US campaigners call for national insurance programme to cover care needs

BMJ 2009; 339 doi: (Published 26 October 2009) Cite this as: BMJ 2009;339:b4398
  1. Bob Roehr
  1. 1Washington, DC

    The health reform debate in the United States has so far failed to consider the important matter of helping people with care needs stay in their own homes. But this is crucial to precluding or deferring use of much more expensive health services, say campaigners for a voluntary national insurance programme that would cover the cost of home assistance.

    The Community Living Assistance Services and Support (CLASS) Act legislation, which was first proposed by the late senator Ted Kennedy, is just such a scheme. It would provide cash payments to disabled beneficiaries to buy assistance that would allow them to remain functional, productive, and independent, explained Connie Garner, senior staff member of the Senate health education, labour, and pensions committee, at a briefing sponsored by the Kaiser Family Foundation on 20 October.

    More than 10 million US residents need help with their daily functioning and more than 40% of them are under the age of 65, said Judy Feder, a policy analyst at the Georgetown Public Policy Institute. Their needs span many services and most rely upon family members for assistance.

    Medicaid currently helps disabled people, but its primary focus is on nursing homes (73% of expenditures), where care costs $70 000 (£43 000; €47 000) on average per person a year. Additionally, Medicaid covers only poor people. Middle class people must pay for these expenses out of their own pockets until they exhaust their financial resources and become poor enough to quality for Medicaid.

    Ms Garner said that the legislation hopes to “jump start” a strictly market based insurance plan, with no government subsidies. Individual premiums would be about $125 a month. All people who choose to join must pay into the system for a minimum of five years before they would become eligible to collect benefits.

    Benefits would be a minimum cash payment of $50 a day, adjusted upwards according to the extent of disability. Both premiums and benefits would be indexed for increases in the cost of living. Participation by students and poor people would be subsidised.

    Focus groups with young people around the country, now totaling 22 000, showed that “they had an appreciation that they may not be who they are 24 hours from now” because of accidents etc, said Ms Garner.

    The “mainstreaming” of students with special needs into the typical classroom rather than isolating them in special programmes, and family discussions about ageing grandparents also increased their awareness of the need for insurance.

    Although interested in such a programme, the young people said that their participation would depend on the premium charged for such insurance. Ideally it would be about $65. Ms Garner said that was not economically feasible and some kind of subsidy would be required to entice this healthy low risk pool into the programme.

    Larry Minnix, president of the trade group American Association of Homes and Services for the Aging, said that his members are among the 275 national organisations that support the legislation.

    “If something like the CLASS Act had been in place, Medicaid expenditures, which are $100bn a year and growing, would be half that,” he said, citing a study his group had commissioned.

    Germany adopted this approach more than a decade ago. It changed the business model of that industry from building nursing home facilities to creating networks for the coordination of a broader variety of services for people in their own homes, said Mr Minnix. He called the CLASS Act “good public policy that focuses on the consumer, is solvent, and allows people choice.”


    Cite this as: BMJ 2009;339:b4398