The Foglight - Modern Aging: The Hidden Costs of Elder Home Care in America
July 2024
Issue 13: July, 2024
In This Issue: The challenge of paying for the care older Americans need.
As medical advances extend life expectancy, many older Americans find themselves needing ongoing support and hands on care. This article explores the challenges of funding elder home care, the limitations of insurance coverage, and the difficult decisions families must make.
Modern Aging: The Hidden Costs of Elder Home Care in America
In most societies, older people lived with their children, especially once the older person needed assistance. Often, it was the eldest daughter’s responsibility (whether she liked it or not). Today, in the United States, moving in with family is often no longer possible. It’s all different, in so many ways. Daughters, as well as sons, have professional commitments. Older parents and their grown children may live far apart from each other. Many people have children late in life, and those adult children may still have children living with them at a time when their parents’ needs increase significantly.
At the same time, because of medical advances such as easily attainable antibiotics, people are living much longer. A case of pneumonia that would have been insurmountable could now be curable at home with a pill. As a result, we can now expect that there will be significant periods during which many older people will need hands-on help.
This period when an older person needs hands on help or life activity support (such as bill paying) is no longer limited to the last short stretch before he or she passes away. More people are living a long time, with impairments, no matter how healthy they had been.
All of this means that, for our rapidly growing population of old people, the odds are significant that they will end up in some sort of supportive care. And with the traditional support of family and local friends not always available, more people will need to receive help from “strangers.”
This then raises the question of how to pay for it. In my practice, I have found that many people—thoughtful, educated people who have done their best to plan ahead—are surprised, even shocked, when they discover that Medicare does not pay for many of the care needs during recovery from an illness or surgery or long-term.
After an illness or injury, a person may need help with walking, bathing, dressing, getting in and out of bed, using the toilet, shopping, preparing meals, or taking medication. Medicare will pay for doctor visits, hospitalizations, some rehabilitation, and a limited amount of home care. But Medicare does not pay for an aid to stay with you all day while you are recovering at home. And Medicare does not cover long-term care at home, in a nursing home or in an assisted living facility.
I have seen estimates that 80 percent of people don’t understand this limitation of Medicare. I have had numerous clients who experienced a tremendous shock when their loved one went from a rehab facility or the hospital, only to discover that the visiting nurse covered by Medicare will stop in for an hour or two a week. The nurse might send in physical therapy and maybe an aide for a few more hours a week. Medicare will not pay for someone to be with your loved one all day.
Just last week, I suggested to one client, whose husband’s neurological problem made it hard for him to leave the house, that she ask his primary care doctor about visiting nurse services. Perhaps the visiting nurse could evaluate whether PT and OT at home could help him be safer. The therapists could provide strengthening exercises, evaluate the home for tripping hazards, and make suggestions for modifications (such as grab bars). Hearing my suggestion, my client asked me, “Will Medicare cover it?” and then “How many hours a day will they be here?” And I had to tell her, “It’s a few hours a week.”
Dismayed, she said, “But he needs help every day.” And she is right, he does need help every day. Understandably, she thought the visiting nurse would provide round-the-clock care, paid for by Medicare. I had to tell her that she would have to pay out-of-pocket for aides to help him if there were not others available to do so.
And that is the story for so many families. A sick relative comes home, they need someone around the clock, but insurance doesn’t pay for that kind of help. The (relatively) healthy spouse discovers she must do it herself, lean on friends and family, or hire someone. Many spouses try to do it themselves and become exhausted.
Home health aides can be prohibitively expensive. I’ve seen rates between $25/ hour (private arrangement) to $50 /hour (for an aide from a licensed agency). Someone I know recently needed to increase the help for her mom, living in an independent apartment, after a trip to the emergency room. Her mom was not sick enough to be hospitalized, but nor was she safe to be alone. Her aids cost $30 an hour—$720 each day. She considered a temporary live-in, at about half that daily amount. But a live-in does not work 24 hours a day. Since the situation was temporary, and her mom needed constant help in the night, she paid $720 per day for several weeks. That is a lot of money.
So, what is to be done? If you are lucky enough to have family that can and will care for you, that could work. We know that more parents are moving in with their adult children. But there are also more solo agers, and more adult children who are unable or unwilling to take in their aging parent.
To fund this kind of care, most people tap into their savings. Some people bought long term care long-term care insurance policies when they were young and healthy enough to qualify. When such policies first became popular, 30 to 40 years ago, they were written without the expectation that so many people would live into their nineties—so they were affordable. Now, while many good policies exist, the days when you could pay a modest amount and get good benefits are long gone. For people who are interested, I suggest that they work with a good insurance agent, one who specializes in long-term care insurance and who will help you choose among the many options.
Second, a person can raise money for their care by using a reverse mortgage. These allow people 62 and older to borrow money against the value of their home. The upside is that reverse mortgages allow older people to get equity out of their homes on the downside, the home is lost to their heirs. And some reverse-mortgage plans have terrible rates, so be sure you are educated before signing up for one.
Third, when there is not enough money to cover the care needed, people end up on Medicaid, the state-funded health insurance program for the poor. While Medicaid can make an enormous difference for people, it comes with limited options. Unfortunately, because reimbursement rates are low, it can be hard to see a desired doctor or get into a good facility. And no one wants to go to the nursing home of last resort.
In the end, there are many “ifs” in our vast, wealthy country, how to afford care in one’s final years should not be one of them.
Email me with your questions, comments, or subscription requests at gm@mymdadvisor.com. I’d love to hear from you.
Warmly,
Gerda Maissel, MD, BCPA
Dr. Gerda Maissel, Author
Dr. Maissel is a Board-Certified Physical Medicine and Rehabilitation physician and a Board-Certified Patient Advocate.