One more inappropriate, but desperate admission. An 86-year-old woman with advanced dementia whose husband, of equal age, could no longer care for her at home. So he called 911, and there she was in the Emergency Department, with minor symptoms, not technically warranting an inpatient admission, but not safe to go home. So we admit her, enlist the aid of the case manager, have many discussions with husband, and try to figure out the best “disposition.” It is a terrible situation.
The health care team is caught between insurance and hospital rules, families’ needs and expectations, and ultimately wanting to do what is best for the patient.
Sadly, we can’t always do what is best for the patient. Cost is a limiting factor. Many people don’t realize that Medicare does not pay for long-term assisted living, memory care or nursing home care. It will cover, up to certain limits, skilled nursing care following an inpatient admission of at least 3 nights, for appropriate conditions, such as the need for physical and occupational therapy before the patient is strong enough to return home. Medicaid will pay for nursing home care, but patients need to essentially be bankrupt to be eligible, and these benefits vary by state. Medicare will cover hospice care, for those who are nearing the end of life and who therefore forego curative treatments in favor of comfort care.
For the rest of the frail elderly, care in facilities is reserved for those with the ability to pay. And what this ends up costing is shocking, and for most people, impossible. It means these average national costs (in 2016):
§ $248 a day or $7,441 per month for a semi-private room in a nursing
§ $279 a day or $8,365 per month for a private room in a nursing home
§ $133 a day or $4,000 per month for care in an assisted living facility
§ $24 an hour for a health aide
§ $23 an hour for homemaker services
§ $78 per day for services in an adult day health care center
Consider that the average length of stay for residents in assisted living facilities is approximately 28 months, at an average total of $112,000. And according to the National Center for Assisted Living, 59% of those residents will eventually need nursing home care, where the average length of stay is estimated at 835 days.
This stay would result in a whopping cost of $207,080 for a semi-private room.
Our lives have changed dramatically to necessitate this outsourcing of care. Families used to be larger, with more children available to help with care of their parents. Family members tended to live near each other, but that is no longer the case. And more women than ever are working outside of the home. So providing care for aging parents has become increasingly difficult.
This often leaves the burden on the spouse (if there is one), who is also frail him- or herself, which is the case with the scenario presented above. The couple lives in a rural area an hour outside of the closest large healthcare facility and city. The choices are hard and limited—maybe hospice care with a private aide a few hours a week. That is all they can afford.
Recently, Sen. Bernie Sanders reintroduced his Medicare for All bill, which would create a single-payer universal health care system in the US. One of the main differences of this new bill from his previous bill is the inclusion of some long-term care (LTC) coverage, namely home and community-based services. Institutional long-term care would still remain under Medicaid. The Medicare for All Act of 2019, introduced by Rep. Pramila Jayapal, would include institutional LTC. This past week, the House Rules Committee held its first-ever hearing on this act to start the process of determining how to best provide universal and affordable health healthcare.
We still have a very long way to go before either or any of the bills being proposed in the Senate and House, or by other presidential hopefuls sees the light of day.
To be sure, not all long-term care is excellent, but continuing to publicly underfund it is not going to solve that problem and may contribute to it. But until that day, the best option at this time (for the majority of Americans who do not meet the criteria for Medicaid long-term care) is LTC insurance. Currently, only about 7.2 million Americans have LTC insurance, which covers many of the costs of in-home, assisted living, or nursing home care. Stand-alone LTC insurance policies are available from only about 15 companies nationwide. As with life insurance, the earlier one applies, the lower the premiums. For a couple at 55 years of age, the annual premium is estimated to be about $2,100. Initial premiums at age 65 are 8-10 percent higher than for those at 64. It is best to purchase insurance through an employer—often no medical exam or questions asked at initial enrollment, or a large organization. People need to start planning well in advance, which is not easy for many families with competing expenses. Unfortunately, without this planning, they may be left with few options when assistance is needed.
We can also dream of a day, when an “Affordable Nursing Care Act” or a “Medicare for All Act” is enacted by Congress and people can rest assured of that their future will include affordable and high quality nursing care if and when it is needed. Until that day, planning is key!
Fern R. Hauck is the Spencer P. Bass, MD Twenty-First Century Professor of Family Medicine and Professor of Public Health Sciences at the University of Virginia, Charlottesville and is a Public Voices Fellow with UVA’s OpEd Project. The views expressed herein are solely those of the author.