Thursday, February 26, 2009

Personal follow up to how we die

First, I'd rather go quickly. I guess that means cancer, although I assume that dying in one's sleep leads to a similar health profile.

To recap, about 20% of Americans die of cancer. Deaths here peak around age 65.

Organ failure kills about 25% of Americans, and peaks around age 75.

Slow decline kills about 40% of Americans, a lot of them beyond age 85.

Other rich countries can expect similar results, except that Americans tend to have a comparatively high rate of chronic diseases. Presumably a lot of these end in death type 2. Better prevention and treatment of chronic diseases should reduce the number of such deaths. America will reform her health care system, and she will better prevent and treat chronic diseases in the future.

Presumably, that leaves more people dying from slow decline. That adds a financial burden to families and individuals. Given that American families are decreasing in average size, that's more burden shared by fewer individuals.

Long term care insurance is still young in the US. You need to buy it early. You need to pick an established name that you're sure will be around for a long time (snide remark: in this financial crisis, who knows how many insurers will go under?).

A large part of LTC financing in the US is done through Medicaid - which is supposed to finance medical and public health services for the poor. The elderly often need to spend their incomes down to qualify for Medicaid. One has to ask if they're crowding out the actual poor, since LTC is expensive.

In aggregate, the US spent around 36.6% of the FY 2006 Medicaid budget on LTC. Hat tip to the Kaiser Foundation's State Health Facts. LTC is not solely used by the elderly - I'm a brain injury survivor and had to use some LTC services - but most of it is. Kaiser's data shows that the US spent 43.7% of Medicaid LTC dollars on nursing homes, which are mostly used by the elderly and 40% of Medicaid LTC dollars on home and community based services, which are mostly used by the elderly.

Medicare is very acute-care oriented. It pays for almost no LTC services (except, I believe, nursing home care shortly after hospital discharge). Yet, since Medicare serves the elderly, it would make sense, organizationally, to put LTC services in Medicare.

The US has not thought of a coherent way to pay for long term care services. It will need to do so. In Singapore, LTC services are paid out of pocket. Family members become caregivers. They also hire maids from countries like Indonesia and the Philippines; Singapore has no minimum wage law, and the maids are paid what some would see as near-slave wages. Singapore's LTC insurance market does not, to my knowledge, exist yet. I'm not sure that's a coherent response, either.

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