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EDITORIAL
Op-Ed; Seniors can't rely solely on Medicaid
THOMAS M. KEANE

02/28/2003
Boston Herald
All Editions
029
(Copyright 2003)

Gov. Mitt Romney's plans to restructure health care have more than budgetary implications. They involve fundamental changes in philosophy - particularly when it comes to the care of the elderly.

Just under 10 percent of senior citizens (those 65 and older) in Massachusetts are poor. But well over 75 percent of those admitted to nursing homes have their care paid for by Medicaid - the joint federal-state program that is supposed to provide health care for the impoverished.

Medicaid - at least as it relates to nursing home care - isn't a program for the poor. It's for the middle class.

That's the same middle class that is cheering as Romney vows to make welfare mothers with pre-school children work 20 hours a week and is thrilled when he holds the line on new income taxes.

Will they still be clapping when he takes mom or dad off Medicaid?

Medicaid was supposed to be a small program, designed for only the very poor. Created in 1966, it originally covered only 4 million. Today, it pays for the care of more than 33 million (1 million in Massachusetts).

And Medicaid's growth is linked tightly to changes in the ways we care for the elderly. Where once families cared for the old at home, today we consign the care of seniors to outsiders. According to the U.S. Health Care Finance Administration, 43 percent of seniors will eventually be in a nursing home; many - 25 percent of seniors - stay for a year or more.

And where seniors and their families once paid for the costs of care, today the taxpayers do.

How so? Because people have figured out how to game the system.

The federal government has a complicated set of rules in place for determining whether someone is poor enough to be eligible for Medicaid. But, as radio advertisements for self-styled "eldercare" specialists make clear, there are lots of ways around those restrictions. Those include transferring assets - usually to children - to try to make someone appear impoverished even when she or he isn't.

The budgetary implications of this have been enormous. Medicaid is now the single largest item in the Massachusetts budget (next year it will be $6.5 billion out of total proposed spending of $22.8 billion). Moreover, the cost of Medicaid rises much more quickly than the rate of inflation.

Ronald Preston, head of Health and Human Services for the state, figures annual cost increases are consistently 10 percent to 12 percent. In other words, every year, more and more of the budget gets chewed up in health care spending, leaving less for other programs.

So what to do? One common response has been to cut Medicaid payments to health care providers. That fix is a major part of the Romney administration's plan for the upcoming fiscal year as well. But in the long run (and long run here means the year after), it falls apart. Cut too much and nursing homes and other health care providers close.

So Preston's answer is to rethink who gets covered in the first place.

Other states, such as Connecticut, have begun to move to tighten up their eligibility rules considerably. Preston wants to follow their lead, allowing Massachusetts to look back on past transactions - as much as five years before someone is admitted to a long-term care institution. The goal? Force people to use their own assets to pay for their own care.

But he wants to do more than just that. Preston wants to follow the example of other states, such as Maine, which demand that someone must be severely impaired to get Medicaid reimbursement for nursing home care. And he wants to push people out of nursing homes and back into their own homes, relying on non-institutional care - such as home health aides and day care - when it's really needed.

All of this may sound good on the surface. But if government isn't paying the freight and nursing homes aren't housing the elderly, then children, relatives and neighbors need to pick up the slack.

And that's something we don't want to do.

As Preston says, "Every poll that has been taken everywhere shows that the general public feels entitled to inherit their parents' Mercedes, bank accounts, homes and every other thing, and that the state government should take care of their parents."

In other words, fixing Medicaid is about much more than saving some money.

It means an entirely new way of thinking, one that thrusts responsibility for the elderly back onto the shoulders of adult children and relatives. It hearkens back to idealistic values of family, community and mutual support.

Many will doubtless argue that Preston's goals unrealistically run against the culture of today's world, where people see themselves as autonomous and unconnected to one another. Yet, one can't help but think he is right: We, not government, should be responsible for our parents.

Tom Keane can be reached at tomkeane@tomkeane.com.