Interview conducted by April Cashin-Garbutt, BA Hons (Cantab) on July 12, 2012.
Please can you tell us a little bit about the Affordable Care Act (ACA)?
The intent of the Affordable Care Act (ACA) is to provide all Americans with medical insurance. Thirty-five million additional people will be covered, in part by government premiums and in part by making it easier for them to buy their own insurance.
It all started on March 23, 2010, when President Barack Obama signed the ACA into law. The law is phased in over the next five years, and while it covers millions more, there are still 10 million Americans who won’t be covered.
The ACA has become controversial because it is so complex. Also controversy has arisen because few Republican ideas have been incorporated into the law. There has also been heated response to the so-called individual mandate. This requirement had inspired considerable litigation, ultimately leading to public arguments before the Supreme Court of the United States.
This idea had been proposed by Democrats and Republicans alike.
Please explain to us what the Supreme Court decided on June 28 with regard to the ACA?
The key issue was whether Congress can require individuals to buy insurance or pay a penalty. The Supreme Court said, “Yes,” deciding that the individual mandate is constitutional. This means the provision will be retained in the legislation. As of June 28, 2012, the Supreme Court has decided that the health insurance mandate is valid as a tax and will therefore be upheld.
Yesterday, our lower chamber, the United States House of Representatives, which is controlled by Republicans, passed yet another bill to repeal the Affordable Care Act. They’ve already voted more than 30 times to repeal all or part of it.
Our upper chamber, the Senate, which is controlled by Democrats, has always resisted these repeals. So the latest repeal is not likely to succeed.
We have an election coming up, which is a long process. After November, depending on who has control of the Senate and the White House, there may be some changes to the ACA. However, the odds are long that it will ever be repealed.
What does this decision mean for home health providers?
It means that in this effort to expand the number of insured, Congress will also, to some extent, expand the number of people eligible for home health services under our Medicaid program.
This number is uncertain since many of the uninsured are younger individuals who do not tend to use home health services as much as people who are older and have multiple disabilities.
Nevertheless, there are millions of additional lives that will be covered for home care services.
We think that’s a good thing because we constantly see people who are in need of care and assistance that we cannot provide because they don’t have the means. In some cases, our agencies provide that care for free. But this type of care is a trickle, and what we need is a river.
There is more and more need for home care as acute care becomes less important than the management of chronic disease. Our system, however, is built on acute care which means it is not germane to what we need now. Therefore, the system needs to be altered.
Will extra pressure be put on home health providers?
It will to some extent. It will also provide opportunities.
Our Medicaid program is issued through the states and is somewhat variable in how it pays providers. It certainly doesn’t pay as much as federal government does under Medicare, America's uniform health insurance program. And it is far less than providers get when people pay privately. Thus Medicaid is a burden in one sense, but it is an opportunity in another sense by expanding the number of patients.
How does the National Association for Home Care & Hospice (NAHC) feel about the Supreme Court’s decision?
The way we feel about it can be broken down into several parts.
Number one regards the procedure rather than the decision itself. It was a very important decision because it re-established the independence of the Supreme Court. There had been a great deal of worry that the Supreme Court would simply vote on party lines.
In other words, five of our justices were appointed by Republicans. They tended to vote in line with that party, and the four justices who were appointed by Democrats voted according to a Democratic point of view.
In the Supreme Court, we need to have an impartial referee with America’s best interests at heart. I think the court demonstrated that independence in this decision.
With regards to the decision on the mandate, it's not without precedent. There are many U.S. laws, including some dealing with health care, where the federal government requires individuals to take action. The states have done the same thing.
From this point of view, there is no reason to have the decision struck down. One example I can give you is that you cannot drive a car in Maryland, or indeed in most states, unless you have insurance.
There are many other examples. If the Supreme Court had overruled this decision then those other examples would also be declared unconstitutional, so there was not much risk of that.
The second question relates to severability. If the individual mandate fell, would that then mean the whole law was unconstitutional? All of the lower courts said no. The Supreme Court said no as well, so the law would have survived. It would have been considered constitutional, although you might have had difficulty making it work without the mandate.
The third part of the decision related to the question of Medicaid, a giant federal grant and aid program. The amount of money that comes to an individual state depends on its per capita income.
In wealthier states like New York and California, the states pay 50 percent of the money and the federal government pays the other 50 percent. In poorer states, like Mississippi, about 80 percent of the money that comes in for Medicaid is federal.
With respect to the Medicaid expansion I spoke of — the additional 35 million people who will be covered starting 2014 —the federal government is putting up all of the money for that and will be giving it to the states for the first four years of the expansion.
Many of our governors were featured in the news yesterday saying, “We’re not going to expand the Medicaid program” and “We’re not going to take the money.” That to me is posturing and not reality. Nobody is going to turn down all that money when there really are no strings attached to it other than using it to provide care for the needy in your state.
It is important to remember that what we’re trying to do is provide another option to going into a hospital emergency room. At the moment, that is where the poor go for care. If you have ever been to a hospital emergency room in the United States, you know there is everything there except emergencies.
This means there is such a backlog of people that people with legitimate emergencies have to wait in a queue until they can be seen. Thus, the expansion is an effort to lessen the burden on our emergency rooms because we are overusing the most expensive part of our health care system, the hospital emergency room.
In what ways do you think the ACA could be improved?
The answer to this relates to the fact that the U.S. still has a system geared toward acute care. There is now a greater need for care and management of chronic disease due to the progress that medicine has made in helping people live longer lives. Yet both private insurance plans and federal programs do not put much emphasis on providing help with chronic disease.
The act needs to address the question of long-term care, which relates to individuals who have multiple chronic diseases. I only need to give you one statistic: 5 percent of the public is responsible for 50 percent of health care bills in the United States.
This is a staggering amount. These are of course infirm individuals who are long lived: they have multiple disabilities and are very expensive to care for. They’re also in the last year or two of their lives. We continue to give them heroic care. Our hospices have made some impact based on wonderful ideas that we borrowed from the British, but we are nowhere near what we could be doing to help people face the end of life in comfort and peace.
The ACA needs to be expanded to help people with long-term care and make home care the primary means of doing so. In 1999, the Supreme Court issued the Olmstead decision saying that states must make every effort to care for individuals in their homes before they can consider institutional placement.
That principle needs to be acted upon so as to give wider support to individuals who need help with home and community-based care. This goal was addressed to some extent thanks to Senator Edward Kennedy whose last wish was the enactment of a program that would help people with a chronic disease. The program was called the CLASS Act, and it was part of the Affordable Care Act.
CLASS has not been implemented in the Obama administration. They have put it on the back burner, saying that it may not be viable. This belief is debatable, but we do need a viable program that deals with the issues of long-term care and focuses on chronic disease. America’s population is aging very rapidly, and we don’t have the infrastructure or policy to cover our seniors’ growing health care needs.
How is NAHC planning on working with Democrats and Republicans to improve the legislation?
We have worked very hard to tell the story that home care is the one issue that unites Democrats and Republicans, liberals and conservatives. That is a fact whether we’re talking about Ronald Reagan or Bill Clinton or any other figure. They all agree that home care, if not the answer, is one of the most important answers.
Our governors are adjusting their Medicaid programs to keep individuals at home more often rather than put them in state-run institutions. These institutions tend to be very expensive and you can save a lot of money by keeping people at home with intervention from home care.
It’s also important to make every effort to support family caregivers and not make individuals dependent on outside sources when they could care for themselves. This is an important principle that NAHC has tried to support.
We believe that the baby boom generation is called upon to help their peers who are less well off. There is not enough money in the world to pay for all the care that the 78 million baby boomers will need as they reach old age. It is going to require every form of help that we can think of, including a significant push from volunteers.
How do you see the future of the ACA progressing?
I believe that once the legislation takes hold, it will be very difficult to have it repealed. Right now, it is being phased in, so it is not giving all the benefits that have been promised to individuals. Therefore, there may be some opportunity to have it amended.
The Republicans have talked about repealing and replacing the ACA. The headline of Politico, our Capitol Hill newspaper, stated how the Republicans have made a move toward repeal but there has been no mention of replace and no alternative has come forward.
I suspect that the Affordable Care Act will survive, and I think it will be perfected. This was the intent because no law is ever perfect the way it is written. Congress will act out its role and the American public need to continue chiming in its views on what it would like to see.
There is plenty of evidence to suggest that people have an opinion, one way or another, but I do think the ACA will survive. Whoever wins the election, whether President Obama or former Governor Romney, will be committed to that result. Their means and the funding might differ slightly, but I believe either one will move the ACA ahead, leading to wider use of home care and hospice.
My prejudice is obvious because here at NAHC we’re in the business of home care and hospice. We’re waging the last great civil right battle to make sure people can get the care they need at home. The Constitution and Bill of Rights guarantee Americans the right to live freely until the end of their days. But this right seems to evaporate, in large part, when you become old and ill. Too many of the aged wind up living in institutions where they lose the freedoms they deserve.
What I am giving you is a framework. The real issue is whether America is creating a policy for people to live fully to the end of their days. Every other great society has had one and the historian Arnold Toynbee said that you can tell the durability of every society by a common yardstick: the manner in which it treats its vulnerable populations.
When President John F. Kennedy talked about the need to enact Medicare, he gave all of the usual economic arguments. Then he described it as a moral right and warned that “what is at stake is the very survival of American democracy and how we are going to be viewed through the prism of history.”
I think he was exactly right. The U.S. is trying to decide what it wants to be when it grows up. The members of the baby boom generation are very uneasy about their retirement years. They realise there is no safety net, there is precious little home care available, and there is no system to deal with the problem of long-term care.
How do you see the future of home health care progressing?
I see home health care being the heart and soul of American health care. I am a big proponent of home care augmented by technology. I think all of us will someday carry around smart phones that will be able to take readings and see how we’re doing in terms of health.
These smart phones will be able to send the data to home care agencies where nurses will be sitting in front of computer screens. They’ll become what I call health traffic controllers, like you have with airplanes except they’ll be monitoring individuals. For example, imagine I was a patient with a tendency toward congestive heart failure. Right now the protocol is for me to go see a doctor every Tuesday and Thursday. In the doctor’s office, they’ll put me on a scale to make sure I’m not putting on weight and measure my heart to make sure there are no arrhythmias. The smart phone and apps would make it possible for me to avoid these trips to the doctor unless something untoward happens. Then the phone would signal that I am having a problem and the doctor could intervene.
I see home care being very much in the driver’s seat as we switch to a health care system that evolves mainly around the prevention and treatment of chronic disease. I do think home health, augmented by telemedicine and mobile health, is the key to the future of America’s health care system. A lot of high-tech products are already coming on to the market. My favourite example is a device that displays your blood sugar reading with no invasion, no pin sticks or anything like that. The revolutionary tools that we’re going to have available will help us radically. They will also help us increase access to health care in rural areas. I am someone who grew up in a rural area and I know what that means: shorter life expectancy, no access to health care providers, driving 3 or 4miles to get to a hospital. All of that is changed by new products that level the playing field. Technology is a great equalizer that makes high-quality health care available to all, wherever they live.
Where can readers find more information on NAHC?
They can learn more about us by going to http://www.nahc.org/. We will also be rolling out a home care app to help consumers choose home health agencies based on their credentials. We will give each agency a certain number of Michelin stars based on objective criteria and patient satisfaction.
About Val J. Halamandaris
Val J. Halamandaris is founder and president of NAHC and the preeminent voice of home care and hospice. For 30 years, he has led NAHC to become one of the country's most respected associations. Under his guidance, NAHC has broadened support for home health in the halls of Congress and in homes around the U.S. About 20 percent of the public knew about home care and hospice when he founded NAHC. Today over 90 percent know about home care and hospice and support their expansion.
Numbers like these speak for themselves and show the progress the industry has made. There were about 3,000 home care agencies in 1982 when NAHC began. Today, there are 33,000. Similarly, the number of hospice programs has grown from 59 to 5,000. About 100,000 people worked in home care in 1982. Today, there are more than two million. Some 1.3 million people received home care services in 1982. Today, more than 12 million people receive medical and non-medical services at home.
Each of these gains brings us closer to winning what Val calls "the last great civil rights battle." It's the fight he has long waged to ensure that the aged, disabled, and ill can receive care in their homes. Ever since his youth in Utah, he has agreed with former Vice President Hubert Humphrey that "the moral test of good government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadows of life, the sick, the needy, and the handicapped."
He acted on this thought after earning a degree from Catholic University Law School in Washington, DC. Over the next 20 years, he served as counsel to both the U.S. Senate Special Committee on Aging and the U.S. House Committee on Aging, where his achievements were vast. He helped write legislation that created Medicare and Medicaid, including the Medicare home care and hospice benefits; federal minimum standards for nursing homes; state Medicaid fraud units; and the Office of the Inspector General in the Department of Health &Human Services.
Since coming to NAHC, he has founded the Caring Institute, the Frederick Douglass Museum, the Foundation for Hospice and Homecare, the Private Duty Homecare Association, and the Home Care and Hospice Financial Managers Association. Most recently he founded the Home Care Technology Association of America, which looks to the future as does Val.
He has been featured in The Visionaries, a TV series hosted by acclaimed actor Sam Waterston. He has appeared numerous times in Modern Healthcare magazine's "100 Most Powerful People in Health Care." His work has been featured on 60 Minutes and 20/20. It has earned praise in publications such as the Washington Post, Newsweek, and Time. And as a keynote speaker, he made a persuasive case to the National Governors Association in 2004. After hearing him, the governors resolved that long-term care is the greatest problem facing the United States and home care is the best solution.