NYT ran a story this weekend about the practice of “spousal refusal” — that is, one spouse refusing to pay for the other’s long-term medical care (think nursing home) so that the ailing spouse can have the care covered by medicare. Which it otherwise wouldn’t be if they have assets of more than $110,000. (Assets including, you know, the money you were planning to live on for the rest of your life, since you’re retired, and stuff.) Nurse and lawyer take a look at some of the complexities of this practice — which seems heartless, but then, so do the alternatives, no?
Nurse: Yikes! Well, my first instinct is, can you blame ‘em? The cost of nursing home care is so outrageous, and it’s true that medicaid pays less than a regular consumer, so I totally get the instinct. If you’ve saved your whole life for a comfortable retirement and then you are basically S.O.L. because your spouse has a particular kind of illness that medicare won’t cover the cost for, that is pretty lousy.
Lawyer: I wonder if the consequences of signing a refusal form like that are limited to health benefits, or if they endure or extend. (In other words, is there some kind of “penalty” you end up paying?)
It also made me wonder why the man in the story who was being sued by the state hadn’t just transferred more of his assets. If the whole point was saving for the next generation, couldn’t he have avoided the problem by giving as much of it to his children/family as he could (depending on tax situation?) I’d also note that surely that suit could settle for far less than the cost of the care, making this kind of thing economically efficient for the refusing spouse.
Nurse: The counter-argument presented in the article talks about millionaires gaming the system. . .which I see is possible, but probably not really the issue. It’s more about people who made a lot of sacrifices to amass some savings who are never really going to see it now. I don’t think it’s really a good thing to essentially “cheat” this way, but what you are allowed to keep and still be covered by medicaid isn’t super generous. . . and it sort of discourages saving, in a way.
Lawyer: Sure does. (If we assume that people are thinking about this and planning for it. Which some people are.) Why don’t they raise the amount of savings you’re allowed to have, and still qualify? It’s $110,000. That is… not much, in terms of life savings for retirement. They could set it considerably higher, avoid the “millionaire problem,” and keep people’s savings from being wiped out by catastrophic illness. This is crazy-making because of course spousal refusal is no kind of solution to the huge problems we face. And it might seem to make our health care budget crunch worse. But for the people facing the choices at the time, they have to do something.
Nurse: So. . . let’s reform the system! (that is apparently my standard answer, no?). You know what’s cheaper than nursing homes, has better outcomes, and better patient and family satisfaction? Home care! Day programs! There’s a place for nursing homes, we need them. . . but they aren’t the only option in a lot of cases, but they may be the easiest to set up, or the only one that has some insurance benefit.
Lawyer: Love it! The problem isn’t refusal — it’s that the cost of care if way too high. The article mentions that in New York, home care is covered by the same kind of benefit. I wonder how the decisions get made — I imagine it’s not by the patient/family, given your info on satisfaction.
If you were going to design a policy, how would you do it? Who gets home care and who goes into a nursing home? By disease? By preference? By. . . what? Are the decisions made by people who have financial incentives one way or the other?
I like this solution because it seems like it shouldn’t be controversial. It… works better AND costs less? AND doesn’t involve letting a government official appear to be making very personal decisions for you? But then, we’ve had all kinds of good ideas that can’t get any traction. The political system is busted. Beyond belief. Excuse me while I go bang my head against the desk for a few hours before I start working on solutions that won’t involve congress.