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Research Agenda for Long-Term Care



The federal government should move aggressively to contain costs
and mitigate human suffering by funding research and
development program aimed at preventing, delaying and dealing
with long-term illnesses and disabilities. This effort should
include research

outcome measures and national

practice guidelines in long-term care. That effort should move toward a funding level of $1 billion annually and should do the following:

Explore how to reduce the risk for certain physical and mental disorders (e.g, Alzheimer's disease, osteoporosis, breast cancer, urinary incontinence) that are associated with increased need for long-term care



Examine how to enhance the quality of long-term care including the integration of services and case management.


Improve functional assessment tools to best target services to populations in need of care

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Examine the special long-term care problems of subpopulations such as disadvantaged racial and ethnic minorities and the rural elderly and nonelderly disabled.

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Evaluate the implementation of the home and community-based care program.

Revenues for Long-Term Care

A. Although some of the revenues necessary to support the above recommendations could come from savings achieved elsewhere in the federal budget, the Commission is committed to raising whatever additional revenues are necessary.


In considering what
recommends that the

revenue options to adopt, the Commission choice be guided by the following three


The final tax package ought to be progressive, requiring a higher contribution from those most able to bear increased tax burdens. That is, families with higher incomes would be asked to contribute a greater share of their incomes than required of lower income families.


Since persons of all ages would benefit, persons of all ages should contribute to financing the recommendations.


Revenues chosen should

grow fast enough to keep up with benefit growth so that new sources of revenue will not need to be enacted over time. Rates of growth would need to be in excess of 8% to 9% per year.


Various combinations of revenue sources may be used that together meet these criteria even if individual tax sources may fall short in one category.


Written answers submitted for the record by Louis W. Sullivan, M.D., Secretary of Health and Human Services in response to written questions submitted by Chairman Edward R. Roybal and Ralph Regula

Chairman Roybal


Questions #1

A. Am I safe in assuming that you personally intend to be a helpful force in moving this debate forward toward the goal of universal health care access and full long term care protection?


Let me reassure you that I am personally committed to finding solutions to the problems in the financing of health care and long term care services.

At the end of last year, I requested that a comprehensive review of our public and private health and long-term care financing policies be initiated. I asked Mrs. Horner, the Under Secretary, to lead this effort and to report back recommended approaches to these complex issues. And, in his State of the Union message in January, President Bush reinforced the importance of this initiative by designating me as the focal point within the Administration for addressing concerns of health care access, quality and costs. We are committed to health care policies that improve health care quality while constraining costs.


B. The Commission has laid out funding criteria including progressive financing, multigenerational financing and financing that grows as fast as costs. Is this approach acceptable? If not, how would you finance these increased costs? What specific concerns do you have with the "access" portions of the Commission recommendations? What specific concerns do you have with the long term care portions of the Commission recommendations?


First, I believe that it is premature to discuss specific financing mechanisms to assure access when we have not yet agreed upon what it is we need to finance. The Pepper Commission recommended spending an additional $66 billion in Federal monies to ensure access and $20 billion more in incremental private sector costs. I am not sure that it is necessary to spend $66 billion to achieve the Pepper Commission goals. As you know, the Commissioners disagreed among themselves as to whether this was the proper level of costs.

The Commission recommendations on access and long term care represent the nature of this debate: after careful deliberations, the Commission members could not reach a majority view on access, and could provide long term care reforms only at tremendous cost. My staff and I are also involved in thoughtful deliberations, but it is too early to reject or accept solutions to these complex problems.

Chairman Roybal


Questions 12

A. Would you support better funding for Alzheimer's Disease Research, let's say an increase from the current $130 million to at least $300 million?


The FY 1991 President's Budget requests $152 million for Alzheimer's Disease Research supported by the National Institutes of Health and the Alcohol, Drug Abuse and Mental Health Administration. This is an increase of 4.2 percent over the FY 1990 level of $146 million and 18.2 percent over the FY 1989 level of $129 million. A spending target of $300 million appears to be a reasonable goal, and we believe the FY 1991 request continues a steady increase in support for Alzheimer's Disease Research toward this goal.


B. Would you support improved mental health care by setting aside some mental health block grant funds for the elderly and by reducing the Medicare coinsurance rate from 50 to 20 percent?


I believe adequate and appropriate mental health services should be available for all those who need them and the block grant approach is an idea to pursue during our review of health care issues. However, I would be reluctant to encumber community discretion in the use of block grant funds unless there was clear evidence that there was a need to do so and that this would be the most effective and efficient means of addressing the problem.

As you will remember, OBRA 89 included a major extension of mental health coverage under Medicare. In light of that expansion, I do not believe that any further changes are desirable in this area at this time. After the Domestic Policy Council review of the recommendations on comprehensive approaches to improve the nation's health care system, we will be in a better position to evaluate how our limited resources can best be used.

In addition, the cost of all health care services continues to rise and I believe we encourage the careful use of services through mechanisms such as coinsurance and deductibles. Medicare coinsurance for coverage of mental health services parallels that of private insurers. Deductibles and coinsurance emphasize the partnership of government and beneficiary by compelling beneficiaries to pay a share of the total cost.


C. Would you support better health care for rural and inner city citizens through better Medicaid coverage, a fairer Medicare payment system, more support for health programs targeted at the underserved, and increased access to private insurance?


The proposals in the President's FY 1991 budget indicate his commitment and mine to better health care for all Americans and touch on several approaches you mention. We continue to target our most vulnerable citizens poor mothers and their children through the Medicaid program. We are proposing a managed care initiative to encourage comprehensive care for all Medicaid recipients. We believe the Medicare prospective payment system promotes fair, cost-effective delivery of health care. However, our budget recognizes the special circumstances of the innercity "safety net" hospital and the rural hospital and proposes to continue disproportionate share adjustments, sole community hospital status payments, and rural referral center payments. We propose to continue activities, such as rural research and demonstration set-asides, and rural health clinics programs, which are aimed at addressing the health care needs of rural Americans. We are committed to working with the private sector to increase access to affordable health insurance for the working poor, Medicare beneficiaries with long-term care needs, and citizens with AIDS.

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