Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.

Days until marketplaces launch: 13. 


The Affordable Care Act started with a sweeping plan to overhaul our country's long-term-care system, what one observer described as "the most important innovation in helping Americans with disability and long-term care needs since the creation of Medicaid."

It ended, three years later, with a 114-page, bullet-point-laden report that only nine of its 15 authors would agree to endorse.

This is the story of the CLASS Act, or, the Community Living Assistance Services and Supports Act, and how the largest part of the health law to be repealed came to an end.

Enacted as part of the Affordable Care Act, it was meant to create a long-term insurance plan that would be run by the government, with optional enrollment, to cover living assistance costs that Medicare and Medicaid don't include. These would be things like home-care aides, accessible transportation and home modifications.

The CLASS Act, to the delight of congressional Republicans and pun enthusiasts, was dismissed in October 2011, after actuaries at Health and Human Services couldn't figure out a way to make the program financially viable. Their worry was that with the program being optional, only those who were sick and anticipating needing long-term care would enroll. It would enter a death spiral, with premiums becoming prohibitively expensive.

But that wasn't the end of the long-term-care saga: After Congress officially repealed the CLASS Act in January, it created in its place the Commission on Long Term Care, a 15-person group tasked with writing a "plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services."

The timeline was short, just about 100 days to come up with a solution to problems that have vexed Congress for decades. The commission began meeting on June 27 and, by Sept. 12 had to publish its proposal. It held nine executive sessions and four public hearings.

"The commission had a very short time frame," says Judy Feder, a Democratic-appointed commissioner and a professor at Georgetown University. "It's a big deal issue, and we just didn't address the issue that was our charge."

"Statutorily, we didn't have enough time," says Grace-Marie Turner, a Republican appointee who serves as president of the Galen Institute. "Not all progress is a breakthrough, but we were able to do research, which I think counts as progress. If you can't get everything done, you don't just give up."

Bruce Chernof, who chaired the commission, says he's proud of what they were able accomplish in the time they had.

"Every commissioner worked hard to make this the best report possible," Chernof, who is also president of the SCAN Foundation, said. "Because this has been such a difficult problem for such a long period of time, many folks have very specific views on the best way to solve it. That you could get nine people to agree on a possible approach, in an incredibly short period of time, I think that's a success."

Feder was among the six commissioners who voted against endorsing the report that the group ended up writing. She felt the report fell short because it did not include a plan for financing a long-term-care system, often the most vexing part of moving forward with any policy issue on Capitol Hill.

"The Commission considered very different approaches regarding the mechanisms needed to make this vision possible," its report concludes. "The Commission did not agree on a financing approach, and, therefore, makes no recommendation."

Chris Jacobs, a Republican appointee from the Heritage Foundation, joined Feder in voting against the report. According to a letter he sent to Chernof, he disagreed with some of the commission's policy recommendations and the "unintended consequences" for the budget that he felt had not been fully examined.

"Some could result in budgetary costs for state and/or federal governments, he wrote. "Just as important, others could also impose higher costs and burdens on the providers who are the critical element necessary to deliver high-quality, patient-centered LTSS.  Collectively, these concerns — on both substance and process — prevented me from supporting the commission’s final report."

As to what happens to the report next, Chernof hopes it will "galvanize people to move forward" on long-term-care reform. When I asked Chernof what he saw as his main obstacle -- and why Congress tends to shy away from the issue -- he replied that it has a lot do with how we collectively view responsibilities for caring for the elderly.

"People see this as something you solve within your family," he says. "They don't normally think of this as an area that needs a public policy solve. The average American family thinks, 'I'll be the one taking care of mom and dad, or grandpa and grandma.' The challenge is to rethink that conversation."

As to whether Congress would act on the issue, Feder, a longtime advocate on the issue, put it this way: "I also worked many years on expanding health insurance. We got that. We'll get this, too. It just takes a little longer to get."

KLIFF NOTES: Top health policy reads from around the Web.

Ex-Obamacare aides are now reaping a windfall. "Washington’s health care revolving door is spinning fast as the new online health insurance marketplaces, a central provision of President Obama’s health care law, are set to open Oct. 1. Those who had a hand in the law’s passage are now finding lucrative work in the private sector, as businesses try to understand the complex measure, reshape it by pressing for regulatory changes — or profit from it. That means boom times for what might be called an Obamacare cottage industry, providing work for dozens of former administration and mostly Democratic Congressional officials whose immersion in health policy minutiae, and friendships, make them invaluable to private business." Sheryl Gay Stolberg in the New York Times.

Republicans are weighing how aggressively to attack Obamacare. "House Republican leaders will present options for dismantling President Obama’s healthcare reform law to their members in a closed-door meeting Wednesday morning as they seek a more aggressive posture in a pair of looming fiscal fights.  A senior GOP aide said it was 'likely' the House would send to the Senate a continuing resolution that defunded the healthcare law but that leaders had decided not to combine it with legislation raising the debt ceiling." Russell Berman in the Hill

Walgreen's is moving workers to a private health exchange. "Walgreen Co. is set to become one of the largest employers yet to make sweeping changes to company-backed health programs. On Wednesday, the drugstore giant is expected to disclose a plan to provide payments to eligible employees for the subsidized purchase of insurance starting in 2014. The plan will affect roughly 160,000 employees, and will require them to shop for coverage on a private health-insurance marketplace. Aside from rising health-care costs, the company cited compliance-related expenses associated with the new law as a reason for the switch." Timothy W. Martin and Christopher Weaver in the Wall Street Journal.

Doctors, not Obamacare, will ask you about your sex life. "Evidently Ms. McCaughey knows some pretty crappy doctors, because if you consider it 'inappropriate and unnecessary' to talk to your patients about their sex lives, then you really shouldn’t be in the business. I agree that it’s not necessary to ask these questions at every visit for every complaint. But seriously, a cardiologist is saying he can’t imagine a single occasion when he might ask a patient about his sex life? Really? I’m speechless." Aaron Carroll in the Incidental Economist.