In my health care class today we discussed the CLASS Act, a part of the health care reform legislation that attempted to create an affordable benefit program for long-term (nursing) care. The program was scrapped after actuaries determined that it could not operate within the financial limits allowed. This should not have been such a surprise, as long-term care can be really, really expensive.
Our professor noted that, in the absence of some federal long-term care entitlement, many people struggle to pay for long-term care. Medicare does not cover nursing services, though Medicaid does. However, in order to qualify for long-term coverage under Medicaid, seniors have to spend through their earnings and, in effect, impoverish themselves. “This,” our professor noted, “poses quite a dilemma.”
My response: huh?
Sure, it is quite a dilemma for the person who must decide between spending through their savings and foregoing long-term care, but how is it a dilemma for society or policy-makers? A person who values nursing services should buy them! Why, though, should the government pay for services of those who live above the level of wealth that society seems to have determined actually merits assistance (i.e. the level at which Medicaid and welfare are provided)?
Surely the strangers who will be taxed to provide for these services derive little benefit for these services. Why should they be forced to pay for them, while the assets of the person who receives the benefits are shielded? The demand for long-term entitlement is a self-serving cry for distributive relief.
Imagine a middle-class retiree with $2 million in the bank, and a lower-class retiree with only a few hundred thousand. Neither one is poor enough to qualify for Medicaid and welfare. In other words, they are not so poor that society has determined that they should receive financial assistance, forcibly obtained from wealthier people.
If the lower-class retiree needs long-term care, he may quickly become poor enough to qualify for Medicaid. The middle-class retiree, on the other hand, may spend a million dollars, on long-term care, and still have savings well-above the level of the lower-class retiree. If society pays for his long-term care needs, they have in effect protected his financial status from erosion, while at the same time ignoring and giving no assistance to the poorer lower-class retiree.
What possible principle could justify this? How about, “I deserve to be about as rich as I am now, even if other people are poorer.” Isn’t that a rather unprincipled assertion of privilege? My suggestion is that, at least regarding long-term care, society cannot justify paying for the entitlements of people who live above the level required for general government assistance.
Here are the responses I received from the other members of the class.
1. Long-term care needs can be unexpected.
So what? Why should we favor richer people with unexpected expenses over poorer people without them?
2. Medicaid provides access only to awful long-term care.
Maybe true, but a separate issue. The premise that poorer people need better long-term care does not yield the conclusion that the finances of richer people should be subsidized.
3. The bar for Medicaid is set too low.
Then it should be raised.
4. A married couple may have to liquidate both of their earnings to pay for care for one of them.
This is a poignant objection. A wife might not really assign much value to the long-term care that her husband receives, but there may not be a realistic way for her to protect her portion of the couple’s assets. She is “locked in” to his health care expenses.
But my same argument holds here too, I think. Surely a spouse values the long-term care of their partner more than the strangers who would otherwise be forced to pay. Why should strangers be forced to pay to maintain a spouse’s lifestyle when other poorer people receive no assistance?