I spent the morning in Westchester with my mom. Once a week, my mom helps out a woman that she used to know in the Bronx. My mom pays her bills, fills out all her paperwork, drives her to doctors' appointments, and listens to the woman's woes. Since this woman has no family of her own, my mom has been burdened with this job, which is stressful and thankless. Without my mom's help, this woman would have died penniless in an old age home that over medicates its patients.
This isn't the only old woman that my mom helps out. This is a rant for another day. There are lots of people out there, who are ignored by their children and by their neighbors.
This woman is suffering from bone cancer and from Parkinson's disease. She is immobile, unable to walk or even turn her head. She requires 24 hours care. Medicare and her insurance cover nearly all of her medical expenses; she is a retired NYC school teacher with excellent benefits. However, it doesn't paid for her aides, who cost her $3,000 per week. This woman pinched pennies her whole life and now her life's savings is being spent on medical care.
What's the alternative to in-home aides? Medicare covers three months in one of those death trap, old-age homes, and that is what lots of old people do. Their insurance pays for three months, and after that, it's out of their pocket. They have to spend all of their savings, sell their house, and have basically not a cent to their name before Medicaid kicks in and starts paying for the old-age homes.
You know what goes on those places? Let me just say, you should be very, very nice to your kids.
Apt. 11d 
What is she supposed to be spending her hard earned savings on (if not a home health care aide)? It’s terrible, of course, that she’s sick. I’m sure that we’d all rather spend our old age spending our life savings on exotic vacations. But if she’s sick, she’s not going to do that anyway. So what’s the problem with spending on something else that makes her life better, like an aide?
I think the question of what happens when the money runs out is a more perplexing one.
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Another way to think of the same question is, “Who is supposed to be paying for this, if not her?” I mean, that’s the point of saving for your retirement: to not be a burden on others, to continue to be mostly self-supporting even though you’re not working.
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I recently had a discussion with a contemporary (we’re both in our mid-fifties) about how to care for our aging mothers. Both of them were about to enter nursing homes. He was trying to figure out how to safeguard his mother’s assets and make her eligible for Medicaid immediately. I was concerned with laddering my mother’s CD’s in order to pay for her care in a timely manner. When I asked him where his mother’s assets were going since it wasn’t going for her care, he replied, “It’s going to me and my brother”.
Shouldn’t an elderly person’s assets be used during their lifetime for their care?
KarenM in NC
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Interesting discussion. My uncle had a benign brain tumor which was operated on last year. Medicare and his supplemental insurance paid for a couple of months in a nice nursing home and then he got kicked out (for not making enough “progress” in physical therapy).
My aunt took him to Brazil where he stayed at my parents’ house for two months and three months at his sister-in-law. They paid about 500 dollars a month for a physical therapist to work with him every day and he improved quite a lot. And obviously aides in Brazil can be found for a modest price too. Uncle is coming back home next week and we don’t know what’s going to happen to him. My aunt will probably spend everything they have to have people caring for him during the day while she works. The problem is that he isn’t elderly, he’s just 68 or 9, I think, and on Medicare, which doesn’t cover anything that would help him in his recovery (therapy). I’m just wondering whether my aunt will have to use every last penny they have or will ever had to pay for his care…
Regardless of who pays for what, health care is deeply messed up in this country, that’s for sure.
Oh, and I cannot imagine what happens in those old people houses. Shudder.
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“I recently had a discussion with a contemporary (we’re both in our mid-fifties) about how to care for our aging mothers. Both of them were about to enter nursing homes. He was trying to figure out how to safeguard his mother’s assets and make her eligible for Medicaid immediately. I was concerned with laddering my mother’s CD’s in order to pay for her care in a timely manner. When I asked him where his mother’s assets were going since it wasn’t going for her care, he replied, “It’s going to me and my brother”.”
I think this guy’s attitude is very typical. I’ve heard people discuss this sort of evasive asset transfer in person, and I’ve heard Dave Ramsey field this question on the radio several times. Depending on how they go about doing it, it’s potentially fraud, but people don’t think of it that way. (And by the way, I believe that you don’t have to be absolutely destitute to qualify for a Medicaid nursing home. I was just looking at an NJ lawyer’s website, and there was something about being allowed to keep $500,000 in home equity. I’m not sure if that’s correct or how they treat income and other assets or how things work in NY, but it sounds like it’s worth poking around some more and maybe consulting a lawyer.)
Anecdotally, a lot of adult American sons stink at taking care of infirm parents. That makes me wonder about how well the traditional Asian boy-preference works as a life strategy (sons being expected to take care of elderly parents), but it has been in place for thousands of years now, so it must work to some extent.
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Another way to think of the same question is, “Who is supposed to be paying for this, if not her?” I mean, that’s the point of saving for your retirement: to not be a burden on others, to continue to be mostly self-supporting even though you’re not working.
So…all that good-faith effort she demonstrated throughout her life…doing all the right things, getting an education, working, saving up….all that should basically count for nothing because the income that she earned wasn’t sufficient to cover her healthcare expenses in old age? Why doesn’t she just up and die already, because she is no (longer) any economic benefit to anyone else?
Just another broken tool?
Shit like this makes me angry. Why are people assigned the tag of “burden”, as if the burdens they’ve shouldered for others (retired schoolteacher, so you can’t say she wasn’t shouldering a metric fuckton of burdens) don’t mean a damn thing?
I read shit like this, and I think: fuck it. Let the human race die off. Let the cockroaches take over. They seem to have more compassion.
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That makes me wonder about how well the traditional Asian boy-preference works as a life strategy (sons being expected to take care of elderly parents)…
I believe the system worked only because of extremely put-upon daughters in-law who didn’t have much choice in the matter.
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I remember listening to my parents in a conversation with someone in Karen Moeller’s contemporary’s position. Afterwards, I expressed a teenager’s outrage that this person’s relative’s assets would all end up going to the nursing home. I remember them quietly explaining to me that “it’s no shame to pay for what you receive”.
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“So…all that good-faith effort she demonstrated throughout her life…doing all the right things, getting an education, working, saving up….all that should basically count for nothing because the income that she earned wasn’t sufficient to cover her healthcare expenses in old age? Why doesn’t she just up and die already, because she is no (longer) any economic benefit to anyone else?”
I think what we mean is that people ought to have spent down their resources before becoming a public charge.
Here’s an explanation of Medicaid policy:
http://www.seniormag.com/legal/medicaid_nursing_home_planning.htm
“With regard to the asset criteria, a single individual living in a nursing home is only permitted to have $2,000 in assets. A married couple living in a nursing home is only permitted to have $3,000 in assets.
“If an individual is living in a nursing home and has a spouse living in the community (not living in a nursing home), the individual is permitted to own $2,000 in assets and the spouse living in the community is permitted to own $89,280 in assets.
“In addition to these asset limits, an individual may retain exempt assets such as a residence, one automobile, personal property and household furnishings and pre-need burial arrangements and burial plots.”
It sounds basically reasonable, although I think that they should allow larger cash assets as an alternative to the house exemption. There are also probably somewhat different rules in each state, particularly for exempt home value.
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Amy: That makes me wonder about how well the traditional Asian boy-preference works as a life strategy (sons being expected to take care of elderly parents)…
MH: I believe the system worked only because of extremely put-upon daughters in-law who didn’t have much choice in the matter.
From my observations in South Korea twenty years ago–which may mean nothing today, given the rapid pace of change in SK–the strong Confucian ethic of taking care of one’s parents in their old age didn’t rest entirely upon first-born sons (who then place the burden upon their wives); there was a whole informal network of social assumptions and resources in place, reflected in living patterns, working hours, and more. Absolutely, that old (and, back in the late 80s at least, still quite functional) ethic probably wouldn’t be able to survive Korean women entering the work force at the level they do in Western states. But it’s not, in my observation, daughters-in-law doing all the heavy lifting entirely on their own.
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I’m getting a crash course on eldercare, so forgive my naive observations. I’m still just shocked that services that are clearly medical related aren’t covered by medical insurance. A nursing home costs something like $17,000 per month. Some of those costs are related to food and shelter, which should be the responsible of the individual. But most of the costs are related to having doctors and nurses on staff. Shouldn’t that be covered by medical insurance?
Also, this system benefits those who have the resources to hide their assets. If you are saavy and get a good attorney, then you start giving away all of your possessions before the dementia sets in. Mom said that legally you have to do it three years before you need those services. Also, I believe that those who know the system place themselves in the best possible nursing home from the beginning and then when the money runs out, the Medicaid has to keep paying for the good nursing home. They can’t ship you out to lesser nursing home.
This whole thing seems so totally weird and inefficient and inequitable to me. Certain sectors have to be raking in tons of money from this. Is there any oversight?
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Ben. I’m not expressing a teenager’s outrage. This is the outrage of a grown woman who has and is fulfilling her part of the social contract….and who knows that it isn’t going to be enough.
It’s a human outrage; anger that a lifetime of pay-it-forward goes unrecognized.
It’s very telling that no matter what company you’re in, when the subject of nursing homes comes up, the conclusion is universal—no one wants to end up there. It’s not just a “bad place to be”. It’s….refugee camps for the elderly, complete with abuse. “Substandard” isn’t a strong enough word to describe the “what you receive” that you’re supposed to be ashamed for not be able to pay.
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“This whole thing seems so totally weird and inefficient and inequitable to me.”
Is there any government program that doesn’t have hundreds of loopholes, special rules, gamesmanship etc.? I’m surprised that a former New Yorker like our hostess can still get shocked by that. Obviously, the more the government gets involved in health care and elder care, the more weird and inefficient and inequitable it gets.
In the case of the woman in question, I don’t understand the outrage that she should have to spend down her assets before qualifying for Medicaid. She has no family. What would be the social benefit of letting her keep assets so they can either escheat to the state or pass to some distant grandnephew on her death?
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Yes, I get the outrage over the condition of nursing homes, but I don’t see why those with money shouldn’t be expected to use it for their medical care.
As for what is covered by Medicare and Medicaid, I’m not much aware of the issues of elder care, but I did used to know how those rules worked for those disabled by mental illness. Like most things that big, nobody can ever sit down and say what makes sense or is efficient and more than somebody could sit down in NYC and say “The city would work much better if we completely re-did the street layout.”
So, you had a tradition of states building hospitals for those with serious MI and the feds said, “You already do that, so we won’t cover it.” And, 60 years later, you have people with schizophrenia making life hard for the elderly because the state of whatever saved $600/day by putting people who should be in a mental hospital in a nursing home.
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s/b “any more than somebody could sit down in NYC”
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“Also, this system benefits those who have the resources to hide their assets. If you are saavy and get a good attorney, then you start giving away all of your possessions before the dementia sets in. Mom said that legally you have to do it three years before you need those services.”
I don’t think it’s necessarily savvy–from my observations, moving the assets around and hiding them is actually the first impulse of people who aren’t savvy at all. It’s conventional wisdom.
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Obviously, the more the government gets involved in health care and elder care, the more weird and inefficient and inequitable it gets.
Yes, which is why the rest of the world, hoping to catch up with America on issues of equity, is clamouring to adopt privatised health and elder care.
More seriously, and to a small degree, some countries have turned to a type of outsourcing, albeit not for those in the very worst health. Norway, for example, gives some people in care homes the option of spending their winters in care homes in Spain, where staff are cheaper and the sun actually, you know, shines sometimes. (And where there’s not so much internal demand yet for care homes, because of cultural norms.)
The “logical” extreme of such an approach might be to ship (literally) the unhealthy elderly to countries where care is cheap. I should say that I’m not in favour of such an extreme approach, but it would address the economic issue – while raising loads of others.
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Reuben,
We have our own cheap, sunny Spain–Florida, Arizona, Nevada, etc. And those states are getting cheaper all the time.
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But nothing in one’s own country (or monetary zone, in the case of the euro) will ever be freakishly cheaper — i.e. cheap enough to make quality long-term care financially feasible for the numbers who will need it. Even for exploited immigrants, Baumol sees to that. You need places where individual workers will do a good job for 10 bucks a day, not places where the site managers are cutting every possible staffing corner because that’s the only way they can make a profit.
And not places where only the most disadvantaged decile does the care work.
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I just watched an old man lose the job he loved and has held 30 years. If he wasn’t a senator, it would have been sad.
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These aren’t medical expenses. They’re nursing expenses, in the old-fashioned sense of meeting someone’s basic physical needs.
Good carers are very hard to find. My mother had a hard time finding day nurses for her father, even working with a reputable placement agency, and being willing to pay the going rate. The supply of good nurses were, and still are, outstripped by demand.
It’s the same debate as the child care question, as the question becomes, can the marketplace, or government, replace the family? While those who want to buy the services of a nanny or senior care worker want to pay the lowest wage possible, the good nannies and workers command much higher salaries from those able to pay.
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With the frail and confused elderly, there’s also the issue of theft by caregivers, both old-fashioned theft and identity theft.
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“It’s the same debate as the child care question, as the question becomes, can the marketplace, or government, replace the family? ”
no, of course.
But,
“more the government gets involved in health care and elder care, the more weird and inefficient and inequitable it gets.”
I’ll agree with weird, but not necessarily more inefficient, and definitely not more inequitable. I’ve had arguments for years with people who seem to think that using money as the method of allocating all resources is somehow the perfect method. I do agree that it has tremendous efficiency, because it allows everyone to convert their wishes into an exchangeable currency, and then exchange the currency, rather than, say trying to figure out how much my wish for 3 bedrooms compares against your wish for high ceilings in trading our houses (inefficient if we try to do it ourselves, and weird when the government decides to do it by coming up with guesses about what should be worth what).
But given that people start with vastly different amounts of the common currency, and then use those differing amounts to obtain vastly different amounts, the idea that the system is equitable (in whatever sense we want to define) has never made any sense whatsoever to me.
Why would it be equitable for a n’er do well who inherited vast amounts of wealth to spend their dying days in the comfort of their home, while our hard working school teacher had to be warehoused in a substandard facility? What’s “equitable” about that?
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Yes, but I’ve seen newspaper reports of family members exploiting the elderly. “Caregivers” includes family.
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We must have posted at the same instant! I was replying to Amy P.
[i]Why would it be equitable for a n’er do well who inherited vast amounts of wealth to spend their dying days in the comfort of their home, while our hard working school teacher had to be warehoused in a substandard facility? What’s “equitable” about that?[/i]
The chances of a n’er do well not spending a vast inheritance are minimal. Given the modern tendency of n’er do wells to, er, self-medicate with thrilling substances, the chances of a n’er do well surviving to be wealthy in extreme old age are even more minimal. There are far more school teachers to be found in nursing homes. On the other hand, school teachers have better pensions, on the whole, than many other workers.
I still haven’t heard a good argument defending the heirs’ inheritance.
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“our hard working school teacher had to be warehoused in a substandard facility? What’s “equitable” about that?”
Let us be clear. If you are elderly, infirm, incompetent, impoverished, and have no family, you are going to be “warehoused.” There is no cure for that. The only thing that makes life worth living, i.e., people who care about you for your own sake, doesn’t exist: your friends are dead or similarly incompetent, we have specified that you have no family, you don’t have enough money such that people will come around and pretend to care, and the supply of saintly volunteers isn’t adequate to the demand.
That being said, I presume we could all agree that such people should not be warehoused in a “substandard” facility. And then we can debate whether the optimal use of social resources is to try to maintain such people in their homes, at public expense, versus educating children, raising the pay of adjunct faculty, curing malaria in Africa, etc.
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One of the reasons that we moved this woman out of the nursing home and back into her home was because it was cheaper. I have no idea what the nursing home was doing with all that money.
Also, the nursing home was over medicating the old people and propping them up in wheel chairs to drool in the lobby of the building.
She’s getting healthier, because she is in her beloved home, even though she can no go up the stairs. She even started walking a little bit again. Those nursing homes are death traps. The problem is that she’s running out of money. We’ll do a reverse mortgage on her home, but if she keeps getting stronger, then we’re looking at a whole different set of concerns.
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I don’t know. I used to work in a NGO that provided non-profit senior care and housing. I worked with people who were really actually passionate about providing a good place for people who were experiencing aging and end-of-life issues.
I’ve seen good long-term care facilities, both for family and when I was at the NGO (10+ yrs ago). Places I would be okay ending up. A couple of them were culture-specific.
Some of these offered things that people really had a hard time accessing from home, not just in terms of medical services but in terms of ease of use, like social groups or shopping trips or whatever. And then when you got into issues like dementia, sometimes having the right equipment and security makes a huge difference in how someone is treated. If the client can wander a safe wing easily it may be higher quality of living than having to be kept safe at home.
I find it really interesting that on this thread the assumption is that all nursing homes are lousy. For sure there are lousy ones. But my experience is that that’s only part of the reality out there.
My parents are pretty adament that they want to be in supportive housing and home when the time comes (they have picked their spots) but expect to be visited often. 🙂 I’m not sure this will last and we’ll deal with it as we go but their feeling is that they would rather have one-stop shopping than be cobbling together services that may or may not connect up.
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If living at home with a health care aide is cheaper than living in a nursing home, and that is what the woman wants, it is obviously the better option. As I read Amy P.’s comment, this woman will be eligible for Medicaid once she has exhausted her cash assets, and will not be required to sell her house. At that point, she will have (i) a home, (ii) social security and maybe a pension to pay living expenses, (iii) Medicare and insurance to pay medical expenses and (iv) Medicaid to pay nursing expenses. All of which sounds pretty workable. We will have to agree to disagree on whether the lack of a cash inheritance for the nieces and nephews is an injustice.
If it turns out that Medicaid pays for a nursing home care but not home health aides, then that is on its face weird, illogical and inefficient, but not worse in that regard than the tax code, the rent stabilization law, etc. I don’t know what the rules are on this point.
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Medicare doesn’t pay for a home health care aide. My dad is paralyzed and bedridden (and only 66, ftr), and neither his insurance company (very good NY state public employee health insurance) nor Medicare pay for a home health care aide, thus leaving my mother bound to the house as much as he is. Medicare did pay for a Hoveround wheelchair, though.
Don’t get me started on all this. My FIL is in a nursing home and was in assisted living. He couldn’t stay home by himself. We tried it and he ended up having a psychotic episode in the bathroom and it was 4 days before anyone realized. At least when he had a pulmonary embolism in the bathroom at assisted living, someone found him within hours.
We’re also doing asset transfers, which causes me some guilt, but really, his assets are still significant enough to pay for his care another 5+ years, and I don’t think he has that long.
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“We’re also doing asset transfers, which causes me some guilt, but really, his assets are still significant enough to pay for his care another 5+ years, and I don’t think he has that long. ”
But, you’re only doing this so that he would be eligible for medicaid if his money did run out (and which it will do now, earlier, because of the asset transfers).
I’m not trying to induce guilt — I think people only have an obligation to behave within the law on this question (and on jingle mail), and that trying to guilt some subgroup of people into not doing so has the perverse effect of selecting for the less moral among us.
But, I think we have to be aware of the ways in which people work the system to obtain the maximum government benefits when we think about the programs. I feel similarly about special needs trusts that try to supplement what is provided by government benefits.
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I guess I’m still baffled and stuck on the point about why medical care isn’t covered by health insurance. An in-house aide or nurses in a nursing home would seem to fall into the category of health care to me.
If this former teacher wants to remain in her home – a cheaper and healthier option for herself – she has to exhaust all her resources. If she goes into a nursing home, she gets to keep the house. That’s crazy.
An old person must spend (or give away) all his money before the government steps in. The government ultimately takes care of its old people, but not before they give all their money to private companies to keep them alive. That’s a huge transfer of wealth to private medical and eldercare industry.
It’s good to hear several anecdotes about nice nursing homes.
As our population get greyer, individuals like my mom grow fewer and fewer, and as health care gets more expensive, we’re going to be talking about this a lot more.
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It is possible to buy long term care insurance that covers in-home care:
http://www.kiplinger.com/columns/ask/archive/2009/q0625.htm
I’m not totally clear on how expensive this form of insurance is, although I’ve seen recommendations that people should buy it between 60 and 65 years of age. Interestingly, the Kiplinger article says that the average nursing home stay is under three years.
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I’m with La Lubu. That is all.
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“That’s a huge transfer of wealth to private medical and eldercare industry.”
Huh? The industry gets paid the same either way. The only question is, should working families pay more in taxes now so that the elderly can leave bigger inheritances? Or does it make sense to require elderly individuals to exhaust their wealth before providing charity care? Either procedure represents a “huge transfer of wealth” from someone. I vote for taking it from other people’s inheritances, not from my paycheck.
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The “sons as old-age insurance” system in China, Korea and other Asian countries worked not only because of compliant daughters-in-law and other family, but because not very many people lived to be very old. This is what is unique about the 21st century and that has never been addressed adequately.
People are living longer, with conditions that would have killed them just 20 years ago. Like the woman Laura talks about – as old and sick as she is, would she even be alive now in any other era?
The whole social contract – not just individual families and Good Samaritans – is going to have to be rewritten to take all these frail elderly into account.
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I don’t know why I’m posting this, other than that it’s slightly relevant, but my FIL happened to pass away this morning. My husband and I were with him at the end. The people at the nursing home were pretty nice though obviously overworked.
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Very sorry to hear that.
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I’m really sorry, Wendy. Best wishes to you and your family.
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Best wishes, Wendy.
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