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170 Chapter 13 How Will We Pay? Planning for the Unknown Underlying the hopeful alternatives in this book are significant questions of who will pay for services that people may need in order to remain out of institutions. Those who say they wish to age in place (unless that place is a continuing care retirement community which includes long-term care) need to consider how they will pay for major adaptations to their home or for help if they need it. Such help may be for mopping floors, mowing the lawn, or bathing, or it may be for transportation when we can no longer drive. If we become truly debilitated we will need to pay for in-home care, which, at $20 an hour, can quickly soak up resources. Perhaps nothing reflects our mass denial about aging more than our refusal to contemplate ahead of time how to pay for help when we need it. Without a plan, aging in place may be nothing more than wishful thinking. The public remains woefully ignorant about such matters. The results of a 2009 MetLife survey were typical. two-thirds of respondents did not know how nursing homes, assisted living, and home care are paid for; they assumed that Medicare, private health insurance, or disability insurance paid for such services. They do not, and they never have. (Medicare only pays for some short-term stays in nursing homes.) “a wide range of the population ages 40– 70 is unaware of its potential need for care and how to pay for it. Most are not taking appropriate steps to protect themselves from potentially catastrophic expenses,” according to the survey.1 Despite what everyone knows is a burgeoning need, the government has no plans to expand Medicare to encompass long-term care. a modest longterm care benefit of $50 a day, known as the CLaSS act, was proposed as part of the affordable Care act. But that was eliminated early on, in part because of partisanship, but as importantly, because the program as designed was not sustainable. It’s no great mystery how to cover people’s long-term care needs. Other countries have done it for decades. In much of europe, for example, home care for older people is a matter of course, not some mountain each family How Will We Pay? 171 must climb alone. as Sara Mansfield taber wrote in her essay, “Caring for Mom, Mum and Maman,” the difference between how the United States handles eldercare contrasts sharply with that provided in Great Britain and France.2 Sara’s mother paid $4,000 a month for assisted living. On top of that, her mother hired private aides for an additional $1,400 a month because she needed more care than could be provided by the staff on her floor, where a single aide had to care for thirty-eight people. In contrast, her friend Fiona’s “mum,” Pat, in england, had terrible pain from diabetes and arthritis but she received considerable public support. “a government-supplied home health aide visits Pat at breakfast, lunch and dinner every day. This costs the family 120 pounds a week (approximately $785 per month), a little more than half of what my mom paid for private aides.” and of course, the British family was able to keep “Mum” at home, where she wanted to be, because of the generous support. Meanwhile, in France, Sara’s friend Juliette also took care of her maman, Madelaine, at her mother’s home. her mother, who has alzheimer’s disease, is assisted through a government program for older and disabled people called the “Personal autonomy allocation.” “Since the government refunds 560 of every 1,200 euros Juliette spends on her mother’s medical expenses, she is able to hire a caregiver who looks after her mother around the clock 31/2 days per week. This allows Madelaine to stay in her suburban Paris home, where her family has lived for three generations, and provides Juliette a regular respite from elder care,” she wrote. The odds of programs like this being enacted in the United States are long, to say the least. In our country, the primary federal-state program that does help pay for long-term care is Medicaid, the insurance program for lowincome people or people who have spent down most of their assets. Indeed, older people in nursing homes consume an enormous chunk of the Medicaid budget—nearly one-third in 2012. Or, put another way, Medicaid...

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