Wednesday, December 30, 2009
The Metro Section of the Dec. 30 Washington Post took up the subject of seniors and driving in an article by Ashley Halsey III, “The Crossroads of aging and driving: how old is too old depends, but seniors face a tough choice between safety and mobility; car-dependent communities can become a trap”, link here, p B01 in print.
The article reports that 5533 age 65 or older died in auto accidents, 107 in Va, 83 in MD and 10 in DC (were they all drivers?) Vision tests are required at age 40 or higher in MD and 80 in VA, and persons with disabilities (including early Alzheimer’s) must apply in person in DC. When I was living in Minnesota, a vision test was required at renewal, including peripheral vision
Questions could be asked whether caregivers (adult children) could be liable if allowing disabled seniors to drive. Adult children sometimes take away and hide keys or take off distributor caps. The question could be particularly troubling legally in some states with filial responsibility laws, where adult children could be held responsible for disabled parents or their actions. Many states reserve the right to require seniors to retest for a license upon a senior driver’s receiving a police citation for any moving offense.
But the thrust of the article was that seniors need more “complete communities” in suburban areas, where many services are available on the premises without even the need for bus or metro or taxi, and where assisted living services could be made available when needed.
Monday, December 28, 2009
In a series called “Health Care Reform 2009” under the Washington Post’s “Politics & The Nation” Amy Goldstein has an important article Monday morning, “The not-so-sweet side of closing the ‘doughnut hole’: Plan widens gap in 2011-2012; Medicare change’s long-term cost uncertain”, link here.
The print version of the paper has a chart on p A3. After a deductible, Medicare picks up ¾ of the cost up to the initial coverage limit, $2700 in 2009. But then the patient must pay for drugs out of her own pocket until reaching the upper limit of $6154. That’s a coverage gap of $3454 in 2009, but in 2010 it will be $3576.
The Senate and House versions, in slightly different ways, would gradually reduce the size of the hole, bringing it to 0 by 2019. Under current law, the coverage gap would expand from $3576 to $6188 in 2019 if the reform were not passed.
The closing of the hole is supposed to be paid for largely by pharmaceutical companies, particularly by encouraging competition, reducing some of their monopoly through the patent process (a very complicated intellectual property issue), forcing them to go generic when possible, and encouraging volume discounts. However Medicare Part D providers (the AARP with United Health Care is the largest) already has negotiated substantial discounts for patients even while in the coverage gap, even for expensive Alzheimers drugs. The involvement of hospice can make the pricing more complicated.
Sunday, December 27, 2009
The New York Times is running a series called “Months to Live,” anchored on the front page. The newspaper for Sunday, December 27, 2009 has a very long and detailed article on terminal sedation and palliative sedation, as sometimes carried out in hospices, which according to the article based on practice in New York State, may be based in hospitals. The article gives detailed cases and goes into the ethical and legal issues, which appear not to be completely settled. The link for the story is here.
The article makes reference to a 1997 case before the Supreme Court, Washington v. Glucksberg, Sandra Day O’Connor’s concurring opinion, as well as the majority holding of the court. The link is here.
All of this makes for careful reading.
Saturday, December 26, 2009
The AARP re-ran on its website a cute article from the New York Times, Dec. 23, “Grandma’s Gifts Need Extra Reindeer,” by Julie Scelfo, link here.
The article goes into indulgent grandparents who want to give their grandchildren so many presents, when parents are concerned about clutter. Surprisingly, media savvy parents are concerned that their kids’ values will become distorted by the offerings of corporations who want to make a profit out of every “fad” that appears in the movies or anywhere in the media. Not that Harry Potter is bad – it gets the grandchildren to want to read – good – but you don’t need all the toys. There will be plenty of blue Na’vi from Avatar around probably, but maybe they provide an opportunity to teach kids about the political and social problems of our own world – or even better, the science of what habitable other worlds will be like. Our grandkids may well live long enough to see real space travel. Will we do EFT deposits of social security checks on a terraformed Mars or even Europa or Titan?
But today’s parents, maybe more that grandparents who are now the babyboomers brought up with TV and in the prosperous 50s and rebellious 60s – know the importance of social development, without so much stuff. It’s our kids – and grandkids – who will have to solve the problems of the world, like stop climate change. Our world will be turned over to them to run, and it better not be for the worse.
Merry Boxing Day!
Thursday, December 24, 2009
Social conservatives sometimes make the argument that social welfare programs allow individual adults a “false sense of independence” and freedom from responsibility for other adult relatives, a part of life taken for granted until the time of the New Deal, at least.
Particularly, sometimes it is said that social security and Medicare free families from responsibility for their own aged. I found this argument in revisiting Jennifer Roback Morse’s “Love & Economics: Why It Takes a Family to Raise a Village”, a permutation of the title of a well known 90s book by Hillary Clinton. Morse was reviewed on the books blog here Sept. 25, 2008. The point came up again in reviewing Bruce Bartlett’s recent book on the failure of Reaganomics, reviewed yesterday on the books blog.
But are Social Security and Medicare really like “welfare”? Most middle class wage earners experience social security as a “forced savings annuity.” For people with enough covered employment (which is most employment), or legally married to people with enough covered employment, their social security benefits depend roughly on how much they made (up to the FICA-taxable limit) over their working lives. They can start social security earlier (age 62) but at some loss of monthly income (it’s rather steep actuarially) but still the concept is roughly like that of an annuity.
The problem is that the promises to recipients are outgunning the tax and revenue system to support them, and the trust fund mathematics seems to look worse every month. That’s compounded by the fact that people are living longer (drawing benefits longer, which works out badly for people who retired too early -- although there can be the option of paying SSA back and restarting at a higher benefit if you are going to “live longer”).
That’s why libertarians want to replace social security with a privatized (if quasi mandatory) pretax but privatized savings system, with some management to prevent overly risky investments. Theoretically, if everyone took care of themselves this way, government could get out, and adult children would not need to become involved with their parents either; everyone keeps their independence.
But one big problem is that social security originally started in the 1930s as like a “welfare” program for the aged. The original recipients had not contributed taxes, so there is a compounded cost in converting to a privatized system (like Chile) which itself has gotten rather large.
Medicare is, of course, in even more dire straits, but a lot of that is due to inefficiencies (in record keeping, and in unnecessary tests to avoid malpractice suits).
In fact, Medicare does not cover long term care (generally speaking). Seniors must use their own savings and then go on Medicaid or depend on adult children or family members. Up to 28 states have filial responsibility laws or “poor laws” allowing states to pursue adult children for long term care expenses of parents. These are rarely enforced (except in “lookback period” situations where parents gave away assets to kids)
One “problem” is that people are living much longer, without working much longer, and many families are smaller than they used to be. Medicine is able to prolong life, often with inexpensive medications, with good quality, but after 10 or 15 extra years of good quality (even prolonging employment and creativity) there may be a much longer period of disability than would have occurred in past generations, where people often died suddenly of life-threatening diseases while still in their 60s and 70s. Furthermore, at all ages, sophisticated life-extending medical treatments can be contemplated today (like organ or marrow transplants) only in environments where there are cohesive families that can make them work.
That’s why the “age of technology” is curiously leading us back to reconsider our “social contract” again.
Wednesday, December 23, 2009
People using Medicare Part D, or particularly caregivers looking after parents using Part D, should be aware that new medications need to be handled carefully. It seems that sometimes the private insurance carriers (like UHC with AARP) don’t get word on the new medication automatically, and pharmacies may greatly overcharge the patients.
Part D beneficiaries must pay for their own medications while in the “coverage gap” or “doughnut hole” which in 2009 was $2700 to $4350. But the discounted prices for the medications, negotiated by the carrier, should still apply, even when the beneficiary is covering the cost. The negotiated discount on some new medications (which can list for several hundred dollars for 30 pills for anti-cancer drugs or anti-Alzheimers drugs, for example) can be considerable. Pharmaceuticals holding patents on new drugs are charging very high list prices, and only competition or negotiation by large insurance companies or exchanges (under health care reform) can bring prices down. Likewise, older medications with several manufacturers (like atenolol) tend to be very inexpensive because of competition.
There seem to be some issues with the information flow (that is, the I.T. systems) between the insurance carriers, the pharmacies, and the prescribing providers. I’ll look into this more and report on what is really going on soon.
Picture: a miniature "Luxor" (not in Vegas).
Monday, December 21, 2009
In September, this blog linked to some analysis by Sloan and others suggesting that Social Security could run a deficit even by 2010 or 2011. Today MSN greets us with a U.S. News & World Report story, “How long can social security last, link here.
The average benefit in 2009 was $1155. According to Social Security’s own reports, it will start running a deficit in 2016.
But the latest story has the trust fund exhausted by 2037, after which social security would be able to pay only 75% of promised benefits until 2083.
One proposal is to raise the Social Security earnings cap (from $106,800) by 2% a year until 90% of all earnings are subject to FICA. But an increase in FICA taxes by 2% would also eliminate the deficit.
The real “kicked can” would be means testing, which (if it looked at family structure and “filial responsibility”) could make social security a morally and politically divisive issue indeed.
Thursday, December 17, 2009
Social Security sent all its retirement beneficiaries a greeting this week. It reads, “By law, Social Security benefits increase automatically to keep pace with inflation. When there is a period of no inflation, the law does not permit an increase in benefits. Base on the Consumer Price Index (CPI) published by the Department of Labor, there was no rise in the cost of living the past year, so your benefit will remain the same in 2010.”
My AARP Medicare Part D premium went up 6.8% however at age 66.
Thank you, SSA.
Wednesday, December 16, 2009
Dear Abby yesterday (Dec. 15, 2009) published a syndicated column on eldercare, with many responses, in apparent followup to an earlier letter “Afraid for the Future in San Antonio” that had been published Oct. 25. Apparently her syndicated columns melt away online (I can’t find the Oct. 25 original anywhere; if someone can find a link, please let me know), so all I could find was the set of responses yesterday. The Washington Times published it on p D10, but there are dozens of copies online, such as here at the Philadelphia Inquirer. The letter writer says “people are living longer and prolonging life by any means, so the problem of long-term care and the financial and emotional burdens placed on adult children are very real.”
One could say it’s just payback, or intrinsic family responsibility. In practice, adult children should sit down with their parents and plan for care years before they need it. This is particularly true for childless adult children. The best strategy for many families may be gradual downsizing, encouraging the parent, while well and active to move into a modern, secure urban community for active senior adults, where help will be available later if needed.
The column certainly fits into the warning of the “Dr. David” column, discussed yesterday, and also recently run in The Washington Times.
Tuesday, December 15, 2009
A "Lifelong Health" column from Dr. David Lipschitz warns of huge increases in disability among baby boomers as they live longer; lifestyle choices?
A “Lifelong Health” column from Dr. David Lipschitz, published on p D10 of the Washington Times on December 14, warns “Boomers face rise in disabilities”. The link (hard to find with search engines) is (web URL) here.
David argues that the biggest threat to the American health care system is not just health insurance company behavior as we debate it today, but “the high prevalence of physical or cognitive disabilities in Americans older than 85 that make them dependent on others and no longer able to live alone.”
Later on he remains equally blunt. “Baby boomers are not as healthy as their parents. They do not eat as well, are more sedentary and weight a great deal more. Although this constellation of features does not necessarily shorten life expectancy, it definitely will affect quality of life.”
The American Public Health Association has a link to an abstract of a study to be published in the January 2010 in the American Journal of Public Health, showing a marked increase in change in disability levels of adults 60 and over who participated in the National Health and Nutrition Examination Surveys in 1988 and 1999. Disability rates for people in their 60s has increased rapidly.
So the eldercare debate has been cast by the right wing in terms of “demographic winter” with longer life spans with disability (particularly Alzheimer's Disease) at the end, and fewer children to support them, leaving to “moral” debates about filial responsibility and family values. But the facts show that disability is increasing rapidly at much younger ages, too.
Monday, December 14, 2009
Here’s a social security benefits wrinkle I haven’t covered before, probably because of lack of “personal relevance.” Past multiple wives (or husbands), because of divorce, can file when the wage earning spouse reaches 62 can file for social security benefits on the spouse’s earnings record, without jeopardizing a current spouse’s benefits. There are a couple of caveats: the marriage has to have at least ten years, the divorce must have occurred at least two years ago, and the collecting spouse must not have remarried. The earning spouse does not have to have filed fort benefits.
Yup, heterosexuals can double dip (or multiple dip). Life isn’t fair, is it? This sounds like another “argument for gay marriage” that gay activists have missed.
The facts appear on p 37 of the December 2009 AARP Bulletin, in the “Ask the Experts: Your AARP” column.
Here's SSA's own web reference.
And, Okay, I'm finding the AARP reference online now, URL link (Mon. late PM) here. The AARP print version is a little more expansive.
Saturday, December 12, 2009
Back in 1989 I worked for the ancestor of today’s company Lewin, and even then it focused on hospital operating margins for Medicare, as could broken down into tables and all kinds of categories (DRG, case-mix, rural/urban, etc). I even worked on the “model”. No, I won’t give away any “secrets” – just say that companies around the Beltway get paid to watch this sort of thing. The issues certainly must be alive today after, on Dec. 11, Rick Foster, chief actuary for the Centers for Medicare and Medicaid Services, warned that Medicare cuts proposed by the Senate to help pay for health care reform could drive many providers from Medicare or make them unprofitable. That’s a little odd; the CMS home page (here) links to reports or others sites obviously supported by the Obama administration regarding health reform.
Lori Montgomery has the main story on p A3 of the Saturday Dec 12 Washington Post, “Medicare cuts could hurt hospitals, expert warns,” link here.
This is all ironic given that the Senate also proposes letting pre-seniors at 55 buy in to Medicare.
Here is the current link for Lewin’s published studies on Medicare.
Picture: Virginia Hospital Center in Arlington in winter (recently completed, late 2004).
Friday, December 11, 2009
My own Medicare Supplementary Part B Premiums from AARP and United Heath Care go up 3.75% in the first half of 2010 and then an effective 8.1% the second half. UHC is mailing out the payment coupons starting Dec 15 but many people use automatic debits. AARP takes the calls and can tell members now their premiums for 2010. I called yesterday to see what would happen -- play Star Reporter -- be a troublemaker!
I started Medicare when I turned 65 in July 2008. Each semester my supplementary premiums have gone up about 4%.
Thursday, December 10, 2009
The Washington Post has a constructive editorial “Medicare sausage: The emerging buy-in proposal could have costly unintended consequences,” Thursday, Dec. 10, link here.
This has to do with a proposal to let pre-seniors 55-64 buy into Medicare rather than buy insurance on the exchanges, which may be much better for them (particularly if younger people pay higher premiums and their premiums are regulated).
What I found with retiree health insurance is that even though the premium was somewhat high and paper benefits limited (70% inpatient coverage the last year – fortunately I didn’t have to use it), ING and United Health Care apparently negotiated huge discounts for insured patients, at least at the Virginia Hospital Center and presumably all similar facilities. So a cat scan (which I did need) that started out as $1700 was “only” $370 when covered by insurance, and I had to make a copay of “only” $170 (plus about $20 for the radiologist).
The same practice exists with auto insurance. Body shops charge much less—flat rates --- for repairs covered by insurance.
Saturday, December 05, 2009
A New York Times editorial, “A Little Pension Refore”, on Saturday Dec. 5 describes a “reform” in pensions for New York State employees, link here. The reform raises the retirement age to 62 from 55, and limits the amount of overtime pay that can apply to pension calculations.
This reform goes along with the idea that employers need to keep people working longer. I “retired” from private industry at 58, when forced to during a downsizing, with somewhat of a decent pension payment given the amount of service and other circumstances. But that’s not a sustainable pattern for everyone.
Wednesday, December 02, 2009
Congress debates the CLASS Act, to provide help for aging at home; it would not replace long term care insurance!
Check out an AARP story on the proposed "CLASS Act" here.
Michael C. Burgess (R-TX) and Chris Van Hollen (D-MD) debate the proposed the proposed The CLASS (Community Living Assistance Services and Supports) Act to give people assistance at home. However Burgess argues that this does not replace Long Term Care insurance. Burgess also argues LTC insurance ought to generate tax credits, and that parents ought to be considerate enough of their children to purchase it! In states with filial responsibility laws, children could have to foot the bill as Medicaid gets stressed.
Update: Dec. 5
Check a contrasting story in the Saturday Dec 5 New York Times, front page, by Robert Pear, "Home Care Patients Worry Over Possible Cuts", link here, regarding Medicare' home health benefit for treatment for homebound patients.
Update: Dec. 14, 2009
Check a front page article today in the New York Times, by Robert Pear, "Insurance for Long-Term Care in Latest Issue in Health Debate", link here. Ironically, the government expects the CLASS program to help reduce health care deficits by collecting premiums, but in the long run the benefit payments would make the program unsustainable.
Monday, November 30, 2009
Medicare and Medicaid challenges will make states enforce filial responsibility laws: and they're trickier than one thinks
Al Gore’s spectacular book “Our Choice” on climate change has a chapter on population demographics. Although I discussed that in my review of it yesterday on the Book Review blog, I’ll reiterate here that he referred to the “safety net” to care for the elderly available in western nations. I said there that I thought his coverage was a bit naïve, in that population demographics and economic contraction are going to strain the safety net, and put more responsibility back on families, especially adult children, and especially the childless.
Then consider the Editorial in the Washington Times: “Rationing Grandma’s health care: Democratic plans will exacerbate Medicaid coverage problems,” link here. Actually it’s both Medicaid and Medicare, as reported by CMS, and there specific (and justified) concerns here about gutting the private sector’s Medicare Advantage replacement programs. (Although, later Nov. 30, TV station WJLA reproted that most ot the Medicare Advantage cuts affect more fringe-like benefits for the better off, and that basic M.A. coverage could improve for some people.)
But the most critical point, and one that I’m surprised the Washington Times doesn’t hit harder, is the way responsibility will fall back on families. Almost thirty states have filial responsibility laws (as I covered on this blog starting July 2007), and they will certainly gain attention soon as states find their Medicaid budgets crimped. (To use the president’s pre-inauguration words last January, that can has already been kicked to the dead end of the road.) One can make a partial comparison to the voluntary responsibilities parents have for conceiving children – doing so might make a good high school English theme. It’s different: it’s not chosen, and it's just about "justice" as an individualist views "personal responsibility"; it comes about from being in a community. And it doesn’t happen to everyone, and one can normally use the parents’ funds to meet the needs until they are gone. But there are other subtleties: even if the parent has money and/or long term care insurance, and even given the presence of Medicare and supplementary coverages, the adult child is legally required to make sure that the parent gets the best available care, even at some self-sacrifice. The adult child cannot behave in a manner that could interfere with delivery of care, and that could become a more subtle point than many people realize. In some special situations, the adult child can be expected to prove that he or she is capable of a stream of support even when there are funds.
We will certainly see our idea of “social contract” challenged. And we need the open debate that has been kept out of the limelight, whether because of ignorance or out of fear of consequences, not just for politicians but more many naïve individuals.
Friday, November 27, 2009
The “Deals & Deal makers” page C3 of the Wall Street Journal “Money & Investing” section today (Black Friday, Nov. 27) has an interesting “pension tsunami” story about how pension funds of major public sector employers may be diverting resources to manipulative but “undeserving” middlemen (call them “parasites”).
The story concerns CALPERS, the California Public Employees’ Retirement System, which reportedly continued using the services of two investment counselor firms (sort of the Vernon Albright – “My Little Margie” kind) after their contracts had expired.
The story is by Craig Karmin, is titled “For Calpers, a blunder on pay”, and has link here.
Such practices could gradually put even more strain on PBGC, eventually, and become a political issue.
Attribution link for p.d. Wikipedia picture of Sacramento waterfront. My last transit of the area was in Nov. 1995.
Thursday, November 26, 2009
A note on hospice benefits: Once a patient enters a Medicare-approved hospice program, the Medicare hospice program pays for hospice services and for medical services and prescription drugs related to the condition (for example, heart failure or cancer) that led to the admission. Other medical services related to other conditions not causing the admission would be paid in a conventional way through Medicare, but all care is coordinated through the hospice (with special billing procedures).
Although hospice provides some home care with items like bathing, the patient (and therefore the patient’s family) is still responsible for proving (either in person or by hiring from a home health company) companionship, safety and custodial care, with necessary and appropriate continuity. In states with filial responsibility laws, adult children able to pay can be held responsible for these costs. (However, many hospices offer short respite stays to relieve caregivers or family members.) Hospice services do continue during hospital stays, skilled nursing stays, and can be arranged in assisted living and nursing home settings. (Assisted living facilities cannot themselves provide medical services other that prescription medication management, but the patient or family can bring services in from hospice.)
Tuesday, November 24, 2009
Lester Holt on NBC Nightly News reported on Nov. 24 that Medicare costs vary enormously from one city to another, even in the same state or region. In Miami, Medicare spends about $16000 a year per beneficiary, in nearby Fort Lauderdale (in Broward instead of Dade County), about $9000, and in some parts of Oregon, about $6000. Much of the problem has a lot to do with how hospitals and emergency services are overused, with little consideration about costs.
Monday, November 23, 2009
Robert J. Samuelson has an op-ed on p. A19 of the Nov. 23 Washington Post that indicates that seniors should back off on demanding their tribute in the way of entitlements. The article is titled “Health ‘reform’ that burdens the young,” link here. AARP says that even a 2:1 max on how much seniors can be charged more in premiums is too much; AARP wants a “community rating” which ignores age altogether.
Who stands to gain quickly by making the young pay more? Probably retirees below Medicare-age. More and more companies drop retiree health insurance; an individual premium from BCBS for me would have been $400 a month at age 64; with the employer retiree insurance it was about $180.
Samuelson does agree that insurance companies could or should be banned from discriminating on the basis of pre-existing conditions for “public policy” reasons, but age is not such a category. Working Americans already pay a Medicare tax. Not allowing insurance companies to price by age undermines the entire system, he says. But, for every one of us, youth is mathematically transitory. The only exception seems to be for the vampires in “Twilight”. (Maybe Robert Pattinson will always be 23.)
Sunday, November 22, 2009
Steve Kroft reports. The segment, "The Cost of Dying," (14:06) says that there is something worse than dying, since 100% of us will: it is “dying badly”. Medicare spends $50 billion a year on the last two months of life, more than on the budget for DHS.
In Medicare, we turn the laws of supply and demand upside down. Hospitals have an incentive to admit more patients to pay off bonds. Perverse incentives in our system “are magnified at end of life.”
By law, Medicare cannot reject any treatment based on cost. However, some say that rules should be drawn, based on age and certain medical condition, which might seem like “rationing” but it could be better than “rationing badly.”
Many people are not familiar with end-of-life options, including hospice, living wills, and the like.
European countries with more socialized systems ration what is spent publicly on end-of-life care.
Saturday, November 21, 2009
AARP stands behind most of the provisions in the health care reform bill recently passed by the House. The link (here) is called “Health Reform: Get the Facts: AARP is fighting for you”.
I’ve personally never liked the idea that I have to depend on any organization to “fight for me”, but many people are not in a position to speak publicly for themselves.
Some of the points AARP makes here should be noted. One of them is the closing of the “doughtnut hoe” (that is, “coffee cup handle) in Medicare Part D.
Another is to provide more help for elderly to remain at home. However, that provision provokes a paradox. That means a need for more home care workers, and the need to provide them health insurance at work. That degree of complexity needs to be thought through, given that the demands for eldercare are increasing so steeply with demographics. AARP needs to watch that Hospice funding does not get affected.
Picture: The “Before and after” for Medicare Part D
Tuesday, November 17, 2009
The Health Section of the Washington Post this morning (Tuesday Nov. 17) has a bit story by Elizabeth G. Olson from Kaiser Health News, “The virtual doctor visit: New technology is helping elderly patients and those with chronic diseases monitor their condition from the comfort of home”. The link is here.
We’ve talked about Life Alert and similar products for out-of-town caregivers to monitor elderly parents, but this allows nurses, home health providers, and even caregivers themselves to monitor medical information like blood pressure or oxygen from a distance. One problem is that Medicare may not cover this service unless (sometimes) the client is legally defined as “homebound”, which means that the client cannot normally leave home with a lot of assistance and does not leave home frequently. Of course, the client must be able to comply with the instructions in using the devices, sometimes when alone.
There is a psychological question: does the client feel overwhelmed by the constant monitoring?
Monday, November 16, 2009
The Retirement Living TV Network (link here ) has become available in many communities on Cable. In Arlington VA on Comcast it is Channel 175. It’s motto is “the Second Half of Life Is the Best Half of Life”. (No more final exams!)
On Sunday morning (Nov. 15, 2009) I happened to notice on my Comcast box that a program “The Voice” about caregiving would come on, just as I left for church. I recorded it. Margaux St. Ledgere hosted a forum on the topic.
One guest talked about her experience in an Italian-American family in the 1970s, before the term became accepted. The show said that 45 million Americans are giving unpaid caregiving, and the president has made November 2009 the month to honor them. The show also said that 40% of our nurses come from overseas.
The show provide a high-level discussion of the “powers of attorney”.
Sunday, November 15, 2009
AARP is reporting that dental care may be an important strategy in preserving memory health for seniors, in this piece by Joene Hendry, link here.
Peridontal disease and gingivitis are sometimes associated with a gum infection by the bacterium Porphyromonas gingivalis. Studies have shown that the presence of by levels of antigen for this bacterium are associated with poorer performance on short-term memory loss, and this may be one reason why dentists recommend root planning treatments, to reduce pockets. The bacterium is associated with chronic destructive gum diseases, or deep bone infections that can explode with sudden swelling. It might lead to systemic inflammation that gradually increases the likelihood of stroke or coronary artery disease, or it might even lead to the greater likelihood of brain plaque formation through mechanism not yet understood. Some people may develop immunity to it with time, however. Here is a “citizen’s compendium encyclopedia” reference on the bacterium, with is anaerobic gram-negative and may tend to be resistant to antibiotics (link).
Picture (unrelated): from Baltimore National Aquarium
Saturday, November 14, 2009
The National Institute on Aging, and Alzheimer’s Disease Education & Referral Center has a useful booklet and web page (link) “Home Safety for People with Alzheimer’s Disease.” The paper takes up, with a great deal of flexibility, critical questions like leaving people alone (at least for shorter periods of time) and driving. The paper seems to be a list of voluntary suggestions, not law or administrative policy.
One of the issues will be practicality. In a given home, some suggestions cost much less and probably address a much greater practical risk. These include providing locked medicine cabinets, installing grab bars in bathrooms, using shower seats and extended nozzles, locking away firearms, prohibiting cigarette smoking (if possible), and maintaining smoke and carbon monoxide detectors. If a family member has a hobby area with tools or electronics, it may be a good idea to keep the area locked. If an area of the house is locked when the user is away, it’s a good idea to go the extra mile with electrical safety, including inspecting or replacing outlets or fixtures in old homes, and periodically (like once a year) replacing surge protectors in homes known to have frequent power surges. The instructions also discuss the possibility that the person with AD uses a computer, and should be protected by Internet filters. But a hobbyist will want to make sure that he or she or another responsible person is present when his equipment is used.
There are other private references on this subject, such as this.
Picture: Baltimore harbor (Nov 2009, mine, unrelated).
Thursday, November 12, 2009
The AARP has an interesting article about older Americans and H1N1, by Katharine Greider, link here. The article says that older adults, especially those born before 1950, may well indeed have some antibodies to H1N1 antigen proteins, but if they get a symptomatic infection, they may, as with a study in California, be more likely to die. This report was carried in the National Library of Medicine and may be found here.
On site H1N1 tests produce false negatives in about 1/3 of cases, and over 20% of severe cases never received antiviral medication.
Anecdotally, it does not seem that seniors are taking any undue risk in going to places where younger adults congregate, such as riding on subways or even going to discos. It does not seem that “social distancing” is particularly necessary.
But seniors should not feel complacent just because so much public attention has been placed on H1N1 in the young. It's true that the 1918 Spanish flu disproportionately attacked the young, but that could partly be because of crowding of people in the military. "Social distancing" public health rules were very strict then.
Sunday, November 08, 2009
I thought I would note that CNN today has been carrying advertisements from MetLife for variable annuities, as offering “buffering” of a guaranteed income flow even during market downturns, while increasing in value when the market goes up.
There is a website called “Annuity FYI” (link here.
There are a number of guaranteed benefits available with many contracts. These include Guaranteed Minimum Income Benefits (GIMB’s), Guaranteed Minimum Withdrawal Benefits (GMWB’s), Guaranteed Account Value Benefits (GAV’s) and Lifetime Withdrawal Benefits (LWB’s). These tend to offer some additional protection to retirees (especially female) who could fear that they could outlive their wealth.
Thursday, November 05, 2009
A column in the DC Examiner (p 23) today (Nov. 7) by Kimberly Lankford, from Kiplinger’s Money Power, may help people do their 2010 retirement savings planning. The title of the piece is “How much can I save for retirement in 2010?” with link here.
The lack of formally defined inflation and therefore the lack of a COLA increase in social security benefits for 2010 does not reduce retirement contribution limits in 2010. Roth IRA contributions can continue at the same rate, and for married couples the maximum permissible income goes up slightly. There is also an elimination of an income limit for converting a traditional IRA to a Roth.
Income tax brackets will rise slightly in 2010, and the gift allowance remains intact.
Wednesday, November 04, 2009
Here’s an important tip from USA Today, “Your Money”, Tuesday Nov. 3, in a story by Sandra Block. “You can skip IRA withdrawals this year – or roll one back.” The link is here.
Late last year, Congress waived the minimum IRA withdrawal requirement for those who are 70-1/2 or older, in order to give seniors a chance to recover some value lost in the 2008 financial collapse. If you did take a withdrawal , you may be able to redeposit one withdrawal within a certain time period, as explained in the article. This forbearance does not apply to inherited IRA’s.
The basic IRS publication on IRA’s is here.
There are more details about the mandatory withdrawal and temporary waiver in Publication 590 (PDF), here,p. 3, and then Chapter 1 on p 34.
Tuesday, November 03, 2009
An organization called the National Association for Home Care & Hospice (NAHC) has a secondary political issue advocacy website “We Can Save Home Health” (link) and makes the argument that the current proposals for health care reform would slash Medicare (and probably Medicaid) benefits for home health care for certain seniors and disabled individuals in many circumstances. The website offers staged links for the voter to contact politicians in his or her state.
Of course, in many situations families (or individuals from their own previous savings or provisions previously made by spouses) must pay for home health care services on their own now, as Medicare typically does not care for many of these services, outside of Hospice on the one hand and rehabilitation on the other.
Monday, November 02, 2009
Chris V. Nicholson has a potentially important story about “virtual estates” on p B4 of the New York Times today (Monday Nov 2). The title in print is “Death in an Online Age Raises Issues of Ownership” and online the title is stronger “Virtual Estates Lead to Real-World Headaches,” link here.
The story opens with an anecdote about the disposition of an imaginary island in Second Life, and even discusses the monetary conversion rate to Second Life. But a more practical problem would concern intellectual property: blogs, profiles and ordinary personal websites, as well as Twitter accounts, and, in act, emails, IM’s and text messages.
There is a suggestion that some day people will need to name “digital executors” to have accounts, and that could present a problem if someone has trouble finding someone willing to do it. Or perhaps an ISP could simply delete all the material upon a person’s death if there is no such agreement.
Saturday, October 31, 2009
The Wall Street Journal, on Saturday Oct. 31, has an editorial that helps shed some light on what is wrong with our pension system. It is titled “Pay-to-Play Torts: pension middlemen get investigated; lawyers get a pass”, link here.
The editorial criticizes the practice of law firms making campaign contributions in order to get selected to represent state employee pension funds in widespread securities litigation.
The concern spreads beyond the financial stability of the pension “tsunami” often discussed here before. It goes to the way public policy is influenced by special interests, whose members often no longer have the legal freedom to speak just for themselves in public.
Thursday, October 29, 2009
Can people with heart or lung problems use oxygen at home? Yes, and there are a number of references on the subject. Here is one.
Use is often intermittent (for short periods, maybe when sleeping), or it may sometimes be continuous. It may result in the need for 24 hour caregiving assistance, or it may not. Certain safety precautions must be followed, such as making sure that all electrical outlets are constructed with three prongs. Compressed oxygen containers do not need electrical power, but liquid oxygen (familiar in high school chemistry class) does.
Here’s a good guide from CIGNA, an insurance company (a bad word in Michael Moore’s world). Blood gas studies are done first to determine the level of need. Often the need is relatively minimal. Often people have oxygen in hospitals or rehab stays but do not need it at home.
Wikimedia picture of home liquid oxygen canisters. http://en.wikipedia.org/wiki/File:Home_oxygen_cannisters.jpg. Note the condensation ice on the canisters.
Wednesday, October 28, 2009
Newsweek, on Oct. 26, 2009, published an interesting perspective by Linda Stern, “Gaming Social Security: Increasingly sophisticated retirees are figuring out how to get the most out of the system,” web URL link here.
We’ve talked here about the strategy of returning social security benefits collected if you get a good job again and then restarting at age 70-1/2 at a much higher benefit, as computed by SSA by actuarial formulas based on life expectancy (as is the case with life insurance company annuities). The break-even point is said to be low, with postponing retirement paying off if you live past 78 (especially more likely for women).
Single income married couples (where the wife was a stay-at-home mom and/or [for whatever reason] didn’t earn nearly as much – not always a sequitir, to be sure!! – maybe there was a stay-at-home dad!) may benefit from a cagey strategy. The non-earning spouse claims at 62, and the “breadwinner” (time for Henry Hyde’s “Mom and Pop manifesto” to be sure) waits as long as possible, whereupon the spouse drops the benefits and the earning spouse claims a spousal benefit on his account. This is your “family wage” scenario.
Then there is the “yuppie” scenario, of approximately equal incomes (so 80s sounding, isn’t it!). The lower earning spouse claims at 62 ("the protective social security application"), the other spouse claims (her) spousal benefit at full retirement age, and (his) own slightly later with delayed retirement credits.
People may start hiring financial planners just to game social security.
The article also mentions that some people claim social security early out of fear that it will get cut drastically later during a political binge of “shared sacrifice” (like the dreaded idea of “means testing”). As Obama said, we can’t kick these cans down the road forever. Sometimes claiming social security early can put someone in a higher tax bracket, according to rules on how social security income is taxed (up to 85% in conjunction with other income in some circumstances).
Tuesday, October 27, 2009
Doing some research this morning, I see that HR 3248, the Lifespan Respite Care Act of 2006, did actually become law during the 109th Congress, under former president Bush, with link here.
But according to a USA Today article by Mindy Fetterman back on June 27, 2007 it hadn’t been funded. It aimed at providing certain kinds of help to people who gave up their jobs to provide unpaid care to elderly parents or other relatives, with link here. For example, social security benefits for the caregiver could be based on the highest years of earnings, caregivers could place their loved ones in publicly supported respite care centers, and caregivers could claim tax credits. Back then the AARP reported $2400 out of pocket expenses experienced on average by family caregivers.
ABC ran a similar story by Fetterman on June 27 2007, “Becoming ‘parent of your parent’ can become an emotionally wrenching process”, link here.
I’m not “for sure” where all this funding stands now, but I’m surprised that I don’t hear more about it in the health care debate. Many of the stories concern parents who themselves are nearing poverty. Sometimes, parents, especially elderly women, have been left well provided for but want personal attention from their own family members rather than hired care. Other times, some people use the need for care to manipulate spouses emotionally.
Is it “selfish” to nudge the parent toward a retirement home? What if the adult child then remains in the parent’s home and looks after it. Should the child “charge” for services and pay market rent at the same time? There’s not much that’s easy to find online about this, beyond IRS Publication 527 (link; see Section 5 especially). It would seem that if the parent comes home occasionally to enjoy the home or yard, that’s personal use (which means they can’t claim depreciation or expenses against any rent that the adult child pays). I would think that the adult child should pay market rent for the space that he or she actually would use (like that of a typical apartment) if the caregiving need had not occurred. But I can find little or nothing written about this online.
Here’s a CNN Money story that may provide a little insight.
Monday, October 26, 2009
Recently the AARP MedicareRx plans for Part D Medicare prescription drug coverage (in my case, through United Health Care) sent out 3-part packages to its members. The first document was an Annual Notice of Changes for 2010 (calculated for the subscriber’s location); the second was an Evidence of Coverage booklet, and the third was a 2010 Abridged Formulary, a partial list of covered drugs.
Premiums went up about 6.8%; for me, the coverage (in Virginia) went from $38.20 to $40.80. The copay for some tier 2 drugs went up; but for some tier 3 drugs it came down.
The Coverage Gap, or Doughtnut Hole, was the range $2700 to $4350 in 2009. In 2010, it is $2830 to $4550.
Beneficiaries can pay for their coverage by check, by automatic withdrawal, or (most often) by deduction from their social security checks.
Saturday, October 24, 2009
The Centers for Medicare & Medicaid Services (CMS) have mailed the 2010 booklets “Medicare & You” to Medicare beneficiaries.
Ironically, not all the 2010 premium information was available when the booklet was printed. The web link for 2010 premiums is here. Contrary to what has been reported in the media, the Part B premiums for many, perhaps most Medicare beneficiaries, do not increase above $96.40 in 2010, but some people will have to pay $110.50. Read the link for details.
Medicare has a “Fighting Fraud” program that in some cases will pay beneficiaries up to $1000 for properly reporting fraud attempts (on p. 97 of the booklet).
The booklet points out some Part B preventive services which are covered 80% (with supplementary insurance often covering the rest). Some of the services are innovative, such as abdominal aortic aneurysm screening, bone mass measurement, colonoscopy, EKG (static, a new benefit), glaucoma, and diabetes
Friday, October 23, 2009
On Wednesday, Oct. 21, 2009, Gabriella Boston wrote a lead story in the “Plugged In” section of The Washington Times, “Why stop at 100: Life spans may expand dramatically”, link here. The story starts by recapitulation the recent Lancet story that babies born today have a greater than 50-50 chance of reaching 100.
The article goes on to explore the idea that lifestyle changes and molecular surgery might eventually make immortality on this planet possible – which means to me, your soul will never go through an Event Horizon to find out what is in the next parallel universe (Heaven). Contemplate the idea that we would have to remain employed forever, and stop social security and pensions. Should we have children? In an immortal society, I’m not sure that depopulation, as Phillip Longman writes about it, is a risk. Would we have a world of permanently perfect people, clones of a 20-year-old Clark Kent? It seems that a world that is fixed on its own presence loses all sense of perspective for the future. But at least we would have a direct incentive to protect the planet; we would be around to see the results of our pillage otherwise.
Barbara Walters had run an ABC special “Live to Be 150” in the spring of 2008, and PBS has run some specials on longevity. Walters is up in years herself, and still glamorous.
The old Omni Magazine had suggested that people’s brains be downloaded and saved permanently on computers back in the 1990s. We don’t really need bodies, do we. Imagine digital copies of yourself, with only the copy protection of the DMCA.
Thursday, October 22, 2009
Sometimes heart patients, especially elderly patients, do receive pacemakers. In less common cases, even young people get them (as in a Sanjay Gupta CNN report). The question that may come up, even for other household members, is do electronic devices, especially microwaves, jeopardize the operation of the pacemaker?
In general the reassuring answer is no, they do not. Modern pacemakers are well shielded. Patients should be careful about some specific situations: working on automobile ignition systems, welding systems, being very near high tension power lines, and the like.
The American Heart Association has a reference here.
The Arrhythmia Association has a link here.
Wednesday, October 21, 2009
Milt Freudenheim, in a column on p A22 called “Prescriptions: Making sense of the health care debate: A plan for higher payments,” link here. The issue is Medicare Supplemental insurance, often called “Medigap” (link) The Senate Finance Committee is suggesting that seniors make copayments on Medigap claims by 2015. The mandatory copayments woukd apply to all doctor’s visits under Medigap, to discourage overuse of services by some seniors, who are comforted by the “first dollar” coverage of most services under Medigap, with a net result of increased expenses to Medicare.
Caregivers are often quick to take seniors to doctors at the slightest problem, believing that it is their obligation to do so.
Tuesday, October 20, 2009
Some people question whether elders should be placed in nursing homes or other facilities at all; the personal responsibility of family?
There is a website called “Associated Content” that has a number of cross-referenced articles by Shalanda Jenkins, from back in July 2007, “Is your loved one really safe in a nursing home: things to know in search of the perfect nursing home and care facility?” link (website url) here. On the right frame of the page there are links to related articles about elder abuse and nursing home abuse. In the body of this article Jenkins writes “Studies show that when you participate in the emotional healing of a dementia or alheizmer patient, they are more inclined to more communication of some aspect if they know that they have someone close to them in reach. Better they are taken care of at home with a screened, skilled home nurse than being in a nursing facitlity under responsibility of an aide who has eight other people to look after, one of which requires more attention than your loved one..” Home health care, for 24 x 7 , may be more expensive than nursing home care and certainly more than assisted living.
She encourages family members to look very closely at any care facility, and seems to suggest that at some level care really cannot be bought or outsourced. She also writes, anecdotally without naming any institutions (and I do not identify them on my blogs either), that when she worked as a CAN (certified nursing assistant), that in some facilities, people would say that certain patients could be neglected because no “family” looked in on them. This is certainly an egregious attitude from employees of an institution, but it might grow worse with demographics.
Here is a nice reference on choosing between a nursing home and an assisted living center, from October 2008, here. Assisted living facilities are not allowed to give medical treatment, although they can dispense (and keep accurate track of) medications from a pharmacy (and must, for most patients, especially those with any cognitive impairment at all), and charge separately for the service.
Sunday, October 18, 2009
How do airlines handle the travel of seniors with disabilities, including “cognitive disabilities”?
Southwest Airlines has a typical policy, stated here.
Airlines will allow people who bring seniors to airports to get “Escort passes” to accompany the customer all the way through boarding (including going through security at many airports). Most airlines say that they cannot attend to personal needs once the customer is on the aircraft. For example, the customer should be able to comply with seat belt regulations and be able to walk unaided in the cabin to the lavatory. In many cases, flights with stops or especially with connections should be avoided. Airlines do offer preboarding and wheelchair service. Generally they will not verify the identity of people meeting the customer on the other end.
Some literature on the web says that the simulated higher altitude is bad for heart patients or patients with early dementia, but doctors seem to permit it.
But an article by Ed Perkins discusses an Adult Assistance Program at Northwest Airlines, that offers complete supervision for an extra $50 each way (link here). This sounds like a good idea for all airlines.
It is probably surprising for many people to learn that people with considerable cognitive disability, as measured by tests, are allowed to fly as well as to drive (previous post, Aug. 17, 2009). But a physician, and a professional who has worked with the patient, should be consulted for permission. Lists of symptoms for various stages listed in diagnostic criteria often don't match the reality of the individual person.
Thursday, October 15, 2009
The Washington Post has a front page story Thursday Oct. 15 “Hidden costs of Medicare Advantage,” Plans’ free perks are subsidized by government,” by Philip Rucker, link here. Some of the perks, like gym memberships, would not seem to belong to a program that the government subsidizes. Medicare Advantage was developed as a replacement for Medicare, which sometimes offers a better deal to relatively healthy, active seniors, but does not work well in certain situations.
I have been approached, during “retirement”, to be interested in selling this product; but I do not want to peddle products to others and to manipulate others into buying things that may not be in their best interest.
Medicare Advantage plans are likely to increase premiums and reduce benefits because of the indirect “burden” placed on them as part of “paying for” health care reform.
The media is also repeating the story this morning that seniors will not get a social security increase in 2010 because of the lack of formally defined price index increases.
Tuesday, October 13, 2009
Well, everyone ought to peruse the Time Magazine (Oct. 19, 2009, p. 28) article by Stephen Gandel, “Why it’s time to retire the 401(k): Last year’s market wipeout showed the vulnerability of the popular retirement-savings accounts. But the data are telling us that even in the long run, consumers need better options”, link here.
The article discusses the life of an Occidental mechanic, and then goes on to give examples of how people turned out financially if they retired before 2008 compared to during 2008, during the meltdown and “Bailout” crisis.
Companies began to freeze their defined benefit pension plans in the 1990s, in lieu of matching 401(k) contributions. Gandel calls this a con job. Toward the end, Gandel, toward the end of his piece, talks about the idea of wedding savings with insurance. One reason for this is that a huge factor in determining your nest egg is when you retire, and you might be forced to “retire” in a corporate downsizing following a traumatic event like 9/11 (that’s what happened to me), or the 2008 financial crisis. Gandel wants an insurance against this kind of unpredictable “systemic” risk.
The ERISA Industry Committee (ERIC) proposes paying a premium (6%) to a retirement insurance provider, with the end result of a guaranteed “pension” paycheck. But one wonders how insurance carriers of products like this would weather financial hurricanes like than in 2008. Here is a typical link from ERIC, title “ERIC's New Benefit Platform Featured in GAO Report on Alternative Approaches to Current U.S. Pension System”, Sept. 1, 2009.
Monday, October 12, 2009
Recently, I got an appreciative comment on the July 12, 2007 (two years ago) entry about filial responsibility laws (in almost 30 states) in this blog, and I suspect that the visitor might actually have intended to place it on the July 7 2007 entry, where there is a detailed comment by another visitor. I had just added a comment to the July 7 entry about some subtlety as to what these laws may mean, with respect to the Virginia statute. I really appreciate these comments about a legal issue that the mainstream media seems to be missing completely, or perhaps deliberately avoiding to prevent a firestorm. Perhaps the recent case in New York, where Brooke Astor’s son (himself elderly) was convicted of embezzlement and commingling have drawn some sudden issue to the problem, as there were some media reports (not necessarily correct) that Astor was neglected sometimes. (Ironically, I don't think New York State has a filial responsibility law.)
The public’s impression is that these laws deal with the Medicaid giveback period, which the federal government bumped up to six years back in 2006, and that’s true; but they are also used as “poor laws” requiring adult children to support indigent parents (a concept that might be even more applicable before retirement age when social security can kick in, although poor people draw less social security; but the possibility of tapping social security disability benefits should not be overlooked in some cases).
Actually, some of them require even more: that the adult child or children make sure that care is arranged for disabled parents, even when the parents have sufficient resources. Adult children should not behave in a manner that disrupts the delivery of care, and should prove that they can support themselves and their own families without commingling. Even when the parents have resources, they may resist outsourced help and want adult children who were themselves childless or only children may find the demands for emotional loyalty disturbing. Some comments have suggested that this not “fair”, but that depends on how one looks at things; in a community of generally free people, not everything can turn out to be perfectly “fair”. The growing eldercare dilemma will make us rethink "family responsibility" and raise the question as to whether responsibility for parents (as in the Ten Commandments, quite literally) is fundamental the way responsibility for one's own kids is.
Indeed, in our individualistic value system, we emphasize the personal responsibility that goes with one’s own choices (raising children one has sired, and not having children until one is “ready” economically as well as emotionally); Dr. Phil covers the latter all the time. But, with the rapidly increasing life spans and sudden increase in Alzheimer’s disease (in people who no longer die “naturally” of heart disease and stroke), the genesis of responsibility for others surely goes beyond the control of one’s “choices”. Indeed, the eldercare issue could bring back the old-fashioned idea that children are in some sense “economic assets”. The pro-natalist crowd of writers like Phillip Longman, Paul Mero and Allan Carlson will dance in the streets. Maybe this is part of what Rick Warren means when he says “It’s not about you.”
None of this means one does not love one’s parents and family; but our individualistic values assume that everyone should be able to define the course of his own life and define his own dreams. President Obama said so Saturday night when addressing the Human Rights Campaign, but did not go so far as to say explicitly that the demographics of elder care can change the lives of LGBT people disproportionately. He did mention the importance of the health care debate in the larger sense, probably as including elder care: but filial responsibility deals with custodial care issues not generally covered by Medicare, and long term care insurance is only now coming onto the scene as a strategy to address it. I did hear a remark tangential to eldercare obligations Sunday at the National Equality March rally.
The media ought to start to cover this issue promptly, and start quizzing the politicians. Right now, it’s up to the bloggers, and their visitors who post comments.
Sunday, October 11, 2009
David Cho has a major story in the Sunday Oct. 11 Washington Post’s “Consequences of the Crisis” style, “Steep loses pose crisis for pensions: two bad choices for funds: cut benefits or take greater risks to rebuild assets”, link here.
There is an email list around called “pension tsunami”, and indeed public employee and union pension funds are in a bind: workers have been promised certain defined benefit pensions, that cannot be sustained in the “casino like” money factory that Michael Moore described in his recent movie (“Capitalism: A Love Story”), so either they make sacrifices, or there are more huge taxpayer bailouts down the road, primarily of the Pension Benefit Guaranty Corporation. Right now, the PBGC does guarantee most benefits up to a maximum amount, as has been explained before on this blog.
Thursday, October 08, 2009
Take a good look at today’s (Oct. 8) “The Color of Money” column in the Washington Post by Michelle Singletary, titled “The forecast is sunny if you weather the 401(k) storm,” link here.
Singletary discusses an EBRI-ICI (Employee Benefits Research Institute/Investment Company Institute) report, showing that over 2003-2008, balances rose over 7%, even with the horrible year in 2008, where balances dropped markedly. That report appears to be at this link.
401(k) plans are intended to work over the long haul. If you’re young and can put anything away at all, you should, and keep the strategy of dollar cost averaging. When stock prices are depressed, you buy more shares.