Banner Graphic, Volume 10, Number 72, Greencastle, Putnam County, 27 November 1979 — Page 7

'Not the way Americans should act

Farmers not backing Farm Bureau call for Iran food embargo

c. 1979 N.Y. Times News Service CHICAGO - The announcement last week by the American Farm Bureau Federation urging a food embargo against Iran has not won wide support from American farmers. The farmers traditionally have opposed

opinion

LARRY GIBBS Publisher

Aging America

S2O million study seeks alternatives for long-term care of elderly, infirm

By SUSAN FOGG c. 1979 N.Y. Times News Service WASHINGTON The rising costs of nursing homes and a humanitarian urge to improve the quality of life for a graying America are prompting the federal government to take a hard look at long-term healthcare. The government will spend S2O million by next October to explore alternatives to nursing homes, hospitals and similar facilities for the care of the elderly and infirm. Federal health experts want to test the contention that home health care, homemaking services, adult day care programs, congregate living facilities and programs such as meals-on-wheels will cost less than institutional care. Also to be tested is the premise that such alternatives will enhance, or at least not compromise the quality of life for those who need help with day-to-day living. Grants will be awarded by Sept. 30,1980, to 15 to 20 demonstration projects, which will experiment with alternative means of long-term health care for the aged and infirm The money will come from the Department of Health, Education and Welfare. “These will be demonstrations in the true sense of the word,” says John Palmer, HEW assistant secretary for planning and evaluation. “It’s not the federal government coming in and saying, “We think we have the answers to your problems —try this.’ “We really want to learn what the consequences of different ways of financing and delivering long-term care are on the local level.” The view that nursing homes can be replaced by other types of health care an idea pushed strongly in Congress has had little chance to prove itself under existing federal policy, Palmer and fellow HEW planner Mary Harahan said in interviews. The bias in federal policies on long-term care is toward the use of institutions hospitals and nursing homes often resulting, Palmer says, in the inappropriate placement in nursing homes of individuals who could live on their own with only a modicum of help with shopping, cooking or medical care. This bias both in the Medicare program

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any attempt to use food exports as an instrument of U S. foreign policy. The Farm Bureau Federation’s decision, however, was not capricious. “There were a lot of long faces around here,” said Mel Woell, a spokesman at Farm Bureau Federation headquarters in

ERIC BERNSEE Managing Editor

for the aged and in the Medicaid program for the poor, which finance the bulk of public payments to nursing homes, reflects in part the health insurance practices at the time the legislation was written in 1965. But it also reflects the simple fact that it is easier to keep track of whether taxpayers are getting what they pay for when the care is delivered in an institution than when it is provided in a private home. This concern for accountability is one of the major issues to be explored in the demonstrations. The health experts will determine which financing system will best prevent rip-offs .by health care providers.

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At the same time, federal planners want to avoid creating, in the name of preventing fraud and abuse, the kind of complicated and rigid regulatory structure that advocates of home health care feel afflicts the Medicaid program. By way of illustrating this dilemma, Ms. Harahan points to a family now served by one of the most innovative alternatives to institutionalization in the country, Triage in Hartford, Conn. Triage is a private, non-profit group, operating with funds provided by Social Security under a waiver from the Health Care Financing Administration. Some 1,500 clients receive an initial assessment on their medical, social and economic needs by a Triage nurse-social worker team. The client who without the program might be a candidate for nursing home care is then provided with daily home nursing care, help with housework or other at-home arrangements. “In one family I visited, the client was an 80-year-old man living with his wife and

Kennedy admiiustratipti \ J WEHzld deal with inflation.... I M . \ here's uy chief adviser j M

Park Ridge, 111. “But as repugnant as we found the idea of using food as a weapon, we found the events in Iran much more repugnant.” The Farm Bureau Federation, which claims more than 100,000 members, called for a temporary halt to shipments to Iran. But the call was not taken up by other farm groups. “I feel that an embargo would not be an effective weapon in this situation,” said Harold Dodd, president of the Illinois Farmers Union. “The Iranians can easily buy their food elsewhere. If we felt that an embargo might have any influence on getting the hostages released, we would go along with it, because that’s our first priority, not food sales.” Mast agricultural experts say a U S. food embargo against Iran would result in an increase of sales to Iran by other food-

daughter,” said Ms. Harahan. “The old man is bed ridden, physically helpless, and his daughter, a nurse, takes care of him, changing catheters, that kund of thing. “But his mind is still sharp, and it was clear that he is the emotional strength of that family. What the Triage team does is give emotional support to the daughter, who’s a very unstable person, so that she can keep her job and the income that makes it possible for the family to remain at home. “You could never legislate the kind of flexibility and commitment an agency needs to keep that family together,” Ms.

Costs will continue to grow as the proportion of the population over 65 increases from 11 percent today to nearly 20 percent by some projections in the year 2020.

Harahan said. “Joan Quinn, the director of Triage, is a remarkable woman. You can’t replicate the personal commitment and love of people she has and insists her staff has.” But Triage is financed through Medicare, and that in itself presents a problem for making Triage a long-term health care model for the nation, Ms. Harahan said. “Medicare is a highly unlikely vehicle to pay for a wide variety of social services,” she said. Medicare’s primary purpose is to pay for hospital and physician services in the treatment of acute and specific illnesses, rather than to provide the kind of supportive services that those with chronic conditions or the simple infirmities of old age need to live independently. Medicare finances about SSOO million a year in home health care services, but only if the services are ordered by a physician to aid in the recovery from a specific illness. It does not pay for simple nursing care to maintain the patient at home rather in an institution.

producing nations and a decrease in the confidence food-importing nations now have in U S. suppliers. “We have a great deal of pride in our ability to be a reliable supplier of food,” said Keith Heffernan, executive director of the lowa Corn Growers’ Association. “Farmers are worried that if the U S. develops a policy of cutting off food to this or that foreign country because of political considerations, U.S. farmers will no longer be thought of as a reliable source of food.” Heffernan was shocked at the Farm Bureau Federation announcement supporting an embargo. He quickly polled the members of his board of directors to see whether the intense passions aroused by the Iranian crisis had changed farmers’ opposition to the use of food as a weapon. The corn harvest is still going on in parts of lowa, so Heffernan had trouble reaching

About 2 percent of total Medicare expenditures go to home health care, and another 2 percent is spent for nursing home care. Most federal funds to nursing homes are provided by the Medicaid program Unlike Medicare, a federally administered program financed through Social Security, Medicaid is an amalgam of state and federal funding and administration. Minimum benefit levels are set by the federal government, and states have wide leeway in extending other services to recipients, who must meet varying standards of “medical indigency” to qualify for aid. Although commonly viewed as a health care program for welfare dependents and the poor, Medicaid is the major source (89 percent) of public funding for nursing homes. Close to 40 percent of the Medicaid budget goes for nursing homes billion in 1977 and in 19 states more than half of their Medicaid expenditures are made to these facilities, where nearly 90 percent of the patients are over age 65. Nursing home care costs per patient averaged SB,BOO a year in 1977 the last year figures were available and have been rising at 10 percent a year for the past decade. About half of the total expenditures for nursing home care comes from public funds, and such long-term institutional care is the third largest item on the nation’s overall $162-billion health bill cent of the total. Expenditures for long-term care in nursing homes have been the fastest growing items in the Medicaid budget, Palmer and Ms. Harahan said. These costs will continue to grow as the proportion of the population over 65 increases from 11 percent today to nearly 20 percent by some projections in the year 2020. By one estimate, Medicaid spending for nursing homes alone could reach $26 billion a year in the next century, compared with $6.4 billion two years ago. Common sense suggests that home health care and non-medical support services could keep the elderly out of highcost nursing homes, and in the bargain speed up the movement of patients from hospitals to nursing homes where rehabilitation continues at a far lower cost

some board members, but all those he did talk with opposed a food boycott against Iran. Aside from the fear of losing future sales, farmers also oppose the use of the food weapon because they believe they are responsible for feeding the world’s hungry. “Food is the symbol of people-to-people relations,” said Rep. James Leach, Rlowa, whose office has been flooded with letters of outrage over the Iranian situation. Few of those letters, however, have advocated use of the food weapon. “To use food as a club in foreign policy should only be considered as the last resort,” Leach said. Dodd added: “People can’t exist without food, and thus using food as a political weapon is not the way Americans, as a decent and humane people, should act. I just don’t like the idea.”

than in acute care beds. But hard evidence for these propositions is lacking. The small-scale studies conducted to date suggest that from 10 to 30 percent of 1.3 million patients in the nation’s 18,300 nursing homes do not need the 24-hour skilled supervision these facilities provide, according to a report by the Congressional Budget Office. But the level of care such patients need a daily visit from a home health worker or homemaker services may be beyond the private means of the patients or their families. They may be ineligible for public money, or the services may not be covered by public programs, depending on where they live and on their personal economic situation. The problem is especially pressing for those who need non-medical services. “Medicare coverage of the homemakerhome health aide is limited to so-called health activities,” says Dr. William G. Weissart of the National Center for Health Services Research. Healthrelated services, such as meal preparation and help in bathing, shopping or housework, are paid for by Title XX of the Social Security Act. “Some providers argue that the distinction (between health and related social services) is meaningless,” Weissart said. Medicaid expenditures for home health care totaled about $Bl million in 1977, far less than the amount spent on nursing homes. Moreover, eligibility requirements for public aid under Medicare, Medicaid and Title XX are not uniform, Ms. Harahan said, making it difficult to put together a comprehensive program of care. Another alternative to nursing home and hospital care is the adult day care center, which provides hot meals, opportunities for socializing and recreation for the elderly and, in some cases, medical and rehabilitative services. The centers are popular in England where they are funded by the national Health Service, but only 200 day care programs exist in the United States. Congregate living facilities, from small boarding houses to large high-rise apartments, can provide group meals, some nursing care and help in housekeeping, these facilities are financed mainly by the

November 27,1979, The Putnam County Banner Graphic

What farmers think, however, may be a moot point. The International Longshoremen’s Association has taken matters into its own hands by refusing to load grain ships headed for Iran Just how seriously Iran will be hurt by a cutoff of U.S. food supplies is not dear Iran spends about $2 billion a year for imported food, but only about 25 percent of that, $490 million, is spent on foodstuffs ini ported from the United States. In August. Iran announced it was attempting to shift its food purchases away from the United States and toward such countries as Australia for wheat, Thailand for rice and Brazil for soybean oil. While the revolutionary government has enough cash to buy what it needs, U.S sources say Iran may be short of experts who know the intricacies of the complex international food market.

Department of Housing and Urban *• Development or the private income of ■ residents. Both private and public congregate living programs report long waiting lists for admission. But before the federal government rushes into creating what Palmer calls an « equivalent of national health insurance for ‘ • long-term care, two major considerations *• remain. First, families of the infirm now provide J • most of the home care for the elderly in *> this nation at no cost to government. The , Congressional Budget Office estimates J* that 3 million to 6.7 million infirm in- •- dividuals are cared for by their families at J home. “If we start to pay for services that have i been traditionally rendered by the J* family,” Ms. Harahan said, “we want to »• do it without destroying the existing in , • formal care system.” Second, there is no proof that the alter »• natives are less expensive than nursing |* homes when . computed for a large »• population of elderly. On a per-case basis, though, the costs J* ARE less. Day care programs cost 12 to 35 »• percent less than nursing homes do. * Home care costs are estimated in some *• studies as half that of nursing home. >• charges, or about $428 a month compared; ’• with SBOO in 1975 dollars, according to the health Care Financing Administration. But Palmer said that if these home «* based or day care services are expanded <• to a much larger population, the total costs * i of long-term care may not be reduced. The central feature of any of the HEW ) demonstration projects, Palmer said, will be a single “channeling” agency that 4 ‘ monitors and coordinates services that its J clients receive. j * In some cases the work may be done by a private, non-profit group such as Triage in*v-< Hartford. Or a local Medicaid office may 4 - - have the responsibility for the program, as in Rochester, N.Y. In some programs, the channeling agency may limit its role to assessing the patients’ needs and referring them to appropriate public and private agencies. It may arrange for payment of these services, whether provided by private or ' public agencies, or it may finance, ad minister and provide the services itself The demonstrations will be financed through a combination of direct grants and waivers from the thicket of restrictions on funding in Medicare and Medicaid Palmer said he expects that a wide, range of financing methods will be used,' ‘ from traditional fee-for-serviee to a flat ”, cap on expenditures to a prepaid scheme; in which the project would get funds in advance and provide all the services that clients would need. The last would be' similar to Health Maintenance Organizations, where patients pay one seh fee and get all the care they need. ; i’ “State and local agencies have money T coming at them from a lot of different • streams, with different conditions at- ; tached,” Palmer said. "In return for -' agreeing to work with a fixed budget' • (something not generally required under Medicaid. Medicare or Title XX), they'd have a great deal more flexibility ." :..'V This flexibility would allow the demonstrations programs to match their.programs to local needs Home health care, programs may be in big demand in one area, while day care centers or homemaker services may be better suited to another. This flexibility would give HEW plan ners a variety of approaches to compare for costs and impact on in stututionalization. and also would make it easier for health planners to determine th ’ *'' demand for services. At the same time. HEW would be able to• v explore how the different approaches*,, prevent the potential for ripoffs by un-. , scrupulous operators of home health and-.*, homemaker services, day care programs. boarding houses, or even hospitals for ter-..» minal patients.

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