Plan on Growing Old? Then the Medicaid Debate Affects You

Here’s how the various Republican health care bills germinating in Congress might affect Medicaid — and how they could reduce your options in old age.

Comments: 270

  1. So many people haven't a clue about how Medicaid contributes to the care of most of the elderly at some point in their lives. When you add a large influx of babyboomers ( including me) who are just at the cusp of old age, in 12 to 15 years elder care services - and nursing homes and home care services - will be overwhelmed - especially if funding is withdrawn. And if various financial reports are correct, few have savings enough to pay for anything. It's going to be ugly.

  2. Thanks for your long-overdue article. I have agitated for some time to get more of what you wrote in The Times. Nursing home fees and the connection to Medicaid is a critical subject and, as you say, is largely unknown to the ignorant general public. You didn't mention the possibility that relatives, meaning sons and daughters, could wind up being partially responsible for parental nursing home charges. Spread that word around and you will have created a concern that could approach panic in many people.

  3. Thanks. How? Medicaid eligibility does not look to adult children's assets unless there has been a recent gift/transfer, right?

  4. Some states have laws on the books known as filial responsibility laws. They require adult children to help provide for their parents if they are able to. They often aren't enforced but if budgets tighten they might start being enforced more often.

  5. Many of the Trump enabler´s and voter´s of the Republican Congress and Senate will probably die penniless on the streets of their rural communities and cities due to the cuts in Medicaid proposed by the Republican leadership. It´s the price they will pay for willful ignorance and prejudice. As Senator Bernie Sander's has said, ¨We are not a nation of compassionate people.¨

  6. The argument: I want a semi-private room at $82K/year and I want someone else - not related to me - to pay for it has a logical fallacy built into it.

  7. But what is the alternative for people who didn't earn much along the way, lived a long life and have no kids or relatives? I don't mean for this to be a rhetorical question -- I'd like to know what you propose. I don't know of nursing dorms, but maybe they're out there.

  8. Even elderly with kids or relatives may not be able to afford nursing home care, if their kids or relatives don't earn enough to pay for it. And then, of course, if family members are contributing to elderly relatives' nursing home care, how are they supposed to be able to save for their own future care?

  9. A semi-private room is not a luxury; and $82K/year gets you only basic care. Remember that at this point you have no savings or income of your own. You are stuck with the food, clothing, decor and roommate that the facility is able to provide. I am sure that no one in that position is happy to be there.

    And, in fact, the patient *has* paid for it himself. What we are talking about here is insurance. Some number of us are going to burn through our savings because of Alzheimer's or frailty or living to be 90 years old; and, knowing that, we choose (collectively) to have a portion of *our* taxes go to care for the ones who draw the unlucky lottery number. I am praying that it won't be me.

  10. The dog and I visit once or twice a month nursing homes that care for Medicaid and VA clients. She does the work. I just tag along to help her. These are sad places, sad. We do not visit the high-rise, luxury facilities with continuum care. These homes are for folks at the last station on the line who have nothing, just a ticket for the next stop. Most are sleeping, or daze speechless at her, or lie askew under the sound of a television. The staff are somber, leaning on each other's humanity to care for the shadow of the humanity around them: a young man disabled by a botched brain surgery, a veteran weakened by multiple strokes, a man resigned to his wheel chair after diabetes took his feet one by one, the young woman whose elderly parents could no longer manage her care, and a heavy-set man rocking on the piano bench playing the same few chords quietly, but over and over. Think that you can stand alone in the wind of years that grow stronger the closer you approach the source? I tell you, you cannot. You will not. No one has ever. If you will let us, the dog and I will stand with you.

  11. Thank you, Michael, and for some reason it brought to mind 'The Heart of a Dog'. In the meantime, it would be heartless on my part to share this article with my peers. My parent died in a nursing home in Paris which she thought was a small hotel. A widow, her husband left her comfortably off and counting multiple blessings that her son and I did not have to go through this trauma. She was also frightened enough before her descent into dementia.

    Most, or many of the people, where I am staying voted for Trump, or in fairness on The Republican Ticket. A lot of them seem to be ill at a relatively young age. Keeping this latest from Mr. Lieber up my sleeve, and again, you sound kind and considerate.

  12. The odds are good that most of us will die either in hospital or a nursing home. Few will have the blessing to die sleeping in our own bed, in our own home, at a time we choose.

  13. If this is true (and I wonder if the data bear it out), I don't think it will continue to happen in this way. It isn't what people want, and it costs too much. It can't go on like that, right?

  14. Trump voters: Granny WILL be moving in with you. You will be legally responsible for her care, 24/7. For the rest of her life.
    Think about that, please. Enjoy.

  15. No, you are not legally responsible for a parent's care. If you want to put grandma in a wheelchair and leave her at the entrance to an ER, you cannot be thrown in jail or charged for her care. You are legally responsible for your children's care.

  16. Actually, 27 states now have "filial laws" that state if you are financially able to care for your parents, then you must do so. Most states don't enforce those laws, but it doesn't mean they won't at some point in time. The fact is with 79 million baby boomers coming down the retirement pike, the government cannot possible afford to pay for everyone's care. We must get folks to understand that they have to make plans to care for themselves.

  17. Old people - I'm looking at you, Sun City! - are going to be ruined by the actions of the GOP and its candidate (whom they, in huge numbers, voted for, most especially in retiree-laden states like Florida and Arizona).

    These old folks voted in GOP power because the GOP and its standard-bearer were going to reduce their already low taxes. But - voila! - the biggest tax of all, (eliminating their life savings and/or whatever they planned to leave their heirs), is knocking on their doors.

    Will they notice that their finances are falling (into notorious hands) and may not be able to get up?

    Probably not. That is why this demographic is often victim of scams - they never see what is as plain to others as the nose on their face.

  18. Hi Ron,
    Thank you for requesting reader feedback. There is a related issue flying under the radar that urgently needs your attention. One of the tax cuts under TrumpCare is a stealth attack on Medicare funding. i have been hoping someone would discuss this issue as well and not bury it in the final paragraphs.
    Linda Burke

  19. Thanks. Lieber @ nytimes dot com is my email address if you want to share more -- or do it here.

  20. The Democrats are absolutely pathetic at conveying the great achievement and importance that is Medicare and Medicaid. No one under 55 even knows what Medicare is - or thinks about it. Who would? No one wants to consider that they'll eventually get old. A simple explanation about what Medicare does would put across what a truly miraculous program it is. No one who hasn't dealt with an elderly parent who's run through all his/her money truly understands that Medicaid saves them from literally dying on the street. The Republicans are ruthless liars - and that is not fake news. I don't understand how Republicans get away with it, considering the people they hurt most are their supporters. Their genius is that they convince their supporters "someone else" is ripping them off, when in fact it is the wealth-kowtowing Republican establishment, with the president on top of the pyramid scheme. Republicans weren't always this way, but the whole culture of that party has become deeply corrupted and hateful.

  21. I don't know that I've heard any lies about this issue in particular. If anyone sees any about Medicaid and elder/long-term care from either side of the aisle, please post them here or send them to me. (I'm aware that President Trump said early in the campaign that there would be no Medicaid cuts. Somewhere along the way, I think he stopped including Medicaid in his Medicare/Social Security list of things he would not cut. I'm curious to know who revised his script, if anyone knows, and when exactly.)

  22. Excuse me, Madam -- any fool can spend the earnings of others. It is a lot harder, making sure the money is spent properly. Contrary to the Democrats, there is no such thing as a free lunch -- someone always has to pay.

    And raise taxes? OK -- lose jobs. Which one?

    Reality bites. Someone tell the Democrats, please. Thanks.

  23. Yes, B, let's create more Detroits. Heck, USA's already $20,000,000,000,000 in debt, with Asia rising -- why not just keep spending? Whose afraid of bankruptcy? /sarc/

  24. Great column. I'm sure that many of my fellow boomers will sleep a little less comfortably because of the reality you so aptly described. But not here are two factors which may make nursing home care fiscally out of reach for many. First is of course the funding for such care. This has been pretty well covered. Less often mentioned is the cost of such care.

    Thinking of the expenditure for nursing home care ( health care as well) as a giant pie, most of the slices should go to the people who actually provide care, the nurses, doctors and aides, and most of the rest to providing a decent physical facility and operating costs. However when the average CEO of a nursing care facility is paid an AVERAGE of $484,000 in total annual compensation, and elder care attorneys take also their slices, what is left for providing care? When we can get the expenses for people who do not provide a single bandaid or help an old person sip their soup, reduced to more reasonable levels, then perhaps the Medicaid expenses can be reined in and better coverage can be had.

  25. Good point, Concerned Citizen, but what about the expenses for raising children?

  26. Thanks for the article. The Medicaid connection to nursing home charges has been woefully under-reported. Too many people are ignorant of Medicaid's importance in paying for nursing homes. My father tapped out his savings in about two years and then was covered by Medicaid, with no change in care. One point that should be emphasized is the possibility that if Medicaid funds are reduced, relatives of nursing home patients now covered by Medicaid could be asked to contribute. This possible liability, for good reason, would panic many people.

  27. Cutting Medicare will affect everyone, as the cost of elder care will trickle down to the adult children. Can you save for your own retirement AND pay $80k a year for your parent's nursing home? I know I can't.

  28. Three friends in their mid-to-late 60s continue to work and tell me that they may never be able to retire. A childhood friend in Canada, another hard worker but retired, is border-line poor but receives excellent health care.

    If you had asked me in my 20s if I could save for retirement and pay $30k a year for my parent's nursing home, I would have thought you were making a bad joke at my expense.

    Ron Lieber is discussing the pitfalls of cutting 'Medicaid'. Bad news all around.

  29. My husband and I are still working at age 72. But can't save much because we're helping our children. A lot of people our age are in this position. Things are tough all over.

  30. So right on, but don't forget about paying health insurance premiums of $20,000 or so while you care for that elderly relative, save for retirement and get your children educated!! That's assuming everything is going well and no family member develops a serious (expensive) medical problem. Meanwhile, Trump and his fellow billionaires will be partying over at Maralago! Infuriating!!

  31. So interesting, no one wants to talk about divesting. That is people who do have wealth giving family members their assets so they can qualify for Medicaid. Then "the state" needs to pay for their nursing home care - while the kids go on their merry way.

    This is wrong. It defunds the Medicaid supply so poor and disabled will have less benefits if the present legislators continue to prevail with their plans.

    Taxpayers should not be responsible for nursing home care for those that have divested. It's not right.

  32. How, precisely, would you change the loopholes that exist? Which ones? All of them? And do you take every legal tax deduction and accept all tax breaks? (I do, even though I know that 529 plans disproportionately favor the affluent. Should I stop saving this way for college?), for instance Or do you not believe that the two issues exist on the same plain?

  33. Agreed! Perhaps if the government didn't offer to pay for people's care when they get older they'd take saving for retirement more seriously. The fact that there is an entire industry set up where lawyers help people shelter assets so they can qualify for Medicaid and get taxpayers to pay for their care is ridiculous.

  34. I will probably write about this industry too. More/more detailed comments about why this is not akin to CPAs helping you get every tax deduction are welcome.

  35. For Ron Lieber. No obligation now for relatives to help pay nursing home fees, but if Medicaid funds are reduced significantly, relatives could be one possible source of revenue. Now, no such possibility. I believe at one time, years ago, California did look at relatives as a possible source of payment. My brother, a retired county social worker, tells me it was amazing how seemingly very prosperous citizens suddenly became near-paupers, thus evading liability.

  36. In some other countries, there are far more people cared for by their families in some way shape or form, come what may. And a lot of bad things do come.

  37. Also, in some countries, e.g., the UK, care outside the family may cost less. I think state-provided care in the UK is pretty restricted to people who really can't pay for it (and don't believe they have the "asset protection" strategies we have) but have always had the impression from people I've talked to there that care in a "care home" or the like isn't as outrageously expensive as in the US for self-payers (like over $150k a year in NY -- I have been told nursing homes here "have" to do this o make up their "deficit" from Medicaid patients).

  38. The fact that there is an industry that helps people shelter assets from the government in order to qualify for Medicaid, ie Medicaid planning, is ridiculous. No one should plan to go broke and rely on the government to pay your bills. I hope states start enforcing filial laws to reduce fraud in your system. Besides why shouldn't families be responsible for taking care of their parents instead of taxpayers? I think people would plan for their senior years more carefully if they knew their kids might be on the hook for their nursing home bill...

  39. Some people have no family to take care of them. What are they supposed to do?

  40. One of the major problems with our system is the requirement to practically run out of money before Medicaid kicks in. As a pastor I worked with more than one couple in which one needed nursing home care, but the spouse was healthy. Their assets are joint, so the options are terrible. Should they spend down all that they have in order to get nursing home care for one leaving the healthy spouse in dire poverty? Should they get a divorce after decades of loving marriage so that the healthy spouse can hold onto some assets (I knew one couple who struggled with this agonizing question)?

    Old age is a crap shoot. Some will die suddenly without needing a nursing home; some will die within 6 months of entering one (a fairly common outcome); some, though, will spend years in such a place.

    Even with resources and the best of intentions, sometimes nursing home care is necessary. We kept my dad home with live in help for a while, but at age 90 with moderate vascular dementia he was becoming unmanageable at home. We were, in a way, 'fortunate' for while decisions were in process, he had a stroke and died at home. That saved us the painful decision of moving a man who did not want to leave his own home to an institution. It also saved money, as 24/7 home care was definitely more economical. That said, he did not have many physical medical problems - those often cannot be managed at home.

  41. We have legal industries that assist folks navigate all kinds of tax laws not only those pertaining to receiving Medicaid assistance. We also have the fraud and other sad manuvuerings. We have folks who plan, those who do not and everyone in between.

    But our elderly still need care. Even if you have the resources, the miserly ,less generous and kind environment towards our elderly seeps into our culture Money does not afford an escape.

    Very interested to learn what is going on in Oregon.

  42. Thanks much for your timely, and sobering, column Mr. Lieber. During the upcoming Congressional recess, I wish it were possible for you to be booked on every major t.v. network and cable outlet. It is vital that the subject matter you discuss be disseminated far and wide. Millions of American futures depend upon it.

  43. It is always better to have money and be able to pay yourself. Government programs can be cut, or they can lower the costs by cutting the quality. You don't want to be the helpless old guy in the cut-price nursing home.

  44. Jonathon writes, "It is always better to have money and be able to pay yourself." Thank you for those words of wisdom! Now explain how someone earning minimum wage can save enough money to pay $80,000+ per year for nursing home care.

  45. Any ideas about how we can all do that, say, if you make $40,000/year?

  46. @NorCal, Chadwick - Of course they can't. These people are screwed.

    But if you are making $150K or $200K, save as much as you can. I know more than a few people who made big money, and saved little or nothing.

  47. I agree. Since one-in-five Seniors merely on Medicaid to pay their Medicare premiums. So, if Medicaid said is slashed, as expected many of us older folks will deforced to decide between food or health care. Generally, the younger and healthier Medicare participants would be the ones to forego it--choosing food.

    Even those of us--the other 80%--who pay our own Medicare premiums will probably see our premiums jump, the the risk-pool, the universe of Medicare participants, will become more skewed toward older and sicklier participants.

    Health Insurers take-on risk, and protract us from illness and injury. So, in order for them to remain in business, their premiums have to adjust to increasing risks--older and sicker participants--as the pool of participants changes.

  48. Great article Ron. I have been a RN Case Manager for over 25 years, making those referrals and transfers to nursing homes for many patients.
    Many people in this country do not have the amount of savings necessary to pay for nursing home care when they age. Those that did, took in their adult children during the recent recession and supported them. Many baby boomers will be working much longer than their parents to pay for their retirement and healthcare. Families are smaller, and the kids move away to better jobs. It will not be possible to put that burden on the adult children.
    I believe quality healthcare is a right and not a privilege. If affordable health care was available to all, especially those with chronic illnesses (e.g. Diabetes, heart failure, respiratory disease) the cost of treating people as they age would not be so astronomical. The inability to discuss death and dying and how one wants to live out their last years drives up the costs.
    Preventable healthcare, treating diseases early speaks to a single payer system. We already have that in Medicare. Taking the profiteers out of healthcare would allow money to provide more healthcare to more people. It's not impossible but takes innovative thinking and courage.

  49. Excellent points. Like your reminder that many baby boomers took in their adult children during the recent recession. Try telling that to the Millennials who constantly post how everything is the fault of the baby boomers. And that boomers will all be dead soon and that's a good thing.

  50. Ron, please explore the idea you touched upon that by being penny-wise and pound-foolish, society may end up paying more than it has to. The person who can't afford proper assisted living now may become more of a financial burden on society later. Just as insurance companies have recognized that paying for gyms, smoking cessation programs, etc., will keep their insureds healthier and generate fewer health care claims, society should recognize that taking appropriate care of the elderly and disabled may save us money in the long run.

  51. Oregon has led the way here -- I'm going to look and see if there is any data showing how this has worked out for them. Readers, if you have any leads, please send them my way or post them here.

  52. This is a very important point. WHen my mother reached her mid 80s and started to find living on her own challenging she fortunately had a home that had appreciated a lot that she could sell and use the money to move into assisted living near me. Not everyone has that.( By the way, my brother didn't want to let her sell the house -- he wanted to force her to stay in her house in a remote area and die "naturally" --when that failed, she sold the house, and later got sick, he wanted us to take all the money that remained, claim poverty and put her in a nursing home, as "Elder Planning" lawyers would likely suggest).

  53. This raises a really important point, which is that even if the individual/couple plan for their care and agree on it, the kids (if there are any and there are more than one) may not agree and may attempt to influence the outcome in their financial favor. This goes on all the time, and it's not an easy thing to solve for. Families are complicated.

  54. Everyone who has access should check out Tom Donlan's editorial on Medicaid spending in today's Barrons.

    He gives the basic facts: total Medicaid spending is $553 billion, of which $118 billion is long-term care. This number will probably increase dramatically as the first group of baby boomers reach 85 in 2030.

    The substance of the editorial is criticism of the asset-hiding methods used to make large numbers of people eligible, and the looseness with which the current rules are enforced.

  55. Those "asset hiding methods" are what most people call retirement savings. In our on-your-own society, they are essential in order to spin off enough interest and dividends to pay for things like rent and food and even things neither Medicare nor Medicaid will cover for health reasons.
    True, if we lived in a society where everyone got an old age income sufficient to live on - which Social Security generally isn't - one would not need such a large store of assets, and then that money could be put to better use than in the bloated asset markets.
    But that is not the world we live in, is it?

  56. The problem is that the asset hiding is often either being undertaken by or instigated by employable adult children looking to guarantee an inheritance.

  57. An excellent column and long overdue. Now, how can we reach the people who don't read the business section of the NYT, especially reality-denying Trump supporters? The Dems certainly haven't!

  58. Have you talked to Trump supporters? Facts just don't penetrate their brainwashing.

  59. Many of us would rather die than accept this expensive care, which often comes with very low quality of life. More and more of us will have no family and therefore no advocate to protect us from nursing home abuse. We need to make assisted dying more widely available. And there's no such thing as "preventive" care. Just risk reduction and early detection which do not always equate to prevention.

  60. I was waiting to come across a comment like this.

    How much anguish, grief, and ultimately monetary expense (if that's what we're concerned about) would be allieviated if people were given the humane choice of euthanasia to leave this life behind? I wish like a DNR or living will, I had the opportunity to outline the circumstances where I'd like my life to be terminated if I can't do it myself. I have no desire to live in pain, or with my mind gone, let alone burden my fellow humans with exorbitant expenses just to extend the length of my life. I don't want to be saddled with debts to pay for others who have no quality of life, nor do I want others to do that for me. Leave the money for the living, not dying. I fear my body living on when I ought to be dead far more than my life ending. We have to decide if we actually value life: let's care for children and adults, their healthy eating, education, and mental and body care over those who given the choice would rather die.

  61. Ron,
    My experience with elder lawyers is that they have people divest themselves of their assets so that Medicaid will pay for their nursing home. That way their dependents get their money and Medicaid gets the bills. In NY state their is a 5 year look back period and the amount you can divest without paying inheritance tax is 5 million dollars. Perhaps the way to control Medcaid costs is to changes these laws. What do you think?

  62. I think this exactly the right question. Watch this space. And if you have a professional or personal interest in this one way or the other, please drop me a note at lieber @ nytimes dot com.

  63. Ron, great info. I'm in my 60's and I have no health issues, but I'm worried that if I have dementia or I'm hit by a car that affects my ability to think, how can I put an iron clad directive in place so I'm not on a ventilator/ feeding tube for 10 years? I've lived a good life. I've read, once your in the hospital system and you have assets, they won't let you go- you are a cash cow.

  64. Love to have an analysis of long term care insurance. Who should buy it, how much to buy, hybrids versus non hybrids etc. how much assets are needed to self insure. I spent a lot of time with our financial planner who pulled in a LTC broker. We turned these programs upside and inside out. I have expertise in insurance for corporations, but not LTC coverages. Frankly I could not find a LTC package that was that great. Maybe we are missing something?

  65. Google my name and "long-term care insurance." I wrote a lot about it when the cracks in the straight-insurance market first appear. The hybrid life insurance policies seem... complicated. But I should return to this... thanks.

  66. Ron, thanks and I had read your articles when assessing LT C insurance policies. Your article were very helpful. It appears the crack in the straight insurance market have widened since then. It would be great if you would return to this topic in another article. I spent hours analyzing these policies with experts and I just did not see where the current LTC nor hybrids made sense. But I may be missing something.

  67. Agreed, it's time to return to the topic, thanks.

  68. Thank you Ron! I am going to print your article and give it to a person who does not realize the reality of it all, or does not want to realize.

  69. People can stay in their homes or have their children care for them. But sometimes (stroke or such) people need skilled nursing around the clock and that is where it gets very $.

  70. This is sohy on Fred's account. I have worked as an RN for over forty years, primarily either in certified home health agencies or for the last 18 years in a small long term care facility. I am well aware of how these programs work. About half of my current clients are receiving help from Medicaid. Many of these folks could be cared for by children but most children don't want the responsibility of caring for their aging parents, and often times aging spouses are not physically capable of caring for a spouse with dementia.

    Dementia is the primary reason why people enter long term care facilities. Caring for people with dementia, especially in the middle to later stages is very difficult and due to our longer life spans, more of us will be afflicted by some form of dementia if we live beyond our 85th birthday. This is a huge problem which will only get worse as my generation ages. Even for those of use who have what might seem like adequate savings, long term care is not affordable.

    I don't know what the answer is to this pending problem, but I know that I don't want any aggressive care once I reach the point where I am not fully cognizant or fairly independent. Maybe that's where we need to start the conversation. We need to stop thinking of quantity of life and start discussing quality of life and work on what we can do to remain fairly independent until we are very close to the end of life.

  71. What is long-term care? Long-term care is custodial care, which means that we need help with some of the everyday activities of living: eating, bathing, dressing, toileting, continence, and transferring (mobility). Or, because we are cognitively impaired, we need guidance.

    Custodial care is different from medical care, as you can see. I may need help because I am weak, for example, or unsteady on my feet--but I do not need to go to my doctor for it because this is my condition now, and the doctor can't cure it.

    Most Americans do not have a plan to handle long-term care needs. They mistakenly think that Medicare will take care of it. And now, the real backstop--Medicaid--may not help us either.

    Some plan is better than no plan. Accepting individual responsibility for planning is the first step. There are only three ways to pay for long-term care expenses: private money, long-term care insurance, or Medicaid. If Medicaid will not be an option, how will you pay for your long-term care?

    Time to make a plan.

    Jim Robertson, lifelongcarenetwork

  72. My grandfather died 18 1/2 yrs. ago - at 97 - after spending 1 1/2 yrs. in a nursing home. He had severe dementia and his physical condition had also deteriorated significantly. He'd carefully saved what seemed like a lot of money - in order not to be a burden to his family and to also leave us some money - but most of it was used to (private) pay for the nursing home. It was supposed to be one of the better nursing homes in the (D.C.) area - and if so, I'd sure hate to see the worst....

    Six months later, my husband & I (then 47 & 43) decided we'd better take out LTC policies. We don't have children, but we were very worried about potential payments for private-pay aides wiping out our (eventual) retirement savings and therefore possibly leaving whichever one of us survives the other one nearly bankrupt. After observing my grandfather's experience at the nursing home, we most definitely didn't (and don't) want to ever end up in a nursing home.

    We have a very good LTC policy because we were young and very healthy at the time of its inception, but it costs a small fortune and naturally we must pay for it forever. This year there was a big increase (for the first time) - and they legitimately obtained permission from NY State - because people are living longer and the company must remain financially viable. Still; we would have to pay 50% of the aides' cost, and that could still "wipe us out" financially if we each required many years of (separate) care.

  73. Lots of good points in the article. But perhaps a different perspective would be helpful.
    - if we do nothing, the federal medicare and medicaid programs will not be here in our future. The current funding / benefits gap is simply not sustainable. Some may rather raise taxes than cut benefits, but that has other negative consequences.
    - The health care bills currently on the table seek to move the provider of health care from the Federal Government to each state. Currently it's about 90/10 and the goal of the current Senate version is to get it closer to 50/50 split - which is consistent with much other spending. Many people want to see spending decisions made locally rather than by a federal government that has different perspectives. Again, pros and cons of this approach but the portrayal of spending cuts (by the Feds) need to be balanced by the expectation of state increase. Obviously many states will not be able to sustain this fiscally without major changes.
    - Money is a limited resource. Therefore some sort of cap in terms of spending is necessary. Basic Economics. The current law has no caps on spending. Another fact that makes it unsustainable. Limited resources mean that there have to be hard decisions made - which in turn means that someone has to lose and someone has to win. Choices have consequences. Sorry but unless we invent a way unlimited funding, some will have to suffer.
    Just some alternative perspective to the discussion.

  74. Thanks. The federal government does not pay 90% of Medicaid. It's more like 60% I think -- the poorer states pay less and the richer ones pay a bit more. The feds do set rules for what Medicaid must (nursing homes) or can (community/home-based care) cover, but they do not provide the care -- there are no federal nursing homes or hospitals that I know of save for the VA.

  75. Excuse me, Ron -- isn't it working taxpayers who pay, with their taxes? Last time I checked, the government was a bunch of buildings and workers with better benefits than most Americans.

    You may think that is picking nits. Well, visit the post office on April 15, please. Thanks.

  76. This TrumpCare (talk about an oxymoron!) plan IS the Death Panel the Republicans were talking about with the ACA. The Dems should make that perfectly clear.

  77. The only facts you need to know from Kaiser Family Foundation are these: 1 out of 3 of us who turn 65 will end up in a nursing home. Of those people, 62% or more will need to rely on Medicaid to help pay their bills.

    According to the Population Reference Bureau, there were 46 million Americans 65 or older in 2016. It predicts that number will grow to 98 million by 2060. Of course, this doesn't take into account medical advances which might make that number far greater.

    The damage this administration and GOP leadership in Congress is planning on doing to Medicaid will have a damning impact on recipients now and for years to come.

    Nursing home bills don't simply threaten the fiscal wellness of the patient. Countless adult children and other family members will be bankrupted attempting to pay for their care, or unduly burdened by attempting to take care of chronically ill parents in their homes.

    Medicaid isn't a government "handout". It is a services provided to protect those among us who cannot protect themselves.

    In the Preamble calls on the government to "promote the general welfare" of our citizens, not hang them out to dry.

  78. BUt do the Kaiser Family Foundation data also show the average length of stay? I have heard it is generally not years and years, but more like months, especially in the case of women. I would be curious to know if the Kaiser data supports that, as they are a reputable group.

  79. Hard as it is to face, it is inevitable that the baby boomers (I am one) will have to accept that the normal healthy lifespan is about 85 years. Fifty percent of those who make that mark will have dementia. Many others will have conditioins that rob them of life quality. Those who are living miserable lives simply have to timely die, rather than bankrupt society with life prolonging, expensive and utterly pointless treatment.

  80. The 'comfortable' people can plan for their future by having an insurance policy for Long Term Care. No need to wait for the government to do everything for you, Think ahead! Let Medicaid do what it was designed to do and not expect it to stretch it into the single payer plan. The country cannot afford nor do they know how to be in the business of healthcare!

  81. Long term care insurance, as offered by most private insurers, has become too expensive for most middle class people. The upper class people don't need it because they have enough money to pay on their own.

  82. What most people dont realize that coversge is limited even WITH these insurance policies. And the number of companies offering them is DECREASING, since they are not profitable for the companies. Those that remain have raised their prices. While helpful, they are not the solution to the problem. And "comfortable" people will go thru their assets very quickly. My uncle was a doctor, but when both my aunt, then himself, had to go into a nursing home, they quickly went thru all of their assets, including a reverse morgage on their home. Once both were in the nursing home, the bank quickly claimed the home.

  83. My mother was fortunate enough to have long term care. She got it at age 69 when my father passed away. Initially, it was 800.00 a month. By the time of her death at age 90 it went up to 1300.00 a month. My mother was not rich. She was a nurse with a good pension and she also had my father's pension. He worked for the Port Authority for 30 years. Those kinds of jobs and pensions don't exist anymore.

    My mother was able to have 24-hour care at home up until the end but even then the care was not great. My mother lived in Newark, NJ and only one provider in NJ would service here there. Over a 10 year period, we fired close to a dozen aides for stealing, incompetence, or neglect. We discovered that one aide who had been working with her for over a year couldn't read and was giving her the wrong medications at the wrong time.

    Yet, my mother was very fortunate because she did not have to liquidate all her assets and sell her home.

    Only the very richest in our country with an endless supply of assets and money get the best care.

  84. Hey fellow seniors...just wait till those Congressional geniuses (all of whom have lifetime health insurance and generous pensions) come after Medicare and Social Security. Don't say you weren't warned.

  85. Thanks so much for this "health exchange". I spent several hundred hours visiting my mother during her last several years in a nursing home. It was good for her. Stopped her smoking and falling, extended her life I think. However, I observed that few men adapted and lasted long. Too passive for them. A sports room, a stock market room, and a horseracing room would help men abide. Are there relevant stats? As for governments problem with money - our economy can afford custodial care for the old. Improves productivity and life quality for prime age people, provides jobs for a spectrum of workers from physicians to cleaners.Medical costs are peaking now but will trend down per capita as people live and eat better, as treatments advance past development stages, and genetic science becomes applied.

  86. Congratulations to Ron Lieber for shining a bright light on a critically-important subject.

    Ron -- I volunteer for the Medicare Rights Center and I'd be thrilled to help you dig out and publish information on all of this. PS, I am an Amherst alum.

  87. Thanks! You'll be hearing from me.

  88. Great article and long overdue. Now would you write something about how the ACA affects Medicare. As I understand it, it does.

  89. The anti-male bias in this article is sickening, it is not even perfunctory, it is deliberately going out of its way. I certainly will not read on after that, and having spent my life with ongoing ridicule and venom spewed at me because the few top executives tend to be mainly male.

  90. Is this directed at me, Ron? Or is it from some other piece and it randomly ended up here? In many older couples, the man is older. And men die younger. Which means more often than not, women take care of men. If the money runs out before their days on the planet do, well...

    That's the only reason I mentioned gender here. Sorry for any offense caused.

  91. I just came back here after reading the article about Pence not meeting with women alone. Lots of anger in the comments over there. Sounds like this was meant for that area and not this one.

  92. It amazes me how little lower to upper middle income Republicans understand about what Mr. Lieber and many others are saying about the grim future they face as the result of what our Republican run government is trying to do to dismantle Medicaid and their ability to get adequate health care now and in the future.

    Unless information like Mr. Lieber's gets through to millions of unaware voters, they will not appreciate the safety net that protects them until they fall without one. Charities will only be able to pick at the edges of this worsening health care nightmare.

  93. The Republicans may not understand much about this legislation, but believe me, when the time comes REpublicans are among the sharpest at figuring out how to get someone else to pay for their parents' care.

  94. Thank you for finally stating the obvious: that it is much cheaper and better for government to support in-home care for the elderly than nursing homes. For years, the home health industry has been trying to get this argument across to members of Congress and state governments with little success.

    The reason for the failure, frankly, is that the industry hasn't had enough dollars to spread around as campaign contributions. The hearing of legislators suddenly improves when campaign dollars accompany the discussions. Because of this lack of clout, many home health providers don't even participate in Medicaid because the slim government reimbursements for such services don't even cover their costs.

    Journalists have also largely ignored the efficiency and quality of life available through in-home elder care. They have preferred to focus on sensationalizing the isolated incidents where a home health aide is accused of stealing grandma's jewelry.

    So, thank you, Ron Lieber, for highlighting something that many of us have known for years. If we took all the money spent annually on nursing homes by Medicaid, individual families and long-term care insurers, it would probably be enough for Medicare to offer a new, in-home care benefit to all elderly Americans.

  95. Not in New York it isn't. There are people here on Medicaid who get 24 hour home care, which is more expensive than nursing home care. I am not saying they shouldn't get it; I am just saying it is not cheaper than nursing home care.

    For people who don't qualify for Medicaid, say are more "middle class," and want some in home care, even 4 or 6 hours a day, it can be terribly expensive here, and what drives people from middle classes to lower classes, and ultimately either out of state to some place less expensive, or perhaps just into a local nursing home.

  96. And of course no government program is way cheaper than anything. Not that I am proposing that but insisting that there are only a limited number of solutions is foolish.

  97. Maybe I wasn't clear enough Ellienyc, but there are many cases where the elderly could function well in their own homes (including not needing 24-hour care), but they are shunted into nursing homes because there is no other choice if relatives can't or won't provide the care or if the family can't afford assisted living, which is not covered by government programs, except in certain circumstances.

    There is no in-home care benefit for Medicare that is not tied to a medical procedure or to hospice, but there should be. There are many cases where older people could stay in their own homes and receive adequate help for daily functioning that would be far cheaper than institutional care. No, I'm not talking about a 24-hour home health aide at $20-$25 per hour. I'm talking about a set number of hours a day or week in which an aide would help with cooking, cleaning, bathing, toileting, medication compliance and checking vital signs. This could be a new Medicare benefit that would cost far less than nursing home care in NY, which I believe is well north of $10,000 a month these days. It would help to relieve stress for many families with limited time and/or incomes and for the elderly who are still too alert to endure a nursing home.

  98. Those who need nursing home care in BC are not required to lose everything to qualify. They are charged according to income, from 0 to sometimes $50K or more, depending on their annual incomes. But they don't have to drain their savings or sell their homes. This seems like a fair plan to me.

  99. NY state, as a result of ACA Medicaid expansion, made some money available for in-home care for seniors. Moreover they extended funds beyond charitable organizations to for profit service providers. Early results show that keeping seniors in their own home lowers total care costs, and has better patient outcomes.

    The basic "philosophy" of the ACA is that regular, secure, access to healthcare at any age improve health outcomes and system costs. In country after country with universal healcare, that's the experience.

  100. What will happen to nursing home residents on Medicaid if this bill passes? Will the family's get billed? Will they get put out? My 94-yo Dad is in a nursing home on a trache. He never recovered from an infection 6 months ago. He has not been approved yet.

  101. I do not believe anyone will be put out in the street. The cuts won't come fast and hard enough for that kind of crisis to emerge that quickly, if anything like the current proposals pass. But things will change for people who are 5-10 years away from needing care.

  102. I think what it mostly boils down to is states will have more limited amounts to deal with and at some point in the future may have to decide what they are going to continue funding. I agree it is unlikely to affect your father, and don't believe they can bill the family, at least not yet.

    I believe the proposed federal legislation also places a cap on the amount of home equity exempt in determing Medicaid eligibility -- think will be around $500,000 -- but am not sure of that.

  103. Good thing that guns are legal and retirement plan going.

  104. I'm booking a flight to Switzerland for assisted suicide as soon as I'm diagnosed with anything terminal. You need to be lucid to do this, but I will NEVER go into a nursing home- I would rather have my children spend the money than stare at the ceiling day after day.

  105. But David Devonis, who is going to pull the trigger? Will you for yourself "at the right time"? And will you be able to? Will you be able to for your loved one or friend? And if you do this for your friend or family at their written and notarized request will you be prosecuted?

  106. Genworth, quoted in the article and a key provider of Long Term Care in the US, has now begun increasing premiums to the point of forcing many elderly to cancel their coverage (after decades of faithful payments). This is creating an economic bomb ready to go off and most state insurance agencies would rather not talk about it.

  107. Yes of course such care and its use is larger than insurance companies expected, In fact I expect such insurance to disappear as it is basically impossible to estimate the future costs.

  108. Personally, I think ltc insurance has become a waste of time to even think about, unless perhaps issued and guaranteed by a public entity, like a state.

  109. Exactly what happened with my parents. Genworth has capped their reimbursement at the amount they paid into their accounts for several decades, but getting Genworth to agree to pay for anything at all has been a nightmare. The company sends someone to re-evaluate my parents' "condition" every six months in case they maybe don't need assistance any more. My exasperated mother finally said to one of them, "there's no cure for being 98, you know. We're old, we need help with everything!"

  110. Plenty of research now demonstrates the link with stress, immune response, poor health and so on. What could be more stressful than being elderly and confronted with complex, and now uncertain, medicare/medicaid decisions? This is another part of Ryan/McConnell policy changes that rarely receives much coverage. Not only does BCRA create cruel uncertainty in our most vulnerable but these changes could be cost INeffective as well due to the declining health linked to mental stress. The developed world has figured this out while we wallow in some fuzzy mindscape of unbridled capitalism. With careful planning, less greed, and compromise we can create an equally reasonable policy for all.

  111. I paid the nursing home bills when my mom was a dementia patient. Three years came to over $200,000. We sold the home my parents lived in, which my dad had built, to pay for it. (She died in 2011, so I'm sure the costs are more now.)
    And if the family is paying like we did, it's absolutely critical to track when Medicare picks up the tab (if your loved one ends up in and out Of The hospital), because trust me, the nursing home doesn't want you to know so they can keep the family payment as well as Medicare payment. the nursing home bills come ahead of the coming month, you see, you pay it, meanwhile mom goes back into the hospital and when she initially goes back to the nursing home, Medicare pays for some days.
    After my mom died the nursing home and I had different figures for what refund we were due. I had to get assistance from a S.H.I.P. counselor and in the end the refund was $9,000 . Buyer beware.

  112. Caps on Medicaid will be devistating for the overwhelming majority of our society, although everyone wants to think it is the other guys who will be hurt. On the other hand, I am really disturbed by the notion of asking the rest of us to pay for your end of life care while you "Protect Your Family's Assets." Or, in harsher words, "How to make sure your children remain rich while you plead poverty."
    This is another distortion created by the lack of universal health care. Access to health care and quality education are two of the biggest factors in perpetuating the ever growing class divide in the US. Covering everyone from before birth until death is not only far cheaper (as the experience of the rest of the OECD nations have shown) it is the only approach to health care that is consistent with the idea of a democracy with universal sufferage.
    Capping Medicaid converts it from a defined benefit to a defined contribution program, placing the burden of the out-of-control health industry on people who do not have the means to carry it.
    Medicaid can be viewed as an "entitlement" only in the sense that life, itself, is an entitlement.
    Leaving your fortune (such as it is) to your heirs, however, is not.

  113. Unfortunately, many, if not most, Americans do not know how these things are handled in other countries. It makes a huge difference in quality of life and productivity when people can count on at least basic universal health care and when children can attend university by working part-time and not by taking out huge loans it will take them decades to repay.

  114. I too find it offensive that people are allowed to "gift" their money away to their children and then ask the rest of us to pay for their care. I don't mind paying for their care if they truly are out of money. Why is this allowed to happen. Congress should be outlawing the practice.

  115. While your argument is good, Medicaid and inheritance rules aren't nearly this clear cut or fair. Why is the house exempted in some states, but not others? Here's my case: I've spent the last 8 years providing elder care for my parents, in addition to working full time. My siblings and I provide coverage at their home 8+ hours/day, hopefully to avoid a nursing home. All of this is completely unpaid. Yet, if nursing home care is needed, the house must be sold and all proceeds used before a dime of Medicaid benefits kicks in. This is really unfair to all involved.

  116. Ron,
    I am almost 65, retired, with a public pension and SS income of $53,000, with no debts. I have about $40,000 in savings but nothing else, not even a house. I am presently in good health. Under today's Medicaid rules, if I needed to qualify for Medicaid in the future for a nursing home, would it be easier or harder for me to do so than someone who had more assets but less income? My mother had around $100,000 cash but only $400 monthly SS income when she needed a nursing home, so she went to assisted living for 6 months and then transferred to a nursing home while she still had around $50,000 cash. This allowed us to choose the nursing home because she wasn't entering as a Medicaid patient. After the $50,000 was gone she received a Medicaid bed in that nursing home. We consulted an elder lawyer who advised us about all of this and who did all the paperwork to qualify her for Medicaid. I'm just wondering how difficult it would be for me to get Medicaid assistance if I need a nursing home since I have a much larger income than she had but much less cash. I realize Medicaid would take my income once I was in a nursing home; I am just curious about eligibility. Thank you!

  117. I don't know, but the link to the NJ rules from that master link in the piece should get you started. Good luck.

  118. And they could change at any time.

  119. You need an instrument called a Qualifying Income Trust. It lets you keep excess income (if any).

    Not a lawyer - just helped both parents go through this.

  120. Exactly what has happened in my own family. We are working class and when my mother's dementia got so bad that she had to go into a nursing home, all of her savings was turned over and once that ran out, she went on Medicaid. If Medicaid funds are pulled, what are we supposed to do? Even if we tightened the belt and were able to contribute a hundred or two a month each, it wouldn't make a dent in the cost, so then what?

    People need to stop using the term burden to describe the elderly. Aging is not negotiable. Some people are lucky enough to be lucid and go in their sleep eventually. Not everyone is though. I cannot help but be irritated reading headlines about the opioid crisis and that billions and billions of dollars are being set aside to help people who chose to take drugs and made a mess of their lives yet our parents are considered burdens who should be put into the street and just die already because they are a drain on the system. No one seems to care much about that. It's all about cutting them off because since they are old and helpless, their contribution to society has been exhausted so let's just get rid of them.

    Watch the show Intervention and see how difficult it is for people-- who fully want to, and with one on one assistance-- to get off drugs. Relapses, follow up care, we will be paying in perpetuity to keep these people off drugs if they can manage to do it at all, but we can't enable our elderly citizens to live out their lives in a nursing home?

  121. We should set aside the funds to do both. Taxes need to go up. Trump, always creative, said taxes are the highest in the US. nothing could be further from the truth. The far left candidate in France, Melenchon. who I don't agree with, wants to tax the super wealthy 100 percent. So no, the US with 35% tax and all the loopholes and havens is NOT the highest. Let's take care of our elderly, drug addicts that have no hope, and make higher education affordable again.

  122. Yes, just like smoking. Musician Tom Petty (R.I.P.), a great guy, said on VH1 that he was a "smoking addict" and had been vaping in the last few years. And his system just wore out. Ditto, George Harrison of "The Beatles." Former addicts will tell you -- you quit when you realize, you must be the one to do it. For others, and for yourself.

  123. The article brings out one of the moral issues dealing with this subject, but misses a big moral issue that I never hear as part of the conversation. (1) Should we as a nation pay for all Medicaid services that a politician determines should be included? (2) The missing moral issue, that is not discussed, is whether we should leave a financial legacy for our children and grandchildren that they cannot afford. As Suzy Orman always says: Show me the money! The long-term moral issue is discussed when we talk about climate change, but the long-term financial issue is not discussed when we talk about Medicaid or other social programs.

  124. Perhaps your moral issues are best handled by charity, putting morality into government laws is quite dangerous. Is it moral to say change your gender?

  125. Our family never thought our parents would have to rely on Medicaid. Our mother, a public school teacher, and our father, a minister, were middle class. They lived frugally, couldn't save much because of their salaries, but had a small inheritance from my grandmother. That $350,000 allowed them to get into a "good" nursing home and for 2 years they both payed in full for nursing home care. But, coincidentally, the month my Dad died, the money had been exhausted. My mother lived another 4 years, until she was 93, and had to rely on Medicaid for that entire time. Every month her whole pension went toward paying the cost of the nursing home and the remainder was paid for by the State of Georgia. We were fortunate in a couple of ways. First, we consulted an elder care lawyer as our parents were headed down the nursing home path, and thus we knew how to manage their limited funds; the chief benefit was knowing to pay for the funeral in advance. Second, my sister researched many nursing homes to make sure to choose one where they would not be "kicked out" when they had to rely on Medicaid. Mr. Lieber, please continue your informative articles. Most folks do not understand Medicaid or Medicare. Our family learned through experience.

  126. I'm glad it worked out for you. As I understand it, nursing homes that take Medicaid never kick out current full-pay patients who run out of money and end up needing Medicaid later. Admission staff know that is a possibility and, I think, try to suss out how long any funds will last. If anyone knows or has experienced something different, please let me know.

  127. I should have said that my sister had to work hard to find a nursing home that would accept Medicaid after their money ran out. It was difficult to find. There were other places that met our standards but it was clear from the outset that these didn't
    accept Medicaid. We didn't want to risk putting them in the latter places, and we're glad we didn't, as things turned out.

  128. Nancy, I'm sorry to hear it was so hard. One thing that is way less than clear to me generally (and varies by region and luck/circumstance too), is if you draw a circle around you 100 miles in each direction on any given day, what % of nursing homes in that circle do not take Medicaid at all and what % won't have Medicaid beds on any given day? Maybe she'd be willing to post here or send me a note at lieber @ nytimes dot com.

  129. Only a fool who has never seen parents through old age would still be telling him or her self these "I'll never be poor" stories."

    As far as "The most detailed, plain-English guide I’ve found to the rules so far is called “How to Protect Your Family’s Assets From Devastating Nursing Home Costs" is concerned, this is one reason why Medicaid costs us taxpayers so much, especially in states like New York, where people spend thousands setting up "Medicaid trusts" for middle and upper middle class (and above) parents, to guarantee the kids an inheritance. I can understand protecting something for a surviving spouse, but for the life of me do not understand why I should be expected to guarantee an inheritance for a fellow taxpayer's children. I am told former NY Republican Governor George Pataki's father, who owned millions in Hudson Valley real estate, was on Medicaid when he was in a nursing home.

    While I think we should be voting on universal healthcare, not Trumpcare, I also think we should be setting up more stringent rules on "preservation of assets" for people who want to go into a nursing home on Medicaid or who want 24-hour home care on Medicaid (yes, NY provides that too).

  130. I am now curious if there is some way to know how many people are setting up these sorts of Medicaid trusts (in addition to those who do plenty of advance planning/gifting in other ways). It doesn't seem exactly practical, since nobody knows when their time of need will come or if they'll ever have one...

  131. And no matter what system you create there will be a way around it for those who care more about their money than their country. As with most programs elimination is the way to eliminate corruption. Charity is much more effective in eliminating such.

  132. Lots of them, not only for Medicaid but for Military benefits as well. Here lawyers want you to put your assets in a trust very early.

  133. I have had first hand experience in opposite sides of the spectrum regarding elderly care. The first one was when my mother-in-law became widowed in 1998 at the age of 84. We noticed that she had more significant dementia than my late father-in-law let us to believe. We then went through the 5 year process of spending literally all her money. since she did not have ling-term care insurance.

    At that point, we have no choice but to have her admitted in a nursing home and to get her on Medicaid, This was after we were audited by the state of Maryland, to make sure all her financial assets were truly used for her physical and psychological care. ironically, after being accepted by Medicaid, she died just 1 month later.

    The other scenario was my own mother, who at the age of 87, was suddenly stricken by stage 4 pancreatic cancer, after living a very vibrant life. Because she worked at the A. Holly Patterson Home for the Aged and Infirm at Uniondale, NY for 20 years, she was aware of the financial problems her residents has, Therefore, she purchased Long-term care insurance, with a 90 day waiting period, to be used in case she couldn't live independently. This covered at home care as well as nursing home care.

    The premiums, to say the least, were not inexpensive. She died 30 days later without benefit of using the insurance.

    Therefore, the only solution I can see is to have the ACA or some facsimile offer long-term insurance as either a rider or having it mandatory.

  134. Some version of this was tried with the "Class Act," during ACA but it ended up being actuarially unsound. It's very difficult to pull it off without sky-high premiums and/or collecting smaller amounts from younger adults for a very long time. The political will/personal discipline/desire just isn't there, it seems.

  135. So as usual progressives only see two solutions, how stupid. People make choices if your relative had just saved that money instead of buying insurance they might have been fine. Everyone will die eventually sometimes sooner is better than later. And the government is not responsible for everything.

  136. If I were to advise a young person, I would recommend they take out a big whole life policy instead of long-term care insurance. The plan would be to use it for exhorbitant medical co-pays and nursing home care in the event of severe illness or debility by borrowing against it if needed. I'm in my 50's and followed the conventional "wisdom" of buying term life because life insurance would not be needed after raising the kid and paying off the mortgage, whole life is not a great investment and term insurance was cheaper. The plus side to a whole life policy is you are not at the mercy of market fluctuations when you need it and it covers your need for life insurance as a younger adult.

  137. We are in denial about the realities of both our own destinies as we age and become more infirm AND what the NY State Nursing Home sub-par care offers patients even at luxury prices most can ill afford.

    Homework is required by NYT's readers as well as by Ron-though much of what the journalist is spotlighting, is appreciated and long overdue.

    First-note that Leading Age (Ron references) is a lobbying group for the owner/operators of the nursing home industry and among the biggest donors to Governor Cuomo & our legislators who determine nursing home freedom from
    accountability. I wouldn't trust my dog with these people.

    Secondly, the NYS DOH Public Health & Health Planning Council continues to license the worst predatory consortia of long term care facilities in NY all the money you will for your dotage-but these are too often, places that victimize and over-medicate old people into stuporous lethargy because greedy owners don't want to spend the money to improve aide/nurse to patient ratios...and are now trying to force binding arbitration so victims are no longer able to sue if they are harmed.

    I recommend you open this video says a lot about the state of nursing homes and all the reasons that you must try to avoid being placed in these miserable facilities...miserable with rare exception.

  138. I hear you, Sandy Reiborn. Too familiar with what happened to the residents of the Prospect Park Residence. Any suggestions on what we can do to protect ourselves?

  139. Unless or until investigative journalists (such as those at ProPublica) keep peeling back the scam that is the NYS /DOH enabled Nursing Home predation-we are lost.

    The LLCs and shell maneuvers by the owner/operators must be exposed and are not. The incriminating actions of the Governor , yes and the AG who rarely prosecutes (!) and the many state legislators who defer to powerful long term care lobby groups which fund their campaigns must be revealed...and they are not.

    Individual's actions can do very little in the face of a welter of unconscionable owner/operators and government inertia or even actual collusion with these greedy predators.

    Perhaps Mr Lieber will do some more digging? The NY Times has failed to step up to this urgent matter and one can only wonder why.

  140. Since unconscionable government inertia keeps a shameful system of harm to the most vulnerable in place while benefiting predatory owner/operators...we must hope that reporters such as Ron and the NYT will emabrrass lawmakers into vigilance. They have failed to do so.

  141. Most Republicans "engaged" in the Medicaid "debate" have already resolved this issue to their own satisfaction.

    They simply once again posed their guiding question:


    For Republican legislators, asking that profound question is always so enlightening. Republican policies are generally self-evident and predictable responses to this Scrooge-query.

  142. It has not been settled but it should be. Block grants to the states under some formula for the next say 10 years. States can decide what their citizens want and are willing to pay for.

  143. Place this article on the cover of the New York Times with 'Your Money' by Ron Lieber in bold Capital letters. It may receive the care and attention it deserves.

  144. Permanent nursing home coverage needs to be put back into Medicare. Everyone will be hurt by cuts to Medicaid to think otherwise is foolish, well unless you are Bezos, Gates or the like who can pay for anything.

  145. Who pays for it? We are 20T in debt and way behind on some actual constitutional federal responsibilities. And I am not like them but I bet I won't be needing Medicaid, or accepting it if I might need it either.

  146. Sounds like you have a plan ?
    How old are you?
    How are you insured now. How much money do you have for retirement.
    Do you have a Long Term Care Insurance policy?
    How do you know that a serious debilitating illness, loss of employment, or living so long as to outlive your savings informs you that " I bet I won't be needing Medicaid, or accepting it if I might need it either."

    Are you that clairvoyant to know your future, or so wealthy that you know you would never need Medicaid and you are bragging that you would not accept it if you needed it. Doesn't make sense - what will you do if you did need it and not accept it? Live on the street?

  147. My husband and I have no children. We're retired now. We had good professional jobs. lived frugally, and saved money like crazy. We still live frugally and do all that we can to take good care of ourselves. We got long-term care insurance almost 10 years ago and faithfully keep up the premiums. We have no one else to take care of us so we have done our best to save as much as we could to pay for much if not all of our own care when the time comes. I am well aware that many, many people are not in our position. They are the ones who really need Medicaid for nursing home care. I have major problems with people in our income bracket and those who make a lot more who hide their assets (with the help of lawyers) and expect Medicaid to pay their freight.

  148. Say what? I do not know how many fraudsters you know, but that is the least of our problems.

    Single payer, civilized society, which we are not.

    We spend more per capita om healthcare and have the poorest outcomes. Even your money could run out and the hucksters here will figure out how to scam your long term nursing home plan.

    It's a country running off the rails and the huge aging population will get us there faster.

  149. Believe it or not, my fellow Americans, there are countries in which elder-care is viewed as a not-for-profit publicly financed communal endeavor.

    Of course we know better. It is self evident that profit-making enterprises are always run with superior economic efficiency. Indeed to be an American is to believe that every enterprise is so much more economically efficient when its chief end-in-view is the enhancement of shareholder-owner value. Economic efficiency, of course, demands that the interests of consumers and workers must always be subordinate to this central goal.

    Sure consumers pay a lot and workers are called upon to make sacrifices in order to maximize profits and shareholder-owner value. But such costs and sacrifices are ennobling. Those paying the costs and making the sacrifices should bask in the glow of patriotic pride: They are underwriting the blessings of freedom, American style--the freedom to choose among the many varieties of available eldercare, for example, and the freedom to have access to whatever level of eldercare either you or those who love you can afford.

  150. Thankfully, there is Medicaid in our country to pay for elder care for poor Americans. At least we have that to fall back on if we're not able to afford long term care insurance.

  151. For profit enterprises do not provide better outcomes if the people that consume the services are not the ones paying the bills.

    "Economic efficiency, of course, demands that the interests of consumers and workers must always be subordinate to this central goal."

    Sorry this is simply wrong. A competitive system demands that the interests of shareholders and workers are subordinate to, those making the buying decisions and spending the money, the customers. Watch how quickly shareholders abandon a company if sales drop because customers switch to a competitor.

    Customers can remake any industry as long as they are making the spending decisions. Look at any industry that does not have significant government involvement and you will see businesses fighting to please customers.


  152. Most ardently anti-socialist Americans vote Republican and have no idea how the Social-Democratic nations handle the elder care issue.

    A Swiss friend of mine recently helped move his mother-in-law into an elder-care facility, secure in the knowledge that she would be humanely treated and that her care would never cost him anything out of pocket, period.

    Socialized elder care diminishes anxiety on the part of both elderly parents and their aging children. (My friend is himself in his late 70s.)

    The GOP agenda seems dedicated to raising the anxiety levels of the poor and lower-middle income families. I guess high levels of working-class anxiety and job insecurity must be good for business and highly beneficial to plutocratic interests.

    Widespread anxiety makes so much sense within America's gun-saturated environment!

    You have just have to applaud the GOPs agenda: Increased economic anxiety is a brilliant basis for securing social order and domestic tranquillity.

  153. We are not the Swiss give me their population and culture and then such benefits would be appropriate. With our much more varied population it is not.

  154. Dear Vulcanalex,

    You argue that in America, since we have "a more varied population" and such cultural diversity, a Social-Democratic approach to eldercare is not appropriate. As a Tennesseean you no doubt endorse states rights. Perhaps the state of Utah, which is certainly far less varied in population and culture, should run an experiment to see whether this more communal approach to eldercare would work within our fairly homogeneous context.

    I'll make that recommendation to Governor Herbert, and to Senators Hatch and Lee.

    As John Dewey urged, within our democratic republic, it is important to keep the spirit of social experimentation alive and vigorous.

  155. vulcanalex,
    Are you planning to return to the Land of your Ancestors?

  156. Yes it might effect you depending on your state and what they do. Federal medicaid has expanded too much, not only can't we afford it, it is not in the constitution and is doubtful if it is actually in the "common good".

  157. vulcanalex,
    Are social security and Medicare mentioned in The Constitution for the Common Good?

  158. You better pray that you or one of your close family members never has to go to a nursing home. The cost is about $80,000 annually. Better start saving now if you don't like Medicaid.

  159. This article is informative (and the facts need to be better known, but I think the denial of aging is widespread). Here is a related issue that I would like to know more about: long-term care insurance. My husband and I are older (late 60s/early 70s) and retired with pensions and Social Security sufficient to live on. We are also both still working part time, which pays for things like trips and dental implants. We do not have a huge amount of savings, are not in much debt, but do have quite a bit of equity in our CA house. We wanted to buy long-term care insurance and applied though Calpers, which offers the insurance for employees, current and former, and their relatives. After extensive interviews and giving access to medical records, the underwriters accepted me, but not my husband (pre-existing conditions!). The LTC I signed up for would also pay for home care. Still looking for an option for my husband. I read about a type of life insurance that turns into long-term care, but not sure if it is valid. Practically all the information I can find on this topic is advertising. I surely wish there were something straightforward to read. Maybe there are just not many good options.

  160. It indeed has been too long since we wrote about this, so I'll fix that soon. Here's a piece from 2010 and another one from a few weeks later when a big player backed out of the market. This lament from 2011 has some good links. And here's our Wealth Matters columnist Paul Sullivan from late 2016 on the life insurance/long-term care insurance hybrids that 1-2 of you have mentioned here in the comments.

  161. Susan,

    As a CFP in Southern CA, I recommend you not rely on CalPERS' long term care insurance (LTCI) as the first and last word on your husband's coverage eligibility. They're not exactly a mainstream insurance carrier. Please see an independent agent that specializes in LTCI (and no, I don't sell insurance, I'm fee-only, so I'm not touting my services) to see what the major providers in the field might offer him.

    And yes, a good agent can also talk to you about alternative products such as life and/or an annuity with a LTC rider.

  162. Perhaps I can assist Susan regarding her husband and long term care. It is my understanding that the hybrid policies that are longer term care and life insurance combined are not as restrictive regarding pre- existing conditions. If you have not looked at the hybrids, you may want to speak with a financial planner who works with an insurance broker who has access to the various hybrids that are on the market. You should look at multiple policies from various companies.

  163. Ron, a question about the stats in your third paragraph. You say that a majority of people cannot and do not pay for their expenses themselves in old age. Then you say that one in three people (i.e., 33.3%, and thus less than a majority) who turn 65 end up in a nursing home, and of those, 62% can't pay the bill. So, did you mean to say that a majority of nursing home residents can't pay their expenses, rather than a majority of all older people?

  164. Well, that was inelegant. Or incomplete at least. I should have also cited the number of people on Medicaid getting help outside of nursing homes and the % of folks who get some help from family too... Thanks for pointing it out, I will look for a way to add/adjust/correct.

  165. Medicaid for the elderly, disabled, and children is caring for those who have no other alternatives. There are 76 million on Medicaid now. The qualification has long been those at 138% and below of the poverty level.
    During the Obama Administration and with the advent of the ACA 11 million more adults were added from 31 states in 2009. 20% of the spending is on children that comprise 43% of the total enrolled. 8% are elderly and 13% are disabled. The 36% of adults number and the additional 11 million people that were added in 2009 should be looked at again in 2017.
    Being elderly and aging is going to happen to us all. A child born and being dependent is understandable. Having a disability that keeps that person from caring for themselves and earning a living is a given...Those that are able-bodied, can work, and on this program need to be matched with jobs, trained and assisted to get off this program in a determined reasonable time-frame.
    What is the plan?

  166. Thank you for sharing this information. Too many people do think that Medicaid is just for "the poor." My father went into a nursing home after having a massive stroke; his pension paid much of the costs. I got my mother to "gift" my siblings and me so she would qualify for Medicaid, if need be. After Daddy died, the state Medicaid office came after my mother for $44,000, threatening to take her house. I hired an attorney and she kept her house. After my father died my mother was diagnosed with Parkinson's. She landed first in an assisted living facility, paid for with her assets and money from my brothers and me, and then in a nursing home in my state. The only reason she got a nursing home bed was that she was coming from a hospital, and bringing two months of full payment with her. I don't know if the system still operates like this, but I'm sure you do. She died in the nursing home. Unlike her home state, my state doesn't take houses from Medicaid recipients. When I sold her house, I had to pay the $44,000, but I was happy to do so. If you haven't dealt with Medicaid and/or Medicare, you have no idea how it works. Thanks again for your work to inform the head-in-the-sand public.

  167. Every state has the right to recover Medicaid Dollars - some states just don't enforce it as well as others do. And the majority of people don't realize it - they think Medicaid is "free". This is just another way a long term care insurance policy can help. Most states have passed "Partnership" legislation. This means if you buy a long term care policy that meets the specifications, the policy will protect your estate on a dollar for dollar basis. Here's what that means in English: Let's say you have a policy that pays out $250K on your behalf. You go on claim and use up all the benefits and now you have to apply for Medicaid - because you had a policy that paid $250K, you will be allowed to protect $250K from the spend-down that Medicaid will require. If your policy paid $400K, then you get to protect $400K! Again...most people aren't aware of this feature. Just another reason to consider looking at long term care insurance to help protect you and your family.

  168. Ron,

    You could check with the National Academy of Elder Law Attorneys to see if they have some data for you, although I imagine they wouldn't want to publicize it.

    Ron Lieber is an NYTimes reporter Your Money columnist 2 hours ago
    I am now curious if there is some way to know how many people are setting up these sorts of Medicaid trusts (in addition to those who do plenty of advance planning/gifting in other ways). It doesn't seem exactly practical, since nobody knows when their time of need will come or if they'll ever have one...

  169. There is no way to know the number of families making transfers or setting up trusts. These are done privately with the help of attorneys who’ve learned hundreds of medicaid regulations. The transfers / trusts must generally be completed 5 years before the client makes a medicaid application. Otherwise, they create a period of ineligibility. As they should, because if one could just transfer assets or set up trusts a week before applying, the abuse of the system would be worse. So the attorneys calculate how much each client must keep to “last” the 5 year ineligibility period, an inexact science that can expose clients. The look back period could be made longer, or penalties for lying about prior transfers scarier, or applicants required to disclose more financial records going back farther. But to process all that additional info, more agency staff would have to be trained, managed and paid, reducing funds for the intended population, and adding to more processing mistakes and delays. It will remain a thorny problem to fix, until citizens of some means feel more shame in doing it. My view is we keep discussing the issue with legislators, friends and family, and not be afraid to point out behavior that while may appear justified given the cost of care, desire to ensure heirs an inheritance, and anger at the perceived greed of nursing homes, really makes victims out of us other taxpayers who pay for their care, and who may not have the safety net in the future.

  170. I also suggest looking into tightening up the rules -- e.g., perhaps requiring the trusts be set up further out -- like 10 years. Also some states are better than others at determining whether assets have been taken out recently and, as a relative once pointed out to me, can't do much about out of state relatives who may have recently helped themselves to some money.

  171. A frightening article but all too true. Sadly, not enough people know this and many of them believed Trump when he started attacking medical care. They voted for him, and half of the senate and house members and put the deplorable members in charge. I am looking at my retirement now, and should I go into a nursing home, my wife will have nothing to live on, if I pay even half the amount stated in this article. That is on a government retirement after 29 years of employment. Over the years I have paid hundreds of thousands in taxes, figuring that was going into medicare and medicaid, plus retirement funding to cover me until end of life. This administration wants to help the rich, and to hell with the rest of us. Thankfully we had no long term disabilities, children that were healthy, and able to make it on their own, but no extra to help us out. Tell your neighbors and friends, and the folks down the street, what is happening here. Get them involved in telling their representatives to obey the Lord 11th Commandment: Do unto other as you would have them do unto you.

  172. About 45% of all Medicaid spending goes to 6% of Medicaid recipients in nursing homes. Clearly things have to change in Medicaid spending for long term care of the elderly by allowing at home care in place of only nursing home care. The better alternative to protect against forced destitution of qualify for Medicaid is LTC insurance. With LTC insurance, there is the option for home care in addition to nursing home care. Affording LTC insurance is another story.

  173. As long as we allow insane laws to regulate that in home care IS NOT covered while the far more expensive residential nursing home care IS covered, we are only digging ourselves into a hole. The nursing home industry, usually a collection of shell corporations with impossible to find owners (in order to protect them from any liability as a result of the miserable state of their care) lobbies for these policies that benefit no one but the corporate masters of the health care industry. Wake up!

  174. I looked into it. It would cost me $1200./month to insure against the distant possibility of needing long term care. Only the wealthy can afford that kind of premium. It's not the answer for middle class seniors.

  175. as long as the policy covers what you think it will, and as long as the insurance company stays in business, and as long as you already haven't spent nearly as much money on your LTC insurance premiums as the actual cost of the home care...

  176. Thank you for your article about this opaque subject.
    It was explained to me by a street-wise end-
    of-life planner that Everyone in the United States ends up on Medicaid.

  177. Everyone does not end up on Medicaid. As the article point out, 62% of nursing home paitients end up tapping Medicaid at some point. Medicaid is insurance for Americans in poverty and is not a good place to be. At least our poor have access, which keeps them off the streets.

  178. The reason this fight makes little sense to the average citizen is because they don't really understand how the Republicans are funded for office and where their loyalties are. As a result of the 2010 Citizens United decision and the 2014 McCutcheon decision congressmen can receive unlimited secret money. The Republicans are simply trying to create the best health care system for their secret donors NOT Americans in general.

  179. Secret money? Do you have objective evidence of that or is it just more alternative reality?

  180. Vulcan, it is very real. It's more commonly referred to as dark money. Money can be contributed to campaigns with anonymity from big donors, like the rich and corporations. This is completely legal and a possibility due to the Citizens United decision.

  181. We have Pennsylvania's Republican Sen. Pat Toomey to thank, should drastic cuts to Medicaid destroy the lives of the most vulnerable Americans. For Toomey has been credited with writing the Medicaid sections of the Senate health care bill.

  182. Never elect sociopaths to government positions.

    Simple truth.

  183. Sorry but this is a very shallow truth.

    The real lesson that everyone should learn is that elections do not guarantee wise or even competent leaders.

    If you don't trust Trump to have X authority, then the presidential position should not be granted that authority. If you wouldn't entrust the Congress packed with Trumps, Republicans or Democrats, to spend wisely then no congress should be entrusted with that amount of money to spend.

    If the energy used to try to sway government to address the problems we care about was instead used to find creative private solutions we could worry a lot less when the election process gave us another joker.

  184. Oligarchs are not interested in this boring topic, except perhaps as an investment.

  185. The Democrats need to start running television commercials to get this information out to the electorate. People need to understand that this is how the GOP wants to not address the challenges of a rapidly aging society. As someone now in their mid-fifties, I find it absolutely terrifying and despicable.

  186. I would say that the Democratic Party excel at poor communication...

  187. You are absolutely correct. Where are the Democrats? Where are the TV spots disseminating and explaining this to the masses and the Dump dopes et al. who think it doesn't apply to them? This is our future and I know it all too well. It matters and this needs to be out there pounded into people's heads until they GET it!

  188. Indeed, it does. Tossing elderly out of nursing homes would wreak havoc in the economy for generations because to care for them family members would have to quit working (thereby losing their own health coverage), stop paying for their kids' college and futures, and abandon the chance to save for retirement, etc. And let's understand, too, that not all can be cared for at home even with support, and that many nursing homes are excellent.

  189. Ron, I'm still trying to get educated about all this ( on a detail level, not the politIcal ) so wanted to leave you a big THANK YOU for all your reporting, which, especially crucial at this particular point in time. This story along with the entire so-called "debate" on this subject still screams to me the only way is Medicare for ALL, cradle to grave. And one less war could pay for it.

  190. Thanks. Please keep reading/subscribing, we appreciate your support.

  191. Medicaid covers adults without health care who are poor, children who live in poor families, disabled people, and the nursing home care for elderly people. In short, these are people who cannot help themselves and must be supported by the program (i.e., by us who pay the taxes). Now, the Republicans are trying to cut back on those funds in order to subsidize a tax cut by their supporters (mostly wealthy). So, which of these groups will be hurt the most? Poor adults (34% of Medicaid recipients)? Children (43%)? Disabled people (14%)? Elderly under nursing home care (9%)? See:

    Republican Senators, which group's Medicaid subsidies do you cut? I would like to know. Is any one of you willing to stand up and tell us which group of people have to take less so that you can fulfill your promise "to repeal and replace the ACA"?

  192. Medicaid is welfare.

    Medicare is what you pay into from your paycheck.

    Medicaid is welfare.

    The debate concerns 1.) a regression to prior levels of federal funding and, 2.) the requirement for individual states to pay more. The bill reduces the federal government's fiscal burden and empowers citizens of the individual states.

    California's Governer Jerry Brown hates it because he's got a big money challenge and doesn't have the skills nor the sway over the public employees unions to fix it.

  193. Medicaid is 'welfare' until it's your aged relative who has exhausted all her savings and can't afford nursing home care. When it happens to your family, and you don't have the money in your budget to cover your own family's living expenses plus $9K/month nursing home expenses for your geriatric parent, then you'll think differently.

  194. Whoever the states decide, or nobody if they can improve the costs.

  195. Unless you live long in perfect health -- which is possible, but those are the outliers -- or have children who are devoted, responsible and who live near you, man, old age is terrible.
    Save, save, save. Get LTC if you can. And mostly, pray for a swift, painless, drama- and hospitalization-free death.
    Right-to-die legislation nationally would be a huge help and relief to so many.

  196. In California, current law prohibits nursing homes and the state asking adult children to chip in for nursing home care for a MediCal (Medicaid) recipient. Do you think this could change in the future?

  197. My 86-year-old mother died last year after spending her last year in a nursing home. She qualified for Medicaid after selling her house and draining her meager assets down to almost zero to cover her assisted living costs. When she became too ill, she had to be transferred to the nursing home. Medicaid took most of her Social Security, leaving her with about $100 a month for personal needs. I provided additional funds as best I could, but my mother was essentially destitute. The financial and physical downward spiral led to severe depression for my mother, which hastened her death. Many other family members will experience similar scenarios as their elderly parents age and deteriorate. If you think Medicaid is only for the poor, think again. You too are likely to be reaching out for Medicaid when you least expect to need it.

  198. You are in a nursing home so I assume you get food, shelter, etc. What more do you actually need? And yes Medicaid is only for the poor.

  199. How about clothing, a book, a pen, an occasional treat, a birthday gift for a grandchild, a haircut? Would a cellphone be considered an extravagance?

    (Writing from a nursing home)

  200. "What more do you actually need?"

    Laundry services, which are an additional cost. Shampoo, deodorant, etc. A haircut. A newspaper. Adult diapers. My father and father-in-law required assisted living and a nursing home, respectively. Staring at the same 4 walls can be depressing, so the facilities did field trips, such as lunch at a restaurant, minor league baseball, an evening outing to see fireworks, etc. All of these events were charges above the basic charge. Both places had cable television, but patients were billed as though each room was an apartment. Television is not necessary for life, but, I considered it a necessity as the option was staring at the walls every day. My father had tremors, and refused to eat in the dining room. We paid extra for meals to be taken to his room. My mother-in-law would visit only if it was during a meal, and, of course, we paid for her meals. My father paid a cleaning staff separately for weekly dusting and sweeping.

    While I consider shampoo, deodorant, haircuts, cleaning, diapers, and laundry essential, the other items were quality of life expenses. We paid for my FIL's television. My MIL didn't consider it worth the money, though it was in their home, and she watched it most of the day. We found many families used the other expenses as a way to punish or torment.

    We have long term care insurance, but it is a gamble. My ancestors lived until their 90's. What if we need more than 3 years?

  201. Ron,

    This might be a good time to revisit the topic of Filial Responsibility Laws that require children to financially support their parents. In 2012 a Pennsylvania appeals court found a son liable for his mother's $93,000 nursing home bill under the state's filial responsibility law. Health Care & Retirement Corporation of America v. Pittas (Pa. Super. Ct., No. 536 EDA 2011, May 7, 2012).

    The last time I asked an attorney about this there were 30 states that had such laws, including CA. I haven't seen a lot of publicity on states using these laws, other than the Pittas case, but we might see more of it in the years to come.

  202. Yes they need to be eliminated.

  203. A very important issue for all people to become familiar with so they can be prepared. Thanks for posting.

  204. Thank you for this article! You have spelled out in plain language something that has alarmed me from the beginning of this debate. I spent 42 years working in health care as a social worker, advising people about their options. People are often shocked to find out Medicare does not cover long term care. I also have personal experience; my mom had Alzheimer's. she went from her home to an apt to an assisted living to a nursing home during the last years of her life. She exhausted her Long term care insurance and all her funds before going on Medicaid. And she still lived 2 years on Medicaid before finally dying last year. Finally, this has consequences not only for the huge numbers of my fellow baby boomers heading to old age, but also for all the family members who will have to fill in the gaps. This will have an impact on their income, their own retirement savings and the economy in general.

  205. My sister in law was threatened with neglect by a hospital over her estranged father's care. He had no assets, no savings and no credit cards. He was using the ER repeatedly for basic care. His second wife was in the later stages of Alzheimer's and in a nursing home. The hospital wanted his first wife and children to step in take care of him physically and financially or they were going threatened legal action. My mother in law had divorced him 30 years prior and she was still bitter that he had refused to pay spousal or child support. My in laws were getting called by healthcare vendors looking for payment for my father in law's outstanding ambulance and Medical bills. My mother in law had to remind the vendors daily that she had divorced the SOB 30 years prior. My sister in law ended up reaching out to Lights for Seniors for support and advice. For a fee, they helped the family get services and support for my father in law and the hospital backed off. My sister in law still has to cover the cost of adult diapers, take his middle of night calls, and deal with his nursing home disputes. My husband steps in and helps physically and financially whenever needed. The whole situation has has shaken the entire family to the core. They openly talk about how grateful they will be when he passes away.

  206. Gross. If he didn't pay any child support, there should be a way to divorce your parent who divorces you.

  207. You bring up an important point. Every state has different laws on whether, or not, nursing homes and health care providers can come after the rest of the family for payment. I fear this will become a common practice when the states experience huge cuts in funding. We all need to look at our own state's rules (and any future changes to them) and be prepared.

  208. Medicaid helps poor people both young and old, that's how it was designed. There was never any intention that poor people would lose Medicaid availability just because they got older.

    Thank goodness there is some support for our growing ranks of elderly poor.

  209. Have relative who married into liberal - leftist redistributionist family, centered mostly in Massachusetts, 25-30 years ago.

    Well, starting with the grandparents, who were essentially as socialist - communist "tax the hell out of the rich," "you people who work have to be taxed heavily to help the poor, aged, minority, education, blah, blah, blah, etc." as they come, suddenly they became "do as we tell you, not do as we do."

    So many "estate planning attorneys" arrived, and shortly there after the two generations of grandparents and parents, quickly set up all manner of complex trusts, deed transfer + shell games over a multi decade period.

    End result,

    19 + 12 years of Massachusetts medicaid care in a top notch nursing home on Medicaid for Grand Parents 1 + 2. 6 and 13 years of similar care for other set of grand parents.

    Then for the parents, 18 years for him (Parkinson's) and 13 years for her...infirmities of age, both also in a well paid for Massachusetts medicaid nursing home.

    And the three houses in Hamilton, Ipswich and Manchester by there Sea went to the kids of my generation, scott free.

    Do the math, these people were the Bernie Madoff family of the Medicaid asset diversion industry.

    The extended family scammed Massachusetts, legally of course, out of what was probably millions of dollars, when you count the interest on the draw downs over two plus decades.

    And people wonder why I don't really love liberals, as everything applies to us and not for them.

  210. An important goal of healthy communities is to share the risk of catastrophic events so no one individual pays the entire cost of life events that cannot be foreseen such as many of the diseases which occur or extensive damage to community and personal assets from weather or wildfires. People are often eligible for funds when their property is damaged; their use of this legal benefit is morally neutral despite their voting record on sea level rise due to climate change.

    Many other catastrophic life events are subsidized by federal and state funds including paying for medical expenses in nursing homes after an individual's assets have been "paid down" to the state regulated number. Lobbying by the nursing home industry and senior living facilities is the primary support for this decision, not the "kindness" of the legislatures. Families who apply and qualify for Medicaid benefits for members in nursing homes must be eligible for this benefit. No official asks a "moral" question about using Medicaid dollars to keep one's parent or spouse alive. No one's voting record is checked (yet) to determine the "worthiness" of a person receiving Medicaid. This is a legal benefit provided to every person who can manage the qualification process and is determined to be eligible.

    When we use "loaded" words like " scam", "shell game", "scott free" and liberal as an insult, the conversation is damaged so little progress in reaching an understanding of the Medicaid problem happens.

  211. To assume that all "liberals" (and "conservatives," for that matter) are the same is exactly the kind of rhetoric that is making working together towards a real solution so difficult. Anyone can spend the day firing off tales to make the bully's case for their thinking. It's whiny and unhelpful.

  212. So because a rich family took advantage of legal loopholes, like many rich people do, that justifies removing all legal protections for those who aren't wealthy? Just because one family gamed the system, we should throw the whole thing out rather than try to fix it? Of course, throwing the whole thing out just plays right into the hands of all those rich people who control the Republican Party and who will get a huge tax break by getting rid of Medicaid. Seems to me we should be fed up with rich people, not liberals, and focus - as the article does - on the middle and lower class people who will suffer most if Medicaid is gutted.

  213. Here is what asking adult children to pay the bills for nursing home care for parents means in the long run: Those adult children's assets could be drained so that when THEY need nursing home care, guess what - they have nothing. I suppose the thought is that then THEIR children will pay, and so on. Basically you bankrupt the retirement of each generation. My Dad was in a nursing home for 4 months. All his retirement income (with no allowance for tax with holding by the way) went to the nursing home. My Mom was left with about $1,000 a month in income, from which she had to pay the nursing home the tax deducted from his gross check. In my state, someone on Medicaid in a nursing home can only have $2,000 in assets. Had my parents not done some estate planning years before, my mother would like have lost her home as she would have been unable to afforded to maintain it. Does driving the well spouse into poverty solve any problems? Does draining the retirement savings of the children solve anything? These are important questions. My Dad was 17 years older than my Mom, so some estate planning was vital. I am now retired and am the caregiver for my 85 year old mother. I'm doing my share. I have no children, so I have long term care insurance. I hope I don't need it - but I worry a lot about my future. A nursing home could have my assets, but given the rising cost of care they probably wouldn't last long. Then what -into the parking lot to die?

  214. Yes, exactly. The buck stops when you don't have your own children to rely on. Or your children simply can't afford to keep you going.

  215. My mother's ALS terminal illness was not covered by her long term disability plan or Medicaid (california). After all their assets were sold, house, stocks, insurance policy, my husband and I refinanced our home twice to pay for their in- home 24-7 care running 15k per month. 2 years of juggling. No insurance or plan paid for anything. Medicare available of course but nothing could treat ALS. VA great for my WWII dad. We did all this on our own and proud of it. We now have our long term plan and hope it pays for some home care costs. We are not wealthy but we are saving for these costs. They died at home within 10 days of each other. They were never "warehoused". His biggest fear he would be warehoused.

  216. You are to be commended for stepping up to help your family. Only wish there were more like you.

  217. Terrific article, especially with the many links to more detailed info. My wife will be retiring next year. I will retire a couple of years later. So, we are definitely trying to wrap our heads around this issue. Thanks!

  218. My mother, a survivor of the Depression and employee of Curtis-Wright Aviation during WWII (she didn't rivet, but worked the line building planes) required nursing home care the last year of her life because her dementia was beyond what could be cared for in home. In Philadelphia, her costs were between $11K and $13K per month. At the end, I had to fight to get the care she needed despite being private pay.

    My parents saved and saved and saved. She had enough to cover that year and a little more, but I had to shift to part time work in the last five years of her life to coordinate her medical care and deal with other issues for her. As a result, my children, 14 and 17, do not have college savings, because we didn't have extra to put away. I'm saddling my kids with loans because I took care of my mother - where does this make sense.

    While Medicaid helps, the requirements are so arcane that even as a lawyer,, I wasn't always sure I had interpreted things correctly. I don't know what the answer is, but something needs to be done so my children do not suffer this same fate when I'm older. As it is, I probably won't retire - my youngest will graduate college when my husband is 68 and I'm 64. I'll be working until 80 to help them pay their loans. I might squeeze out a year or two before they carry me out of my office in a pine box.

  219. If you and your husband are/have been working and you're a lawyer, then it seems to me you would have had enough income to pay the costs for a family of four that CAN/COULD be low enough -- and comfortable enough -- to have allowed you to still save money over those 5 years.

    It was your choice to reduce your work time and do things for your mother. No adult child MUST take care of a parent. Period.

    You assume your children will take out loans for college, but that is not necessarily true/always the case. Maybe junior prefers to be a plumber; college isn't the answer for everyone. Community colleges allow One to acquire basic college credits at reasonable prices prior to having to attend a 4-yr. college. Also, Junior could work during college years -- I did, paid my way -- of course when tuition fees were so much less-expensive.

    Time to stop Oh Woe Is Me-ing for goodness sake. Some of what you report is/are YOUR choice(s), and some are merely assumptions.

  220. You may find that your idea to work until you are 80 years old will not pan out because no one will employ you. If we are going to deal with "reality", we should undertake a bit more scrutiny of the "work til you die" idea. See who will hire you when you're 77.....or 67? And while our health care is tied to our employment, I suspect employers will not be eager to front your care at that age. Warren Buffet is correct when he says that having to provide health care to employees makes our businesses non competitive with those that are not on the hook for this unpredictably expensive necessity.

    The choice to fund our parents last years in the misery of a nursing home or our children's education is a bargain no one should have to make. Health care needs to be single payer and cost controlled using evidence based medicine, and education needs to be free. Then our society can move in the direction of sanity. What we are setting up for ourselves now is madness.

  221. Working until you are 80 is a valiant but unreliable plan. I thought I would be doing that, too, but had to retire at 63 for health-related issues. I saved as much as possible during my working years and have always lived frugally, but I can't see that I'll be able to do more than cover my basic living expenses if my retirement years stretch on and on.

  222. Euthanasia and assisted suicide should be a viable option to mitigate the problems related to nursing home care.This would help families save on spending,preserve assets for heirs and save society a boatload of MONEY!!!

  223. Yes except think of the potential for abuse when the elder has given up the right to make medical decisions (i.e. a medical power of attorney) to an heir. They are the ones that can make a decision to kill the elder for the inheritance (current and unfortunately common model is child denies medical care for parent to hasten death). Right to die is great in principle but without very strong safeguards for elders they will be at great risk from coercion and pressure from families, even if they (supposedly) retain their right to make medical decisions. Spending your last days on this earth feeling selfish for living if you chose life not assisted suicide??

  224. Jerry (from my home state I see), I definitely agree. It might seem a cold thing to say, but I've been thinking the same way lately. (I'm in my mid-70s). For one thing, I don't want my family financially destroyed trying to keep up, knowing they would soon be facing their own needs, to say nothing of their current obligations. Further, after working almost 60 consecutive years (Aug 1959), I really don't need the (quite understandable) hostility that's bound to occur from the younger generations who themselves are facing more and more financial insecurity. It's crystal clear to me that I will never have the financial ability to pay for long-term care and anyhow I need the rest.

  225. Assisted suicide, yes. Not to save money, but to give a suffering person a right to end the suffering. Euthanasia implies someone other than the person or loved ones is making the choice. A slippery slope.

  226. "Long term care is the largest unsecured risk facing Americans today" – Money Magazine.
    Jonathan Pond, America's Financial Planner, says that 90% of estates are spent this way: 1) nursing home, 2) IRS, 3) children, 4) grandchildren, 5) charity. More people are worried about the IRS taking their money than about having to spend it on a nursing home.
    The Federal Deficit Reduction Act provided for every state to have a Partnership program to provide asset protection for those who buy qualified long term care insurance policies.

  227. Great article!
    1. Less than 6% of age eligible adults have long-term care (LTC) insurance, and note, it is insurance, the carrier can deny coverage to anyone. My application was denied due to a comment; I discussed and my doctor documented in my medical records that I was concerned about having dementia in the future. Take away: one cannot have a confidential discussion with physicians because you’re required to release medical records to LTC insurance companies if I want to be considered for coverage.

    2. There is a tension between the GOP wanting to cut Medicaid while also expecting you to take care of yourself, for example, by having proper insurance. If you live on minimum wage or less, you cannot afford both health care and LTC insurances. If you are healthy without a preexisting condition, LTC premiums alone, may run between $4-$6,000 annually (if you purchase it early enough in life). If you are unhealthy, you won’t be charged more. You will be denied coverage. Period. End of story.
    The tension is that people CAN afford taxes if they are working (regardless of the wage), but they CANNOT afford the premiums if they are unemployed or working and earning less than $50,000; and the median wage is in the US is about $50,000 (about $24/hr). So where does that leave half of the population who earns less?

    The GOP plans to let the safety net (Medicaid) dissolve, give the dwindling monies to the states and to let them play bad-cop when forced to conduct triage on its citizens.

  228. Mom had dementia-found unconscious by a neighbor in 2008. I flew down, stayed at her bedside in the hospital for 2 weeks, then thrice-daily visits to her during her follow-up nursing home recovery stay. Most of it was covered by Medicare. Medicare didn't cover $48,000, which was fortunately picked up by mom's Medicare Gap Insurance. After release from the nursing home, I moved her into my home to care for her.
    I thought I was prepared. Large home, successful home-based business, supportive network of friends, pre-arranged assistance for in-home help with her care.
    Skip forward to two years later...
    Mom's dementia continued to worsen. What started as simply preparing her meals, assisted bathing, watchful eye on her to prevent mishaps, turned into 24/7 monitoring--mom would try to get up at night and wander, often falling.
    My business, which could support her needs at the beginning, couldn't keep up with her increasing care costs. 3 hours a day, twice a week, is nothing compared to an 8 hour night nurse.
    Unable to cover her increased care costs, I cut back on my business hours, thinking it wouldn't be much longer.
    After three years, she entered hospice. Finally, enough help to keep mom safe, and help me stay sane. But that only lasts 6 months, even though it was obvious she was not thriving.
    Skip forward another year. Mom dies.
    By the end: mom's savings gone, my savings gone, my business gone, my house foreclosed. I declare bankruptcy. I am 61 and surviving on SSI now.

  229. Alys, you said hospice lasted 6 months, then your mom died a year later. What happened after hospice until she died?

    I'm so sorry. What an awful story. Reading yours and other stories in these comments has only added to my anxiety about the future. If you assume $100k/year for nursing home that works out to $1 million for ten years...per person. Double that for a married couple. Who has that kind of savings after a lifetime of house payments and child expenses like college?

  230. 25% of Medicaid spending in New York is funded by the counties resulting in some of the highest property taxes in the nation. Trumpcare would have only the state pay. In most other states, only the state government pays that state's share.

  231. I feel so sorry for you Americans. Instead of a thoughtful and democratic process to reform and improve your health care Repubicans are sabotaging your social safety net to reduce taxes on the rich. The revenues for health care subsidy should not come from taxes on health care they should come from general revenues and a graduated income tax system. All Americans should have confidence that they will not face financial ruin or destitution because of poor health like other first world nations.

  232. New Yorkers should know about NYSARC. My father had transferred his assets to family members well in advance of the "look-back" period then in effect.

    When he needed full-time care, he qualified for home care through Medicaid because his pension and social security went to NYSARC.

    They paid his monthly expenses ( rent, food, clothing, etc.) out of this income.

    The paperwork was onerous but worth it. He lived out his days at home with home care attendants paid by Medicare.

    His assets remained with the family. And nobody went broke.

    The rules may be changing , but it's worth looking into.

  233. Well, aren't these elderly people in nursing homes just lazy? Sure they used to work, but now aren't they merely "takers"?Shouldn't our octogenarians and nonagenarians get jobs instead of lying around in nursing homes with their alleged infirmities?

  234. This is Nina Castro:

    Even the ACA (Obamacare) began to address the issue of management of geriatric citizens by planning to offer a daily stipend to the 40+ million caregivers (as per AARP). It addressed, even if only in a planning capacity, every healthcare issue we face for the foreseeable future. It is comprehensive in that way, I believe. Medicaid too, has begun at the state level to offer "assisted living waiver" programs for those needing help but not reduced medically to the point of needing nursing home care. As a functioning country, we had already begun to manage our insurance company driven healthcare system, with its needless mark-up inserted between providers and patients, and a millstone around employers necks. Now, we face the prospect of having healthcare reduced to a budget problem picked to pieces by people who are clearly able to count, but don't have a lot of other pertinent skills for this job. To the GOP moderates who maybe have some idea of the social disruption to come, I say, do not vote for this Senate bill and rebuke the House bill as well. I hope that you do not lack imagination and/or compassion for the consequences which will come. Even maybe, after you're out of office. But, I think, we're strengthening our memories for this issue.

  235. So depressing. Is it that other countries honor their elders more than here that they truly do care for their elderly? This may sound way out of whack but this is a country that is willing to crucify Medicaid, eliminate the ACA, as proposed by our lovely president, to repeal without replacement. But the country almost in every state is opposed to assisted suicide.

    Not so sure that would be a personal mission, but for those that absolutely do not want to suffer for what could be years in a nursing home, is it wrong to deny them of an alternative?

  236. I've given up hope. You would not think that there would be no more then 10,000 Americans in favor of the GOP bill, and that everyone in Congress that votes for the bill would be out of office the next time their seat came up for a vote. It is so obviously harmful to the vast majority of Americans that even the GOP is having trouble packaging it so that it appears palatable. They are again removing coverage and lowering taxes on the wealthy. Of course, what else do they ever do?

    But it will eventually pass and they won't lose their seats. I guess that American is getting just what it deserves, with too few voting, and the few voters we have not investigating the issues. To the pols, the population must appear to be complete fools, and who is to argue with that assessment?

  237. This is terrifying. It would be interesting to know how the senators and congress people pay for their elderly and how many former members of congress are destitute and in nursing homes.

    These guys are happy to tell the rest of us how to live while they don't have to participate personally in any of it.

  238. We have mandated hospitals and physicians to provide free or very discounted health care to patients since Medicaid was implemented. It is time to do the same to the for-profit multi-billion dollar nursing home industry, where average annual charges are $82,000 per your article. Surely cost savings, discounting are in order for that sector. How about analyzing how "cost-effective" the current Medicaid expenditures are on durable medical equipment makers, pharmaceuticals and other various vendors that thrive on Medicaid.

  239. This article affirms the truth about the Republican plan to replace the Affordable Care Act. The plan will greatly benefit the wealthiest Americans, as the prelude to large tax cuts that will transfer more of the nation's wealth to their Cayman Islands accounts. The plan will also benefit Republican members of Congress (at least in the short term), by finally delivering the principal promise they've been making to their loyal "base" for the last seven years.

    But these benefits for Republican politicians and the wealthy donors who fund their campaigns are to the detriment of everyone else in the country. The CBO has quantified that detriment as at least 22 million people losing their access to health insurance. Under the Republican plan, health insurance also will become unavailable, unaffordable, and/or unusable for many millions of older and sicker people. And there are numerous wide-ranging detrimental effects, including the loss of Medicaid support for elderly people in nursing homes (who clearly can't just go out and get a job with health benefits, the facile solution offered by Trump's spokeswoman).

    As the truth becomes widely known, support for this indefensible plan continually erodes among all but the few who will benefit from it. That's why Republicans feel they must shroud it in darkness and rush it through Congress. The bills solely address the partisan agenda to cut taxes for the wealthy and erase Obama from the history books. They serve no other purpose.

  240. For my Dad the last 18 months have been many trips to the hospital and into lengthy rehab. We moved him into assisted living in January.
    We specifically chose a place with a continuum to nursing home; this puts you at the front of the line. Nursing homes in southern Maine are a 1-2 year wait. While he is not rich, he could pay for about 4-5 years. Seeing his own father and then recently his sister have 5 and then 10 year nursing home runs we figured he'd be in for a long stint. We did see an elder lawyer and we were indeed advised to move his assets and place them in a trust. This really is presented as "the rule" not as advice, and the state as the Medicaid provider goes along and has a plan in place for this practice.
    Even if you can manage to pay it, $6500/month for assisted living, then $10,000 for a SHARED nursing home room is astonishing when you see what you get for it.
    When the time came in June for the nursing home, there was exactly one bed available for a man at this place, and they had clearly taken a single room and put a curtain between. Instead we moved him back to his apartment where the staff there required us to provide our own 24 hour care in addition to theirs. Meanwhile my sister and I were still running over there all the time. He could afford that for maybe 18-24 months.
    Now deemed hospice, my Dad is in my house where we have extra care 30 hours a week and can increase if needed. I think this type of arrangement will be more common in the future.

  241. We, as citizens, as voters, over time allowed healthcare to become another commodity. It happened to housing; the same thing is happening to education.
    The corporate private sector and the elected officials they fund do not care about the sad anecdotes of real life. Citizens need to stand up and assert themselves with their elected representatives and in their communities to change housing policy, change health policy, change education policy, in order to regain control of these fundamentals of our standard of living - one of the things that really made us great.

  242. I have had long term care thru Genworth for the past 15 years my premium wasn't suppose to go up but Genworth has increased my payment. I hope it doesn't increase past my means I have yet to use it but if I land up in a hospital it will pay for that and we might not have medicate which pays for nursing homes. Everyone should wake up we are all going to be there some sooner than later. NYT times has a great article on forest cemeteries that ought to brighten up your reading experience for today.

  243. Thanks for illuminating what may be the most important, and neglected, personal finance issues most families will have to face. Our family and my wife's family have had to deal with devastating dementia of our mothers. My mother died after 3 years in a very good nursing home and my mother-in-law is moving into a nursing home next month after a year of in-home care. Both are fortunate -- lots of loving family and enough money for excellent, but not gold-plated, care in their final years. Where did the money come from? In both instances, their children bought long-term care policies while they were in their 60's (my mom died at last year at 84 and my mother-in-law is 83). In my mother's case, we paid a long-term care premium of $4,600 per year for 14 years before she need the benefit -- and the insurer paid out $274,000 over 3 years. New York nursing homes are expensive.

    Truthfully, our motives in buying those policies were both love for our mothers and selfish concern for our own finances. All of us children knew we would mortgage our houses and "borrow" from our retirements rather than put our mothers in sub-standard facilities. And it has been bad enough even in places where they have received compassionate and skilled care. Not everyone can afford to buy long term care insurance, but everyone needs a financial plan for the potential costs of nursing home care.

  244. Solid concise article. I could fund Medicaid in its entirety if I received a nickle every time someone expressed surprise that Medicare doesn't pay for nursing home care (non-rehab).

  245. Ron Lieber. I can't find your "digital byline." So, I'm using the "comments" section to register my remarks. Wow, what a wake-up article. I'm 73 and I'm in good health. So, perhaps, I haven't been thinking about this subject as much as I should. I realize, of course, health insurance and health care will be vitally important to me as I age. I've been following the healthcare debate. I've paid closest attention to the Medicaid issues as, I understand it, Medicare is not being affected and no one is talking about changing Medicare. So, your article is very enlightening and eye-opening to me. Fortunately, for me and my siblings, my parents were financially able to handle this healthcare needs. Therefore, my brother and sister and I didn't experience the devastating financial impacts that some of your readers describe. Thus, we are not as acutely aware and informed. Bless them for taking care of their parents and loved ones. Please keep your articles coming! Your links to additional information are very helpful. Thanks.

  246. I've read through nearly all of the comments and it seems to me that we are talking about putting a bandaid on a major laceration.

    The ONLY solution is Single Payer for all. Health care should be a birthright, not something doled out by a Congress. Furthermore, if members of Congress had to purchase their own health care insurance and incur their own medical care expenses, just imagine how good and how fast we'd have a national health care program, and one that is far better than Obamacare.

  247. Great call to action - but what's the 'go do'? Protest in the street? Call our local representatives?

  248. I remember the horror stories of the '70's, and with our government fully in the hands of laissez-faire capitalists, I expect a return to those dark days. But perhaps with a difference: the Internet. Instead of just hearing about the lack of care, we will all get to see it up close and personal. I won't have the stomach for it, but a certain political party and all its supporters apparently do.

  249. The question is, how much must people save in order to take care of themselves in older age?
    Of course, no one knows the answer to the question. Last year, at 64, I bought long-term care insurance to the tune of $3,100 a year -- until I turn 90. That protects $156,000 of my estate that Medicare pay down can't touch. I can use that if I outlive the 2 years my long-term care insurance will cover.
    I still work full time and will until I am not competent at my job or drop dead, whichever comes first. I am afraid to retire because of the looming costs of healthcare.

  250. I acutely aware of what cutting back on medicaid might mean to senior citizens. My mother and aunt both died at home, ages of 98 and 95. I was the coordinator of their care and part-time caretaker.
    For a while, around the clock care was paid for by their savings, after that community medicaid was available to them. This enabled them to have 24/7 care at home. The program subsidized the cost of their home health aides. This did not mean that they had no living expenses, it was a combination of their remaining money and some help from me that enabled them to live at home comfortably. It also meant that I was available to help shop, make and keep medical appointments, and assist them with almost all other activities of keeping a household running. I am grateful everyday that we had such a program available to us. During this time my husband and I were raising our children, paying for college and saving for our retirement. I might also add that my husbands parents were able to maintain themselves at home without medicaid services, which they did until they, too, died at home.
    I fear that many who have not yet had to rely on such programs don't understand how fortunate we are to have this available. By the time this administration get done with their idea of health care reform it will be too late.
    Yes, this program and more like it cost money, but I believe it is money well spent and that a society that appreciates that is one which I want to live in.

  251. I have been looking into LTC insurance and have not found one that will pay out more than 5 years of care, not much good if one has an illness requiring nursing home care that lasts longer than that. Anyone have luck finding a policy that will cover the remainder of your life? I understand that such policies were sold years ago but no longer....

  252. I have wondered about that. Presently I do not have a LTC plan. My mother was in assisted living the last 8 years of her life (paid for by her thanks to $$ my father left her). When I hear of plans that pay for 2 years of assisted living, I am not encouraged to buy it. 2 years is nothing.

    The cost of the assisted living (memory unit) that my mother lived in was about $6600 a month.

  253. Estate planning and probate attorney in Texas, and this article is spot-on. Many people are surprised to learn that Medicare and private health insurance don't cover long-term care. The proposed Medicaid cuts are a huge issue for seniors with ripple effects impacting everyone.

  254. I will be able to pay for myself in my old age.
    I worked hard and well for 40 years.
    I lived within my means.
    I take care of myself and my health as not to be a burden on my family, friends or society.
    I chose to limit the number of children I have.
    I saved my money and invested well, seeking professional advice along the way.
    I will be able to pay for myself in my old age because I have always had a plan.

  255. Your tax dollars will then pay for others who have been less fortunate and/or who spent all their money along the way or who took it out of their name and put it in their children's names so as to qualify for Medicaid . Like you, My father paid for himself after a lifetime of planning to do just that. That being said, the cost of assisted living and nursing homes is outrageously high and the quality is not good, in many cases, regardless of what you pay. So something has to happen there

  256. Thank you for pulling the covers back and exposing the inevitably uncomfortable decisions and conditions we must ponder as part of a responsible retirement plan. This is very important stuff. As important as any aspect of estate planning. Even if we've planned for what income we will need in retirement to provide the lifestyle we envision, there will be the downside of ever advancing years when lifestyle becomes not so much a choice but a condition to be managed.

  257. The article speaks of nursing home cost, but tells us nothing of why the costs are so outrageous. Is it due to regulations and are they reasonable?

  258. So we have to soak the taxpayer so that heirs can inherit a home and an elderly parent's other assets ? Shielding family assets to stick it to society is reprehensible, and that is what this article advocates.

  259. It's not reprehensible. It's legal, and in that sense no different than good tax planning.

  260. I have not seen mentioned here that one needs to check if you have an air tight "do not resuscitate" legal document, one that is written by a lawyer with living witnesses and updated by you at intervals. It needs to be entered into your hospital's system. In some states it covers EMT and ambulance staff who will resuscitate unless you have a document to hand to them (manila envelope on the back of a door or on the fridge). If you do not want to be in an expensive vegetative state, do it. Now is a good idea. Everyone should consider this including the young who might want to have their preferences honored and spare parents some agony.

  261. I'm sure that people commenting in support of euthanacia for the elderly are doing so with the best intentions. But to me it says a lot about our priorities as a nation that we are so unwilling to find a solution that will allow our elders to live with dignity and in a safe/caring environment, that our first solution is to advocate for the right to commit suicide if we can't afford to continue to live. What a time we live in!

  262. Far too many people believe that this system and its huge costs are static. We fail to take into account our choices make on health care providers. If a much greater level of long term care came from consumers pockets an new players would enter the market to offer lower cost and specialized care options. Competition between the various options would drive down costs and drive up quality over time. This is true in all competitive industries including long term health care. It would be true of medical drugs as well if the government did not make the patent protection and approval so complex.

    As a society we would be far better off giving every adult a SMALL guaranteed income and allowing individuals to determine how to spend or save it, than arguing endlessly over the vast number of retirement, healthcare, unemployment, etc programs and the correct amount for each.



  263. My father, who died last year at 99, was savvy enough to know that toughing it out at home w. a nearby sibling to care for him, was the best of all not so great choices available to him. He managed to stay at home till the last 15 days of his life. My mother was home up until 3 days before she died. They were both keenly aware of the costs involved and I'm grateful they passed away before incurring debt. In fact they left a modest sum for each of their 5 children. And as other contributors here have said: my father in particular as a son of immigrants worked hard his whole life to earn that money that eventually came to each of us. I'm grateful they are gone in that the current end of life care system would have failed them both miserably. And it is, frankly, a terrifying look ahead at what can happen to the aging, the poor, those w. disabilities. Cruel times ahead.

  264. I don't understand why this kind of information isn't common knowledge. Thank you, Mr. Lieber. Keep it up. Please make this and subsequent articles accessible and easy to find.

    I'm sad that nursing home insurance is one of my few options for growing old with a shred of dignity. I don't want to live in a urine-soaked warehouse for people. I can foresee that a little bit of assistance at home will keep me healthier and away from institutional care for years. Where's the lobby advocating insurance for that?