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Business as usual

October 1, 2008
by Robert H. Binstock, PhD
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No substantive changes seen in LTC with new president

Dr. Binstock: Not of significance that I'm aware of. It's certainly something that's reasonable to do, in my opinion, considering how Alzheimer's became a movement led by just a handful of people. A man in Chicago named Lester Stone whose wife had Alzheimer's said we ought to do something about this to other people. This “word of mouth” gradually expanded and a group of lay people turned Alzheimer's from being described as senility into being a disease in public perception. They “medicalized” the condition. They've been able to be very effective in getting federal funds for research on Alzheimer's. If you think about it, Washington is populated with what are generally called voluntary health agencies and many of them have very large public policy operations, including the Alzheimer's Association. Think about the American Cancer Society, the American Heart Association. There are tons of these associations. There's a National Alliance for Caregiving, but I don't think it's become much of a strong national political force. The article in the New York Times said there were 9 million caregivers of persons with Alzheimer's. How accurate that is I don't know, but Alzheimer's transcends state lines, class, and income. Sure, the rich can get more help with care, but still it's not an easy situation to be in, both emotionally and otherwise. Anybody who's been through it in one way or another certainly has a bond with someone else who's been through it. Our resources on this are really limited. The costs alone of long-term care ought to unite people for action. The annual average cost of long-term care is getting close to $80,000 per year. New York City has the highest average-about $116,000. I just want to make a point here concerning cost. A lot of people feel that home care is cheaper, but if the person needing the care is appropriate in terms of their functionality for institutionalization, the cost at home is just as great or greater, much to the chagrin of people who keep asserting otherwise. Studies that have been done show this over and over again. My own experience with my mother, with nursing home care and home care, bears that out. It was slightly more expensive at home.

Hrehocik: With so many associations and so much interest in the problem, why hasn't anything begun at a grassroots level to fix the problem? It certainly doesn't seem like there's a lack of interest.

Dr. Binstock: It would take some leadership to ignite some interest and to help people see what their common interests are rather than saying, “Oh, yeah, I know someone else who's going through this.” They're not seeing this as something that can be dealt with through public policy. You need a Ralph Nader or Lester Stone who founded the Alzheimer's Association. Look at T. Boone Pickens. He's got everyone thinking wind turbines. So, I don't know who it is who could lead the long-term care charge. It'll need to be someone with a lot of resources.

Hrehocik: Have you gleaned anything from presidential hopefuls Barack Obama and John McCain on their thinking toward long-term care policy?

Dr. Binstock: I pay a lot of attention, and I haven't seen anything in their debates or speeches.

Hrehocik: What will it take for substantive change in the long-term care industry?

Dr. Binstock: One thing that would be helpful in the way of long-term care reform would be for the federal government to follow the example of some states, such as Ohio, in allowing premiums for long-term care insurance to be deductible from income tax. At present, the only way you can get a federal deduction for long-term care insurance expenses is to bundle them into medical expenses. Generally, you can start deducting when they exceed 7.5% of your gross income. If you have any sort of healthcare insurance, it is virtually impossible for your healthcare expenses to exceed 7.5% of your gross income. Being able to deduct it would be helpful for persons who need long-term care, their families, and for the organizations that provide long-term care as well as for the insurance industry. Certainly, the question of whether the government should have any new program to pay for long-term care beyond Medicaid is a tricky political question. Many advocates in the field of aging have heard this for years. Clinton certainly had this in his healthcare reform bill on a sliding scale if I remember correctly. But the question is, who pays for this, and it would be fair if someone said, “Why should I be taxed to pay for the long-term care of someone? Why don't they use their own resources and when they exhaust those, there's a safety net program called Medicare.” So what's the function of the government paying for long-term care for people who could pay out of their assets and income? Some might say to preserve an inheritance for their children. That doesn't make sense. On the other hand, if you made the taxes part of the social insurance system, say added it into your payroll tax, then you'd be sharing the risk widely, just as we do in terms of retirement income in old age and for Medicare Part A. There are countries that have done this. I think the first one was Germany which has long-term care available as a benefit under its social insurance program. It's funded through part of the payroll tax. Frankly, I think that might be the ideal policy—spread the risk on something that can affect anyone. That would be politically palatable if we weren't in the present environment of the national debt being so high and going higher and higher and the economy going so badly. I think that's the most viable and sensible approach for the future.

Hrehocik: How do you feel about long-term care insurance?