Map of life expectancy at birth from Global Education Project.

Wednesday, January 14, 2009

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.


kathy a. said...

we cared for my grandmother the last 6.5 years of her life, when she was mostly bedridden and also had dementia. things went pretty much as you described: we started with assisted living, but her physical and mental challenges required more care; we got her into a rest home before her money ran out; and there she stayed. it was not a great rest home, but there were no better options when we needed a place, and finding a new one later was next to impossible.

my stepfather is 86 and reasonably healthy, except for the dementia. he has 24/7 caretakers in his home, and fortunately can afford that sensible and humane solution for the foreseeable future. [it costs less than a nursing home, and it is a huge boon to be in familiar surroundings. making that option available to more people would be great.]

the dementia problem in our family that really scares me involves my sister-in-law, who is only 50. she cannot work, cannot make reasonable decisions, and could easily live another 30 years. between her relative youth and her very challenging personality, there aren't any great solutions.

robin andrea said...

My sister and I were chatting about our mom's situation yesterday. Mom is going to look at senior facilities near my sister today, places where meals are served twice a day, where she'll have social contact and be assisted if necessary. The cost for these places is incredibly high. My sister wrote that she'd never be able to afford a place like that for herself when the time comes. She said "a bullet will be looking pretty good to me about then." We had a good, macabre laugh about it, but we knew it wasn't that farfetched. Sure would be nice if we lived in a society that really focused on quality of life issues.

Whining Procrastinator said...

I'm very sorry to hear about your father, and I don't just mean about his death.

Most, if not all, of the states have some kind of homecare program for their elderly population. Here's a link to the State of Connecticut's Homecare Program for Elders.

The documentation there doesn't give you much, but I would like to explain that some of that money is Medicaid money - if you're poor enough to go onto Medicaid, Medicaid will pay for medical services to keep you home. There are some newer programs that wouldn't have been available when your father became unmanageable. I'm sure you realize that this is all a work in progress for the government.

There is even a federal attempt to get people of all ages out of nursing homes. (Named Money Follows the Person) If you qualify for a federal waiver program (Medicaid), you have one year to spend as much money as it costs to keep you in a nursing home to stay in your home. At the end of that time, the cost of your needs has to be within the amount allowed by an existing waiver homecare program.

I would strongly suggest that anyone looking for assisted living facilities or nursing home care should contact their local Department of Social Services and ask about options for staying in their home. Homecare is the obvious way to cut down on nursing home costs, and in the last few years our government (state and federal) has begun to create programs to take advantage of that option.

Anonymous said...

In Texas, Medicaid pays for home health aides to assist with daily
living for a various number of
hours. It also pays for transportation to doctors, in=home
nurses visits, limited physical
therapy, and adult day care. Medicare will pay for
hospice in-home or nursing homes for any terminal patient. So some
states do cover inhome care for
Medicaid recipients.