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.

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