Abstract
More than 250 million Americans—more than 80 percent of us— have health coverage, usually through employers or Medicare, Howard Gleckman points out in a USA Today commentary. By contrast, just 7 million have long-term care insurance. That, it seems, is the real crisis of the uninsured.
What about long-term care?
USA Today, May 26, 2009
By Howard Gleckman
Natalie Fenninger did everything right. She worked hard as a secretary in churches and libraries, lived modestly and saved. Her husbands — she outlived three, to her amazement — were also careful savers. So when Natalie fell ill while in her mid-80s, she had a nest egg of well over a half a million dollars, the envy of most Americans.
As she aged, Natalie suffered from an unusual brain disease that causes temporary amnesia, as well as a series of small strokes. She rarely needed a doctor's care and would live with her chronic illnesses for many years, but she could not take care of herself. Like 10 million other Americans, Natalie needed assistance to maintain her best possible quality of life — help getting in and out of bed, dressing and going to the bathroom.
That care is tremendously expensive — a nursing home stay costs an average of about $75,000 per year, and home health aides cost $20 per hour. So it was no surprise that months before she died, Natalie ran out of money and went on Medicaid. While this government program was created to provide health care for poor mothers and their children, it has become the nation's biggest payer of long-term supports and services for those with disabilities and the frail elderly.
Natalie spent her last months in a nursing home, impoverished, and sharing a tiny room with a stranger.
Universal long-term care
Today, as Congress debates the biggest changes in health care policy since the 1960s, it has a once-in-a-generation opportunity to remake the way we deliver and pay for long-term care. With the right reforms, what happened to Natalie won't have to happen again.
Congress and President Obama could create a system of universal long-term care insurance, built on a combination of public and private coverage. They could end the reliance of millions on the welfare-like Medicaid system while reducing the tremendous pressure that program is putting on both state and federal budgets. And, they could further shift the focus of long-term assistance to community care instead of nursing facilities.
But sadly, there is a real risk that millions of the frail elderly and disabled like Natalie will be forgotten. While lawmakers are focused on expanding insurance to cover acute care — such as visits to doctors and hospitals — they are largely ignoring those chronically ill who need mostly personal assistance rather than high-tech medicine.
This is how strange the system is: If you are 65 or older and suffer a heart attack, Medicare will spend tens of thousands of dollars to perform life-saving surgery. But if you are living with congestive heart failure — among the most common diseases of the elderly — you are largely on your own. That's because there is no aggressive treatment for most heart failure patients. More than anything, they need help getting through the day. And Medicare won't pay for that.
It is the same for those with Alzheimer's or Parkinson's, and for younger people with disabilities who might be living with diseases such as multiple sclerosis, or with traumatic brain or spinal chord injuries. Unless they are impoverished and eligible for Medicaid, they get little government help.
Medicare pays for limited nursing care, but not for long-term services, even though many Americans are convinced that it does. Similarly, most health insurance, including Medicare supplement insurance (Medigap), will not pay for this care.
Private long-term care insurance does cover these services. But few Americans own such policies, which are expensive, complicated and hard to buy if you are already ill. A 65-year-old can easily pay $3,000 annually for good coverage.
Lawmakers often talk about the crisis of the uninsured in America. And it is true that more than 40 million of us have no medical insurance. But more than 250 million Americans — more than 80% of us — do have health coverage, usually through employers or Medicare.
By contrast, just 7 million have long-term care insurance. That, it seems, is the real crisis of the uninsured.
We spend more than $230 billion annually on paid long-term services,even though most care is provided informally by family members and friends. And those who help their loved ones in this way often pay a horrific financial, emotional and physical price.
What will we do when the Baby Boomers start needing this care over the next few decades? As 77 million Boomers reach old age, today's challenges will become a full-blown crisis.
What to do?
There are solutions. Sen. Edward Kennedy, D-Mass., and Rep. Frank Pallone, D-N.J., propose having the government provide long-term care insurance, similar to what Germany has been doing successfully for a decade. While Kennedy and Pallone don't estimate the premium cost, it would probably be close to $100 per month.
Leonard Burman and Richard Johnson of the Urban Institute propose paying for such care directly through Medicare. William Galston of the Brookings Institution suggests that every American buy mandatory private insurance.
Sadly, despite Kennedy's enthusiasm, Obama and many congressional leaders seem reluctant to include major long-term care reform in any health overhaul. It will be a tragedy if they miss this opportunity.
Howard Gleckman is the author of Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America's Most Urgent Health Crisis. He is a senior research associate at the Urban Institute and a frequent writer and speaker on elder care issues.
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