Sen. Bernie Sanders (I-Vt.) is raising the stakes of the "Medicare for All" debate by expanding his proposal to include long-term care, a move that is forcing other Democratic presidential candidates to take a stand on addressing one of the biggest gaps in the U.S. healthcare system.
Medicare for All is unlikely to advance in the GOP-controlled Senate, but it's a defining issue in the early days of the Democratic primary and candidates have pointed to their support of Sanders' legislation as proof of their progressive bona fides.
Some moderate Democrats have criticized the cost of such an expansive proposal and by adding the long-term care provision, Sanders could further expose that divide.
So far, 2020 candidates Sens. Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y) and Kamala Harris (D-Calif.) say they'll support Sanders' more ambitious bill. Sen. Elizabeth Warren (D-Mass.) also backed the 2017 version of Medicare for All but has not said how long-term care might affect that.
Sanders' move, confirmed by his office, follows action by Medicare for All allies in the House to incorporate a generous long-term care benefit in their newly introduced legislation. Medicare for All would replace the current mix of private and government financing for health care with a system paid for by the government and funded by higher taxes
As with the rest of Medicare for All, supporters aren't saying how they would pay for long-term care, which experts estimate could cost several hundred billion dollars a year. Several independent estimates for the broader program have ranged from about $25 trillion over 10 years to $36 trillion, although supporters say it would be considerably less.
Still, the general idea of a government long-term care program has broad backing.
About two-thirds of U.S. adults favor a long-term care program similar to Medicare, according to an Associated Press-NORC Center for Public Affairs Research poll last year. That includes 76% of Democrats and 56%of Republicans.
The attention from Sanders as well as House Medicare for All leaders Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) comes after advocates for disabled people lobbied them to step up coverage for long-term care in the push for a national healthcare plan.
Many Americans assume that Medicare covers long-term care, but that's not the case. Qualifying for public coverage under Medicaid, which covers low-income people, involves spending down lifetime savings.
Long-term care has "always been the stepchild," said Marc Cohen, a gerontology researcher and professor at the University of Massachusetts Boston. Cohen says he thinks the House plan recently introduced by Jayapal and Dingell would be "unaffordable," but says it recognizes a need. "That is really a positive thing that someone is trying to address it," he added.
Recent state-level efforts on long-term care have sent mixed signals. Maine voters last year rejected a referendum that would have provided home care to all seniors and disabled people regardless of income. But last month the Washington state House approved a plan creating a limited cash benefit to offset long-term care costs. The measure, sent to the state Senate, is financed with a payroll tax on employees.
Only an estimated 7 million to 8 million people have private long-term care insurance, which is costly and generally requires applicants to pass a health screening.
In Congress, the new House Medicare for All bill from Jayapal and Dingell offers the most generous benefit.
People of any age could qualify if illness, injury or age limit their ability to perform at least one "activity of daily living," such as bathing or dressing, or one or more "instrumental activities of daily living," such as managing money or taking prescribed medications. There would be no income or assets tests to qualify, and no copays or deductibles.
The House bill — known as H.R. 1384 — emphasizes home- and community-based care in the "least restrictive setting." But it would also pay for nursing home care. The earlier version of the House bill included a few mentions of long-term care but did not specify benefits.
"We flip the model on its head," Jayapal said. "Instead of saying institutional care is the default we say ... you should be able to be taken care of at home, in your community."
In his 2017 bill, Sanders left the current low-income Medicaid coverage for long-term care in place. His office says a new edition to be introduced in coming weeks will include added coverage for home- and community-based services, available to people of any age as Medicare for All benefits. Such services can include adult day care, a housekeeper, or home improvements like grab bars in the shower.
The shift by Sanders and his House counterparts came after intensive lobbying from disability rights advocates. The groups were a central part of the coalition that defeated President Donald Trump's effort to repeal the Affordable Care Act and restrict federal financing for Medicaid.
The activists realized during that effort that even Medicare for All came up short on the needs of disabled people, said Nicole Jorwic, policy director for The Arc, which serves people with intellectual and developmental disabilities.
"If you don't include long-term supports and services, it cannot be considered a bill that is for all people because it leaves out huge portions of the population, including people with disabilities and aging Americans," Jorwic said.