit-exploding tax bill, in the eyes of both the bills’ detractors and proponents, would pave the way for efforts in 2018 to mount an assault on social-net spending programs, including Medicare and Medicaid. Such a longer-term impact was openly predicted and welcomed by House Speaker Paul Ryan in a radio interview reported by the New Yorker’s John Cassidy, Ryan talked about what will happen after Trump signs the GOP tax bill into law, assuming the House-Senate conference can agree on a final text. “We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said. Programs like Medicare and Medicaid “are the big drivers of debt so we spend more time on the health care entitlements, because that’s really where the problem lies, fiscally speaking.” For years, Cassidy continued, “privatizing Social Security and Medicare, the great liberal creations of the New deal and the Great Society, and radically downsizing Medicaid, another Great Society innovation, has been the (GOP’s) primary goals. During last year’s election campaign, Trump repeatedly pledged to protect these popular programs from cuts—but he still called for the abolition of Obamacare, which would have involved drastic cuts to the Medicaid budget. Now, Trump’s attitude toward Social Security and Medicare appears to be changing, too. Ryan, in his radio interview, said that he had been speaking privately with Trump about the approach they should take to entitlement programs, and he added, ‘I think the president is understanding choice and competition works everywhere, especially in Medicare.’”

Elimination of the Medical Deduction Impact on Middle-Class Families

The tax legislation’s short-term projected $25 billion Medicare cut and medical expense deductibility could be averted if Congress, in the first matter, follows previous precedents and waves the “pay go” cuts, and, in the second, adopts the Senate’s version, which retains the medical deduction, rather than the House’s, which does not. Writing in The New York Times, reporters Kate Zerniki and Abby Goodnough spoke of Adrienne Lynch in Austin, Texas, who characterized the potential loss of the medical expense deduction as a “gut punch.” “According to an analysis in January from the Joint Committee on Taxation,” the Times reporters continued, “most taxpayers who claim the deduction have incomes below $100,000, with about 40% below $75,000. Half of those who claim it are older than 65, according to AARP. They often face staggering medical and long-term care costs. The deduction also helps younger families struggling to pay the enormous cost of caring for children with chronic conditions or disabilities, and couples going through costly fertility treatments like in-vitro fertilization. In interviews, some who claim it said the deduction is the difference allowing them to afford mental health care, chemotherapy drugs, or cancer surgeries by doctors who fall outside insurance networks.”

Advocates Continue to Raise Alarm Over Cuts to Programs for Older Americans in Proposed Tax Overhaul

Advocacy organizations believing they had finally won a decisive health coverage victory with the Senate’s earlier failure to repeal Obamacare found themselves having to raise their voices once again as the tax bills moved toward passage. In late November, as the Senate readied its vote, 40 groups joined to urge that a result that triggered a Medicare sequestration cut, ends the medical deduction, and provides a future fiscal reason to undermine Medicare and Medicaid should be turned down. AARP added its powerful voice separately, writing that it “opposed repeal of the individual mandate that will increase costs and cause millions of Americans to lose health insurance coverage. Most troubling is the negative effect the Tax Cuts and Jobs Act will have on the nation’s ability to fund critical priorities. The act will increase the deficit by approximately $1.5 trillion over the next 10 years, and an unknown amount beyond 2027. The large increase in the deficit will inevitably lead to calls for greater spending cuts, which are likely to include dramatic cuts to Medicare, Medicaid, and other important programs serving older Americans. Indeed, the Congressional Budget Office has confirmed that unless Congress takes action, the reconciliation legislation will result in automatic federal funding cuts of $136 billion in fiscal year 2018, $25 billion of which must come from Medicare. Such sweeping cuts would be detrimental to already vulnerable populations.”

Federal Tax Plan’s Punch to California and Other States

This week, the California Department of Finance issued a letter to the Members of the California Congressional Delegation on the impact of proposed federal tax plan on the state. While the details are specific to California, they are relevant to any state considering the impacts of this massive tax shift to favor upper income families and corporations over average working families. What is not mentioned in this letter are the immediate cuts to Medicare and other social safety net programs in the next budget needed by family caregivers and their relatives needing assistance. And if passed, the plans to go after more permanent cuts and restructuring of entitlement programs such as Social Security, Medicaid, and Medicare are scheduled for next year.

Recent CMS Decisions on Bundled Payments

CMS has issued a formal notice of its decisions regarding the future of bundled payments. Entirely canceled were mandatory hip fracture and cardiac bundled payment models, while the Comprehensive Care for Joint Replacement model was given the go-ahead, albeit with changes. “While CMS continues to believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, we believe that focusing on developing different bundled payment models and engaging more providers is the best way to drive health system change while minimizing burden and maintaining access to care.” The CMS announcement capped several moves by the agency revisiting the goals of the Center for Medicare and Medicaid Innovation, established by the Affordable Care Act to test models aimed at improving medical care and reducing costs. “While the Obama administration had pushed large, mandatory experiments to test new models of pay,” Times reporters Zernike and Goodnough wrote , “the Trump Administration wants to encourage smaller, voluntary programs—and has asked doctors to help design them. The Obama team had sought to shift 30% of fee-for-service Medicare payments to alternative payments based on quality or value by 2016—a goal that was achieved—and 50% by 2018. To do so it required doctors and hospitals in many regions of the country to adopt these new payment models. Many in the healthcare field, however, had criticized some of the rules issued by the Obama administration as overly prescriptive and welcomed the department’s effort to review them.” (For a somewhat jaundiced view of bundled payments see the Media Watch section in the September issue of Caregiving Policy Digest.)

CMS Pay Model Under Consideration Impacts Access to Services

CMS will also be considering a variety of future payment models as it sifts through comments submitted in response to a Fall Request for Information that offered a slew of options—including the introduction of direct patient-provider contract arrangements. Advocacy groups took strong exception to that idea in comment letters arguing that “demonstrations that erode the universality of Medicare coverage by segmenting beneficiaries into those who can afford to pay additional amounts to providers and those who cannot do not advance the goals of the Medicare statute. Demonstrations that impose additional cost burdens on struggling Medicaid beneficiaries or shrink their access to needed services do not advance the purposes of the Medicaid statute. We strongly urge CMS not to pursue such models. Advocates are enthusiastic about instead working to increase consumer-directed care and empower beneficiaries within models that provide positive incentives and that do not threaten bedrock principles in Medicare or Medicaid.”

Proposal Allowing States to Define ‘Essential Health Benefits’

As previously reported (in the November issue), CMS has proposed allowing states to individually define their own “essential health benefits” health insurers must offer, rather than mandatory federal definitions covering 10 benefit categories. Comments are now in the agency’s hands and, as Shelby Livingston reports in Modern Healthcare, the insurers themselves are not exactly jumping for joy. “In its proposed notice of benefit and payment parameters for 2019, CMS suggested letting states either adopt another state’s 2017 benchmark plan, pick and choose a few elements of another state’s benchmark plan, or completely build a new essential benefits package from scratch, so long as the plan is not more generous than it is currently and is in line with a ‘typical employer plan.’” On the one hand, Livingston pointed out, “health reform experts worried that the added flexibility would lead to a proliferation of less costly, albeit much skimpier plans on the market. Major health insurers, on the other hand, have stated fears that states would somehow expand the benefits health insurance must offer, causing insurers to spend more on medical care.”

Hospital Readmission Reduction Program and Impact on Mortality Rates

The ACA’s Hospital Readmission Reduction Program (HRRP) continues to operate, generating positive impacts on hospital quality improvement and transfer policies, as well as penalties for failure to achieve benchmark reductions. As the program matures, however, it is also generating some controversy regarding its overall impact on mortality rates. In the case of Utica New York’s St. Elizabeth Medical Center, Modern Health’s Maria Castellucci reports that, as a result of the HRRP and the 2013 $393,000 penalty imposed on the hospital, “all patients are now screened for risk factors that might signal they are vulnerable to a readmission. Those high risk patients are set up with navigators, who call them after discharge to ensure they have a follow-up appointment with their primary care provider. And if they don’t, the health system sets up a visit at one of its outpatient centers within 10 days after discharge. The efforts have worked. The financial penalty at St. Elizabeth has dropped from 0.21% of net revenue in 2013 to .03% in 2018. The hospital’s penalty will be $52,000 in 2018. Overall the penalty program, has effectively motivated hospitals to change wasteful care practices and better manage populations.” On the downside, some researchers are raising concerns that, in the case of heart failure, for example, as hospitals reduce readmissions mortality rates may consequently be increasing. This program, Castellucci quotes Harvard health policy professor Dr. Ashish Jha, “has gotten hospitals to focus on readmissions and a lot less on everything else. The big penalty for readmission rates has meant hospitals put less attention reducing complications and reducing mortality.” Adds Johns Hopkins’ Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality: “There was a lot of good by increasing attention on care coordination and thinking about patients when they leave the hospital. But now we have a signal that there are unintended consequences, so I think policymakers and researchers really need to come together and talk about why this might be happening and what we should be doing going forward with this measure.”

Nursing Home Resident Rights and Safety at Risk

How to assure nursing home resident rights are protected was the focus of several reports in November. The Center for Medicare Advocacy joined the Long-Term Care Community Coalition in documenting the threat to resident safety arising from “no harm” designations used by state survey agencies in assessing the severity of nursing home inspection deficiencies. Their report finds that out of 7,715 nursing home inspections in the first half of 2017, 95.3% of 4,413 deficiencies were deemed “no harm.” Drawing upon nursing home inspection reports in various states, the advocacy groups argue that the deficiencies were anything but harmless. Their conclusion: “the nursing home industry is currently campaigning for deregulation. Additionally CMS has proposed removing language connecting specific scope and severity levels to specific categories of remedies; instead, CMS wants to allow regional offices the flexibility to choose remedies that ‘encourage’ providers to obtain compliance. CMS also wants to allow regional offices to consider whether a deficiency was a one-time mistake. Resident harm, however, is never a mistake. At best it is negligence and, at worst, it is intentional harm. Nursing homes should not be ‘encouraged’ to obtain compliance; they must be in compliance. Nursing home residents do not waive their civil rights upon entering nursing homes.”

Nursing Home and Assisted-Living Residents Increasingly Face Eviction

In addition to potential threats to their health and safety, nursing and assisted-living facility residents may also confront a sudden eviction notice. Minnesota Star Tribune reporter Chris Serres conveyed the severe nature of such an event by detailing several instances, particularly involving assisted-living facilities. “In thousands of interviews, seniors describe being threatened with eviction for acts such as installing a surveillance camera in the room, refusing costly nursing services, or discussing poor care with fellow residents. They take threats seriously because, in the tight market for senior housing, elderly Minnesotans can face waits of a year or longer for a room in an assisted-living facility.” Cheryl Hansen, Minnesota’s long-term care ombudsman, told Serres that “Vulnerable adults with complex medical issues are being retaliated against for the simple act of speaking up. Someone needs to take the lead here and stop the practice.” Responding to Serres' report , Justice and Aging directing attorney Eric Carlson observed that “most states have at least minimal protections, such as the right to a hearing, for seniors being discharged from assisted-living facilities. And several states, including Montana and Oregon, have mandatory criteria for discharge similar to nursing homes. However,” Carlson continued “these newer assisted-living facilities still have a huge amount of discretion to push residents out as they wish. And people don’t see an obvious way to challenge the evictions so they just pick up and move.”

Newly Published ‘Eviction Defense Guide’ for Nursing Homes and Assisted-Living Facilities

Seeking to address the eviction problem in nursing homes, assisted living facilities—as well as with respect to the provision of Home and Community-Based Services—the National Center on Law and Elder Rights has published an eviction defense guide. The six-page issue brief offers extensive discussion of residents’ rights under federal and state law. “Residents of nursing facilities and assisted-living facilities are particularly vulnerable to eviction, given the unfamiliarity of most residents with the relevant law, and the power dynamics of eviction being threatened by an entity that provides personal assistance as well as room and board. Resident representatives and advocates should be both vigilant and aggressive in pushing back and defending residents against inappropriate evictions. Particularly in nursing facilities, the relevant laws favorable towards residents, and should be cited to enable residents to remain in their chosen residences.”

Guidance on HCBS Implementation and Funding Allocation

Two publications offer guidance on more effective implementation of long-term services and supports, including the proper allocation of funding for home and community-based services (HCBS). From the National Consumer Voice for Quality Long-Term Care comes a guide to “Understanding and advocating for effective implementation of the home and community-based services settings rule.” “In March 2014, the centers for Medicare and Medicaid services published the first ever regulations setting standards for the settings in which HCBS are provided. These rules will impact the services, quality of life, and rights of HCBS participants, as well as the environment in which they receive those services. Each state must develop and implement a plan for how it will come into compliance with the HCBS rules. The involvement of advocates, including elder law attorneys, in influencing the plan and monitoring its implementation is critical.”

Toolkit for LTSS Reforms

The Center for Healthcare Strategies has published a toolkit for “Strengthening Medicaid long-term services and supports in an evolving policy environment.” The toolkit “provides a targeted menu of LTSS reform strategies adopted by state innovators that may be replicated by other states. It identifies concrete policy strategies, operational steps, and federal and state authorities that states have used to advance their LTSS reforms. It also highlights opportunities and challenges that states have faced in designing and implementing reforms.”

The Case for Medicare LTSS as Family Caregiver Numbers Declines

While Medicaid funding underlies LTSS for low income adults, Medicare beneficiaries face the prospect of depending upon paid and unpaid personal help for such care. In an issue brief , the Commonwealth Fund argues for enactment of some form of Medicare LTSS program. “Long-term services and supports are not covered under Medicare despite many beneficiaries reporting needing help with self-care activities. The resistance to a public financing option for LTSS is based largely on the cost of such a program and the concern that it would substitute for care that is already being provided by family caregivers. This issue brief confirms that older adults who need LTSS rely heavily on family caregivers. However, this method of providing care is unsustainable, given the increasing numbers of older adults who will require LTSS as well as the declining availability of family caregivers. In addition, study results find that significant numbers of community residing older adults with a need for LTSS do not receive help. Our analysis shows that the amount of unpaid care provided varies little between those who receive both paid and unpaid support, and those who receive unpaid support only -- suggesting that paid care does not replace unpaid care, but supplements it. Addressing and supporting the need for LTSS can result in savings to individuals and the government through delayed nursing home and Medicaid entry. A public LTSS financing solution, like Medicare Help at Home that supports individuals and family caregivers, would improve the supply of long-term services and supports and allow for their quality to be monitored to ensure older adults can live safely in the community.”

First National Care Model Addressing Post Intensive Care Syndrome

Caregiving Policy Digest ( May and July) has previously included mention of the phenomenon that has come to be known as Post Intensive Care Syndrome (PICS). Now researchers in Indiana have concluded that a program originally designed to care for dementia patients—the Healthy Aging Brain Center—can be utilized to address the needs of PICS sufferers. “ICU survivors have high rates of persistent cognitive impairment similar to Alzheimer’s disease due to a combination of critical illness, medications administered during hospitalization, and physiological aspects of delirium that are not well understood. The Critical-Care Recovery Center care model developed by the Regenstrief Institute and the Indiana University Center for Aging Research is the nation’s first collaborative care concept focusing on the extensive cognitive, physical, and psychological recovery needs of intensive care unit survivors and decreasing the likelihood of serious illness after discharge from an ICU. The CCRC is an outpatient clinic with an interdisciplinary care team working closely with family caregivers as well as the ICU survivors themselves after hospital or rehabilitation facility discharge.”

Study Finds Better Outcome When Inpatient’s PCP Is Involved

As hospitalists continue to expand their responsibility for inpatient care, concerns about the loss of primary care physicians’ connection to their hospitalized patients also continue to grow. A study from researchers at a number of institutions raises some new alarm bells. “Our findings suggest that engaging a patients PCP in his or her hospital care may be an approach to increasing the rates of discharge home, an outcome important to the patient and the hospital system, without increasing the risk for readmissions at seven days. When elderly patients are discharged to postacute care facilities, their likelihood of returning home decreases, which has substantial implications for quality of life and spending in ensuing years. We found that, although patients cared for in the hospital by their own PCPs had slightly longer lengths of stay, they also were more likely to be discharged home and had improved survival, even after controlling for differences in patient and hospital characteristics. A PCP’s prior experience with the patient, in other words, may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home, but also were less likely to die within 30 days compared with those cared for by hospitalists or other generalists.”

Successful Phone-Based Cognitive Behavioral Therapy (CBT) With Family Caregivers

German researchers have reported a successful outcome of a trial of telephone-based cognitive behavioral therapy (CBT) in ameliorating the stresses of family caregivers with dementia. Intervention group participants received 12, 50-minute sessions of individual cognitive behavioral therapy by trained psychotherapists within six months of the onset of caregiving. At the end of the intervention caregivers in the intervention group showed improvements with regard to their well-being, symptoms of depression, physical symptoms, and ability to cope with the burden of care and the care recipients’ challenging behavior.

Research Investigates Robots as Companions/Caregivers for Older Adults

Robotics is an exploding field of research and activity across many disciplines. At the Arlington campus of the University of Texas a new Emotional Robotics Living Lab has been launched to investigate how robots can be integrated into the home as companions and caregivers. “The idea here is not to replace humans but to fill a gap,” said Julienne Greer, UTA assistant professor of theater arts and director of the lab. “We are using theater arts to design ways for robots to create bonds of trust and emotion with humans of different ages and improve their quality of life.” Greer and colleagues recently carried out a study with older adults at an independent living facility in Texas where the robot and adults interacted using well-known sonnets from Shakespeare. The study found that “after three weeks of interactions, there was a significant drop in depression and increasing human-robot social engagement among those older adults. We are now looking to make the experience more immersive so that the robot and the adults play out an entire scene of Shakespeare together, such as the Romeo and Juliet balcony seeing. We hypothesize that the more immersive the theater intervention, the deeper and more positive the responses in older adults will be with regard to depression and social engagement.”

1115 Medicaid Waivers: The Trump Administration’s View

With state requests for section 1115 Medicaid waivers receiving considerable attention, Sara Rosenbaum has posted a detailed Health Affairs blog analysis of the section’s history and the Trump administration’s pronouncements about how the waiver requests will be handled. “Medicaid’s major program objective,” Rosenbaum observes, “as seen through the administration’s prism, is to alter the behavior of individuals. Medicaid becomes a pathway not to coverage but to ‘positive outcomes,’ ‘responsible decision-making,’ ‘upward mobility,’ ‘greater independence,’ and ‘improved quality of life.’ In all of this there is absolutely no mention of Medicaid as insurance. Thus,” she concludes, “it seems that the administration is set to embark on a new era, in which 1115 will be used to limit access to coverage by attaching conditions of eligibility whose utility rests on little if any empirical evidence, and to deprive people of access to assistance by reconfiguring Medicaid as commercial insurance.”

‘ Old and Sick in America: The Journey Through the Healthcare System’

Harvard professor Dr. Muriel Gillick has authored a 326-page book entitled “Old and Sick in America: The Journey Through the Healthcare System.” Praising the book’s contents, Kaiser Health News’s Judith Graham sets the stage for Gillick’s analysis and recommendations. “Being old and sick in America frequently means a doctor won’t ask you about troublesome concerns you deal with day-to-day–difficulty walking, dizziness, a leaking bladder, sleep disturbances, memory lapses, and more. If you’re hospitalized, you have a good chance of being treated by a physician you never met and undergoing questionable tests and treatments that might end up compromising your health. It means that if you subsequently seek rehabilitation at a skilled nursing facility, you will encounter another medical team that doesn’t know you or understand your at-home circumstances.” Graham goes on to give Gillick an opportunity to outline her many recommendations via a transcribed interview.

The Cost of Caregiving

The great cost burden of caregiving is no stranger to recent articles, reports, and suggestions for alleviation. Writing in the Washington Post, Jonnelle Marte adds to the literature in her article “The cost of Caregiving: a sacrifice for our entire family.” Marte profiles a 42-year-old daughter who felt it imperative to leave her job to care for her car-accident-disabled mother. “I gave my boss two weeks notice and told him that I had to quit and that I had to go take care of my mom,” the daughter told Marte. “It was a sacrifice for our entire family.”

Managing and Finding Paid Caregivers Through Online Platforms

Uber, Lyft, and Airbnb’s dramatic impact on service delivery derives from what some are calling the new “sharing economy.” If it works so well for ridesharing and vacation rentals, why not home care employment, a prospect aired by Kathleen Webb, cofounder of a company providing payroll and tax services to families who employ household workers. “Much in the same way Airbnb acts as a vehicle to connect guests with hosts–who transfer payment securely through the Airbnb platform–families are using new platforms to find and pay their caregivers through a dedicated system.” Webb points to the creation of such companies as CareLinx and KindlyCare as examples of the emergence of a marketplace or registry that facilitates the private meeting, interviewing, and hiring of caregivers. “These sharing services not only provide secure means for delivering caregivers’ paychecks, they also support families in managing taxes appropriately, and fostering the employer to employee relationship in the home.

What Kind of Care Do We Want at the End?

End-of-life issues are the focus of two Health Affairs blog posts. In the first, Jessica Nutik Zitter ponders the impact of ever-evolving technologies designed to prolong life. Using the example of extracorporeal membrane oxygenation (ECMO), a form of cardiopulmonary bypass originally developed for use during heart surgery—what was “intended as a bridge to recovery or a bridge to transplant—has become, for some, what is called a ‘bridge to nowhere.’ If a patient’s organ will not recover and the patient is not a candidate for transplantation, the remaining options are bleak. Such patients will likely suffer many complications aside from their underlying condition. But arguably more difficult is the decision they face about how to proceed. Unlike patients on breathing machines, ECMO patients are often awake and able to communicate. And so they must answer an important question. Are they willing to live the rest of their lives in an ICU? If not, when to disconnect the machine? ECMO,” Zitter writes, “is only one of many emerging technologies or treatments becoming available to the modern physician. While these technologies can be truly miraculous for the right patients, others—specifically, the frail elderly, terminally ill, and the dying—will not be so lucky. As the U.S. population ages, the current epidemic of overly mechanized tests threatens to explode into a major public health and fiscal crisis. For ECMO alone, there was a 433% rise in its use in adults between 2006 and 2011. And for each patient, the mean estimated total hospital costs, including pre-and post ECMO procedures, was $213,000. The projected costs are staggering.”

Three bloggers—Terri L. Maxwell, Ian Duncan, and Matthew Harker— offer a much different vision in their post “Changing The Conversation: New Model of Home-Based Palliative Care for Patients with Serious Illnesses.” The writers highlight the services of Turn-Key Health, a national company that serves payers by providing specialized palliative care to patients who are struggling with advanced illness and living at home. “Through its palliative illness management program, Turn-Key contracts with local hospice and palliative care organizations that have dedicated teams of nurses and clinical social workers. Turn-Key then deploys these clinical teams to patients’ homes. Turn-key also provides the clinical teams with training, oversight, and support, and makes available to them health assessment tools to guide and document all home and telephonic visits. A one-year program at Mount Carmel Hospice and Palliative Care tested and validated the approach for seniors, demonstrating that community-based palliative care teams equipped with the right tools and training can improve care quality and address burdens associated with advanced illness.

The Rush to Pass the Tax Bill

Returning to Caregiving Policy Digest’s opening focus—the rush to enact tax legislation—two different aspects of the lawmaking effort are addressed by two reporters. If in fact Congress repeals the ACA’s individual mandate observes New York Times reporter Reed Abelson, one great danger is an opening of the floodgates for skimpy or “skinny” health plans. “If repeal is approved, many consumers would likely turn to the cheap, short term policies that already skirt provisions of the law and may not cover pre-existing conditions or basic medical needs. These plans—sometimes sold by brokers using tactics rife with fraud—were only supposed to last for three months. But President Trump recently signed an executive order to allow such coverage to be extended up to a year. Without an individual mandate, the cost of coverage could increase by double digits on top of already high premiums as healthy people leave the market and sick people needing costly care stay on it. Examples abound of people who were dumped from such skimpy policies or denied coverage, ending up mired in debt and medical bills totaling thousands, if not hundreds of thousands of dollars.”

Finally the Washington Post’s Erica Werner takes a look at the deliberative process—or lack thereof—driving the pre-Christmas push to achieve passage of the tax package. “Republicans are moving the tax plan toward final passage at stunning speed,” Werner writes, “blowing past Democrats before the time to fully mobilize against the measure and vulnerable to all to the types of expensive problems popping up in their massive and complex plan. Democrats accuse Republicans of whisking legislation along to avoid extended public scrutiny and prevent them from mounting an offensive at public hearings or over lengthy congressional breaks. ‘The frenzy, and I would call it a frenzy,’ said Steve Bell—a senior advisor at the Bipartisan Policy Center who was staff director of the Senate Budget Committee during the 1986 tax overhaul effort—‘to get it done and have a Christmas present for America, number one, I think it’s unnecessary; it’s a self-imposed deadline, and number two, it makes the possibility for error much greater. This is a rush without a reason other than the political desire for a Rose Garden signing ceremony.’”

Recent Visits to Washington, DC

Last week, Executive Director Kathleen Kelly was in Washington, DC, for meetings with the Eldercare Workforce Alliance, a group of 31 national organizations (including Family Caregiver Alliance/National Center on Caregiving) addressing the workforce crisis in caring for an aging America. This week, Director of Operations and Planning Leah Eskenazi attended AARP’s Family Caregiving 2018: An Executive Summit. Panel discussions began with Senators Susan Collins (R-ME) and Tammy Baldwin (D-WI) on Family Caregiving in Congress addressing policies that work for family caregivers, including the RAISE Family Caregivers Act. For those on Twitter, visit the hashtag #futureofcaregiving for a run down of the summit.

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