Where Clinton and Trump Stand on Caregiving and Long-Term Care
Considering that Americans 65 and older are the demographic group most likely to vote, it is astounding how little the major parties’ presidential candidates have talked about two issues that loom so large in older adults’ lives: caregiving and long-term care.
About 34 million Americans provided unpaid care to an adult 50 or older in 2014, according to a 2015 report by the National Alliance for Caregiving and AARP. Half of those so-called “informal” caregivers were caring for a parent or parent-in-law. And the impact of that caregiving on their pocketbooks is profound. About one in five said caregiving created a financial strain on them.
The availability and affordability of long-term care is another growing concern for the aging boomer population. About 8 million people received long-term care services in 2012, according to the Centers for the Disease Control. Those services those provide through home health care, nursing homes, assisted living centers, adult day centers and hospice care. Among people 65 or older, 69 percent will develop disabilities and 35 percent will enter a nursing home at some point, according to a 2007 Urban Institute study.
This article details Trump’s and Clinton’s stands on issues relating to caregiving and long-term care. It is the fourth in a series of Next Avenue’s Election 2016 blog posts on where presidential candidates Hillary Clinton and Donald Trump stand on key issues of interest to Americans over 50. The first article that we shared was about where they stand on Social Security. The second article was about health care and Medicare. The third article explored their views and policies on retirement security.
To read the entire analysis of the candidates, you can find the article HERE.
PROVIDENCE, R.I. — About 70 Rhode Island Department of Human Services employees received layoff notices Thursday as the agency reorganizes in anticipation of installing a new $350-million-plus technology system to verify eligibility for social service programs, officials said. The system replaces one that’s 30 years old; it goes live Sept. 13. The reorganization also marks a change in the way social-service eligibility is applied for and determined. Clients will be able to apply for and
Medicare will pay for long term care in a nursing home only if the following requirements are met:
A. Skilled care is being provided to the individual in the nursing facility. Skilled care is continuous 24 hour per day care provided by licensed medical professionals under the direct supervision of a physician. Only about ½ of 1% of all nursing home residents receive skilled care. Most residents get either intermediate” (4.5% of nursing home residents) or “custodial” care (95% of nursing home residents).
Intermediate care refers to occasional nursing and/ or rehabilitative care under the supervision of skilled medical personnel. It is often referred to as intermittent care and may include physical therapy, occupational therapy, speech therapy, etc.
Custodial care often involves non-medical personnel such as nurses’ aides who provide assistance with the activities of daily living including bathing, eating, toileting, transferring and dressing.
B. The nursing facility is a “Medicare participating” nursing facility. Many nursing homes will not qualify under this requirement.
C. The nursing home care must follow (within 30 days of discharge) at least a three day hospital confinement. Most often those who require nursing home care do not enter directly after a hospitalization. Often individuals are simply aging and finally realize they cannot manage any more at home or in a relative’s home. Since nursing home confinement frequently does not follow a hospitalization, many states now prohibit prior hospitalization prerequisites in long term care policies.
D. In the past in order for Medicare to pay in a skilled nursing facility, the care the individual received had to be “restorative” in nature. The patient had to be getting better. However, on January 24, 2013, the U.S. District Court for Vermont approved a settlement in the case of Jimmo v. Sebelius which states that Medicare provided skilled care may not always have to meet the expectation of improvement. Generally, if an individual meets the four aforementioned requirements (of skilled care, Medicare participating facility, a 3 day prior hospitalization and care that is “restorative” in nature- now a somewhat unclear term-) Medicare will pay all of the costs of the first 20 days and the individual pays $161 for an additional 80 days (in 2016, adjusted annually). (At a current daily nursing home rate of about $250 or more, one obviously cannot depend on Medicare to pay for most of the cost for these other 80 days.) Beyond day 100, Medicare will pay nothing.
Medicare will pay for long term care in a home health care situation only if the similarly stringent and difficult to meet requirements are met. Home health care coverage includes part-time or intermittent skilled nursing care, physical therapy, and speech therapy, through a Medicare Certified Home Health Care Agency. If the patient requires skilled nursing, physical therapy, and/or speech therapy and if the individual is confined to the home and is under the care of a physician, Part A of Medicare can pay for some other services.
A typical individual who requires nursing home or home health care is someone with a physical disability who simply needs help with the activities of daily living -someone who is simply aging. Medicare will not pay for such custodial care. Alzheimer patients, Parkinsonians, stroke victims, and those who have other organically related mental disorders, form another large group of those who need long term care. Typically, since these chronic ailments of aging don’t “get better,” Medicare benefits are not available.
The bottom line is simple: A wise person will not count on Medicare to pay for long term care services.
So what is a person supposed to do? Contact our office to discuss what long term care planning means to you.
Source: This article is an excerpt from LISI Elder Care Law Planning Newsletter #17 (March 3, 2016)
Schemes Targeting Elderly Not Limited to Tax-Related Scams
While tax-related fraud schemes aimed at seniors have been in the news, financial schemes targeting the elderly aren’t restricted to those involving Internal Revenue Service impersonation calls or tax refund fraud.
The U.S. Department of Justice has filed a civil complaint alleging multiple international mail fraud schemes that have defrauded elderly and vulnerable U.S. victims out of tens of millions of dollars. According to the complaint, U.S. residents received fraudulent direct mail solicitations that falsely claimed that individual victims had won, or would soon win cash, prizes or other bonus. The solicitations appeared to be personalized even though they were really form letters mailed to hundreds of thousands of potential victims.
The solicitations typically matched one of three types:
False claims that the victim is the winner of a lottery or sweepstakes and will receive winnings if they pay a processing fee;
False claims that the victim has won a large sum of money and should purchase a “guaranteed,” “secret” method for winning lotteries and other games of chance; or
Solicitations allegedly from a psychic who has “seen” the victim winning large sums of money through the lottery or other contest which will only happen if with the purchase of various supernatural and divinatory objects or services.
In some instances, the solicitations claim that the recipient has already been confirmed the winner of a prize in bold, prominent lettering, but then explain in smaller text that the prize drawing has not yet taken place or that there is no prize drawing. Potential prizes touted were said to be in excess of $20,000 and included cash, checks, amounts held in trust, and cars. DOJ estimates that more than half a million victims responded, netting the defendants $18 million.
Elder Abuse from Children – the Opioid Crisis
Reports of suspected elder abuse in Massachusetts have surged over the past five years, according to state figures — a troubling increase that law enforcement and elder advocates say is fueled in part by the opioid crisis and addicted adult children exploiting parents and other relatives. Since 2011, abuse reports have climbed 37 percent, with more than 1,000 additional cases reported each of the past five years to protective services offices. The Executive Office of Elder Affairs, the agency that tracks and investigates abuse, recorded nearly 25,000 cases last year, but the state’s numbers do not delineate how many involved opioids. More adult children addicted to opioids are moving back in with their elderly parents, Middlesex District Attorney Marian T. Ryan said. Retired parents, with their monthly Social Security and pension checks, become easy targets for financial, physical, and emotional abuse.
Protecting the Elderly from Fraud
Want to protect your elderly loved one? While people certainly have the right to choose where they spend their money, we don’t want our loved ones prayed upon and taken advantage of. Keep in close contact with your loved one. Watch for any changes in spending or behaviors. Review mail received for any solicitations that are seeking donations of payments. If irregularities are noted, inquire into spending habits. If possible, review banking and financial records.
Consider executing a Durable General Power of Attorney to address any competency issues. A fully considered and executed estate plan will often minimize the chance that the Elderly will be targeted by fraudulent activity.
Death comes in many forms. It may arrive suddenly without warning or approach slowly after a long illness. In the latter case, families have time to prepare for the inevitable. What’s more, they may have access to hospice care, which can simplify life by bringing doctors directly to patients and providing myriad support services.
Unfortunately, not everyone who is eligible makes use of hospice. “The truth is half of patients never get hospice at all,” says Joe Rotella, chief medical officer with the American Academy of Hospice and Palliative Medicine. “What we see is patients either avoid hospice or call it very late.”
Some people may not use hospice because they are unaware or misunderstand it. Other times, people may not want to go into hospice because it means ending all attempts to cure a patient. “A lot of times, doctors are reluctant to give up,” says Ellen Windham, author of “Hospice: The Last Responder,” a guide to hospice care.
When the end is in sight, here are:
10 things hospice experts say seniors and their family members should know.
1. Hospice is not a place but a type of care. While it’s true some hospice organizations operate facilities, hospice itself refers to a type of comfort care that can be provided in any setting. “A team of professionals provide emotional and spiritual support to a patient and family anywhere,” says Richard Fife, president of the Foundation for End-of-Life Care.
2. Medicare pays for almost everything. Seniors who receive Medicare will find their hospice care is covered almost completely. That coverage includes everything from doctors and nurses to social workers and homemakers. Patients must pay a $5 co-payment for prescriptions and 5 percent of the Medicare-approved amount for respite care, should they need it. In exchange for this level of coverage, Medicare stops paying for any medical care outside of hospice.
3. You need to have a life expectancy of six months or less. Under Medicare rules, a hospice doctor and a person’s primary care doctor need to certify a person has a life expectancy of less than six months before hospice care can begin.
4. If you live longer, that’s OK. Six months or less is the life expectancy required to enter into hospice, but estimating a person’s lifespan is an imperfect process. “It’s not always easy to predict for a patient with Alzheimer’s, for example, when they’ve entered their last six months of life,” Rotella says. As a result, it’s possible for some people to remain in hospice long after six months have come and gone. Michelle Riddle, a patient advocate at Complete Dignity in Phoenix, says people don’t need to worry about losing their coverage if they do outlive expectations. “If you haven’t passed in six months, they don’t cut you off.”
5. It isn’t only for those with certain illnesses. Some people might mistakenly believe hospice is only for those with certain diseases, such as cancer. However, this type of care can be used by people of all ages with terminal illnesses of any kind.
6. Hospice is about more than medical care. A critical component of hospice is the support services they provide to family members.“Loved ones don’t have to run out to the drug store to get supplies,” Riddle says.
Hospice organizations are available 24/7 with on-call nurses and doctors who can make home visits at whatever time they are needed. Plus, hospice staff coordinates prescriptions, arranges for respite care and meets other needs families might have. Once people are able to stop juggling appointments or worrying about the logistics of their care, they may find their quality of life increases.
“People equate hospice with immediate death, Windham says. However, she advises people enter into this care as early as possible. “Going into hospice sooner rather than later gives patients and family members more quality time together.”
7. Services continue after someone dies. After a person passes away, hospice typically offers grief counseling or other bereavement services to family members. “Many hospitals have a chaplain, but that doesn’t mean you’re going to get the emotional support you get with hospice,” Fife says.
8. You can choose the hospice you want.Hospice isn’t offered by a single entity, but is a form of care offered by thousands of providers. In 2014, there were 4,000 hospice care agencies in the country, according to the Centers for Disease Control and Prevention. “A lot of nursing homes have a hospice they use, but it’s OK to pick a different one,” Windham says. She recommends families interview at least two hospice providers before making a choice.
During those interviews, the most important question may be to ask whether the hospice is Medicare-certified. If not, Medicare won’t pay for its services. Beyond that, patients and families should ask about the type of services provided, frequency of care and who will serve as the family’s point of contact. “If they are getting irritated with your questions, look at a different hospice,” Riddle says. “Don’t be bullied into a choice you don’t want.”
9. More transparency may be coming to hospice organizations.The government doesn’t publish hospice information for consumers as it does for nursing homes. That may be changing, Rotella says. It could be years before it’s fully implemented, but a move is underway for Medicare to publish quality measures of hospice organizations to make the process of selecting one easier for consumers.
10. Hospice is focused on life, not death. Entering hospice might feel like quitting on life, but those who work in the field say accelerating death is not the focus of this type of care. Instead, it’s intended to help people live fully and comfortably in the time they have left.
“[People] think it’s morbid and focused on giving up,” Rotella says. Instead, he says “it’s focused on quality of life while facing the reality of what’s going on with an illness.” Rather than feeling like they are at the mercy of a medical process that entails countless appointments and tests, people in hospice care may finally feel like they are back in control of how they live.
This article was written by Maryalene LaPonsie and can be found here.
Five Health Care Issues the Candidates Aren’t Talking About — But Should Be
The nation in the next few years faces many important decisions about health care — most of which have little to do with the controversial federal health law. Here are five issues candidates should be discussing, but largely are not:
Out-of-pocket spending. As insurers have shortened their lists of “in network” doctors and hospitals, another out-of-pocket spending problem is becoming more common: The “surprise medical bill.” Those are bills for services provided outside of a patient’s insurance network that the patient did not know was out-of-network when he or she sought care.
Drugs — more than prices: Rising drug prices at the pharmacy counter have also proved problematic for patients.
Long-term care. Every day, another 10,000 baby boomers turn 65 and qualify for Medicare. An estimated 70 percent of people who reach that threshold will need some sort of long-term care.
Medicare. Medicare, which provides health insurance to an estimated 55 million people — 46 million older than age 65 and another 9 million with disabilities, is also in a financial bind.
Dental care. Research has shown repeatedly that care for the mouth and teeth is inextricably linked to the rest of the body. Oral problems have been linked to conditions as diverse as heart disease, diabetes and Alzheimer’s disease.
Social Security: Where Clinton and Trump Stand
Social Security is one of the most vital issues for older Americans. And, as things now stand, unless the Social Security system is changed, benefits will be cut by 21 percent in 2034, due to solvency issues. The only way to shore up Social Security is by raising taxes, cutting benefits (which could include raising the retirement age) or both. Forbes Magazine has prepared a head-to-head rundown on where Donald Trump and Hillary Clinton stand — as best as anyone can tell. Incidentally, Trump’s website makes little mention of Social Security; most of his policy positions come from what he has said in debates or speeches. Clinton’s site has more details about her proposals and she has fleshed them out elsewhere. Both recently gave a pretty good summation of their views to AARP. Two caveats: Trump’s positions sometimes differ from the Republican Party platform, are still unknown or may change if he’s elected. Some of Clinton’s positions have been evolving (her threshold for higher payroll taxes is new, for instance) or are vague.
As of June 9, 2016, California joins Oregon, Vermont, and Washington in permitting terminally-ill residents to request a lethal prescription under its End of Life Option Act.
A Brief History of Options at End of Life: The Right to Refuse Treatment
Do Not Resuscitate Orders
In 1976, the decision by a patient to decline resuscitation was fought all the way to the New Jersey Supreme Court, where the court upheld the rights of Karen Ann Quinlan’s parents to order her removal from artificial ventilation. In 1987, New York became the first state to pass a law allowing patients to file a “Do Not Resuscitate” order with their medical team. In Rhode Island the Department of Health recognizes Medical Orders for Life Sustaining Treatment (“MOLST”) which are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet.
Advance Health Care Directives
In 1991, Congress passed the Patient Self-Determination Act, requiring hospitals to honor a patient’s decisions with regards to their own health care, including decisions to withhold treatment.
Rhode Islanders have the right to control decisions related to their medical care and to authorize others to make medical decisions for them if they become unable to do so themselves.
The Rights of the Terminally Ill Act allows individuals to instruct their physicians to withhold or withdraw life-sustaining procedures in the event of a terminal condition. If you wish to establish a Living Will, as part of your estate plan, we would prepare a form that reflects your goals and wishes compliant with the requirements of the Act.
Durable Power of Attorney for Health Care
Rhode Island law allows an individual to authorize another person to make decisions affecting their health care if they become unable to do so. You do not have to have a terminal condition to activate the Durable Power of Attorney for Health Care. If you wish to name an agent for these purposes, you must use the statutory that we prepare and complete as part of our estate planning services for our clients.
The Office of State Medical Examiners supports the donation of organs and tissue. Organ donation can help families through the grieving process and give others a second chance at life.
“End of Life Options Act” in California
Patients must make two oral requests, at least 15 days apart, and a written request. Their attending physician must make a determination that they have a terminal illness with a life expectancy of less than six months, and must make a determination that the patient has the mental capacity to make the request for aid-in-dying medication; a consulting physician must make the same determinations. The patients must be able to ingest the medication themselves, although they may have assistance in preparing it.
The cause of death may not be listed as suicide; any insurance benefits, wills, or contracts shall be treated as if the person died a natural death from their underlying terminal illness.
At least one challenge has already been filed, seeking a preliminary injunction against the implementation of the Act. The California Department of Public Health shall release annual reports, beginning July 1, 2017, with statistics on prescriptions issued and deaths resulting from those prescriptions, so it will be a year before we know if anyone has availed themselves of this Act.
Does Rhode Island Have an End of Life Option?
Rhode Island currently does not have similar End of Life Option legislation, though there have been several bills similar to the Oregon-style physician-assisted dying bills that have been considered in the Rhode Island state legislature before, in 1995, 1998, 2001, 2006 (H 7428, S 2766) and 2007 (HB 6080). Most recently, Representative Ajello’s submitted a bill, H 7659, the Sapinsley Compassionate Care Act, which was heard in a House Committee on March 23, 2016, and held for further study.
The citizens of Oregon passed Measure 16, “Oregon Death with Dignity”, in November 1994, by a slim margin of 51.31% to 48.69% which authorizes physicians to provide aid-in-dying to terminally ill patients.
Four states now have aid-in-dying statutes: Oregon, created by voter initiative in 1994; Washington, created by voter initiative in 2008; Vermont, created by the state legislature in 2013; and California, created by the state legislature in 2015, effective June 9, 2016. Three states have statutes prohibiting aid-in-dying: Arkansas, Idaho, and Georgia.
Concerned with your Medical Directive and want to discuss further?
Contact our office to discuss drafting a Medical and Health Care directive that reflects your wishes.
Portions of this article were cited from LISI Estate Planning Newsletter #2440 (August 4, 2016).
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About Mathew J. Leonard ESQ.
Matthew J. Leonard's practice is concentrated in business law, estate and asset protection planning, elder care, civil and probate litigation and real estate. He is a member of the Rhode Island, Massachusetts and Florida bars. He is a frequent lecturer and has authored and spoken on in many occasions through the state.