In the new law to avoid the so-called fiscal cliff (the American Taxpayer Relief Act of 2012, ATRA), approved last week, Congress and the President repealed the entire Title VIII of the Affordable Care Act (ACA, Obamacare), arguably the largest change in the national health reform law since it was signed nearly 34 months ago in March 2010. One might assume this repeal involved lots of budget savings -- that would be untrue. Savings = $0.00. So what happened?
Title VIII is called CLASS: Community Living Assistance Services and Supports, and was the personal cause of my Senate boss, the late Senator Edward M. Kennedy, who advocated for its inclusion in the ACA until his very last days in August 2009. What was CLASS?
Had it been implemented, CLASS would have been a voluntary federal insurance program to provide daily cash support to permanently or temporarily disabled persons to help them to live in their communities and to avoid institutionalization. To qualify and to collect benefits in the event of disability, enrollees would have to pay premiums for at least five years, premiums estimated to be about $150 per month, for daily cash benefits of $50-75 in future disability payments.
Senator Kennedy personally committed to this cause in the 1980s when his mother, Rose, suffered a stroke and needed to use a wheelchair until her death at age 104 in 1995. Though his wealthy family could afford round-the-clock private duty nursing, Kennedy realized that this kind of support was inconceivable for most Americans who had no choice but to spend down to poverty to qualify for Medicaid. He hired a street-smart pediatric intensive care nurse from Philadelphia named Connie Garner as his disability expert to seek a national solution.
With a broad-based coalition of disability and senior advocates, determination, and more than a little luck, Kennedy's friend and colleague Senator Chris Dodd (D-CT), Garner, and the advocates got CLASS included in the ACA in spite of strenuous and unanimous Republican opposition. To get it, they had to accept language in the ACA giving the U.S. Secretary of Health & Human Services broad authority to suspend the program if finances were insufficient to balance the program financially over at least 75 years.
In October 2011, HHS Secretary Kathleen Sebelius suspended implementation of CLASS because she could not make the finances work under the CLASS language in the ACA. The Obama Administration did not advocate repeal, and publicly hoped for a time in the future when Congress would agree on changes to CLASS to make it workable and implementable -- something inconceivable with a Republican/Tea Party-controlled House of Representatives, and conceivable in the future when the friction over the ACA might abate.
Following the Sebelius move, House and Senate Republicans repeatedly moved to repeal CLASS with Democratic leaders resisting. Nothing happened.
Right after Christmas 2012, when House Speaker John Boehner failed in his attempt to rally House Republicans around his "Plan B" to avert the Fiscal Cliff, attention turned to Vice President Joe Biden and Senate Minority Leader Mitch McConnell (R-KY) to negotiate a solution to the fiscal cliff. On New Year's Eve, 2012, progress became apparent and the details of the deal were released to Members of the U.S. Senate. At McConnell's insistence, the deal included repeal of CLASS; even though it had no impact on federal spending, it was part of the price of McConnell's consent.
Senator Jay Rockefeller (D-WV), a CLASS supporter, knew he could not stop repeal, and pushed to include establishment of a new Commission to recommend to Congress a replacement program to achieve the purposes of CLASS. Advance CLASS, an advocacy coalition established by Connie Garner and her allies after she left the Senate in 2010, had drafted the language more than six months ago in response to repeated threats to repeal CLASS. In the final fiscal cliff law, their version was stripped of accountability and teeth -- so when the Commission releases its recommendations, nobody needs pay attention and nothing is guaranteed. The 15 Commission Members (9 Democrat and 6 Republican appointees) are to be appointed no later than 30 days after the new law's signing.
And Connie Garner is optimistic.
Long term care insurance in the United States is a failed market. Four of the major LTC insurance carriers have left the business, and the rest offer no bargains. The nation's disability burden -- one out of 70 children is now on the autism spectrum/ two thirds of Americans are overweight or obese -- will only grow worse, as will the demands on state and federal Medicaid budgets. Like it or not, the real human needs that led to the drive for CLASS are not going to lessen; they are going to increase and increase.
CLASS I is dead. Long live CLASS II. The nation needs it.
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