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Long-Term Care

By Rich Joseph
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Now that I am deep into my first year in medical school, I understand the push to go into a sexy specialty like plastic surgery or interventional radiology. It pays better, it sounds cooler, and there is a better food selection at the interest group info sessions! The drive towards specialization starts as soon as you walk into medical school, and it is easy to get sucked into the hype without realizing that you are becoming part of the problem, rather than the solution to America’s health woes. The technicality and specialization of American health care is one of its great assets, but also one of its major pitfalls, and it is unfortunate that medical education perpetuates this trend. Of course, if you have a rare type of cancer or genetic disease, you are in good hands at many major academic medical centers here in the U.S. But what if you are one of the million of Americans struggling with a variety of chronic conditions that require constant management and coordinated care? As statistics show, you may as well just be in another country, and actually, you may in fact fare better seeking care outside the U.S.

Although this is not a revelatory observation, I bring this up with particular concern for the elderly population, which is the fastest growing demographic here in the U.S.

We must remember that in our drive to find innovative cures for disease, the result is the preservation of health, which is also an extension of the road towards death—two sides of the same coin.  The difference between preserving health and evading death is a charged philosophical debate that is lurking deep at the core of our health care woes. For now, I will happily pass on touching this issue, but I would like to point out that as we continue our advances in treating diseases, a result will be an increasing elderly population. This is just simple math—when more people live longer, the number of people who reach old age increases. And since none of us have been successful thus far at avoiding death (it is on my to-do list), an extension of this reality is that the elderly population will require the lion’s share of our health care resources. Unfortunately, we have designed a medical system that is great for the quick fix, but deplorable at managing complex conditions that involve not only physiological, but socio-cultural, mental, and age-related etiologies. Over the next few decades, rates of dementia, frailty, and sarcopenia are guaranteed to explode. For such multi-factorial conditions, for which there is no cure, the inevitable struggle will be to provide love, care, and support for elderly patients without saddling their loved ones with the crippling costs of long-term care.

This month, health reform faltered and took a step backwards in properly addressing this issue of affordable long-term care.  Tucked within the 900 pages of the Affordable Care Act were 20 pages devoted to the Community Living Assistance Services and Support program, or CLASS Act for short, which was intended to provide a benefit which averaged at least $50 a day ($18,000/year) for long term care insurance.  Although the measure passed along with the ACA legislation, it passed with an amendment that it must be self-sustainable for 75 years. Considering that a certification like this is not even possible for a program like Medicare right now, the program was virtually dead on arrival. By allowing anyone—particularly those with serious health conditions—to sign up for the program and receive infinite benefits after paying premiums for only five years, the program would have been bankrupted by adverse selection without huge government subsidies.  The problem, of course is that more than 10 million people here in the U.S. have long-term care needs and that number is guaranteed to rise dramatically as the baby boomer generation comes of age. While most people believe that Medicare covers the cost of long-term care, Medicare actually stops paying nursing home bills after 100 days. Those in the middle class, who do not get assistance through Medicaid or who do not have the resources to pay for services out of pocket, hang perilously in the balance of providing for themselves while covering expenses for the care of aging loved ones.

One of the major tasks for health reform over the coming years will be to empower middle class families to provide affordable long-term care for loved ones, absent the perpetual worry about crippling costs. It is simply not right to demand hard-working people to choose between their own sense of financial security and the long-term care of loved ones who brought them into this world. This may well feel like a choice between life and death itself for many, and rightfully so. Right now, given the current political climate, it seems politically infeasible to introduce a new CLASS act legislation that restricts enrollment to healthy people, limits payouts, or eliminates subsidies in order to maintain solvency. Rather than wait for policy to make the first move, it seems that the health care community must take a lead in expanding access to long-term care. Just as we as individuals feel morally compelled to care for our loved ones as they enter old age, we as health care professionals must do our share in serving our elders. Whereas this responsibility is interwoven into the cultural fabric of many societies, such is not the case here in the U.S.  We have an opportunity to change that by focusing part of our time and energy into the local VA, putting in time at nursing homes, or seeing elderly patients in the clinic. If we all do not help to shoulder some of the responsibility, this asymmetric demand for health care will not only threaten the health care system, but the very essence of our commitment to caretaking.  

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