A picture of Senator Maria Cantwell
Maria C.
Democrat WA

About Sen. Maria
  • Affordable Care Act

    by Senator Maria Cantwell

    Posted on 2013-12-18

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    CANTWELL. Mr. President, I come to the floor to join my colleague from Rhode Island. I applaud him for his diligence, making sure this debate happened today, and for his leadership on this issue. It might sound kind of wonky to say there is a group of Senators that have a caucus called the Delivery System Reform Caucus, but we wear that banner with pride because we know that there are savings in our health care delivery system. We want to make sure that they are delivered for the American people.



    While some want to talk about cutting people off of service or raising certain ages, we are focused on the fact that there are hundreds of billions of dollars of savings in the delivery system and that it is our job to improve upon them. I like to say to my office team: There is a reason why Ma Bell doesn't exist anymore. The challenge is I have so many young people, and some of them don't remember Ma Bell. But the issue is the delivery system for telecommunications changed, and look at what it unleashed--a lot of great technology.

    Yes, change, but with ways to drive down costs and deliver better access. That is what we are talking about here with the health care system. My colleague from Rhode Island has had a group for more than a year that has been talking about these delivery system reforms. We are going to come out on a more frequent basis and try to have a dialog with our colleagues about why it is so important.

    We have taken a small but very important step led by our senior Senator from Washington Senator Murray on the budget. But there is so much more we can do if we can include these delivery system reforms. So I thank Senator Whitehouse, the Senator from Rhode Island, for his leadership.

    I want to talk about one area today, the area of long-term care services. I authored a provision in the Affordable Care Act called the Balancing Incentive Payments Program. While that sounds in and of itself like a wonky title, Balancing Incentive Payments Program, this program is really there to promote home and community-based care over nursing home care. If you ask any senior they will say of course they would like to receive health care services in their home or in their community. No, they do not want to go to a nursing home. But the discussion has been limited on how much cheaper it is and how much better the care could be for delivery in the home as opposed to nursing home care.

    According to a survey by AARP, over 90 percent of seniors age 50 or over desire to remain in their home as long as possible. We know that home and community-based care is 70 percent cheaper than nursing home care--70 percent cheaper. So for us in Washington State we thought about this long ago, and we decided that we were going to implement a system to reform our State and put more community-based care in our State and pull Medicaid patients away from nursing home care. We did that. We successfully made that transition. This chart shows you what I was just referring to, that home-based care can be as little as $1,200 a person versus the same person getting care in an institutional facility at $6,000.

    We made the transition in Washington State to be predominantly a home and community-based care State. We did that with our own State dollars, our own program, and it was a transition that took place over many years. We are kind of the antithesis of what the Federal system is. It is still more weighted on a State by State basis towards nursing home care. That means people are going into nursing home care, and we are footing the bill for more expensive care at $6,000 per person when we could have services in the community that would allow them to stay in their home and get more efficient care. So in 2009, the long-term care budget overall for Medicaid accounted for 32 percent of the Medicaid expenditures or $360 billion a year. You can see that this is a very expensive area for us at the Federal level. If we could do anything to help change those numbers, we would be delivering an improvement to the system.

    When we first made this transition from 1995 to 2008, the State of Washington saved $243 million from this investment. But more important, even, than the money--in an article in 2010, the Spokesman Review in Spokane ran a story called ``Dying to live at home,'' the family of Nancy and Paul Dunham, a couple of more than 60 years, said they wanted to age at home. Because of the Medicaid funding for in-home services, they were able to stay. Mr. Dunham was able to stay in his home until the age of 83.

    I am sure many of my colleagues know people who are getting on in years who prefer to stay at home. But the Balancing Incentives Program, which was in the Affordable Care Act, was the first Federal effort that we had that tried to assist States to move away from nursing home care and move towards community-based care. We put some incentives in the program. Here are the States so far that have taken up the Federal Government in the Affordable Care Act on this incentive program: New Hampshire, Maryland, Iowa, Mississippi, Missouri, Georgia, Texas, Indiana, Connecticut, Arkansas, New York, New Jersey, Louisiana, Ohio, Maine, and Illinois.

    It is a diverse group of States, I might add. Some States, probably, where Governors said they did not want to support the Affordable Care Act yet are taking advantage of this provision. Some States probably are forerunners of delivery system reform and have done lots of delivery system reform and want to do more. It is a mix [[Page S8967]] of States. I think we have a lot of great examples in those States and what we can do to transition away from institutional care to home and community-based care.

    The program authorizes grants to States to increase access to their non-institutional long-term care services, and it supports including structural changes that help streamline the system--conflict-free case management, core standardization of assessment instruments, single entry-point systems so it is not confusing, so that the system is very streamlined. States have until September of 2015 to increase their long-term care services in the community and support expenditures of these noninstitutional-based care facilities.

    We are very excited that it has had a robust uptake by these States. I am encouraged that there has been so much interest shown in changing the political orientation, if you will, of States, to how do you deal with long-term care. We know everybody is living longer. We know as baby boomers retire, it is going to be a bubble to our health care delivery system. But this is an excellent idea, a way for us to deliver better care.

    What does it do? As I said in the first chart, $1,200 versus $6,000 in nursing home care. It reduces costs. Reducing those costs has to be a key focus for us.

    These Medicaid recipients are people who maybe even start on Medicare but because of the extreme cost of health care at the end of life, end up spending it out, end up on Medicaid, end up being a Federal responsibility. If we can reduce those costs by driving more community- based care, it is a win-win situation.

    The second thing it does is it helps improve quality. If people can stay at home and get access to the delivery system by these new requirements, making sure it is case managed and has the single point of entry and standardization of the home care system, it helps us to be efficient about the quality of care that is being delivered. Again, when you have a community-based setting, either in the home or where care is delivered through the home, there are lots of ways for us to have checks and balances on the system.

    I have talked to many people who are in the nursing home industry. They will say we like the idea that we are only going to take the sickest patients. We like the idea we are only going to serve people who really need to be there as opposed to some people who may not be ready for those facilities but end up there anyway just because there are not the community efforts to support it.

    Besides reducing costs and improving quality, we save money. That is why we are here today, to talk about these important ideas that save money. This is a simple one, but it is already in place. It has already started. There are many States taking us up on this offer, but it is critical that we understand and score these costs because they can show how we can save billions of dollars in our health care delivery system.

    I know my colleagues, some of them on the other side of the aisle-- well, all of them on the other side of the aisle--didn't support the Affordable Care Act. Take a second look at what your States are doing. Your States are supporting the legislation, at least through one provision. I think when you check, you will see that one provision is going to save your State money. It is going to give your citizens better choice in their quality of care. It is going to help us reduce our Federal costs and expenditures as well, and that is what delivery system reform is all about.

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