Abstract

This paper examines the 2010 Patient Protection and Affordable Care Act (ACA), which includes several provisions that aim to address prevailing deficiencies in the United States' long-term care system. It places these provisions in historical context, looking at the evolution of LTC policy over time. It argues that the ACA provisions are typical of the incrementalist policy-making that has characterized the history of LTC, which has relegated many significant policy innovations to the state, rather than federal level.

Overall, the federal government has played a fairly weak role in the LTC policy arena. The most prominent long-term care provision in the legislation is the now suspended Consumer Living Assistance Services and Supports Act: the implications of its suspension are discussed and policy options raised by it are explored. Other important provisions include incentives and options for expanding home- and community-based care, a number of research and demonstration projects in the areas of chronic care coordination and the dually eligible, and nursing home quality reforms. There are also elements that seek to improve workforce recruitment and retention, in addition to benefit improvements and spending reductions under Medicare.

Overall, the paper concludes that the legislation makes several important advances in improving LTC overall, but, in the absence of CLASS implementation (and the unlikely wide scale adoption of the Community First and rebalancing initiatives), is unlikely to have a fundamental impact on LTC policy in the US. However, the failure of CLASS, along with the difficulties faced by the private LTC insurance industry, raises interesting questions on the way forward for US policymaking in LTC.

Slides