Two years ago, the House rejected a home-care bill sponsored by the late Rep. Claude Pepper (D-Fla.) by a vote of 243 to 169. Opponents flinched at its $9-billion-a-year price tag, its broad coverage of children, the disabled and the aged, and the fact that it had never been carefully studied by the legislative committees on health.
Critics thought that would end the matter for years. But in the last Congress, legislation incorporating the Pepper concept was enacted under the sponsorship of Sen. John D. Rockefeller IV (D-W.Va.) and a Pepper protege, Rep. Ron Wyden (D-Ore.).
The concept, while considerably circumscribed, remains recognizable. The cost of the initiative has been sharply cut back and it covers only the aged -- and only if they are poor and eligible for Medicaid.
But the sponsors view it as merely the opening wedge in a larger campaign for broad long-term care for frail, elderly people -- those who do not necessarily need active medical treatment at home but who do need help with the ordinary tasks of daily living, like eating and moving about.
"This is the next step toward a long-term care policy for the country," said Wyden. "This program starts with the poorest, most vulnerable and frailest."
"Now, more frail seniors who are able to stay in the comfort and familiarity of their own homes will be able to do so," Rockefeller said when he pushed the provision through the Senate.
The "frail elderly" are generally considered the mentally acute, persons able to engage in social interchange, watch TV, read and enjoy conversation with family members and friends. In the bill, Alzheimer's victims are also included, depending on how much functional capacity they have lost.
With the help of someone to perform chores and help them move about, Wyden said, the frail elderly can remain "where they want to be" -- at home.
Medicare does not provide such nonmedical long-term care services for people who stay at home, Wyden said, and while Medicaid sometimes does, the services are limited and usually require a special program waiver. Lacking that, the elderly must be taken out of their homes and placed in nursing homes. "The Medicaid program is biased toward institutional care," said Rockefeller.
Under the new program, a person 65 or over, who is poor and eligible for Medicaid, and who cannot perform two of the three basic activities of daily living (eating, moving about, using the bathroom) without help, is eligible for Medicaid-financed assistance at home.
The initial federal outlays are limited to $580 million over the next five years, to be allocated to the states based on aged population and other factors. About 100,000 people are expected to be helped over that period.