Those of us who have been caring for our parents know very well the physical toll it takes. I helped care for my dad for 18 months. And after he died, one of the first things I did was make an appointment to see my own doctor. I had never felt so exhausted and worn out in my life.

Now, an important new study describes the health effects of caregiving on workers. And the picture is not pretty. Women caregivers over 50 are twice as likely to report fair or poor health than those not caring for elderly relatives. Men are more likely to smoke. Blue-collar workers are more likely to drink. And caregivers across the board report higher rates of depresssion, diabetes, hypertension, and pulmonary disease.

Overall, the study estimates these workers cost their employers an average of 8 percent more in health care costs, or $13 billion annually. And that's on top of an earlier study that suggests absent or distracted caregivers cost their companies between $17 billion and $33 billion in lost productivity. The toll on these adult children and their employers is enormous.

The new report, called "The MetLife Study of Working Caregivers and Employer Health Care Costs" is a joint project of the MetLife Mature Market Institute, the National Alliance for Caregiving and the University of Pittsburgh.    

A White House task force on meeting the needs of middle-class families today proposed to spend an additional $102 million to assist caregivers of aging relatives. The initiative includes an extra $52.5 million for respite care--a program enacted by Congress in 2006 but never fully funded. 

It is very important that the Obama Administration recognizes that caring for our parents is critical to many middle-class families. But as the task force fact sheet notes, 38 million Americans provide unpaid care to loved ones (other estimates are even higher). So, $102 million comes out to about $3 per family--not exactly a difference maker.

There has been a long history of Washington announcing grand-sounding plans for family caregivers, but never delivering. For instance, the Lifespan Respite Care Act passed four years ago was supposed to provide critical assistance to caregivers. The original law called for spending $71 million this year, but Congress never appropriated anything close to that. In 2009, only $2.3 million was distributed to states.

If the President and Congress follow through on expanding the Lifespan program--a big if--this will help a few families. Better for all of us if Obama works to be sure that bigger long-term care changes survive the health reform debate. For instance, if everyone had some form of long-term care insurance (such as the national government insurance in the CLASS Act) they could spend their daily benefit as they wished, and would not have to rely on underfunded government programs that come and go with the political winds. 

Republican Scott Brown's stunning victory in the Massachusetts Senate race has obviously turned the health reform debate on its head. Without a 60-vote majority in the Senate, Democrats are no longer assured of passing a major health bill. But what will this mean for long-term care reform? 

There are three key long-term supports and services issues at stake--expansion of Medicaid home and community based care, new efforts to coordinate care both for Medicare patients and for those eligible for both Medicare and Medicaid, and the CLASS Act, the proposed national long-term care insurance program.

Keep in mind that the fate of all these measures is tied to broader reform. If the big health bill dies this year, so will long-term care reform.There is no chance Congress will pass a long-term care bill on its own this year.

If the House can pass the Senate version of health reform, these proposals will survive, although not necessarily in the best form. If, as President Obama hinted today, he'd like Congress to try to pass a slimmed-down bipartisan health insurance reform bill, the fate of long-term care will be much dicier.

To start, it is not clear that either Republicans or liberal Democrats want to pass a mini-reform bill. But if they do, would long-term care be in the package?

It is hard to imagine that broad expansion of Medicaid home and community care would be included, because that proposal could be very expensive, and lawmakers will be looking to jettison costly provisions. Care coordination has a better chance since it may be sold as a cost-saving measure.

And what about CLASS? It is harder to say. On one hand, CLASS generates substantial revenues in the first ten years, at least on paper, and that has always been it biggest advantage. However, the proposal has also generated a number of important critics, including both Republicans and nearly a dozen moderate Democrats.

CLASS, for all its benefits, is not essential to health insurance reform. And if Obama wants to get something passed quickly, I suspect he'll dump everything that is at all controversial.

Bottom line: the immediate future of long-term care reform is extremely precarious. But whether it is approved this year or not, the issue has generated more attention than at any time in decades. And as long as millions of us need care, or are caring for our parents or other loved ones, it is not going away.  

Why can't The Washington Post ever get it right when it comes to long-term care. Its latest self-embarrassment came with a piece it ran today comparing elder care in the U.S. with similar assistance in France and the U.K.

According to the author, a psychologist named Sara Mansfield Taber, elderly women in England and France receive far better care than the writer's mother did in the U.S. Unfortunately, she hopelessly confuses health care with long-term care and paints a picture of high-quality personal supports in Europe that I only wish really existed.

In truth, the system of long-term care in England very closely resembles the deeply flawed welfare-like arrangement we have in the U.S. through Medicaid. While nursing care is provided as part of the National Health System, government-supported personal assistance such as home health aides provide is only available for those with few assets and very low incomes.

This is troublingly similar to the U.S, and has been the subject of severe criticism in the U.K. for decades. One scathing 2006 report by the Joseph Rowntree Foundation concluded "the public finds the present system incomprehensible and considers its outcomes unjust." 

Because benefits vary so widely by locale in the U.K. the system is often disparagingly referred to as the "postcode lottery." Indeed, the current labour government of Gordon Brown is proposing major reforms to address some of these perceived inequities.

In France, the author's other model, government long-term care benefits are also based largely on income. Unlike the U.K. and the U.S., where those with more than $2,000 in financial assets and less than $700- a-month in income usually receive no Medicaid benefits, in France everyone who suffers from severe enough disability gets some assistance. However, they face some fairly tough limits. First, to be eligible, a person must be significantly more disabled than in the U.S. Second, benefits are sharply reduced for those not in poverty. The average monthly benefit for someone receiving home care in France is only about $600. And while someone who is very poor gets about $1,400 per month, a person with income of about $4,000-a-month would get less than $300 for home care.

The French middle class has found the public long-term care benefit so insubstantial that about 25 percent of those 65 or older feel the need to purchase private long-term care insurance to supplement this government assistance. Fewer than half that many have bought this insurance in the U.S.

Don't get me wrong, the U.S. system for providing long-term care is shameful. And Congress is finally taking some steps to both expand home care benefits under Medicaid and create a national long-term care insurance program to help middle-class people begin to prepare for their frail old age. But despite what The Post would have you believe, the systems in the U.K., and France are hardly panaceas.

When it comes to long-term care, we all have work to do. Especially The Post, which provided wildly inaccurate commentary on alleged "death panels" last summer, and has been unable to write about long-term care reform in any serious way during the current debate over health care.            

Connie Garner, the top Senate staffer on long-term care issues, said today that she is certain the CLASS Act, which would create a new national long-term care insurance program, will be included in the final health bill being considered by Congress. "I don't have any question CLASS will survive," Garner told a long-term care conference sponsored by the journal Health Affairs.

A senior insurance industry official told me today that he agrees with Garner's assessment. He said the industry is shifting its attention to tweaking the bill rather than trying to kill it and will begin to work with the Obama Admnistration on the design of CLASS policies. 

Garner, a veteran Hill staffer and no pollyanna when it comes to legislative predictions, said there were still many unresolved issues as House, Senate, and White House negotiators write a final version of CLASS. Among the issues: how to prevent people from enrolling in the program for the five year minimum, then dropping out for many years before re-enrolling again late in life.

She said her biggest concern now is making sure the Adminsitration will have the flexibility it needs to design insurance policies under CLASS while maintaining the basic framework of the new program. "We have to be careful to watch the structure doesn't change," Garner said.

For her, that means keeping the program's cash benefit and protecting Medicaid for those who need it. As the bill has moved through Congress, it has gradually become less specific about the exact design of the insurance policies. It now leaves many questions--including the premiums and specific benefits--to the Secretary of Health and Human Services.

Garner acknowledged concerns that too few healthy people will enroll in CLASS insurance and that premiums will be too high for many. But she said she believed the program would attract many buyers: "Our gamble is that we'll have a big enough risk pool."

And, as she has often said in the past, she insisted private insurers would have the opportunity to sell their own policies to wrap around the CLASS benefit, which is expected to be modest. "It is not meant to crowd out private long-term care insurance," she said.  

You hear it all the time: "Medicare will only pay for rehab or personal care as long as you are getting better. If you are no longer improving after, say, a stroke, these benefits will stop."

But according to the Center for Medicare Advocacy, a non-profit patient's rights group, this "improvement standard" may have become ingrained in the care system, but it has no legal basis. "It is" says Vicki Gottlich, a senior attorney with the center, "an urban myth."

The center argues that Medicare must continue to pay for care as long as a patient needs skilled services to maintain their health status. In other words, Medicare should continue to pay for treatment as long as a doctor certifies it will prevent you from getting worse or even help you maintain your functional abilities, not just because it will help you get better.

There is no doubt this improvement requirement is hard-wired among providers such as home care agencies or nursing homes. Even advice columns get it wrong. Here is a typical one. Agencies tell clients all the time that they can no longer provide physical therapy or an aide to help with bathing or dressing because Medicare won't pay any more. If you want that extra care, they say, you'll have to pay for it out of your own pocket. Similarly, nursing homes will stop physical therapy once a physician no longer certifies you are improving. "Medicare won't pay anymore," they will tell you. Once again, they'll say you can still get therapy, but you'll have to pay yourself, and few can afford it. 

Oddly, Gottlich says the Medicare law and even the regulations "are pretty clear." But, somehow, over the years, providers have come to believe that Medicare will cut off patients who are not showing improvement. 

The center is now embarking on a full-blown effort to get Medicare to clarify its rules and make clear to home health agencies and skilled nuring facilites that it will indeed pay for services a patient needs to maintain health status.  

One warning: Even a Medicare clarification won't help if your care is paid by private insurance. Individual policies have their own standards for when they will pay for rehab or home health care, and there is nothing to prevent them from limiting benefits only to those who are improving. So, the usual rules apply: When you buy private insurance, read the fine print.     

The Washington Post came out against the CLASS Act today. In an editorial,The Post wrote this about the proposed national long-term care insurance program:

"There are already enough risks and uncertainties in health reform. Long-term care is an important topic, but it is one that deserves more careful scrutiny than has taken place in the context of the broader health-reform debate."

This editorial is very disappointing. While it rehashed many of the concerns that I and others have raised about premium costs and the number of people likely to participate in the voluntary insurance program, it copped out. Rather than suggesting ways to improve CLASS,  it merely suggested Congress abandon the effort and come back to it another time. Well, thanks.

The Post also failed to note that, despite the flaws of CLASS, allowing people to buy insurance to help cover their long-term care costs would be a vast improvement over the status quo, where middle-class people spend all of their financial assets and then go onto to the welfare-like Medicaid program.  

It would have been far more constructive if The Post could have joined me and others and proposed an alternative. Just saying no at this point in the debate is not helpful to those needing care or those of us caring for our parents. 

The CLASS Act, the proposed national long-term care insurance program, is included in the latest compromise health bill introduced today by Senate Majority Leader Harry Reid (D-Nev.). This version of the bill has now been endorsed by all 60 Senate Democrats, including several, such as Nebraska's Ben Nelson, who had previously vowed to oppose the health measure if it included CLASS.

Another critic, Senate Budget Committee Chair Kent Conrad (D-N.D.), said he was now satisfied the latest version of CLASS would resolve his concerns that CLASS premiums would be used to pay for other provisions of the health bill.

I have not yet seen a copy of Reid's 500-page amendment to the health bill, so don't have any details. But it looks as if CLASS will make it to the next step--a House-Senate conference to resolve the many differences in the overall health bills. Reid hopes the Senate will formally approve his compromise before the Christmas holiday break.     

The politics of the CLASS Act, the proposed voluntary government long-term care insurance program, are getting nastier. Critics have taken to calling it a Ponzi scheme, comparing it to Bernie Madoff, and ripping it as a massive new unfunded government spending program. Senator Joe Lieberman (I-Conn) called it "a whole new entitlement program" which it certainly is not.

I've raised concerns with CLASS myself. And it is true that it could eventually become a new unfunded entitlement. But it is not now, and the danger that it would become one lies with  future congresses, and not with CLASS itself. 

The point, though, is that conservative critics of CLASS are missing a huge opportunity. Instead of trashing CLASS, they ought to be trying to fix it. 

Properly designed, CLASS can be a be a huge benefit to the frail elderly, adults with disabilities, and their families. Deficit hawks worry that the government would spend hundeds of billions of dollars to provide long-term care if CLASS passes. What they forget is that Medicaid already spends more than $100 billion a year on this care, and as the Baby Boomers age, that amount will explode.  

It is far better to replace most of those welfare-like Medicaid benefits with a self-funded insurance program whose reserves are fully insulated from the rest of the budget. Doing that would take some tinkering, but there is nothing in the basic structure of CLASS that precludes such adjustments. 

CLASS is a huge opportunity for deficit hawks.  It would be a real shame if they blow it.    

When I was caring for my parents, I thought what I was doing was both the hardest thing I had ever done and the most rewarding. Now, an important new study suggests I was not alone.

The study, called Caregiving in the U.S., is an important snapshot of what life is like for those providing assistance to aging parents, as well as young adults and children with disabilities. The study concludes that a staggering 65 million Americans are providing some assistance to their loved ones. About 17 million are caring for special needs children. The rest--nearly 50 million-- are helping the frail elderly or adults with disabilities.  

Who are these caregivers? Keep this picture in your mind: A 48-year old woman caring for her elderly mother. She is trying to hold down a job even as she spends about 20 hours a week helping her mom, something she's been doing for four years. There is a good chance she is taking time off work to help her mother with transportation, shopping, managing finances, taking medications, and even getting in and out of bed. 

She is getting help when she can from other family members and friends. About 40 percent rely on paid aides for some help, although that's significantly fewer than in 2004, the last time the survey was done. And about 40 percent feel their caregiving puts a "high burden" on them. 

Among those caring for someone 50 and older, the picture is a bit different. Caregivers are older--more than half are over 50 themselves. They are, typically, helping a 77-year-old widow who is living in her own home and who may be suffering from dementia.

The study was done by the National Alliance for Caregiving along with AARP, and funded by the MetLife Foundation. It follows similar studies published in 1997 and 2004. Read it.