Interview: NAHC President Questions Home Care Funding’s Future

Val J. Halamandaris—the leader of one of the home care industry’s most important associations—believes there is not enough money in the world to pay for all the in-home services that will be needed in the coming years.

It may seem somewhat off-message for Halamandaris to say that, considering that “ensuring appropriate and adequate Medicare reimbursement” is one of the 2015 legislative priorities of the National Association for Home Care & Hospice, the organization that he has led for three decades. What might add to the oddness factor, he made his pronouncement at the NAHC’s annual Financial Management conference, which took place recently in Nashville, Tenn.

But his recognition of the fiscal realities is grounded in his keen awareness of the massive scope of home care needs, which he describes as “colossal.” In a chat with HHCN at the conference, he elaborated on his vision for how to address this tremendous need, which only partially involves better governmental policies. It also hinges on a moral imperative that he feels must be met by society as a whole. And he sees the stakes as enormous, with not just the well-being of the nation’s seniors at stake, but the very existence of the American way of life.

HHCN: This is the 50th anniversary year for Medicare, and you were one of the original architects. How do you view the Medicare program today?

Halamandaris: The issue of long-term care is going to be so big, so huge, it will completely dwarf the existing health care system. It will dominate the health care system of the future. Everyone needs to sort of retrofit what we’ve done with health care. Ninety-three percent of all the costs of Medicare relate to chronic disease. And yet we still have a system — and I did help write Medicare, the home care benefit, way back in 1965 — and it was an acute care thing. Now what we need is not so much acute care.

The number of people going into hospitals and spending time there is going down, whereas the amount of time, money and energy spent on home care and community-based care and long-term care is going straight up in the opposite direction. I’m not saying one is right. Both things are going to be needed. But a collaboration certainly is in the best interests of everyone. We need to get everyone off the system that was designed for acute care, which is increasingly irrelevant. What is relevant is the management of chronic disease.

HHCN: Do you think health care reform will de-emphasize acute care?

Halamandaris: What does the Affordable Care Act do for long-term care? Bupkus. I pushed very, very hard to have that dimension, the CLASS Act. Senator [Edward] Kennedy’s final wish, the one most important to him, was that the CLASS Act was included in the ACA. Obama got backing from Ted Kennedy. If he hadn’t, he never would have been President of the United States. And he let this benefit, this so-called CLASS Act, go up in smoke, because, oh, I don’t know if it’s fiscally sound and we can afford it. But we can afford to run two wars and afford to add a prescription drug benefit to Medicare and not pay for that. But not pay for the health care we’re going to need that would have involved a system, which you remember, that would have involved us all buying into it and then having our own accounts. We could access it depending on the deficits that we have, the abilities to perform the activities of daily living. So you would have a credit card that you could use and you could only use it for the purposes that would allow you to stay in your own home.

It was a brilliant idea. One that was self-funding. And yet there was opposition to it, and rather than fight, they said, we’ll throw in our chips on this. If I were Obama, I wouldn’t be able to sleep nights.

HHCN: What’s the answer? How to convince policymakers to address the long-term care system?

Halamandaris: NAHC and others—the American Health Care Association, the American Hospital Association—have to get busy and convince the political groups that things need to change. Washington does a very good job of taking care of the status quo. Those that have the money will continue to have the money because the political influence is tied very closely to that. I’m not saying you bribe and buy your way through Congress. You can’t, you don’t. But if you’re not one of those people or organizations that comes along and raises money for candidates who help you, don’t expect to be helped. When the money is down on the table, they’ll say, well, I like them, but they never give us any money. We don’t care for these guys so much, but they’re always there when we need them and always give us contributions, so I guess I’m going to give them my vote. It’s just axiomatic.

HHCN: Will lawmakers feel pressure from constituents as the population ages?

Halamandaris: I do. And in the end that is the answer to it. A lot of people have quoted the saying demography is destiny. It is. Seventy-eight million baby boomers coming into the majority at once, 10,000 a day turning 65. That’s extremely powerful. Every day that goes by, their influence is greater. How can it not have a colossal impact?

HHCN: The White House Conference on Aging is coming up this month. Do you expect good things to come out of that event?

Halamandaris: We’ve tried to encourage them to do it and do it right. I don’t see a lot of enthusiasm for it. I’ve been to all the other White House conferences, starting back as a young pup still in college. They were very constructive. What are the problems of seniors, what do we do about them, what are the policy alternatives? No one at the White House conferences tried to dictate to Congress. They just said, hey, here is a series of options you may want to consider, and by the way, if you want  a straw poll, we think this ought ot be your number-one priority. And what’s been on that heap over and over again has been long-term care. Doing something about that colossal problem. But the point being, it will happen in any case because of the press of demographics. If we did nothing, it’s going to happen anyway.

HHCN: What about future leaders in the home care industry? Are you worried about who there are, how they’re being prepared?

Halamandaris: I’m not the least bit concerned about the next generation of leaders. If you look at Millennials, I feel the country’s in pretty good hands. I feel very good looking at the younger generation and what they want.

What the baby boom generatoin is called on to do right now is to take John Kennedy’s call, ask not what your country can do for you. I think it’s more important now than the first time we heard it.

HHCN: Why?

Halamandaris: Here’s my premise. There’s not enough money in the world to pay for all the home care that people need. I don’t care where you come up with it, there’s going to be a shortfall.

So what we have to rely on a lot is volunteers who say all right, part of what I do in my life is to give back. Then again, you’re looking at a coal miner’s son from rural Utah. I had a lot of folks who believe in me and helped me out, so I’m obsessed with giving back and creating opporutnities for others. Especially for those in my baby boom generation who are relatively well off, healthwise, what are you called upon to do? Help those who are less fortuante. We need that ethic right now.

SHN: And you see that ethic in the younger generation?

Halamandaris: Another way to put it is, I made a bucket list of people I wanted to meet and interview, and then went after them and met them, and I was never shy. One of the people I wanted to meet was Viktor Frankl, a phycisian who wrote a book called Man’s Search for Meaning. You probably remember, he was in Auschwitz and Dachau, studied why certain people lived and certain people died.

The survivors weren’t the biggest, the strongest, the most physically imposing, the most brutal, the one who could bang someone on the side of the head and take their ration of bread. The survivors were the ones who opened their hand and gave their crust of bread to somebody else. What matters is that you have a passionate purpose which involves caring for others.

So I asked Dr. Frankl, what can we do here in America to ensure the survival of American society? He said symbols are very important. He said, what I think we need, including himself in the answer even though he was Viennese, is a Statue of Responsibility which sits on the West Coast of America to match the statue in New York Harbor. Because freedom without responsibility deteriorates into chaos. I think he’s exactly right. Trust me, the Millennials will do that. They’ll make that happen just because they think of others and have a mindset that says, wait a minute, we’re all interconnected here. We breathe the same air. It’s begining to dawn on all of us that the world’s a very small place. Technology has certainly changed everything.

SHN: Do you see part of your mission with NAHC as trying to instill that sense of responsibility, the importance of caring for seniors?

Halamandaris: President Kennedy could not get Medicare passed after making all the economic arguments. What changed is that he put it on a moral basis. He studied philosophers, Toynbee and others. Toynbee said there was a common yardstick they came up with for why certain societies survived: the manner in which they treat their most vulnerable citizens. The better a society did in taking care of those cohorts, the more likely it was to endure and be well-received through history.

What the president said was at stake in Medicare was the very longevity of American democracy. It was imprinted in my brain, something I never forgot. What we’re working for is the very survival of American democracy.

Written by Tim Mullaney