How The Republicans Plan To Destroy Eldercare

Most of the Paul Ryan budget chatter is about its plan to privatize Medicare into a voucher system that would fall thousands short annually for the average beneficiary. (I'll leave aside the fact that for "no new taxes" Republicans, this is a huge new tax.) Although the Medicare privatization is highly unpopular and Republicans are backing away and hemming and hawing, every Republican in the House--save six--voted in favor of the plan, and 40 Republican Senators just voted for it too. It's not impossible that the Republicans will take over the Senate and the White House in 2012, so the future for Medicare is more than Ryan's hope.

There hasn't been too much of a tumult about Ryan's plans for Medicaid, which will devastate our elder care system. Maybe it's because Medicaid is welfare. It's our safety net for people and families whose incomes are close to the poverty level. Poor people vote at much lower rates than old people--those old people not in nursing homes. Medicare is also seen as a middle-class benefit. You get it because you pay into it with a 2.9 percent payroll tax. People feel entitled to that entitlement. And they vote.

A huge portion of Medicaid goes to millions of people who have lived most of their lives in the middle class, but have to impoverish themselves in order to afford long term care in a nursing home. The average nursing home costs $72,000. The median household income in 2007 was $31,111. So, few can afford a nursing home out-of-pocket. In most states, you can, in effect, impoverish yourself by spending-down--disposing all of your worldly goods and if your income is low enough, that is, you're on Social Security, and not much more, the Medicaid program will take care of your $72,000 annual nursing home nut.

In 2006, $178 billion went for various types of long-term services. Medicaid accounts for 40 percent of that. Over 3 million people, in 2009, according to the Kaiser Family Foundation, 7 percent of the Medicaid population, received aid for long-term care. This long-term care includes both institutional and home-based care, which is becoming a bigger portion of the Medicaid program. In 2009, 57 percent of the $122 billion Medicaid long-term care budget went for institutional care, and 43 percent for home-based care, compared to a 87 to 13 percent split back in 1992. Among the 1.4 nursing home residents, approximately 70 percent receive a Medicaid benefit.

For nursing homes, this is still not adequate. A report by the American Health Care Association concluded that, in 2010, for every dollar spent on a Medicaid resident, the Medicaid program reimbursed 92 cents. Overall, this was $17.33 per resident per day shortfall, or, in the aggregate, $5.6 billion.

Ryan's budget will make things go from bad to worse. His plan would affect Medicaid in two ways. First, it would repeal the Affordable Care Act, i.e., "Obamacare," which plans a hefty increase in Medicaid. Second, it would convert "existing Medicaid financing from open-ended, matched federal spending on behalf of eligible individuals to a block grant. Under the block grant, federal spending would be capped annually and distributed to states each year based on a formula rather than actual costs. The block grant would start in 2013 and grow annually with population growth and inflation," according to Kaiser.

By 2021, block grants combined with a repeal of the Affordable Care Act would yield a 44 percent reduction in Medicaid expenses, $243.5 billion less--a 44 percent reduction.

In a study by the Urban Institute for Kaiser, depending on how much states make up the reduction in funding (don't hold your breath), thirty to forty million people would be cut from the Medicaid rolls by 2021.

Dickensian comes to mind.

The cynical among us might wonder, how could you tell if nursing home care gets worse than it actually is?

And there is something to that.

In 1987, following loads of bad press--unsanitary conditions, abuse, and neglect--the Feds set national minimum standards for nursing homes. The states, which administer these standards on a local level, can choose to exceed the minimum. Per the usual, there is a higher level of state funding in, say, Connecticut than Mississippi. But within the states of Mississippi and Connecticut there is a set level of funding per resident and a mandated number of bottom cleaners per resident. So it doesn't really matter whether you're in New Canaan, Connecticut--the richest town in the United States--or 20 miles away in inner city Bridgeport, Connecticut--one of the poorest--in terms of bottom cleaners per resident. A survey by the Kaiser Foundation concluded that the national median staff minutes per resident day is two hours, twenty minutes. The Medicaid administration itself says that two hours, forty minutes is the minimum level to avoid serious harm to Mom's bottom. But that is the minimum. The preferred standard is three hours. And for Mom's bottom to be fresh as a baby's, the optimum is four hours per day. No state exceeds the optimal standard. Only two states, California and Delaware, surpass the preferred standard. In Virginia and Alabama, Mom's bottom gets only eight minutes of attention each day.

So what would be the outcome? To the extent that people could stay in nursing homes, there will likely be a much greater reliance on chemical restraints, more overcrowding, and even lower staffing levels.

All this might lead to a clash between laws. The same 1987 law, OBRA (the Omnibus Budget Reconciliation Act), mandated not only a minimum level of care but services such as physical, occupational, and recreational therapy.

Forgiveness Essential Reads

How to Apologize, According to a Couples Therapist

The Role of Forgiveness in Romance

What would happen were the low block grants of a brave new Medicaid world to butt up, so to speak, against the requirements of some minimum level of care?

I guess that a government that would reduce care could also lower standards.

Only the other day, Rob Woodhall, a Republican from one of those states already on the bottom of the Medicaid service barrel, Georgia, was asked by a constituent at a town hall about what she should do with reduced government benefits--since her employer provides meager benefits.

Woodall sniped: "You want the government to take care of you, because your employer decided not to take care of you. My question is, 'When do I decide I'm going to take care of me?'"

Unfazed, the woman asked: "Okay, well, so why aren't you leading by example? And go out yourself -- decline the government health plan -- and go to the Blue Cross/Blue Shield, whoever, and get one for yourself, and you'll see how tough it is. You don't have any pre-existing conditions, I guess. You haven't had any life-threatening illnesses like I had last year."

Woodall was unfazed too: "It's because it's free. The same reason I went out to Walgreen's and bought Activon when I don't have any arthritis pain. Because it's free. Folks, if you give people things for free, don't blame them for taking them."

Dickensian, indeed.