Health Care/Joan Retsinas

Long-Term Care Needs Attention Before You Need It

As politicos wrangle over health care, long-term care is missing. Families anguish over long-term care: tomes on caregiver anguish fill shelves. But Congress is oblivious.

In “Long-Term Care in America: The Crisis All of Us Will Face in Our Lifetimes,” John Geyman, MD, a retired professor of family medicine (and caregiver) aims to force that elephant into public discourse.

He marshals the statistics that scream for public action: the number of Americans who suffer from dementia, the number who will need help with “activities of daily living,” who will live to old ages without family who can help. Demographically, some of the putative caregivers themselves need care, as septuagenarians fret over nonagenarian parents. The goal of aging in place at home too often gives way to institutional care (which for 24-hour care may be less expensive). Increasingly older Americans are living alone; that argues against 24-hour home-care. And dementia —whose incidence increases with age — renders most family caregiving all but impossible.

While citing from families’ anguish-driven stints of caregiving, and patients’ own accounts of aging, he points to systemic faults in our political system. The wealth-gap, exacerbated by this President, has left many families financially stretched, with the people at the lowest rung — the paid caregivers — struggling to subsist, cobbling government stipends. This President’s barriers to immigration have shrunk the supply of those low-wage, often poorly often relegating us to poor (profit-driven) facilities.

He stresses the reality: Long-term care is too expensive for most families, whether we construe it as home health care, assisted living, or nursing homes. Yet increasingly we will need such care.

What to do? He promotes Medicare for All, the truly comprehensive plan (no co-payments, with vision, dental, and long term care included) as the solution. Yet whatever statistics on costs the author marshals, the costs of including a blanket “long-term care” may be too high. The Nixon administration had reneged on a more generous nursing home coverage when the first few months of cost overrode the estimates. More recently, Congress rescinded catastrophic coverage (another extension of Medicare), and Community Living Assistance Services and Supports (CLASS), which was designed to help people who become disabled and need long-term services and supports, was dropped from the Affordable Care Act. Congress (and by extension the voters) hasn’t shown enthusiasm for the kind of comprehensive coverage of home health care, assisted living, and nursing home care that Medicare for All would propose. We can more or less predict the demand for vision care, for hearing aids, for cataract surgery; but we cannot predict the elasticity of demand for long term care when people pay nothing out of pocket.

I wish he hadn’t tied hope for a long term care policy to Medicare for All. At this stage I fear that our president will overturn the Affordable Care Act, which has increased the number of insured Americans. (If several states hadn’t decided not to expand Medicaid, the numbers would be higher).

It may devolve to states to tackle long-term care. As the author points out, the state of Washington recently passed a levy that will offset long-term care expenses for residents.

The crucial question, though, is why we as a nation have societally ignored long-term care, even while many of us have struggled with it. Dr. Geyman suggests an “ageist” mindset; but with an aged political elite (president, senators, presidential candidates) that explanation will not hold. Maybe we loathe government-as-actor. Maybe we construe long term care subsidies as a way to insure an intergenerational transfer of assets (which is worth discussing). Or maybe enough of us haven’t taken our individual anguish to our politicians, pressing them for action. This book may do that.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, March 15, 2020

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