Saturday, August 09, 2008

Lengthening life spans and responsibilities of adult children need to be debated cleanly,


In recent years, financial advisors have warned families about the tightening of federal rules on the previous practices of some elderly persons of “giving away” assets to their children as a kind of “viatical inheritance” before applying for Medicaid when going into nursing homes. Recently, I gave reference to a recent Kiplinger explanation of how the rules work now. They are a bit complex, and families should indeed be careful. Right now, I even wonder how viatical settlements from life insurance policies could affect these rules (when elders outlive their expectancies).

But there is a deeper problem, as I’ve often noted on this blog in the past year or so, that 28 states have “filial responsibility” laws that would allow states to pursue adult children for support of indigent parents. These law might apply in nursing home admission situations, or they could occur because of some other use of social services due to indigence. This scenario is different from the “look-back period” problem described by Kiplinger, because they can occur with no giving away of assets at all; they are intended to apply to poverty.

Generally, the media has been very lax in reporting this problem, because states generally have not enforced the laws. In a couple of cases courts have blocked their use in certain specific scenarios. Social conservatives argue that they should be enforced as a way to meet growing state budget problems, especially with Medicaid, and also out of a desire to force the childless and unmarried to share “family responsibility.” Other societies, like China, may have a stronger tradition of “filial piety’ than ours does now; but our country used to, until Medicare was passed in the 1960s as part of LBJ’s “Great Society.”

A few states incorporate grandparents and siblings into their laws. A few have time limits. No one seems to handle what happens across state lines, or how responsibility is divided among more than one adult child; presumably all are equally liable.

The expectation, as I’ve noted, is that some states will feel increased pressure to try to enforce these laws in the future. This is particularly true of medicine keeps people living longer but does not maintain their ability to care for themselves or remain active (or even employed). The life span issue seems to apply more with females than males. It doesn’t take much imagination to see profound ethical questions in the way elder medicine is practiced in the future. These questions persist regardless of whether a society has a full single payer system for non-custodial care (like Canada) or partial (like the US for Medicare).

It also raises serious questions about social and family values. No one is saying adult children should not love or care for or honor their parents. But there are serious questions in a competitive world how individuals can set their own priorities if they face these responsibilities now or in the future. This sort of question goes beyond what we have gotten used to, that if you have children you should be prepared to provide for them. This is not the sort of responsibility that one “chooses”. Moralizing about it in socially conservative fashion is likely to lead to apparent contradictions and send mixed messages about having children. It could become as important later in life to have had children as it is early in adulthood to wait until one is “ready.” Ideas about gender parity can be compromised. Notions about freedom of expression can be made contingent on family responsibility and “blood loyalty”, whether chosen or not. The LGBT community obviously has a stake in this, and this relates to the same-sex marriage and adoption (and even surrogate parenting) issues. These ideas have been expressed by certain areas of the right wing (the “demographic winter” and “empty cradle” arguments about low birth rates in certain communities, as articulated by Philip Longman and others) but they really do need to be taken seriously. We're running into basic biology and mathematics.

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