Long Term Care – The Moral Healthcare Blog

APACHE JUNCTION, Ariz. – In a low-slung building in the vast desert expanse east of Phoenix, a small school of tropical fish peer out, improbably, from a circular tank into the waiting lounge of the Apache Junction Health Center. The hallways of the nursing home are still. Only half of the rooms are filled, and the men and women who live here seem surely in life’s final season. “These are folks that have chronic cognitive and physical disabilities that are not going to improve,” said George Jacobson, administrator of the nursing home.

That this nursing home is sparsely filled with residents too disabled in mind or body to return home is a stunning achievement for Arizona’s public health insurance agency. A decade ago, 60 percent of Arizonans covered by Medicare and Medicaid, and deemed sick, frail or disabled enough to live in a nursing home, resided in a skilled nursing facility. Today, only 27 percent of them do, and the rest – nearly three out of four– live in assisted living facilities or at home with the help of nurses, attendants and case managers provided by government-paid health plans.

As Congress debates an ambitious and far-reaching effort by the Obama administration to streamline medical care and rein in spending for the nation’s sickest and most expensive patients, Arizona – with its finger-wagging Republican governor and Tea Party enthusiasts – is occupying an unusual place in the national landscape: as a model for how a generously-funded, tightly regulated government program can aid vulnerable, low-income patients.

In Conservative Arizona, Government-Run Health Care That Works – Kaiser Health News

Yet Medicare, which pays for all of the above, does not, except in rare instances, pay for long-term care in a supervised, safe place for frail or demented old people, or for home aides to help with shopping, transportation, bathing and using the toilet.
Nationwide, the median annual cost of a nursing home in 2010 was $75,000; room and board in an assisted living facility, with no additional help, was $37,500; and the most basic category of home health aide, who can perform no medical tasks, like the dispensing of medication, was $19 an hour. These expenses are left to the elderly (and their adult children) to pay for out of pocket until their pockets are all but empty.
Then they are eligible for Medicaid, the state-run safety net for the poor. While Medicare, a federal program, is financed by payroll taxes, and thus is an “earned” benefit, Medicaid is “charity,” in the minds of the formerly middle class who worked their whole lives and never imagined themselves destitute.
In the case of my mother, who died at 88 in 2003, room and board in various assisted living communities, at $2,000 to $3,500 a month for seven years, was not paid for by Medicare. Yet neurosurgery, which I later learned was not expected to be effective in her case, was fully reimbursed, along with two weeks of in-patient care. Her stay of two years at a nursing home, at $14,000 a month (yes, $14,000) was also not paid for by Medicare. Nor were the additional home health aides she needed because of staffing issues. Or the electric wheelchair after strokes had paralyzed all but the finger that operated the joy stick. Or the gizmo with voice commands so she could tell the staff what she needed after her speech was gone.
She paid for the room. My brother and I paid for the private aides and bought her the chair and the “talking board.” What would her life have been like without the skilled care she required and the ability to get around her floor and communicate her needs? I shudder to think. But none of this was Medicare’s responsibility.
Yet Medicare would pay for “heroic” care for a woman who was dying of old age, not a disease that could be treated: Diagnostic tests. All manner of surgery. Expensive medications. Trips to the emergency room or the hospital — had she not refused all of them, in the last year of her life. So, in less than a decade, by my low-ball estimate, my mother spent $500,000 of her own money and uncalculated sums from her two children before winding up what she considered, with shame, “a welfare queen.”
A recent state-by-state study of long-term care, the first of its kind, by a consortium of researchers, has found that this kind of essential help costs anywhere from 166 percent to 393 percent of the average annual income of America’s elderly.

How Medicare Fails the Elderly – NYTimes.com