Why nothing gets done

Nursing Homes, Jan, 2005 by Michael J. Stoil

Congress is taking a great deal of heat these days for the poor quality of its policy-making process in long-term care. For example, on the financial side, many commentators have blamed Congress for three consecutive failures to enact the annual appropriations bill for health and human services. Even the White House suggested that it was the failure of congressional representatives to reach agreement that resulted in all nonmilitary domestic spending being authorized by an omnibus "emergency" bill in 2002, 2003, and 2004. Hardly anyone mentions the annual inability of the Bush administration to draft an appropriations bill until eight weeks before the end of the fiscal year (roughly three months after the normal deadline for the annual appropriations legislation. See View on Washington, November, p. 10.).

Similarly, Congress in general often is blamed for the slow pace of initiatives to improve the quality of care among the elderly (see, for example, "NH Scorecard," Nursing Homes/Long Term Care Management, October 2004, p. 22). But is it fair to assign responsibility to all of Capitol Hill for the sluggish pace of reforms in federal support for long-term care services and research? Or is it more accurate to identify a few committee chairs as the culprits?

Let's consider the case of two bills affecting healthcare among older Americans: the Positive Aging Act (HR 2241) and the Elder Fall Prevention Act (S 1217).

Congressman Patrick Kennedy of Rhode Island, the son of Massachusetts Sen. Edward Kennedy, introduced HR 2241 in Congress in May 2003. Patrick Kennedy was the youngest member of his family ever elected to public office, winning a seat in the Rhode Island State House at age 21. As a congressman, he is best known as an advocate for mental health concerns.

The Positive Aging Act is part of Kennedy's focus on mental health. In its original format, it called for establishing an Office of Older Adult Mental Health Services within the Administration on Aging of the Department of Health and Human Services (HHS). In addition, it directed HHS to make grants to states for systems to deliver mental health screening and treatment to older individuals lacking access to such services, and for programs to increase public awareness of the benefits of preventing and treating mental disorders. It also called for federally funded demonstration projects that would:

* provide mental health screening and treatment services to older individuals residing in rural areas or in "naturally occurring retirement communities" (NORCs) in urban areas;

* integrate mental health services for older patients into primary care settings; and

* operate multidisciplinary geriatric mental health community outreach teams.

Conspicuously missing from the Positive Aging Act were any provisions that would be helpful to older residents of assisted living facilities or skilled nursing facilities.

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Congressman Kennedy's failure to identify a role for long-term care facilities in improving mental healthcare among the elderly is not unusual among Democratic healthcare proposals. Many of these legislative initiatives also ignore the potential of SNFs and assisted living programs as well-run "laboratories" for innovative care. Instead, they propose helping community mental health centers, hospitals, nonprofit storefront clinics, and other beneficiaries of the Great Society largesse of the 1960s. This is a particularly strange position for Kennedy to adopt in his chosen area of expertise, especially after the Center for Health Policy and Research (CHPR) in collaboration with the Division of Medical Assistance in neighboring Massachusetts issued its 2003 report on "Depression in Nursing Facility Seniors." The report acknowledged that "nursing facilities have made great strides in identifying, diagnosing, and treating depression in seniors," although it noted there was room for improvement,

Kennedy's indifference to institutional long-term care--which congressional critics say is characteristic of that body--in the long run made little or no difference to the outcome of the bill. The Positive Aging Act was referred to a subcommittee of the House of Representatives whose chairman refused to schedule either hearing or a vote on the measure. Kennedy introduced the bill a second time in 2004, and it suffered an identical fate.

In comparison with Kennedy's legislation, the Elder Fall Prevention Act is much more long-term care-aware. It was first introduced in a previous congressional session and reintroduced in June 2003 by Sen. Michael Enzi (R-Wy.). He immediately attracted a cosponsor, former social worker Sen. Barbara Mikulski (D-Md.). Three more Democrat and four more Republican senators eventually signed onto the bill as cosponsors.

Enzi relied on personal experience with a 90-year-old father to explain to colleagues why he introduced the bill:

    Anyone who has an elderly parent, relative, or friend who lives
  alone knows the concern that is often raised when a phone call placed
  to them goes unanswered. Our first and immediate reaction is often
  worry because we know that for many of our nation's elderly, a fall
  can produce a very serious injury. As the phone continues to ring, we
  wonder if Mom is upstairs and can't hear the phone, or Dad is in his
  workshop, or our friend has just stepped outside to catch a breath of
  fresh air.
    We hang up, wait a few minutes, and place our call again, often with
  a greater sense of urgency. This time, our concern becomes worry as we
  picture our loved one suffering from the effects of a fall, alone,
  with no one to help them. Then, when the phone is answered, a huge
  rush of relief overcomes us as we realize our fears were misplaced.
    Would that every story like that had such a happy ending. For too
  many of our nation's elderly, however, it sometimes ends tragically,
  as brittle bones and a reduction in our sense of balance become a
  formula for serious injury and a dramatic reduction in one's quality
  of life.