Health Care and the Elderly

[Voronwë the Faithful]

I find this discussion disturbing, in large part because I do not consider a person's value to be defined by how much work she can do. Even the old and "worthless" are worthy of respect and love. They deserve humane care.

By this I do not mean that every extreme medical intervention is necessary. We need to make sure the aging population is educated about the benefits of hospice care and more gentle, natural death. It would help if Medicare did pay for non-hospital care at the end of life.

Most of all, we need to fight the cultural assumption that it's a horrible thing to stop fighting tooth and nail against terminal illness. Acceptance that death is near can make the final months or years much more full of life than constant, painful interventions can.

I agree, Wampus. The hospice care that my stepfather got made such a difference. It certainly didn't make his passing easy, but it made it much easier.

The only thing that I would add is that it not just the aging population that needs to be educated. For much of the population, hospice care simply isn't available (as Ethel pointed out in her excellent post above). There really needs to be a major paradigm shift.

[ArathornJax]

I think in some ways the issue of elderly care is also one of money. My in-laws are well off, and have both the money and the resources to afford a really good supplemental insurance, and if needed, they have the cash to pay for what is not. Their needs will be covered until the day they die. My mother on the other hand has very little money, is on medicaid and though she'll have care as she ages (she is 70) she does not have the choice of my in-laws unless my sisters and I arrange for that which we are currently doing. So in this case, I think there is a difference on not only how we as a culture value the elderly, it is also an issue of money, whether you have it or not.

I guess the issue of care needs to be addressed as we look at reforming our own medical system, and as we examine as individuals, communities, and as a society what we value.

[Voronwë the Faithful]

Exactly, AJ. That's just what I mean when I say that there needs to be a major pardigm shift.

[Ethel]

I find it a strange echo of the Respect thread that people who are no longer employed are therefore considered not productive or useful. It's a cultural thing, I suppose.

That really wasn't my point, though I suppose it's fairly close to Jn's. My point--perhaps badly expressed--was that in a country where 40+ million have no health insurance at all, we routinely spend tens and even hundreds of thousands of health-care dollars apiece on people who have no chance of recovery. We do it because that's the way Medicare is structured. It will pay almost unlimited reimbursements for hospital care--but not a penny for hospice or other palliative care, or for nursing care. It's not that I don't want old people to be cared for. It's just that I think we need to stop and think whether what we are doing makes sense for those individuals and for society as a whole.

But unlike me, Jn has done the math, and I don't think we can ignore her points. Social Security and (especially) Medicare constitute a huge financial time bomb hanging over the heads of our children and grandchildren. In a perfect world I would want everyone to have as much health care as they need and can benefit from. This isn't a perfect world. The simple truth is that we are going to have to do things differently at some point in the future. My preference would be that we start thinking about it now, rather than when the system is in crisis.

Another reason I would like to see health-care restructured is the adverse affect employer premiums have on hiring, and the way that anyone who has ever had a life-threatening illness is held hostage by insurance. I'm thinking here of a colleague who had breast cancer at the age of 34. She recovered completely and has now been declared to be cancer-free. But she can't change jobs, because no group plan will accept a person who has had cancer. (I don't want her to change jobs--she's a wonderful employee--but I can't help but believe that under a better system she'd at least have the choice.)

[Jnyusa]

I did not say that one must be employed in the marketplace and earning money in order to be considered "productive."

Actually, I spent about an hour yesterday composing a post about my experience with the death of my grandfather, living subsequently together with my grandmother for about 23 years, her eventual death, and then my experience with my own parents, where I was the one who had to render the primary care and make the medical decisions. These are just worlds of difference between those two generations and what happened to them as their lives ended. My personal experience is anecdotal, of course, but from what I read of the studies that AARP has done on this issue, I think that I am not at all atypical.

I've not posted it yet though, because I found myself becoming quite angry as I wrote it. You know, I am not suggesting that we kill people when they turn age 65. I have friends, and my mother had friends, who are in their 70s, 80s, 90s, and one who passed her 100th birthday last year, and they are all contributing members of society, valued by their children, worth every penny spent on them by social security and medicare. Naturally they no longer have paying jobs (they would lose their social security if they did that), but they provide great-grandchild-care for their families, they volunteer in their communities, they have memories that reach so far back it is a delight and and education to converse with them. And they are not the ones who are bankrupting the system, because they are not the ones requiring extraordinary medical care for years on end while they lie in a bed with insufficient strength to even roll over, much less feed themselves or use a bathroom. Yes, those who are still productive at age 90 and 100 are having unexpected impact on Social Security because they are living longer than actuarial prediction, as Brian pointed out earlier, but this is a teeny-tiny shortfall compared to the magnitude of technically legal but moral fraud taking place in Medicare and Medicaid.

My quibble is with the deliberate creation of vegetables so that the government can be milked. I guess you guys just have no clue about the magnitude of this that is going on because you've not yet reached the age where the mandatory Sunday outing is a visit to the nursing home. And it is just so much like everything else that gets discussed here ... anything that is not happening under your roof, in your neighborhood, among your friends, or beneath your particular steeple is flabbergasting and disturbing, and there goes Jnyusa again telling us all about this weird and disturbing stuff happening outside Mr. Roger's Neighborhood and we really wish she wouldn't. I'm starting to feel like Jane Fonda on the way back from Hanoi. (Starting?) So maybe I'll tell you about my own grandparents later this week.

[River]

If someone waits to obtain health insurance and under national law the insurance company cannot turn them down, they simply pay a higher premium. They should not be eligible for any more government subsidy of their premium than a healthy person would be. In other words, the crime of not obtaining coverage when you are healthy is self-punishing; you pay more at the margin for your coverage. Society as a whole should not be punished for the stupidity of individuals. But we have to talk frankly with one another about individual responsibility in a circumstance like this. We can't be bleeding hearts and try to save everyone from their own high risk choices. If someone behaves stupidly, then they should rightfully pay more than those who behave prudently.

Just out of curiosity, what about those who, through no fault of their own or their parents, became severely ill at a young age while covered by their parents' plan but have since aged off that plan and must now pay their own premiums? What bad choices are these people paying for? Because this is my sister's position and the position of others like her.

[axordil]

you've not yet reached the age where the mandatory Sunday outing is a visit to the nursing home

For me the age is there, but not the circumstances. My dad (who is back in the hospital again, his breathing never really went back to normal) will be 89 this month, my mom 85. We know exactly how lucky we are that they're still able to live by themselves (with some low-key help).

I do recall my first wife's grandmother, though, who had a massive, paralyzing stroke and was in a bed in a nursing facility for 14 years without meaningful interaction with any of her relatives. She was capable of letting you know she didn't want you there, and that was about it. The family had the money for it, but man, it was scary.

[Jnyusa]

What bad choices are these people paying for? Because this is my sister's position and the position of others like her.

River, I was responding only to a previous post about adverse selection ... someone said that if people are not required to obtain the national health insurance (Obama's plan) then they will not sign up until they are sick. That was the "bad choice" to which I referred. This is a typical insurance problem for which an actuarial solution exists, but it is not the kind of insurance problem that you are talking about.

Yes, people who have foreseeably higher health costs pay higher premiums, even if the circumstances of their illness are beyond their control. So it has always been. Under the current terms of private insurance, such people cannot get insurance at all. I had a friend with a congenital heart condition and he simply could not get health insurance. He could not get life insurance. At least under a national plan insurance would be available even if it cost more, because those total costs can be smoothed over time when the population of the insured is larger.

Ax, you are indeed lucky if your parents are still active in their late 80s!

[Ethel]

Yes, people who have foreseeably higher health costs pay higher premiums, even if the circumstances of their illness are beyond their control. So it has always been.

This isn't true of the countries that have national health insurance, though, is it? If it is, I have not heard of it. My understanding is that everyone pays the same, regardless of their risk level. (And that it's possible to do this because the risk is spread across the entire population, from healthy youngsters to the elderly.)

[Faramond]

I'm not sure where this goes, to be honest.

Below are some points from Obama's health care plan:

Guaranteed eligibility. No American will be turned away FROM ANY
INSURANCE PLAN because of illness or pre-existing conditions.

So, no one can be turned away under Obama's plan. This does not, of course, say what an insurer would be allowed to charge to someone who would ordinarily be turned away now. But I think a lot of voters would consider the insurance company going to the actuarial tables and saying, "Okay, we can't turn you away, but we are going to have to charge you 30,000 a year" to be in effect turned away.


Affordable premiums, co-pays and deductibles. Participants will be charged fair premiums and minimal co-pays for deductibles for preventive services.

What is fair? Is that the number in the actuarial table, or is that a low affordable number? When Obama talks about his health care plan in speeches or in debates, when he brings up this point and the previous point about people not being turned away, the expectation of most voters is going to be that a person with pre-existing conditions can go get health insurance from any provider they want at an affordable price. Where do the actuarial tables fit in here?

Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need assistance will receive income-related federal subsidies to keep health insurance premiums affordable. They can use the subsidy to buy into the new public plan or purchase a private health care plan.

This, I guess, is how things will be kept affordable for people who would otherwise not be able to afford the number on the actuarial table.


What I don't see here is the incentive for a young, healthy person to make sure they are covered. Why pay any premiums at all, while you are healthy? If you get sick, well, then you can't be turned down and government subsidies will make sure that your costs are affordable.

Obama has mentioned penalties, yes? I don't know what form these penalties would take. I didn't notice them in the health plan he has online, but I might have missed it. But rather than wait until after someone tries to hitch a free ride on the health care subsidies to fix things? That's what I don't get. If you're going to someone mandate that everyone pay their "fair share" ( whatever that might be ) through penalties, why not just make it simple and mandate from the start that everyone get health insurance.

[Impenitent]

In Australia, everyone is covered for care in a public hospital and for visits to private practitioners at a scheduled fee.

(ie the scheduled fee for an ordinary visit to a GP is $35 and if your GP charges above that rate for a 20 minute appointment, the balance will come out of your pocket)

The problem with public hospitals is NOT the standard of care (which in general is excellent though there are always horror stories to be heard if you want to hear them, but these are the exception) but the waiting lists - for some procedures the waiting lists are longer than others. There are no waiting lists for life-saving procedures but there are very long ones for hip replacements.

If you don't want to go to a public hospital, there are private hospitals at which there are no waiting lists and you get to choose your doctor (which is not as much of a boon as it sounds as the public hospitals are also the big teaching hospitals and the expertise and experience tends to be concentrated at this big institutions.)

Some procedures undertaken in a private hospitals may also be eligible for a medicare rebate - I don't know why that is, but it is - but you never get 100% coverage at a private hospital. One example - maternity. If you choose to have your baby at a public hospital's maternity ward, you pay nothing. If you choose to have your baby in a private hospital, you get to pay exorbitant rates for your accommodation, which is not rebatable, but much of the medical stuff is rebatable albeit not at 100% of the costs.

But back to the medicare levy...which is 1.5% of taxable income for every working Australian. If you fall below the taxable threshold, the levy may be reduced or you may be completely exempt.

This general medicare coverage works together with a private health insurance sector, in the interests of choice. If you choose to take out private health insurance - so that you can choose to go to a private hospital, or claim for optical or dental care for example - you are entitled to a private health insurance rebate in your yearly tax. The rebate is determined by the age of the oldest person insured, not by your level of income, and the rebate doesn't go very far in covering the cost of insurance.

Mind you, private health insurance in Oz doesn't seem as exorbitant as in the US. We have health insurance for a family of four - both adults are non-smokers and no one in the family has any long-standing or severe illnesses, we have chosen to cover ourselves for private hospital care plus extras (dental, optical, physio, natural therapies but NOT obstetrics as I'm over that ) and our health cover costs us under $3000 a year.

If you are eligible for private health insurance, and you choose not to take private patient hospital cover, and your income is above a certain threshold, you will also have to pay an annual Medicare levy surcharge of an additional 1% (above the 1.5% everyone pays). I guess this is by way f penalty: you can afford health insurance, but you choose not to and therefore place an additional theoretical burden on the public health system.

Personally, I'd be willing to see an increase in the medicare levy up to 2% but only if there could be some kind of transparent guarantee that the increase in funding would result directly in improved medical resources - reduced waiting lists, more medical staff, better resources - rather than increased waste (unnecessary tests and/or rorting of the system). Not sure that's possible though. *shrugs*

As for elderly care...with the ageing of the population staring us in the face, and the galloping improvements and innovation in health care (with accompanying galloping increases in the cost of that care), I think it's about time we took the bit between our teeth (I threw that in there for Anthy ) and create a specific, integrated umbrella organisation for elderly health care. I can only speak from my very limited knowledge of the system in Australia, where much of the nursing home, respite and palliative care has been fobbed off to small, community (often charitable) organisations, which do their best but don't really have an over-arching view or policy directive. It's so bitsy, bitsy, inefficient and opaque.

It needs to be solved before all the babyboomers hit the charts and overwhelm it to the point where the system comes down.

[Jnyusa]

My understanding is that everyone pays the same, regardless of their risk level.

That's the way group insurance usually works, yes, but that's because there's an automatic correction for adverse selection when everyone who is a member of the group has to be insured. Traditional group plans do not allow you to opt out, and I thought that what we were discussing here was what would happen if you let people opt out.

(This goes to what Faramond was saying, too.) If everyone is required to participate in the plan, then you don't need rated premiums because the risk is averaged over the population. But if people can pick and choose whether and when to join, then the risk and the premiums start to increase because people will postpone paying for coverage until they need it. And when people join one by one the insurer also has opportunity to examine their health history individually and adjust their premiums to their individual risk.

So if participation is voluntary, then one of two situations is likely to occur:

(1) the insurer whips out his actuarial table and charges an appropriate premium to the individual, and that is OK with us as a society because it is certainly fair. These people were given a choice, and their karma is mathematically precise.
(2) when we hear just how high that fair premium is, we go all smarmy liberal and say, "Oh noooo! They're sick and poor. Society has to pay for this. We can't let it happen," then we will be stuck with a whopping big bill of the sort we are choking on with Medicare, and everyone who opposed national health will wag their fingers at us.

All my previous responses regarding the actuarial tables were predicated upon this initial supposition that people could decline to participate. If people are required to carry health insurance (as they are in Massachusetts, for example), then the program becomes a straight group insurance problem and the risk gets averaged and everyone can pay the average premium.

[Impenitent]

...If people are required to carry health insurance (as they are in Massachusetts, for example), then the program becomes a straight group insurance problem and the risk gets averaged and everyone can pay the average premium.

...which is the situation in Australia. A universal health scheme and you can't opt out of it, with the option of also taking out private cover and being rewarded for that because you reduce the burden on the universal scheme. Except it's a Federal program, not state, and that works better for Oz because our population in total is so miniscule compared to the US. A Federal scheme in the US would be a nightmare.

[Frelga]

Can someone explain this to me in small words with pictures? Does Obama's plan mean that consumers will be legally required to carry coverage (or pay penalties?), the insurance company will be required to provide coverage regardless of pre-existing conditions and the taxpayers will subsidize coverage for low-income working families? Is that it?

I know more than working family, which through no fault of their own (layoffs, accidents) found themselves with a choice of paying for insurance or groceries. Guess what they chose. In one case, the family income was $34 above the limit that would qualify them for benefits.

[Jnyusa]

Frelga, here's the link to his plan as it has been outlined so far.

http://www.barackobama.com/issues/healt ... ge-for-all

How this would actually pan out, in terms of who would use it under these terms, is anybody's guess at this point. Personally, I rather doubt that the population as a whole bears much resemblance to the Members of Congress, and what works for Congress might not work nearly as well for everyone else, precisely because of the question that Faramond initlally raised.

[Frelga]

Yeah, but those are long words.

5. Lowering Costs Through Investment in Electronic Health Information Technology Systems: Most medical records are still stored on paper, which makes it hard to coordinate care, measure quality or reduce medical errors and which costs twice as much as electronic claims. Obama will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records, and will phase in requirements for full implementation of health IT. Obama will ensure that patients' privacy is protected

ZOMG! Well, the good news is, I have a whole new work market in front of me. The bad news, if he really thinks he can protect patient's privacy then all I can say is

[Primula Baggins]

Having worked in the VA system, where a patient's "chart" can be a stack of folders two feet high and still lack vitally important information, I prefer the risks of electronic records. When I got sick a few years ago, entire chunks of my medical history were missing because they were on paper records maintained in various specialists' and clinics' offices—and my medical history was not a complicated one. There was no record even of the name of one specialist who had the records, and I couldn't remember it either. They suddenly appeared when I checked into the hospital, which was beginning to put the records from its satellite clinics into an electronic system.

Someone can show up to an ER unconscious, and it is impossible for the physicians and nurses to access their medical records. I am sure that fact kills people on a daily basis.

[ArathornJax]

Found two interesting items on NPR. One is on the German Health Care System and I noticed two things there. Every worker regardless of income pays 8% of their income to the National Health Insurance. Most view it as a social responsibility to do so, even those making large amounts of money. I'm not sure if we have that same sense of responsibility here, and that I believe is part of the issue with elderly care, it is always someone else's responsibility, coming eventually down to the family.

"If I don't make a lot of money, I don't have to pay a lot of money for health insurance," Sabina says. "But I have the same access to health care that someone who makes more money has."
But she acknowledges that nearly 8 percent of her salary is a sizable bite.
"Yes, it's expensive. You know, it's a big chunk of your monthly income," Sabina says. "But considering what you can get for it, it's worth it."
Actually, it's about the same proportion of income that American workers pay, on average, if they get their health insurance through their job. The big difference is that U.S. employers pay far more, on average, than German employers do — 18 percent of each employee's gross income versus around 8 percent in Germany.

In terms of elderly care the German system allows:

In fact, under the country's system for long-term care, family members can choose to be paid for taking care of a frail elder at home if they want to avoid nursing home care.

The article is interesting and can be found at http://www.npr.org/templates/story/stor ... d=91971406

and I think in reading it you can find a major difference in the US and other countries view of the elderly and of the value of people in general. Much more community and socially centered in Europe versus independent and on your own here in the states.

In terms of money, this is an interesting site also:

http://www.npr.org/news/specials/health ... files.html

that allows us to compare the cost of our healthcare with the cost of some of the other major industrialized countries of the world. I think it is time we readdress healthcare in our own country and make sure that everyone, young and elderly, and middle age are covered.

[vison]

This is still a tough thread for me to take part in. But it's an excellent thread.

Though our health insurance systems are very different, it seems that everywhere "the plan" will pay for hospital care but nothing else. And hospital care is the most expensive!!!

It is SO MUCH CHEAPER to assist people to keep living in their own homes, or with relatives. I guess "the plan" is always afraid there will be abuses of some kind. But the worst abuses are the ones Jnyusa describes, yes, JaneFondaJnyusa, I KNOW you're right.

An old lady I know told me she wasn't afraid of flying. "If I die in a plane crash, at least I won't have to go to a *&^%$#$ nursing home." It's the worst fear anyone has, I can tell you that.

[Primula Baggins]

There are programs at the state and local level that make home care possible. I know in this state you can get a Medicaid waiver that allows you to continue to live at home and get the care you need. Medicare covers hospice care, which in this state is mostly given at home.

My grandmother had that Medicaid care to the end of her life (at 87) and died peacefully in her own bed, with a caregiver sitting with her and holding her hand. (It all happened within a few minutes, in the middle of the night.) That's what I want.

Home care is almost always cheaper as well as better for the person being cared for. That hasn't escaped notice, and if the universe is sane at all, we will see home care become easier rather than harder as time goes on.