April 2009 Archives

I heard a great presentation this morning by Shawn Bloom of the National PACE Association on how goverment tries to coordinate care for those elderly who are both frail and very poor--among the most at-risk people in the country.

PACE is an innovative program that is geared to seniors still living at home. It combines adult day services with medical care and other assistance. PACE so unusual because it is jointly financed by both Medicare, the federal health program for seniors, and Medicaid, the state/federal health program for the poor. This is a lot more complicated than it seems and, because the two program often work so badly together, the more than 7 million frail and poor elderly who are not in programs like PACE often get very poor care.

Here is the problem: Most of these seniors suffer from multiple chronic conditions. They may have heart failure, diabetes, arthritis, and perhaps some dementia. Health experts agree they desparately need someone to coordinate their care, including both medical treatment and non-medical services, such as transportation, housing, and meals. Without this full package, they will almost certainly lose their ability to stay at home.  

Success for these patients often means keeping them out of the hospital. And that's the problem. Because of the crazy way Medicare and Medicaid work--an artifact of a backroom political deal made in the early 1960s--it is easy for these seniors to fall through the cracks.

Take a heart failure patient. When her medications are not working properly, she is very likely to have trouble breathing and, inevitably, will end up in the hospital emergency room. This can be easily prevented by a skilled health aide, who can identify early warning signs simply by checking to see if the patient is gaining weight--a dead giveaway that trouble is ahead. 

But building a system of coordinated care can be expensive, and it usually falls to the state Medicaid program. But because it is Medicare, not Medicaid, that would pay for her visit the emergency room, it is Medicare that receives the financial benefit of keeping her out of the ER.

So states are reluctant to commit to PACE and programs like it. Once, governors talked about a grand bargain: They would turn care of the frail elderly and disabled adults over to the federal government while keeping responsibility for poor mothers and their children. But Washington is not likely to accept such a deal.

Millions of sick and low-income seniors are caught in the middle. Many were once middle-class people who have spent through their assets and now find themselves in these government programs. They deserve better.    

The OECD has just published an interesting new study that shows the long-term care workforce crisis is not just an American problem. Major developed countries all around the world are struggling to find enough qualified workers to care for their growing populations of frail elderly.

The problem in the U.S. is becoming a crisis. We pay home care workers an average of just $9.50-an-hour, often less than we pay the kid at the car wash. Aides rarely get health or retirement benefits or paid vacation days, and they are more likely to be injured on the job than coal miners. And the problem is not just with aides. More skilled professionals, such as geriatricians or geriatric nurses, are leaving their professions faster than they can be replaced.

It turns out, according to the OECD study, that this a problem throughout the developed world. Even countries like Germany that have created a strong system for financing long-term care struggle to find the workers they need to deliver this assistance. Pay is frequently as poor in Europe as it is here and, interestingly, the use of foreign-born workers is increasing there just as it is here.   

As commited as we are to caring for our parents, we can't do it without assistance, and unless we are willing to provide aides with better pay and benefits, getting that help is going to be more and more difficult.    

Having to pay for long-term care puts millions more Americans at financial risk, according to a new study by my friends at the Center for Retirement Research at Boston College. Nearly two of every three of us will be unable to maintain our pre-retirement standard of living once we include the cost of long-term care insurance or the need to tap home equity to finance the personal care we may need in old age.     

Both health care and long-term care have a powerful impact on our financial security after retirement, the study finds. The Center's National Retirement Risk Index shows that at least 44 percent of us will be unable to maintain our standard of living in retirement, even without the savings we'd need to pay for medical care and long-term supports and services, such as home health aides or nursing homes. Figure in health costs, and the percentage of those at risk increases to six in ten. Include long-term care, and it's 64 percent.

Interestingly, it isn't the Baby Boomers who will take the biggest hit. Instead, it will be Gen-Xers (those born between 1965 and 1974). Nearly three-quarters of them will have to cut back in order to pay for their care in frail old age.

The report also suggests that the middle class of all ages will be hit especially hard. The poorest third of Americans have financial assets of less than $22,000--barely enough for three months in a nursing home. They will likely end up on Medicaid, the welfare-like government program that already pays for 40 percent of all long-term care costs.

The very wealthy may be able to buy long-term care insurance or, in some cases, take out reverse mortgages. But those in the middle--who CRR defines as having financial assets of between $22,000 and $200,000--are most at risk. They could buy long-term care insurance, a decison that will give them much better care choices than if they fall into Medicaid. But to pay the hefty premiums, they will have to cut back other spending.

The CRR report is yet more evidence of how the financial burdens of long-term care not only affect the way we are caring for our parents, but also how it will impact our own futures as we age. Give it a read.