HEALTH CARE, ELDERCARE, AND LIBERTARIANS   (uninsured problem; malpractice; bibliographic references)

            If you want the easiest possible panacea for all of our health care cost containment problems, you might indeed pick a universal coverage, single payer system.

            What are the bad effects? Since health care resources are still finite, which diseases and medical problems get the most effective treatment becomes subjects of political barter. Rationing and long waits for necessary procedures become inevitable. Furthermore, behaviors (especially sexual behaviors and substance use) that lead to heath problems become public business and also become subject to political judgments.

            Since our American public has long signed off on the notion that a poverty safety net is a public (instead of just charity and family) responsibility and especially so for care of the aged, we must note that the case for Clinton-style "universal coverage," even though it was shot down in 1994, becomes strong indeed. People uncovered by employment-related insurance often wind up on Medicaid roles anyway, even when it means emptying savings accounts and hiding money under apartment mattresses.

            The current system, which treats employer-paid premiums as pre-tax income, is grossly discriminatory against the working uninsured poor and especially against the self-employed and entrepreneurs (as if the government wanted to discourage people from going solo). Actually, as of current writing, self-employed persons who itemize (that is, homeowners) may deduct premiums when they go over a certain percentage of adjusted gross. So at least treating self-paid premiums as pretax is an absolutely essential reform. It is well to remember how the current system, as a "perk" or corporate (or labor) "entitlement" for the salaried middle class, got started during World War II during wage and price controls when health benefits were about the only thing unions could bargain for. So today we have an ideological notion that health care is something you “earn” by competing in the economic system and proving that you are “better” than others.

            An important suggestion is offering tax-deferred medical savings accounts and getting younger workers to put money into them. Accordingly, most health policies would be "catastrophic only" and would start kicking in only after a high annual deductible (say $3000) was met. MSA's could be used to pay for maternity benefits.

            A key component to reform, at least in conservative to libertarian parlance, is to treat health care as a consumer item and to make people behave more responsibly for their own care. For example, basic checkups could be free to induce people to keep up with their blood pressure, cholesterol, etc.

            Furthermore, persons could, based in income, be required to pay for more of their own care for diseases resulting from behavioral choices, and these might include many AIDS cases as well as diseases related to cigarette smoking and substance abuse.

            On the other hand, well-intended “liberals” do make respectable-sounding arguments for “single payer” systems, which usually would afford (but do not necessarily have to provide) universal coverage.  Proponents point out that there is a lower administrative overhead than in a patchwork private system (especially managed care) and in countries that provide it, general public satisfaction.  However, availability of necessary surgeries and other procedures becomes a problem (as Canadians sometimes come to American hospitals for surgeries), and the satisfied “general public” generally consists of people who have not faced these difficulties.  There will be a temptation for public tax coverage of all health care to cause government to be even more involved in regulating private choices, even if this has not happened much in European countries that have it.  Likewise there will be temptation to politicize one disease against another. The temptation would likely be stronger in our society.  Ironically one benefit of single payer would be the removal of health care from the workplace, a provision that would help the self-employed and remove potential incentives for discrimination (especially for age or maybe sexual orientation).   

            But the biggest public objective to widespread government involvement in health care in this country (Hilary Clinton style) is the perception that persons will lose control over choice of their own doctors and own care, something happening already under HMO’s and managed care.  HMO’s, after all, by owning their own hospitals often have inherent conflicts of interest.  However, in Canada, for example, patients generally retain the right to choose their own doctors, within certain parameters, why the government is the only payer.

            Another argument, often raised by libertarians, is that a single payer system justifies government meddling in “private choices” and personal behaviors, including sex (because of HIV and other sexually transmitted diseases), cigarette smoking, overeating, extreme sports, and drugs. This intervention generally has not increased in other western countries that have adopted a publicly financed system. Still, in the United States it is more likely that there would be political pressure, especially from the “religious right,” to apply this pressure on personal behaviors. (One could use HIV to build or reinvent a case for sodomy laws—Lawrence v. Texas notwithstanding-- in an environment where the public pays for HIV disease, although the public often pays for it now anyway.) Another interesting complication could come if the nation, in a post 9/11 world, decides to introduce universal national service (including military service) because total health care coverage would be a major cost in any such national service program.

            The stunning growth in genetic testing technology will, of course, lead to serious questions about proper public policy and ethics in protecting medical privacy and in protecting persons from employment and insurance discrimination based on genetic test results. It will be difficult to envision doing without legislative regulation, by medical, human resources, and insurance associations should be developing their own privacy practices voluntarily.  The growing knowledge about genetic diseases does pose important philosophical questions about simple ideas of “personal responsibility” as a driving principle for public policy. 

A note about Social Security, Medicare, Medicaid and Eldercare

It is quite possible that the Social Security Trust Fund is in "better" shape than most conservatives believe (the Brookings Institution and the Cato Institute debate this a lot). Nevertheless, Social Security is really a tax, on young people to pay for the retirement and medical care of the elderly (regardless of "means") in a collective and non-familial manner. With people having fewer children, it is inevitable that it will one day be bankrupt.

Therefore, libertarian and neo-conservative proposals to gradually privatize social security and medical savings accounts (to return some control to the individual) make a lot of sense. (There is now more about this at http://www.hppub.com/taxes.htm .)

In fact, the most promising treatment to the eldercare issue is to educate people to plan for their own future financial security, with all kinds of investment devices (many of them tax-deferred), and, particularly, the use of long-term disability and long term care insurance.

Nevertheless, many people will not be able to provide for their own care. Until about 35 years ago (with the advent of Medicaid) adult children could be held legally responsible for their parents' custodial care (and in some countries such as Singapore, adult children can be held legally responsible for supporting their parents). These provisions were called “filial responsibility laws.”  Now, parents must spend down resources before they have access to Medicaid for nursing home care, and it is appropriately illegal for parents to give away an "inheritance" to adult children before going on Medicaid. In fact, in 1994, some members of Congress wanted to hold adult children responsible for nursing home care even after spend-down before federal-participating (FFP) funds could be used, and back in the 1970's New York congressman Ed Koch made similar proposals.

Actually, some states still have filial responsibility laws, but it seems that they are rarely invoked. Medicare rules generally prohibit hospitals from going after children anyway. Since custodial nursing home care in an Intermediate Care Facility (ICF) is not covered by Medicare whereas therapeutic care in a Skilled Nursing Facility (SNF) is covered, it would seem to me that they could be invoked more often, and parents who have not yet reached 65 can be at risk. Perhaps it matters if an adult child does not live in the same state.  Here are a couple of web references. There was an interesting case in South Dakota, and the NYU article would seem to suggest that this issue will come back as the number of children supporting parents who live longer is growing smaller.

Fleming & Curti, PLC: Elder Law Issues, June 2, 2003; “Attempt to Force Children to Pay Father’s Hospital Bill Fails”

http://www.elder-law.com/2003/Issue1048.html

 

“Caring for our Parents in an Aging World: Sharing Public and Private Responsibility for the Elderly” by Karen Wise, May 3, 2002, NYU Law Journal.  Quote: “Aside from filial responsibility laws, which exist only in some states, no legal rules specify what duty, if any, children owe to their parents.”

 

http://www.law.nyu.edu/journals/legislation/articles/vol5num2/wise.pdf

 

This issue may ambush us, so if you have comments email me at JBoushka@aol.com

Continuing this blog: If Medicare, Medicaid, and Social Security disappeared over night, one could speculate that a common law responsibility might exist for adult children to support their parents (despite writings by libertarian Harry Browne that children do not owe their parents anything because they did not "choose" to be borne). One could imagine statutory variations, like placing an obligation on adult children who do not have other dependents, or trying to discourage employers from hiring such adult children away from the areas in which these parents live. Or, one can imagine a debate that envisions a single payer system or more government role in paying for health care, but that must balance limited or finite resources between children and the elderly. In such a world, publicly paid eldercare might be predicated on the involvement of other family members, especially adult children. Such a development would be particularly hard on smaller families and could cause great sacrifices. Clearly such a development is dangerous to gay men and lesbians (and relates to the gay marriage debate). I was nearly caught in a situation like this in my own family back in 1999.

Government, clearly, is going to be less able to cope with the financial burdens of the custodial part of eldercare than it has been even with Medicaid.  Burdens will fall upon individuals and families in a practical and moral way. Private industry is gearing up to help with this problem, by offering long term care insurance, to cover custodial care for individuals and spouses. A good overview is offered by Jacqueline Quinn, “The Shifting Dynamics of Eldercare,” the Journal of Financial Planning, February 2001, at http://www.journalfp.net/jfp0201-art1.cfm.

Even when money is available to pay for custodial care, the practical logistical difficulties (such as dealing with poorly complying nursing homes) can be very difficult for children. Caregivers often make tremendous career sacrifices on their own, and studies show that they are at greater risk for health problems of their own. Nursing homes have employed “feeding assistants” to help severely impaired residents, and recently the Health Care Finance Administration (HCFA) has promulgated rules that require much more training for such nurses’ aides, to the point only family members or unpaid volunteers could give care.

The trends regarding the actual delivery of care to the elderly are disturbing indeed. The reasons come from a combination of factors. Technology is available to keep persons alive much longer even as they are unable to care from themselves. Alzheimer’s Disease is increasing at an alarming rate as the population ages. While AIDS is coming to be viewed now as a financially, medically and logistically manageable problem (at least in the developed world, though not in the Third World) Alzheimer’s threatens to become the next massive public health problem, although (just as with AIDS) there is hope that entirely new classes of drugs my slow down or even prevent the aggressive course of the disease. At the same time, the availability of custodial labor for hire for manual caregiving is becoming problematical.  Home health agencies offer in-home day care and live-in caregivers, but these are often minority immigrants working as “contractors” without benefits in an unstable situation, while nursing homes have increasing difficulty getting conscientious care-giving work from their employees, placing nursing home residents at medical risk.  So over time an increasing burden may fall upon relatives and adult children, especially unmarried ones.  There was a time when unmarried (often “gay”) children were “expected” to stay home with aging parents, but in those days aging parents did not live as long. Today, the availability of life-extending medical and surgical procedures may eventually depend upon the availability of children as caregivers. If one thinks this through, one can see how the “right” to have legal recognition of same-sex partnerships could become material.  

On Dec. 29, 2000 The Washington Post, in "Not Enough Help at Home: Elderly, Health Agencies Face Shortage of Aides" discussed the growing shortage of (properly documented by citizenship, or green cards) home health and nursing home workers, and the likely burden adult children will face in providing custodial care for aging parents even when there are financial resources or long term care insurance to pay for the care.

On July 10, 2001, the Minneapolis Star Tribune (Warren Wolfe) reported an AARP (American Association of Retired Persons) study that showed that non-whites are statistically much more likely to be involved in directly providing custodial care to aging parents than whites.  The percents were 15% of middle-aged whites, 22% of blacks, 27% of Hispanics, and 31% of Asians. 90% of the custodial care received by older Americans is still provided by families, and families of non-European ancestry are more likely to place emphasis on family cohesion as a motivator than the more individualistic family members of typical “white yuppie” culture.   An article by Allison Bell, “Study Finds That LTC Insurance Keeps Workers Working,  in National Underwriter, July 30, 2001, pointed out that 85% of college-educated caregivers for relatives with private LTC coverage kept working, as compared to 45% of college-educated caregivers for relatives without LTC coverage; for the whole population the respective percents are 48% and 33%--rather alarming!      

So it's possible to pose all kinds of questions that go the heart of personal independence. Should any only child (like me) or the only child without dependents live a long distance (e.g. become the first astronaut to land on Mars, Europa or Titan) from an elderly parent? These will sound like moral questions to some, who may not have fully pondered the ethical problems in trying to control one's own destiny (which for many is a "simple" religious matter).

And a libertarian would point out one other closing observation: if you hamper the freedom of an adult child to make his own way, then the child may become a burden on the public later. But then this become the "liberal" argument for letting the government take care of all of these enormous burdens of eldercare.

China, particularly threatened by an eldercare problem because of its “one child per family” policy, and the tendency of younger people to migrate to the cities for jobs (away from the purifying “countryside” of the Maoist Cultural Revolution) has offered mid-life and younger adults the “opportunity’ to “volunteer” to provide intermittent eldercare in their own cities in order to earn “credits” for their own eldercare later.  This indeed sounds almost like an eldercare draft.  

We could eventually come to a point of rationing life-saving surgeries or other major treatments for the elderly based on the availability of family members to care for them, and even to whether the patients themselves have or have had dependents. 

An important issue in 2002 is compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), discussed at http://www.hipaaplus.com/abouthippa.htm. Presumably HIPAA could protect minor children from involvement with their parents’ care problems in some cases. So do other laws, like FDCPA. Debt collectors, for example, may not speak to children about their parents’ debts without a parent’s consent.

The slowing population growth also threatens the mathematical demographics of eldercare. See: Longman, Phillip. The Empty Cradle: How Falling Birthrates Threaten World Prosperity and What to Do About It. New York: Basic Books, 2004.  http://www.newamericafoundation.org/index.cfm?pg=event&EveID=362

2003 Developments

The week of October 20, 2003 ABC “Good Morning America” ran a series on health care, hosted by Dr. Timothy Johnson. The patchwork nature of our current system, with its many anomalies, was pointed out. Small businesses typically cannot afford to pay experience-rated group health care premiums and are severely affected if just one employee has a major incident. In one case, a woman with an advanced malignancy could obtain coverage from her insurer radical life-saving treatment when her university employer intervened and asked the company to.  Administrative costs are also very high in our system, compared to, say, the Canadian system.

Liberals seem to be clarifying their support for single payor. The Canadian system allows patients to choose doctors but only the national plan pays. Liberals claim that increased taxes for such a system are offset by the absence of premiums and doctor bills, and employers are relieved of a major expense, a help to the job market. However, the very latest procedures may not always be as available as in a private system, and is Canada getting a free ride on the private American system across the border?  A single payor system may encourage routine screening and preventative care, also. 

It would be interesting to study carefully the availability of complicated but semi-elective procedures in Canada and Vritain to the availability in the more private system in the U.S.  For example, one could study coronary bypass surgery for those over 80. (Of course, Medicare pays for most of the surgery, hospital and SNF but the treatment paradigm is still tied into the private market.) It appears that this has recently become more available in Canada (with less waiting) than it used to be, relative to the U.S.  But this would deserve a detailed, scientific study by a health care research firm. Here are a couple of references to get started: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=81453 (Canadian Medical Association) and an older study and the New England Journal of Medicine back to 1989 http://content.nejm.org/cgi/content/abstract/321/21/1443

In December 2008 Congress passed a complicated law to provide grudging Medicare prescription drug benefits to some seniors, and also to encourage private health HMO-like plans to compete with Medicare. Criticisms are many, including the idea that private competing insurers will “cherry pick” and that domestic drug prices will remain artificially high. Republicans are encouraging a tax-exempt medical spending account for individuals so that employers can provide policies with higher deductibles.

We still have a basic philosophical split. Some see health care as a “fundamental right” (rather than as an entitlement or “social right”). Others feel that individuals must accept responsibility for their own health in a meritocratic context, should get the care that they “earn” and should not push off the cost of their care onto others; one benefit of this approach is that innovation is encouraged. Would I have gotten a brand new operation for a 1998 acetabular fracture that got be back to work in three weeks in Canada? Perhaps not.  The fact is, however, that the public pays for much of our care even in a private system, through higher rates for paying patients as well as programs like Medicaid and Medicare.

Howard Dean mentions that his own state, Vermont, guarantees universal coverage to those under 21, and hints that this could be tried as a step towards universal coverage. But then would this be funded by a payroll tax on parents (though replacing their higher premiums for family coverage in employer plans—and it would be mandatory), or would childless people be forced to subsidize such a plan (an entitlement or sorts for parents) even when their own health insurance is compromised? 

An editorial, “Placebo” in The New Republic, Feb. 2, 2004, proposes the sensible idea that the Bush tax cuts could be rescinded in order to provide access to group health insurance for millions of Americans. Of course, the political pressure for rescinding would go against the wealthy, so they would be ask to pay for this. The editorial believes that access to group health insurance is worth more than the value of the tax cuts: maybe true, and this sounds like a good Ph. D. dissertation or a good study for a health care think tank. You need numbers and tables for this one.

Some libertarians fear that publicly funded universal care would justify more government intervention in private lives, or even condition some care upon available filial custodial availability of adult children. This doesn’t seem to have happened in western Europe or Canada.

Malpractice

Conservatives (and the insurance carriers) are right in claiming that the malpractice insurance crisis substantially increases the health care costs for average Americans. Tort reform is needed, and punitive damage awards for pain and suffering need to be capped, even if bad doctors need to be weeded out. I am a senior (not yet old enough for Medicare) paying for a high retiree premium with a high deductible. If I go to the doctor to refill a prescription, I fear that the doctor will order unnecessary tests to protect himself, which I will have to pay for out of my deductible. Why should I pay personally for someone else’s pain and suffering caused by someone else? Or is this an example of “solidarity”—we’re all in this together.

The Uninsured 

There has been recent (as of 2004) public attention to the fact that the uninsured are often charged more for medical procedures, office visits, prescriptions, and hospital stays than are those with insurance or on Medicare. That is because Medicare, large PPOs or HMOs or insurance carriers (and Blue Cross/Blue Shield plans) negotiate volume discounts with providers. In some cases uninsured have been pursued for very old debts by collection agencies and lawsuits, and even jailed for failing to show up for court summons, and had their bank accounts frozen or wages garnished. Some providers have been willing to offer uninsured patients discount prices if the patients don’t disclose publicly these arrangements!  Of course, this would hamper the public interest in knowing what prices are charged. Barbara Ehrenreich as written about this problem in The Progressive, Feb. 2004, in the article “Flip Side: Gouging the Poor.”

Cameron Barr provides a story in the Aug. 24, 2004 Washington Post, “Coalition of Clinics Gives Hope to Uninsured: Montgomery Ponders Investment Needed to Expand Venture, Reach More Adults,” a network of ten non-profit clinics that hopefully would provide “de facto” universal coverage in Montgomery County. Md. 

We come back to the debate over whether we can provide universal coverage and perhaps a single payer Canadian-style system, or whether we should expect citizens to start planning for their own (and families’) health care coverage with devices like medical savings accounts and dependent tax-free spending account allowances, as well as other tax reforms. The debate is partly, even largely ideological. Conservatives and libertarians properly fear loss of personal freedom, government intervention in personal behavior, and reduction in doctor choice if a publicly financed system is adopted.  The coverage of behavior-base illnesses and the interventions for the very elderly or terminally ill will likely become politicized (the health care rationing issue, and wait-lists), although the experience in Canada may suggest that these problems could be less than what is feared. Furthermore, with today’s system we all are paying a lot for “other people’s problems” when we pay higher bills and premiums to help covered the uninsured (although volume discounts offered to group policyholders, with their implicit “cherry picking” as opposed to anti-selection, may offset this somewhat). Single payer sounds like a win-win for the job market. It may have a financial benefit of facilitating preventative care and delaying the onset of disability for the elderly, keeping them able to work longer (although that observation invokes other attitudes and practices in job markets). But society will have to make a basic principled decision on the amount of obligation of the healthy to help take care of those who, for whatever reason, have not been able to take care of themselves. Do children deserve more support from the public than adults who have already had “a life”?

Here are some good references from The Lewin Group (I used to work for this company’s “predecessor” as a computer programmer from 1988-1990).

One in Three: Non-Elderly Americans Without Health Insurance

Advances in Alzheimer’s: Impact on People and Related Medicare and Medicaid Spending

Lewin Insight (topic varies)

Another good resource on the uninsured is http://www.covertheuninsured.org/

Return to hppub special topics   see especially discussion about Social Security at taxes  Return to hppub home page

ÓCopyright 1998, 2004 by Bill Boushka, subject to fair use. Contact info: JBoushka@aol.com or http://www.doaskdotell.com/contact.htm

Review of Barbara Ehrenreich’s Nickel and Dimed.   Read movie review of The Barbarian Invasions

Special European Health Insurance links: http://www.versicherungvergleich.info/   www.versicherungvergleich.info/private_krankenkasse.htm

Editorial on doaskdotell site