The "public charge" test, as a part of federal immigration law, is designed to identify people who are "primarily dependent" on certain government benefits. The government can deny admission to the U.S. or refuse an application for a green card to an applicant whom it determines is likely to become a public charge. In August 2019, the Department of Homeland Security published a new final public charge rule expanding the definition of public charge to consider individuals who receive Medicaid, are age 62 or older, are uninsured or have serious health conditions or disabilities, among other "negative" factors. The Supreme Court issued an injunction to block the rule, but the injunction has been lifted, allowing the rule to go into effect while litigation is pending. The public charge immigration final rule began being implemented on February 24th.
Medicare for All - Game Changer for Nursing Home Residents
Medicare for fall will not only improve the lives of countless Americans, it will be an absolute game changer for millions of Seniors and their families. As a career Patients’ Rights Advocate for over 30 years I have handled thousands of cases on behalf of healthcare consumers. I have been eyewitness to how the health insurance industry and “the system” wreaks havoc with the lives of our citizenry in more ways than I can articulate. Medicare for all will undoubtedly have a significant impact on healthcare consumers of all types. However, nowhere will it make a bigger difference than it will in regard to skilled nursing facilities.
Long-term care, particularly skilled nursing home care, has long been a subject which the majority of Americans and policy makers have simply been living in denial, despite the magnitude of the matter. Today there are a million and a half people living in nursing homes. According to AARP the cost of nursing home care for one person is around $104K a year. As reported by the Kaiser Family Foundation, Nursing home care alone now makes up between 30% and 60% of all healthcare spending in the different states. If things continue as they are, those numbers will continue to increase. It is well reported that the number of people over 65 is projected to double in the not too distant future. Denial simply isn’t going to cut it any longer.
Due to the level and cost of skilled services associated with nursing homes the same insurance industry practices for maximizing profits don’t work. So, in order to protect themselves the private health insurance industry has basically left the building. There are a few private long-term care products out there but they are few and far between. Those Plans are so expensive that they are essentially unavailable to the vast majority. On top of that Medicare doesn’t currently cover nursing home care beyond 100 days. Once the 100 days pass the only available option for most is Long Term Care Medicaid. The result is that over 850,000 nursing home residents are all on Medicaid, funded by tax payers to the tune of $55 billion annually. That’s not good for us or the economy.
Setting aside the drain on our economy, the harm caused to citizens and their families by these circumstances touches the very foundation of people’s lives. To begin with, to qualify for Long Term Care Medicaid people can’t have more than around $2,000 in assets (also referred to as resources). These include personal possessions, bank accounts, investments, insurance policies, property, etc. (One’s primary home, vehicle and some other resources are exempt). If someone has more than $2000 in assets, they need to divest themselves of those items until they reach the limit. This often requires letting go of cherished items or assets that they had long planned to leave to their loved ones after they pass. That trauma alone, in addition to having to go into a nursing home in the first place, is not only insulting, it is unamerican.
If that doesn’t sound bad enough, people who could have otherwise gifted any money or possessions to loved ones would have had to have done so over five years ago. Among nursing home candidates this is known as the infamous “five year look back.” To comply with this “look back” period, seniors and/or their family members are forced to go through an extremely intrusive and exhaustive process. They must gather legal verifications of the persons’ assets and income for the past five years. This task alone can be too much for an individual or their family to reasonably complete. Many end up having to spend even more money to retain an attorney or pay a private service in order to comply with this requirement.
In addition to the Long Term Care Medicaid eligibility limits on assets, there is also a limit on a persons’ income. That limit is also around $2000 a month. This time, however, if a person is otherwise eligible but over the monthly income limit, they can remain eligible if they take steps to apply the excess income towards paying for care. And, each month they must surrender what is called the NAMI, or their Next Available Monthly Income. People are then allowed to keep what is called a Personal Needs Allowance, or PNA. In the end, the total amount of PNA a resident is allowed to keep from their total income generally ranges from $50 to $75 a month. This is nothing short of outrageous.
The above process regarding income limits can and does result in nursing home residents being involuntarily discharged and/or denied needed care. Residents have the option of directly signing their checks over to pay the nursing home, or they can receive the income and then pay the facility themselves. When a resident or their family member/proxy refuses to sign their checks over, the nursing home is supposed to send a bill. Often times the resident may not understand the process, bills may be mailed to the wrong address, or a family member/ proxy may just not pay the bill and keep the money for themselves. If this goes on for any length of time, the resident can compile a bill that amounts to tens of thousands of dollars. Failure to pay that bill can serve as justification for an involuntary discharge or transfer, even though the resident continues to need care. This is not an uncommon outcome for many.
Other serious problems can and do occur because the eligibility determination process for long term care Medicaid itself often takes weeks or even months to complete. Consequently, seniors may remain at risk from not receiving needed care while they wait for the eligibility determination to play out. Or, they may even be at risk from having care terminated, as discussed below. If the person is at home the family may be called upon to endure caregiving tasks that stretch beyond their capabilities. If the person is already receiving care in a facility providing rehabilitation services, the 100-day clock for services paid for by Medicare is already ticking. If the person is going to require services beyond the 100 days the facility must begin the application process for Medicaid early in their stay in order to prevent a lapse in funding. Unfortunately, this often does not happen. As a result, the person may be subject to premature discharge, either back home or to another living situation that may be far from appropriate. These unacceptable situations are not rare and are increasing in frequency.
Finally, there is yet another situation whereby seniors who need nursing home care are victimized as a result of financial coverage for long term care. This time, the end result comes about as a direct result of the intentional conduct and profit mentality of the nursing home owners themselves. In some states nursing homes are allowed to provide both rehabilitation services, known as “short term care,” and nursing home or “long term care” services, all under their single state license. “Short term care” is almost always covered by the 100-day limit under Medicare. “Long term care” is nearly always covered by Medicaid Long Term Care benefits. Because Medicare pays a significantly higher rate than Medicaid, residents are often discharged or involuntarily transferred to another facility at or near the end of the 100 days, regardless of their clinical status. This practice of cherry-picking residents based on payment rates has become a business model for many of the corporate owned nursing homes. The detriment to nursing home residents is immeasurable.
By law, when and where a person is to be transferred or discharged from a nursing home must be based on their clinical care needs. As discussed, residents are instead being involuntarily discharged or transferred based only on their ability to pay. For the frail elderly, an involuntary transfer or discharge from one location to another can be an extremely stressful and even fatal event. Most importantly, consumers and family members have a right to participate in deciding when, where and how this happens. Frequently, residents and/or their family members have no idea this might happen until it is too late. For the past few years discharges and transfers have been the number one category of complaint received by Long Term Care Ombudsman programs nationwide.
If you’re having difficulty understanding any or all of the above, imagine what it’s like for seniors and their families faced with urgent needs for long term care services. Thanks to the denial we as Americans live by, people are more often than not totally unprepared. Perhaps we should have seen it coming as we watched an aging parent or loved one becoming frail. All it takes is a heart attack, a fall, a stroke or the death of a spouse and suddenly people are thrown into life changing circumstances that require life changing decisions. Yet, those decisions are being dictated by others, not by what we think would be best, based solely on what money there is to cover the costs. And before the dust settles people are being deprived of their valuable assets, surrendering their incomes, and leaving their homes.
People we should be celebrating and honoring are being stripped of their dignity and self-worth needlessly. In the words of many of those that I have had the privilege of serving over the years as their advocate, “In the United States of America, how can this be.”
I could list case after case of people who have been devastated by the circumstances I have attempted to articulate. I have had more clients than I care to count who have been separated from their families, sent to unacceptable facilities and living situations including homeless shelters, shipped off to faraway places, lose their businesses, actually become lost in the system or even die. I literally could go on and on.
And so, the question is what difference would Medicare for All under the Sanders plan make regarding all of this. Because the Medicare for All plan acknowledges necessary care as a right and funding is tied to a single source, these kinds of problems will simply go away. Before we throw out the entire concept of Medicare for All because of the potential impact on tax rates or one’s political philosophy, consider the following. Under Medicare for All, people seeking or receiving nursing home care would:
• Be able to access the care they need at the time it is needed.
• Not be subject to a complicated, bureaucratic, invasive eligibility processes.
• Not have to sacrifice their valuable assets.
• Not have to divulge 5 years of their financial history.
• Be able to keep and spend their own income as they choose.
• Not have lapses in crucial services
• Be able to pass on their estates however they so choose and preserve their legacy.
• Not be involuntarily discharged or transferred from a nursing home or sent to an unacceptable placement.
• Be able to participate in the critical decisions being made about their care and quality of life.
• Not be subject to facility ownership cherry-picking residents for profit.
The introduction of Medicare For All is a catalyst for us to educate ourselves about the realities of nursing home care. It is time for the denial we have lived by to end. It is time for the harm being done to stop. There are undoubtedly many good, ethical providers of care out there who have struggled for years to work within the current system. They too deserve the opportunity to focus on what is most important to them as professionals, provide care. It is time that we show our appreciation to those who deserve nothing but the greatest respect. It is time that we shine a light on the current circumstances that go against what we stand for as a country. And, it is past time that we put an end to the inexcusable. It is time for Medicare for All.