Sunday, January 20, 2008

Overseas, some countries make LTC an entitlement or require insurance: Mass proposes mandatory LTC insurance

While politicians in both parties talk about making purchasing health insurance mandatory (and some states are doing this or are trying to do it), few politicians have seriously talked about making Long Term Care insurance mandatory.

One reason could be that insurance companies right now are so picky about who they take. But a (Republican, probably) case could be made for making people under a certain age (say 40) start paying for it with pre-tax dollars, and for not allowing companies to exclude anyone for pre-existing conditions, genetics, family history, etc. When started early in life, premiums would be easily affordable. Some diseases that cause the need for custodial care can occur much earlier, as can, of course, catastrophic civilian, non workplace injuries. Such a measure could be a major counterweight to the likelihood that many states will start enforcing their filial responsibility law on adult children.

On the international level, there is talk that long term care could become another entitlement. Japan implemented this in 2000. Naoki Ikegami has an article on AARP dated September 2005, “Design and Impact of Public Long-Term Care Insurance in Japan,” here. The first subheading reads “Making long term care an entitlement.” The article says “Neither the willingness and/or ability of family and friends to provide care, nor income is taken into consideration. The benefits are in the form of institutional or community-based services, not cash, with a 10 percent co-payment.” Japan as a country, even though densely populated with a high standard of living, has had particularly severe demographic problems with an aging population and lower birth rates.

The AARP Global Aging Program home page is here.

Germany also has a mandatory LTC program, as described in BNET, “Germany's long term care insurance model: Lessons for the United States, from Journal of Public Health Policy, 2002 by Harrington, Charlene A, Geraedts, Max, Heller, Geoffrey V. (The link rates yellow on McAfee, so I didn't provide it.) A couple of quotes: “The German LTC program consists of a mandatory system in which employees and their employers make equal contributions to the LTC insurance program. Everyone with an income below the "income limit for mandatory health and LTC insurance" … Those with an income exceeding the income limit can opt either to belong to the social insurance system or to buy private insurance.”

I was told about the program in Germany by a woman living there in a heated debate this afternoon in a chat room, in which there was considerable disagreement over the “moral question” of family responsibility, and whether adult children could be compelled to support parents (or even other family members) when they didn’t ask to be born. It is not possible to resolve that, as it stirs heated emotions. (The language stayed civil enough.)

The practical point is that other countries are addressing the long term custodial care problem with structured programs ranging from entitlements to mandatory insurance, and that a mandatory program might work as part of the total solution to health insurance in the United States, with an emphasis on mandatory pre-tax premiums started early in one’s working life, with supplements for low income persons. Certainly if adults take care of themselves, their adult children or siblings won’t have to. (A quote in a CW "Supernatural" episode from Sam (Jared Padalecki) “I’m a big boy now. I can take care of myself.”) Now, while filial responsibility may well come up in connection with assisted living or nursing home placement, it's possible to come up in general (if a senior is living alone but on welfare and Medicaid).

In fact, a site called PrepSmart discusses a proposal to require Long Term Care Insurance in Massachusetts (which does have a filial responsibility law: check my entry here: The article is called *Massachusetts – Long Term Care Insurance: A Must? No Way Jose., link here. The author suggests creating a trust fund similar to social security.

The Robert Wood Johnson Foundation reports “New York Program to Promote Long-Term Care Insurance for the Elderly Offers Full Asset Protection in Exchange for Mandatory Insurance, “ url here.

In conversations, I find that many people are not very aware of the significance of the demographic changes (fewer children, longer lifespans) or of the potential legal issues with filial responsibility. The problem has developed very quickly, with unprecedented situations occurring for some people. The mainstream media does not present this problem fully, so people tend not to understand it "until it happens to them." It has the log term potential to turn our notions about responsibility v. parenthood upside down.

Visitors may enjoy this somewhat cutting poem by Phillip Larkin, mentioned in the chat room. No, you can't morally just "divorce" your parents unless you were abused or neglected. There is a legal process called "emancipation" which was dramatized with the character Nathan (James Lafferty) in the CW program "One Tree Hill."

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