Sunday, July 22, 2007

Nursing home care in the US, and gaming the system to get on Medicaid

The health system in the US is set up to deliver acute care quite well, and chronic care very poorly. (Admittedly, other Western nations with aging populations are runing into the same problems.) Medicare is the universal health insurance that covers the elderly, and it isn't set up to reimburse properly for chronic conditions, either.

There was one hospital that set up a telephone disease management program (calling patients to ensure they were taking their meds and to check their health), that successfully reduced hospitalizations. This would have saved those patients a lot of unnecessary discomfort. However, the hospital was being reimbursed fee for service - perform a service, receive a fee. Fewer hospitalizations meant less revenue. The program was discontinued.

As I said, Medicare covers elderly Americans. It is almost ridiculously easy to qualify for, and it was designed that way. However, it was designed in the 1960s. People today have a lot more chronic conditions (heart failure, diabetes, cancer, etc). Medicare doesn't pay for nursing home care, which many seniors have to have if they are frail and their children are unable to take care of them (and trust me, that is very stressful, especially for working adults).

Medicaid does cover nursing home care. Medicaid is the safety net insurance for the poor. It doesn't pay much to health care providers, and you do have to be poor to qualify. The Federal government (national government, as opposed to state governments) requires Medicaid to cover anyone under the Federal poverty level. Each individual state runs its own Medicaid program, and they can mandate their own coverage categories that are more generous than Federal categories if they choose. Medicaid does cover nursing home care.

Medicaid is supposed to be for the poor. However, a lot of seniors require nursing home care, which is expensive. And they are often willing to "spend down" their assets in order to qualify for Medicaid. For example, they can transfer assets, like homes, to their children ahead of time. That is basically gaming the system, and the Wall Street Journal has an article detailing how you can do so. This is cheating. The law was written with some loopholes, so what some seniors are doing is perfectly legal, although from one perspective, it is unethical. Medicaid is for the poor. Seniors with some wealth who game the system are essentially stealing resources that society should be using to care for the poor (although Wall Street Journal typically doesn't give a shit about the poor).

However, in reality, I am hard pressed to disapprove. One of the compromises that democracies make to ensure freedom is that they often move slowly on policy. The US is moving very, very slowly on policy that will ensure proper chronic disease care and senior care for all its citizens. And nursing home care is very expensive.

Pray for us as we reform the system.

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