Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, June 19, 1995 TAG: 9506190035
SECTION: VIRGINIA PAGE: C-1 EDITION: METRO
SOURCE: MARGARET EDDS STAFF WRITER
DATELINE: LENGTH: Long
This story came to mind while covering a welfare reform debate in which all of us - churches, civic clubs, individuals - were being asked to think anew about how we can substitute for the role that government has played for the last three decades.
It came to mind also because of a little discussed fact: that while many middle- and upper-class Americans complain loudly about the costs of sustaining welfare mothers and children, there are noticeably fewer complaints about another public policy shift that has done much to add to the spiraling cost of ``welfare as we know it.''
In last winter's debate, Allen administration officials distributed documents putting the state's 1995 welfare tab at $2.9 billion.
What they did not say is that elderly nursing home patients, many of whom lived middle-class lives and today have children or relatives of substantial means, contribute mightily to that tab.
A few decades ago, many of those elderly - like Lillie Downing - would have been cared for by an immediate or extended family. Today, government is filling the elder-care gap created by smaller and more mobile families, longer lives, two-worker households and spiraling medical costs.
Aid to Families with Dependent Children, the program being revamped with much fanfare by welfare reform, accounted for 8 percent of the $2.9 billion tab cited by state officials. The bulk - $2.1 billion, or about 75 percent - stemmed from Medicaid payments.
According to a 1994 government report, welfare mothers and their children contributed $506 million to the Medicaid bill that year; elderly nursing home patients cost the system $541 million. It's unclear how many of those patients are middle class and could afford to contribute to the financial costs of their care, but experts in the field say that it is a majority.
A policy mandating that the nation care collectively for its elderly isn't necessarily wrong. The alternative in many cases would be rapid loss of a lifetime of savings, and possible impoverishment of a spouse.
However, many middle-class families have profited from the government dole, as have the poor who are more frequently chastised for a lack of self-reliance.
``It's definitely a middle-class welfare program,'' said former Secretary of Health and Human Resources Eva Teig, a Democrat, referring to elderly care under Medicaid. ``I'm not saying it's wrong, but it's not women and children who have been causing the costs to skyrocket.''
``Bingo,'' echoed Robert C. Metcalf, who administers the state's Medicaid program as director of the Department of Medical Assistance Services. A Republican whose former law practice included advising the elderly on estate planning, Metcalf said government and citizens must think as critically about nursing home care as they have about those on AFDC.
With two-thirds of all people who have ever lived to be 65 still living today, we cannot afford for government to provide nursing home care for middle-income Americans, he said. ``Medicaid is for poor people.''
That, at least, was the original intent. Medicaid was launched in the mid-1960s as a program to pay for the health costs of poor women and children. Over time, the blind, disabled and elderly were added to the list. Today, such groups account for two-thirds of the medical costs of the program.
Substantial publicity about ``millionaire Medicaid recipients'' has caused major tightening of both federal and state eligibility regulations in recent years. Still, loopholes remain.
``You could own a Lamborghini and be on Medicaid. You could own an estate and be on Medicaid. For that matter, you could own the Hope diamond,'' said Howard Estes, the assistant attorney general who is general counsel to the Department of Medical Assistance Services.
It would be harder to enjoy such largesse today than a few years ago, however. Estes and others say the major remaining loophole is one that allows spouses to get court orders boosting the value of the resources they can retain beyond the $72,660 allowed by law. That figure is in addition to a list of exempt properties, including home, car, contents of the house, burial funds and certain life insurance monies.
In some cases, courts have approved retention of resources of a half million dollars or more if the money was deemed necessary to maintain a noninstitutionalized spouse.
Last year, the General Assembly issued guidelines restricting such orders to ``exceptional circumstances resulting in significant financial duress.''
The state is still assessing the results of that revision. Ann Cook, eligibility consultant to the state Medicaid program, said Medicaid officials are tracking about a dozen requests for court orders involving non-exempt resources of $100,000 or more.
In one case currently in court in Westmoreland County, the wife of a retired farmer who is in a nursing home is seeking to protect family assets in excess of $624,000, according to court papers. The husband has not applied for Medicaid, but the court order, if granted, could be instrumental in allowing him to enter the program. The state is asking the court to dismiss the petition.
What the state has no way of monitoring is the number of cases in which children or other relatives could care for Medicaid recipients but do not.
Elder law attorneys such as Paula Peaden of Richmond argue that abuse is minimal and that most families care for their elders as long as they are able.
Inequities in the system abound, she said. For instance, a 70-year-old man might develop a brain tumor and ring up a $300,000 medical bill that would be covered by Medicare.
But Medicare does not cover the nursing home care that would be required if that same man had a stroke or developed Alzheimer's disease instead. Then, without Medicaid, an entire life savings could be wiped out in a few years or less.
``These people feel like they've been working hard all their lives, and then they look at all these people who are not working and are getting free medical care,'' she said. The conclusion of many is that the government also should help them in a time of need.
The distinction that government has traditionally drawn in deciding who deserves public assistance has been between those who ``can't'' help themselves and those who ``won't,'' said Howard Cullum, former state Secretary of Health and Human Services.
Part of the impetus of welfare reform is the popular belief that many AFDC recipients could do more to help themselves, but won't without a push.
As the parents, aunts and uncles of this generation age, the life circumstances that once led a group of cousins to provide for an elderly relative seem far removed. Nursing home costs average $38,000 a year. An extended family that, in the 1940s, was concentrated in a few towns in a single state is disbanded across the nation.
And yet, where families are concerned, perhaps the questions that are being applied to AFDC should extend to Medicaid as well.
by CNB