School of Medicine, Oregon Health & Science University.
Global Brain Health Institute, University of California, San Francisco and Trinity College Dublin.
Milbank Q. 2021 Jun;99(2):565-594. doi: 10.1111/1468-0009.12500. Epub 2021 Feb 16.
Policy Points To address systemic problems amplified by COVID-19, we need to restructure US long-term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near-term and long-term policy solutions. Seven near-term policy recommendations include requiring the uniform public reporting of COVID-19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations. Long-term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age-friendly public health system.
The heavy toll of COVID-19 brings the failings of the long-term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID-19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long-term disinvestment and neglect of state- and local-level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.
We analyze several impacts of the COVID-19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states' fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.
We propose seven near-term actions that US policymakers could take: implementing a uniform public reporting of COVID-19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age-friendly public health system.
COVID-19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.
为了解决因 COVID-19 而加剧的系统性问题，我们需要对美国长期服务和支持（LTSS）进行重构，使其与医疗保健系统和公共卫生系统相关联。我们提出了近期和长期的政策解决方案。近期的七项政策建议包括：要求所有 LTSS 场所统一公开报告 COVID-19 病例；确定并支持无偿护理人员；支持直接护理人员；加强公共卫生部门与 LTSS 机构和提供者之间的协调；加强卫生、LTSS 和公共卫生系统之间的协作和沟通；进一步减少 LTSS 中远程医疗的障碍；为弱势群体提供护理激励。长期改革应侧重于全面的劳动力发展、全面的 LTSS 融资改革以及创建一个适合老龄化的公共卫生系统。
COVID-19 的沉重代价使美国长期服务和支持（LTSS）系统的缺陷成为焦点。尽管这些问题并不是新问题，但大流行加剧并放大了它们的影响，以至于这些问题不容忽视。COVID-19 感染和死亡的高发病率主要归咎于正规 LTSS 护理机构，特别是疗养院。然而，在这次大流行期间，还发现了其他系统性问题：未能在联邦一级协调美国公共卫生系统，以及长期投资不足和忽视州和地方一级公共卫生计划的影响。这些失败共同导致无法与 LTSS 系统协调，无法及早采取行动保护 LTSS 护理机构的居民和工作人员，这些机构是感染、传播和严重负面健康后果的热点。
我们分析了 COVID-19 大流行对美国 LTSS 系统和政策安排的几个影响。对州预算的经济影响是多方面的，大流行对 Medicaid 产生了直接影响， Medicaid 是 LTSS 的主要资金来源，这反过来又进一步加剧了各州的财政问题。种族、族裔和社会经济地位之间的不平等以及无偿护理人员负担的加重都是显而易见的。同样需要更好地将 LTSS 与卫生、社会护理和公共卫生系统整合。
我们提出了美国政策制定者可以采取的七项近期行动：在 LTSS 场所实施 COVID-19 病例的统一公开报告；确定并支持无偿护理人员；支持直接护理人员；加强公共卫生部门与 LTSS 机构和提供者之间的协调；加强卫生、LTSS 和公共卫生系统之间的协作和沟通；进一步减少 LTSS 中远程医疗的障碍；为我们最脆弱的人群提供护理激励。我们的分析还表明，我们的国家需要通过全面的劳动力发展、通过全面的融资改革实现全面覆盖以及创建一个适合老龄化的公共卫生系统来对 LTSS 系统进行全面改革。
COVID-19 暴露了美国 LTSS 系统的许多缺陷，并清楚地表明 LTSS 与公共卫生之间的相互依存关系。政策制定者有机会通过实质性的 LTSS 系统改革和加强与公共卫生机构和领导者的合作来解决这些问题。改革的机会就在现在。
