In my Tuesday post, I basked in the glory of Hartford grantees who were influential in shaping reform of the health care delivery system. It is only by making real changes in what health care professionals ultimately *DO* to treat disease and promote health that we can simultaneously improve older Americans’ health while conserving our health care resources.

But enough basking.

As those who have followed the Foundation’s work know, the bulk of our funding in the last 20 years has gone into preparing the workforce in the health professions (medicine, nursing, and social work) to provide appropriate care for older adults. To do this, we have supported faculty careers, curricular innovation, and geriatric competency development. Things are better than they were, but this work is not complete.

Sadly, by all the measures we can find, the majority of today’s health care providers are still fundamentally incompetent in caring for their older patients. They do not understand the altered presentation of disease, they do not adequately appreciate the need to modify treatment plans in the face of co-occurring health conditions, and they are unaware of the importance of attending to “geriatric syndromes” such as falls, incontinence, or depression. As we have recounted from our personal experiences on Health AGEnda (see here and here), our older relatives have been forced into the hospital by professionals who made rudimentary mistakes with routine prescriptions or failed to reconcile standard medications at hospital discharge. Distinguishing between delirium and dementia still seems beyond some doctors and nurses.

This is why I am very frustrated by the lack of attention and funding for geriatric care competence in the workforce provisions of the health reform legislation passed by the House on Sunday night.

Don’t misunderstand me. The Patient Protection and Affordable Care Act (HR 3590) includes some useful workforce provisions, and I am proud of the efforts of the Eldercare Workforce Alliance to get them into the bill and keep them there.

Here are summaries of some of the key provisions in the bill:

  • Sec. 5302. Training opportunities for direct care workers. Authorizes funding over three years to establish new training opportunities for direct care workers providing long-term care services and supports. (Full text available here.)
  • Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education. Authorizes funding to geriatric education centers to support training in geriatrics, chronic care management, and long-term care for faculty in health professions schools and family caregivers; develop curricula and best practices in geriatrics; expand the geriatric career awards to advanced practice nurses, clinical social workers, pharmacists, and psychologists; and establish traineeships for individuals who are preparing for advanced education nursing degrees in geriatric nursing. (Full text available here.)

All told, this is $30.8 million in suggested appropriations over five years for a substantially expanded mission. For most people, whose household budgets run in thousands rather than billions of dollars, $30.8 million might sound like a lot. However, it’s pocket change for the federal government. Moreover, actual appropriations may vary.

By contrast, consider section 5203, Health Care Workforce Loan Repayment Programs. This section amends section 775 of the Public Health Service Act, Investment In Tomorrow’s Pediatric Health Care Workforce, with real money. This loan repayment program is slated to be funded at $30 million PER YEAR over five years for non–mental health pediatrics professionals and $20 million PER YEAR over four years for pediatrics mental health professionals. All told, this is $230 million over five years, nearly five times the funding for geriatrics health professions.

I love my three children (12, 9, and 5), and I appreciate the need for skilled health care professionals at the first stages of life. However, I also love my parents in their mid-seventies and my mother-in-law in her eighties, and I know who is more at a disadvantage in getting skilled care.

Am I missing something, or are we still gearing up to meeting the health care needs of the 1950s and 60s at the beginning of the baby boom, rather than the health workforce needs of the 2010s and the 2020s? We all need to face the fact that soon there will be nearly as many Americans over age 65 as under 18. How can it be that loan repayment for pediatric specialists is such a priority while loan repayment for geriatric specialists (or even generalist physicians trained in chronic disease care and geriatrics) is not? What am I missing?