Some feeble reflections

First of all, thanks to all for the condolences and good wishes. I suspect that long-time readers may have figured out the situation -- that my father had progressive dementia. It was a terribly long process, and his death I'm sad to say really came too late. But it's a relief that it has finally happened.

I have not written a great deal about the problems of long term care and the related issue of the growing prevalence of dementia. That is essentially because I haven't felt I had much to say that was in any way original or profound. There are some policy reforms that would ameliorate this problem to some extent, but there is no real policy solution. It's going to be a great burden on families and on society, part of the price we pay for increased longevity, unless we come up with some technical fixes to prevent or greatly slow the progress of dementia.

As for policy reforms, there is certainly a justice case to be made for socializing the cost of long-term care by expanding Medicare benefits to cover it. As you probably already know, the family has to spend down to near penury, whereupon Medicaid takes over. The quality of Medicaid financed care varies from state to state. Fortunately, in Connecticut, the benefits are sufficient to pay for good quality care, although you have to be lucky enough -- as my family was -- to find a good nursing home. And the only way to do that is for the person to enter the nursing home as a private payer. The good ones won't accept Medicaid patients, although they will let the person stay once they make the transfer.

My parents had a decent nest egg, but it was completely wiped out, as happens to just about everybody in their situation. It takes true wealth to survive four or five years of custodial care. Expanding Medicare to cover this means that everybody will pay more in taxes, but we'll be buying insurance against this catastrophe. It would also end the discrimination against low and moderate income people who must depend on Medicaid and who often end up in situations that we should not tolerate.

However, the most logical existing structure through which to do that would be Medicare Part A, which is financed by a regressive payroll tax. There is nothing unethical, in my view, about requiring all workers to take on a fair share of the burden of caring for their elders, but such a system ought to have progressive financing. And I'm afraid that right now, it just isn't politically viable. Everybody is screaming and yelling that the cost of Medicare is already unsupportable and has to be reduced. To stand up and say, no, we have to raise taxes and expand Medicare is probably feckless. But listen up folks, we're going to pay for it, one way or another.

There are some additional advantages that could come with an expansion of Medicare. It could pay for home based services and adult day care programs, which most people would likely prefer as long they were a viable option; and then for assisted living rather than nursing care. More use of these kinds of services would reduce overall costs. Right now, some people are forced to accept nursing home placement prematurely because that's the only modality Medicaid will pay for.

Sadly, though, this is not going to happen any time soon. In the current discussion of health care reform, it's not even a footnote.