Monday, August 31, 2009
Robert Pear has an arcane but detailed article on p A12 of the New York Times today, “Health bill would cut drug spending for many on Medicare, Budget Office says”, link here.
The essence of the story is that Medicare may increase Part D premiums somewhat over the years, but some seniors who have to spend money in the “doughnut hole” (like a coffee cup, I know, from topology!) of Part D coverage may wind up spending less out of pocket. This is all part of an indirect result of budget trimming in the overall health care reform discussion process.
Again, it comes down to a matter of those do no not use services helping pay for those who do.
Sunday, August 30, 2009
Long Term Care can destroy assets of spouses in second marriages, even for the benefit of first-marriage kids
Nicholas D. Kristof has a particularly disturbing column in the Sunday Aug. 30 New York Times, p. 8 in Opinion, “Until Medical Bills Due Us Part”, link here.
He sketches out a woman who, well provided with an inheritance from a first marriage, enters a second marriage. The second husband develops dementia, with the likelihood of long term care, and they did not have long term care insurance. She has a pre-nuptial agreement, but that does not protect her from her husband’s custodial care expenses, nor does it protect what she would pass on to the children of her first marriage (one of the most important points in the article).
So she divorces, well before the husband actually incurs the expenses of LTC. That’s to protect her assets from his expenses (despite “till death do us part”). The divorce announcement appears in the newspapers (not the Internet, with the online reputation problems, thank you – although probably the newspaper story winds up on the Web anyway) and she fears that the fibbies will come after her, as in a John Grisham novel. Needless to say, the Times story doesn't name names.
Our current health care system destroys families (and contradicts family values) and kills more people than any “end of life” panels could, Kristof says. But reforming health care financing alone won’t address the growing custodial care and LTC issue.
Friday, August 28, 2009
Today, I had another conversation with a representative who sells long term care insurance and other products (like Medicare Advantage) for several carriers. I was not aware that the AARP does work with competing carriers.
A male in good health at 66 might be able to purchase long term care insurance for something like $130 a month, but the rate would go up quickly with age. The underwriting procedure , following a needs analysis, is extensive and includes a cognition interview.
It makes real sense for anyone still working and, say, under 70 and making good money to try to purchase it.
The representative said that about 85% of LTC claims are for home health care rather than institutional care.
During the conversation, we both acknowledged that some day there might be a debate on “mandatory” LTC coverage for some people, and that states might start enforcing filial responsibility laws.
He mentioned that all Medicare supplementary coverage is divided into "types" with letter identifiers that are consistent for the industry. Many categories have extended skilled nursing care and overseas care.
It is possible for people with an analytical or artistic temperament to go out and sell insurance, and some artists and musicians do, he said. Yet, when I had my interview with New York Life in 2005, I was told that no other sources of income were allowed to agents, according to SEC compliance rules (probably aimed at preventing co-existing brokerage business). I am still confused about this, and welcome comments.
Wednesday, August 26, 2009
Tara Bahrampour has an important article in the Washington Post Aug. 26, about bilingual retirement centers “More Retirees Find Facilities Speaking Their Language; Senior Centers, Nursing Homes Respond to Increased Diversity”, link here. The story leads off the newspaper's Metro section today and is presented as local news, but it represents a national trend, particularly in areas with Hispanic, Native American, or Asian immigrant populations. A good question would be whether Islamic retirement centers would develop, given their family culture.
The writer discusses the Rockville Senior Center, where activities and programs in many different languages are available, including not just Spanish, but also Hebrew, Russian, Chinese, and some eastern European languages. That could become a big boon hiring area, multilingual retirement professionals. Ten percent of people in the US over 65 are foreign born.
Tuesday, August 25, 2009
Michael S. Steele, chairman of the Republican National Committee, has an op-ed in the Monday Aug. 24, 2009 Washington Post, “Protecting Our Seniors: GOP Principles for Health Care”. His language recalls the Gingrich “Contract with America” in 1995. He comes down hard on the idea that Medicare or any evolution of it with health reform would ration health care or interfere with end-of-life decisions, which he portrays as private matters.
Nevertheless, the support of family members is obviously important in some cases when physicians contemplate risky or expensive procedures where purely medical prognosis is not good. That would surely affect what services get reimbursed by any program. Medical technology allows a lot more “choice” today than it did in the past (where “natural life spans” were more or less accepted as normal), presenting ethical quandaries for patients, doctors and family members.
The link for the story is here.
Monday, August 24, 2009
ABC “Good Morning America” on Monday, Aug. 24, 2009, ran a report “5 Legal Documents Everyone Should Have: From living wills to power of attorney, how best to protect your family,” by Lee Ferran, web URL link here.
The documents include living wills, advanced medical directives, and powers of attorney (including updated documents reflecting HIPAA requirements, which avoid certain Catch-22 situations involving the knowledge needed to authorize treatment or even nursing home placement). The show also recommends a living trust, although AARP produced an essay disagreeing with this. Powers of attorney must be used with care and good faith.
The list also includes a Kids’ Protection Plan, including who should have custody, to prevent Child Protective Services from intervening too much. In some cases, parents expect older siblings to step in and raise younger ones (they see this as a “lineage right”) or sometimes people invite siblings (even unmarried or childless ones) to take custody, as has happened in a couple of films (like “Raising Helen”).
Sunday, August 23, 2009
Stephen Ohlemacher of the Associated Press writes today that millions will face shrinking social security benefit checks in 2010 and 2011. That’s because there will be no COLA increase (since the actual COLA has not increased, given the decline in energy prices since 2008), while Medicare Part D premiums (for prescription drugs) may increase for many seniors. Medicare premiums for Part B cannot increase when the payment remains level, but Part D can.
Some people suggest that a small pseudo-COLA increase could be funded by increasing the wage base slightly, now at $106000.
The link for the story is here.
The story appeared on Yahoo! today.
Update: September 27, 2009
MSN has an article from Smart Money, "Social Security's new math: Who loses? Barring action by Congress, 2010 will be the first year in 35 years that seniors don't get a cost-of-living adjustment. Benefits won't shrink, but it may feel like a cut because of rising medical costs", link here.
Thursday, August 20, 2009
The AARP Bulletin, on p 63, Sept./Oct. 2009, has a new article “Bamboozled by Madoff”. It describes the possibility that a Madoff victim can claim theft losses on IRS income taxes (in the example given, a credit worth $40000), and eventually recover some monies from the SIPC, the Securities Investor Protection Corporation.
The couple in the story was fortunate not to have any debts. The story has a picture of a New York Post issue with the headline “How I stole $65B”.
Here is the main link for the SIPC.
The AARP story link was not yet available. But a similar story on Aug. 8 is here.
Wednesday, August 19, 2009
U.S. Life Expectancy rose by more than one year from 1997 to 2007, and men narrowed the gap slightly relative to women, according to a WebMD report by Miranda Hitti
The overall life expectancy for babies born in the US in 2007 is 77.9 years. For white females v. white males the numbers were 80.7 v. 75.8.
Men are narrowing the gap because of cessation of cigarette smoking and somewhat better screening for prostate and colon cancer.
However, as death rates from heart disease, cancer, stroke, accidents and even HIV go down, the risk of eventual Alzheimer’s is increasing, although the death rate from it so far is unchanged.
The link is here.
The report was aired Aug. 19 on ABC “World News Tonight”.
Tuesday, August 18, 2009
This blog has discussed filial responsibility laws (particularly in July 2007), and noted that generally they could become a serious concern for adult children when parents want to use Medicaid resources for custodial or long term care. They can also become a concern when parents are in poverty. Federal and state laws also limit “viatical” disbursements of assets to children for the purposes of getting Medicaid, with stiff look-back period laws, that were tightened in 2006.
I heard anecdotally about a Virginia case (not in the DC area) where someone whose parents had resources was forced to spend his own, after for some reason it was determined he had acted in bad faith. I don’t know the identity of the case or have details. The July 7, 2007 posting here gives the link to Virginia's laws, and the way the word "necessitous" is used, there seems to be just a little wiggle room for those with an agenda.
When an adult child has powers of attorney and/or is a successor trustee on an estate, he or she should behave with prudence, especially in the handling of the parents’ financial matters. The legal environment in most states is an a bit of flux and remains somewhat ambiguous and open to interpretation because the demands of eldercare are increasing so suddenly and so rapidly with demographics and with the way health care is delivered. There was a recent prosecution in New York City over a mishandling of an estate of someone who lived to 105, reported in the media.
Authorities may become particularly concerned when the elder has medical diagnoses of dementia, although the matter is far from cut and dry. In some cases, as noted yesterday, the elder is still allowed to drive, with some supervision. There is an ethical problem in that if the elder is not legally able to take responsibility for his or her own actions as an adult is normally expected to, the caregiving adult child may “own” the responsibility regardless of the caregiver’s wishes. Typically, the law recognizes an informal situation of “responsible in fact”, which allows prosecution, for example, of babysitters or nannies if they cross a certain invisible line of neglect. But there could be reason to insist that the adult child caregiver take on a more formal personal relationship (like formal guardianship) rather than look at the caregiving as a “task oriented” issue. Such a formal designation could force other changes in the caregiver’s life, such as what career her or she pursues (particularly if the caregiver is moving into “retirement”) as he or she is forced to behave like a “breadwinner” for a conventional family. It doesn’t seem to me, from looking at the laws, that Virginia presses this point (although I would wonder what Pennsylvania intended by moving filial responsibility from welfare to family law in 2005); but the problem could increase in the future as Alzheimer’s increases – which is another reason to look at this as a major public health problem and not just an individual family’s issue.
Families should plan for these kinds of situations with conferences and consultations before they become critical.
Monday, August 17, 2009
Can people with dementia (including early Alzheimer’s Disease) drive legally? I’ve heard people say, absolutely not, and a caregiver or guardian who allows any diagnosed with memory loss to drive risks prosecution for reckless endangerment.
However, I checked a couple of “reputable” places on the Web. The Hartford Insurance Group has such a site, and here is the reference.
Note that, while dementia presents a “catch 22” in assessment, there is some flexibility in how it is handled. Caregivers generally have some time to ease the patient out of driving and arrange alternatives.
Virginia law allows the DMV to require re-examination upon a report that a person is unfit. The most likely reason would probably be a police report after an accident (which might be too late). The web reference at "Ready Hands" is here. It might happen because of a physicians’ report in some states (but HIPAA figures in here).
Generally, however, it doesn’t seem to be the case that the presence of a particular DRG on the person’s medical records or even taking a memory-related drug automatically means the person can’t drive.
The growing need for personal eldercare, along with the exploding costs of nursing homes and facilities, could lead to new attempts at “creative” family formation, especially involving childless or single adult children.
Single mothers could offer to become live-in caregivers in exchange for help with supporting and raising their children, creating “artificial” families. The adult children involved might feel a loss of autonomy but might find the arrangement economically compelling. Such developments would comport with Phillip Longman’s idea of a new “social contract” that encourages all people to be involved in childrearing and intergenerational responsibilities, and indirectly providing an incentive for people to have more children again. Longman is known for his promotion of the idea that everyone share responsibility for OPC, "other people's children", because everyone eventually benefits from them. (I had discussed this earlier on the Issue Blog here.)
I don’t know how state departments of child services would view such developments. In some cases, marriages might occur only for the economic benefits (not attraction or love), and I can imagine arguments (both ways) about how such developments could affect the institution of marriage. It all gets pretty existential.
But the demographics of what is going on might very well compel people to look at such arrangements. Utilitarianism, the way you study it in Philosophy 101, cuts both ways.
Sunday, August 16, 2009
Jonathan D. Pond has an upbeat article on the AARP website, “Sure, You Can Retire.” He gives some calculation matrices for determining what percentage of your working income you actually need in retirement, and comes out with more optimistic results than the usual 80-110%.
The link is here.
He doesn’t take into account how demographics and the financial shenanigans, of the recent past can complicate things. What about long term care insurance for yourself? What if your adult kids move back and are saddled with student loans. What if you’re part of the “sandwich generation” and even in your 60s yourself have eldercare issues that have come about with rapidly increasing longevity?
It’s more complicated that this piece makes it look.
Update: Monday Aug 17
AOL walletpop has a story by Mary Beth Franklin from Kiplinger, "Repair, Rebuild, Retire" here. The leadin says, the worst is over, so you can repair your 401K now.
Thursday, August 13, 2009
Joe Davidson, in the Washington Post Federal Diary on Aug. 13, has an important story, “Buyers of Long Term Care Insurance Riled by Premium Increases,” p. A13. This refers to the benefit offered federal employees, but some were faced with 25% increases in their premiums this year, because of actuarial underfunding.
The link is here.
The story has a directly link to a Power Point document of the FLTCIP. The basic link for the program is this. The site has a calculator for long term care premiums for federal employees.
Wednesday, August 12, 2009
The AARP has a nice set of tips “Get Brain Healthy” to help keep seniors sharp and forestall memory loss as long as possible in those who may be genetically predisposed.
The link (“50 Ways to Boost Your Noodle”) is here.
There are some specific dietary tips, about eating specific foods with anti-oxidants. Other evidence has surfaced that reducing cholesterol and living in “blue zones” where natural anti-oxidant diets seem to reduce the incidence of Alzheimer’s significantly, at least by statistical measures.
Some tips suggest that social interaction helps brain health, but so do brainteasers or games like chess, backgammon, Go, or some computer games. One wonders if music (especially classical music with its formal mathematical schemes of development) is helpful. Perhaps computer activity like blogging is helpful if it exercises memory (finding specific pictures in a photo album to use, finding specific news stories as references).
Will lifestyle changes really help deal with our demographic challenges?
As I just noted on my Books blog yesterday, Time has a new book on the Brain.
Tuesday, August 11, 2009
NY Post carries scary op-ed on "communitarian" ideas for Medicare (E. Emmanuel quotes); Germany in the 1930s?
Betsy McCaughey has a scary story “Deadly Doctors: O Advisers Want to Ration Care” in the July 24, 2009 New York Post, discussing the inevitable rationing of health care under Obama’s plans, and with particular emphasis on triage for the care seniors get under Medicare.
The link is here.
The article quotes Ezekiel Emmanuel, brother of White House Chief of Staff Rahm Emmanuel. The article refers to a 2008 article in the professional periodical Health Affairs on “lipstick” savings that I could not find.
It then says that E. Emmanuel wants “communitarianism” to determine who gets certain advanced health care, especially for seniors. But what this sounds like is “utilitarianism”, born of hyper-individualism but curiously some of the statements sound like they might have been heard in Nazi Germany in the 1930s. Ezekiel wants to reduce access to “technology” for some populations.
Some of the language in this article is so strong that I would rather not quote it here.
Of course, one could connect this all to discussions about “filial responsibility” or family cohesion. That may come next.
The president denied all this talk in his Saturday morning webcast, and again today (Tuesday Aug 11) at a town hall.
Update: Aug. 14, 2009
Jim Rutenberg and Jackie Calmes have a story in the Aug. 13, 2009 New York Times, "False ‘Death Panel’ Rumor Has Some Familiar Roots", link here.
Update: Aug. 19, 2009
The Washington Times has an editorial on p A19, "Medical rationing: 'Death panels' already exist: Obamacare would hasten a process under way at state level", by Robert W. Painter, link here. The editorial compares the America's Affordable Health Choices Act of 2009 with a Texas Advance Directives Act of 1999, where medical authorities have a final say in cases of "medical futility".
Update: Aug. 22, 2009
The Washington Post today has an editorial "The 'Dr. Death' Distortion: GOP scaremongers would rather malign an Obama adviser than honestly debate health reform", link here. The editorial points out that Sarah Palin "cherry picked" Dr. Emmanuel's remarks and misrepresented his views, which now suggest that there should be enough efficiency gains in health care reform to ease the issue of end-of-life and high-risk care. But it's unavoidable that difficult decisions about care will sometimes come down to family emotional solidarity, and sometimes even a willingness to sacrifice.
Update: Sept. 16, 2009
Newsweek has an op-ed by Evan Thomas "Rethinking end-of-life care" (the rest of the print title is a bit offensive) link here.
Monday, August 10, 2009
Following on to yesterday’s post, I wanted to expand into the area of family caregivers who are not spouses, such as adult children, siblings or other relatives.
It’s important that caregivers (especially adult children who move in with parents) keep some sense of “personal sovereignty”. That means some separation of some life goals, including other consensual adult relationships (especially important for LGBT people), personal expression, social networking and the like. For some caregivers who never raised children, it can mean some boundaries on the degree of intimacy or personal cuing expected. That means that he or she needs (as the caregiver said yesterday about even spouses) to outsource or purchase some services.
That’s easier when the widowed parent was left provided for by a spouse; but if not, in many states, according to filial responsibility laws, the adult child can be held responsible for the parent’s expenses, and an otherwise childless person might be expected to share more of the expense. Filial responsibility laws (that generally kick in when someone tries to use Medicaid to pay for custodial care) have not been enforced very often so far, but they are likely to be enforced in the future as states scrap with recession-damaged budgets. (California could become one of the first states to look at this.)
Given demographics and the evolution of geriatric care, it’s surprising to me that this whole area has not been debated more in public, and doesn’t get more attention as part of the health care funding debate in Congress and with the White House.
As this blog noted before, long term care insurance enters into this debate. Eventually, there could be calls to make that insurance mandatory.
Families, particularly with unmarried or childless adults without intimate family experiences created on their own, should sit down and anticipate and plan how they will deal with these issues in the future. In some cases, an adult child could consider purchasing a home to move the parent into, or consider encouraging the parent to downsize into a community with support services before a problem becomes critical. If an adult child moves back, the expectations should be clear; but they often won’t be clear because of cultural changes that develop between generations. Younger adults expect to live in “alternate spaces”.
Non-spousal caregiver "autonomy" becomes a sensitive topic for some people, because of the "existential" meaning that can be given when some wants to "quarantine" some of his (family-of-origin) life away from his interaction with "his own world." The literature on adult abuse talks about "withdrawal of affection" or "lack of attachment" as if to suggest that emotions normally appropriate in marriage should apply in all caregiving situations.
It’s interesting that British novelist Clive Barker anticipated some of these problems with his 1991 novel “Imajica” and uses the term “reconciliation” to describe what happens when separate cultures must come back together in one space and learn to communicate again.
That song “Let me be myself” plays on the TV now (as part of a blood pressure ad).
Sunday, August 09, 2009
The AARP website has a story by Gail Sheehy about caregivers who feel abused by their loved ones, and gives an example of a wife caring for an obstinate husband who lived four years with advanced colon cancer. She gives the odd perspective of the caregiver “playing God” which does not sound like an intuitive way to perceive it. The story is “The Only One they Trust” AARP link is here.
There is a video “The Labyrinth of Caregiving” on the story where Mary Tinker speaks and discusses how her husband insisted that she be the only person who touches him (even when Medicare hospice became available) and that no one else provide intimate care. The fact that he was a male spouse ("till death to us part") certainly contributed to the situation. She describes this expectation of absolute loyalty as a ”power trip”, often put on women especially; and, she says, a “bunch of bunk.
Gail’s book on the subject is “Passages”. The AARP lead-in is “Abused caregivers: moving on with life”. I couldn’t find the book on Amazon yet.
Gail feels that caregivers should make full use of the hands-on support services available in the community. This would be especially true for adult children, perhaps even more so than spouses. Some people feel that people who do “outsource” the physical care are “exploiting” others (the old left-wing, or sometimes right-wing, ideology) but both Mary and Gail would consider this hogwash.
Tuesday, August 04, 2009
Another question occurs to me out of the health care debate, particularly with the question of making health insurance, whether through employers or individual purchase, mandatory for all individual people.
Could we make the same proposal some day about long term care insurance?
Imagine an argument where people who did not have children able to provide them eldercare could be required to purchase it, perhaps as a way to settle their own filial obligations, which are becoming a bigger issue with longer life spans and fewer children (especially in traditional middle class families). It sounds like a shocking proposal with a right-wing knife edge, but I can definitely imagine how it could come about -- say in a fictitious screenplay, at least. We saw how conservative talk show hosts behaved on the eldercare issue last week (Saturday Aug 1 posting); we can expect to hear more of this in the future, I bet. If such LTC coverage became mandatory for some people, it would need to become a guaranteed issue, which the insurance industry would fight over anti-selection concerns.
I don’t think Congress would take on proposing such a law yet, because the Massachusetts-style individual mandate for ordinary health insurance is itself controversial and smacks of intrusive big government to some people. But I can imagine it down the road.
I did talk to Genworth about the long term care idea for myself in early 2008, and found that even at my age (then I was 64), the medical monitoring required to qualify for coverage is quite intrusive and nosey.
But I can see the debate coming.
Monday, August 03, 2009
Here’s a case of interesting political bedfellows: The AARP is urging the Senate to fund fully a national service program. The AARP July 31 media story is here.
The AARP also has a featured link called “Create the Good” here.
The subsite offers tools and links to search for and post opportunities for service.
The other partner in the story is the Corporation for National and Community Service, here
Saturday, August 01, 2009
Ceci Connolly has a front page story in the Washington Post, Aug. 1, about the spin some conservative radio talk show hosts put on the Obama proposal to have Medicare provide “end of life counseling.” The title is “Talk radio campaign frightening seniors: provision for end-of-life counseling is described by Right as ‘death care’”. The link is here.
The AARP says it has received calls from seniors who have been convinced by conservative pundits that they must “choose how they want to die.” Its "end of life" page is here.
About one third of Americans have living wills or advanced medical directives, but few people understand what they want, the article and mainstream Democratic proponents say.
Conservatives seem to be playing on a demographic change: people living longer because of advances, more likely to have some period of disability (including Alzheimers) than in the past, in a society where middle class extended families are smaller and disbursed. The end of life issue (spurned by the Terry Schiavo case) is lumped with abortion by the so-called “right to life” lobby, but there are moral differences. Pregnancy is usually the result of chosen behavior by the woman (and father, of course). But extension of life incurs costs that must be borne by society collectively or by other individual family members individually. The end-of-life issue comports with the “empty cradle” argument made by Phillip Longman and others, who believe that we need a new “social contract” which encourages people to have more children and earlier, and which makes family loyalty (as it used to be) more expected, and particularly which makes personal involvement with intergenerational care an expectation from everyone, regardless of whether they have their own children.