OCTOBER 7, 2002 VOLUME 10, NUMBER 14 Driving is an enormously important issue to our elderly (and disabled) clients, their family and friends. In the western U.S. and particularly in Tucson, transportation without a car is difficult and inconvenient. Safety of both the driver and the public is paramount, but the loss of independence and self-esteem as well as easy access to groceries and medical care must be addressed when a loved one can no longer safely drive.
There is no mandatory cut-off age for giving up driving. However, even the healthiest senior citizens experience age-related “slowing down” at some point — less flexibility in movement, a decrease in night vision, blurred vision from cataracts, hearing loss, etc. When decreased physical or psychological function cause unsafe behavior —either on the road or in other activities — driving should be suspended until that behavior is evaluated.
If one has difficulty seeing to prepare meals or cannot hear when there is loud knocking at the door, driving is likely also a hazard. All drivers, but especially seniors (who tend to take increasing amounts of medication as they age) must be attuned to the fact that many medications create hazardous driving situations. For example, allergy medications as well as drugs used to treat high blood pressure often have a strong sedative effect.
Seniors and their friends/families have many information resources. Information available online includes the AAA-sponsored website www.SeniorDrivers.org and www.la4seniors.com, both of which help in identifying and addressing driving problems. For drivers concerned about maintaining their skill levels, AARP’s “55 Alive Driver Safety Program” is taught locally at the Pima Council on Aging (enrollment is limited; contact them at 298-3120 first.)
In 1999, the American Medical Association changed its ethical guidelines so that physicians, despite their duty to keep confidences, may report a patient’s driving impairments in order to protect public safety. Physicians or family members concerned that a senior should not be driving may contact theAZ Dept of Motor Vehicles, Medical Review Program at 1452 N Eliseo C. Felix, Jr. Way, Avondale, AZ 85323 [(623) 925-5795]. Advanced age alone is insufficient; the letter of concern should detail the driver’s deficits and must contain the driver’s name, address, date of birth, and if possible the driver’s license number.
Revoking a driver’s license may not stop the impaired driver. In a future newsletter we will discuss some strategies to deal with that problem.
Two recent studies demonstrate that children of the frail elderly spend more time and money on care of their parents than is widely supposed. Despite the popular image of “baby-boomer” children as self-involved and neglectful of their elders’ needs, the research indicates that the amount of effort invested in elder care has actually increased over the past decade.
In 1987, according to one of the studies (sponsored by the American Association of Retired Persons, the National Alliance for Caregiving and others), seven million families were involved in providing long-term care for parents or other relatives. That number has more than tripled, to 22.4 million.
Fully half of employed caregivers have missed work time to care for their elders in recent years, reflecting an increase from just over two-fifths a decade ago. Another surprise: almost half of long-distance caregivers are male, despite the stereotype of daughters providing all the care for aging parents. The average age of long-distance caregivers: 46–which places the average caregiver solidly in the baby boom generation.
Long-distance caregivers make up a distinct portion of the children providing care for elderly relatives. 70% of those out-of-town care providers are employed, and they provide assistance with everything from bill-paying to hiring and managing on-site caretakers.
The second recent study, commissioned by the National Council on Aging, shows similar results. The NCOA focused its study on caregivers who live at least an hour from their elders. While that study showed that only 15% of caregivers have taken unpaid leave from their jobs to deal with elder care responsibilities, it suggests that out-of-town caretakers provide more than just their time to support aging elders. In fact, the NCOA caretakers had spent an average of $196 per month of their own money to provide or oversee care, and spent 35 hours per month on making the arrangements and visits necessary to keep their elders safe and provided for.
The NCOA study (funded by the Pew Charitable Trusts) also revealed another important detail about long-distance elder care: the length of time such arrangements continue. According to the study, the average long-distance caretaker had been involved in helping out for just over five years.
Both studies demonstrate the reality of caregiving at a time when public policy debates focus on the spiraling costs of long-term care. According to the conventional wisdom, children (and especially baby boomers) are interested primarily in receiving their depression-era parents’ estates as quickly as possible. That is the view that invests policy determinations, from Congress’ recent attempt to make criminals out of parents who give away property before institutionalization to Medicaid’s refusal to provide any substantial home care alternative to nursing home placement.
Even as the American population ages inexorably, the public debate shifts away from reasoned solutions of the growing funding problem associated with long-term care and toward demonizing of the segment of society most likely to require assistance. The long-term care insurance industry, eager to develop a market in this growth field (a tiny fraction of long-term care costs is currently paid by insurance, with the majority of funding coming from the federal Medicaid program), has led the charge with a two-fold attack: accusing children of the frail elderly of greed while trying to frighten the elderly themselves with visions of bankrupt government programs and allegedly substandard care. Unfortunately for those who make the first claim, the AARP and NCOA studies clearly demonstrate that the elderly receive tremendous assistance from their children, even across long distances.
With nursing home costs approaching $40,000 per year for most residents, the government’s Medicaid program has for decades been the “safety net” for families with long-term care needs. In recent years, escalating Medicaid costs and increases in the portion of national nursing home bill paid by the program have resulted in Congressional efforts to reduce Medicaid eligibility and coverage. Prudent elders should be considering other ways to ensure that nursing home stays can be paid for if needed.
A relative handful of individuals have long-term care available from religious or service group affiliations. Another small portion of the population can rely on government programs other than Medicaid, but for most elders the only alternatives are to accumulate substantial personal wealth (a common goal, though sometimes difficult to realize) or purchase long-term care insurance (LTCI).
A recent review of LTCI purchasing strategies by Elder Law Forum (a newsletter published by Legal Counsel for the Elderly, Inc., and sponsored by AARP) points out some of the considerations for typical buyers. The review makes several points for the “typical” LTCI buyer:
About half of 65-year-old women and a third of the men will spend some time in a nursing home.
Most nursing home stays will be short, with the median length of institutionalization being slightly less than one year.
LTCI premiums currently average about $1,000 per year for 60-year-olds, and rise to $1,500 for 65-year-olds and $2,000 for 70-year-olds.
If you (or a relative or client) are concerned about long-term care costs, some pertinent questions to consider include:
When should you buy? The average age of new policyholders is currently 67. Many employers now offer group plans, and a few younger people may buy policies. But for most people, waiting until age 60 to make the purchase is probably reasonable.
Should both a husband and wife buy policies? In many cases, one spouse or the other may be uninsurable due to illness or age. The “well” spouse should particularly consider LTCI, since she (most commonly) is likely to survive the “ill” spouse, and therefore have no spouse to care for her. Of course, this is another way of saying that the well spouse is likely to spend some considerable time providing care for the ill, uninsurable spouse, as well.
Does family history matter? If a potential LTCI buyer has a family history of strokes, high blood pressure, dementia, Parkinson’s or other conditions likely to require long-term care, insurance is more strongly indicated. Such persons should make the initial purchase at younger ages, since the onset of disability will usually make them uninsurable.
Does net worth make a difference? Couples with a net worth of less than $100,000 (not counting the family home), and individuals worth less than $50,000, may not need to consider LTCI, since (current) Medicaid rules will permit them to receive government assistance within a year or two of nursing home admission. Prospective LTCI buyers with large estates may not need the insurance, particularly if their estates generate $40,000 in annual income over and above their (or their spouse’s) other living expenses. In other words, LTCI is primarily of interest to the middle-class elderly.
How important are individual policy provisions? Very. Some policies provide excellent coverage for home health care, while others do not; a policy without home care provisions might unnecessarily force the owner into an institution.
A checklist for comparison shoppers can help frame some of the issues. For a helpful checklist, contact FLEMING & CURTI at the fax, e-mail or street address below.
330 N. Granada Avenue, Tucson, Arizona 85701
520-622-0400 / FAX: 520-203-0240
It is (as of January 1) a federal felony for those facing nursing home placement to make gifts for the purpose of becoming eligible for Medicaid (in Arizona, ALTCS) coverage. Much has been written about the ambiguity and unenforceability of the new law. For example, Elder Law Issues, November 25, 1996, and August 19, 1996, focused on the meaning, history and poor drafting of the new enactment.
Now Congress is considering repeal of the two-week old criminalization provision. Congressman Steven La Tourette, a second-term Republican from Ohio, has introduced House Resolution 216, which would strike the new section of Medicaid law before the first prosecution could be threatened. Powerful forces in Washington, including the AARP and other advocacy groups, have lobbied forcefully for the repeal. Indications are that the threat of jail for middle-class seniors will now fade away.
The legislative assumptions underlying the original enactment of this punitive law have remained unchallenged, however. According to some in Congress (and, more importantly, lobbyists for the long-term care insurance industry), the practice of making gifts to qualify for Medicaid is widespread and is costing state and federal governments millions of dollars. Sadly, Congress appears to have bought into this myth without question, and in spite of the actual evidence.
In a study prepared for publication in the periodical Generations, Washington researcher Joshua Wiener of the Urban Institute has analyzed the actual incidence of transfers by seniors. His conclusion: both the numbers of persons making transfers and the amount of money transferred to obtain Medicaid eligibility are much lower than commonly thought.
Wiener notes earlier research which shows that three quarters of nursing home admittees are already impoverished, with less than $50,000 in assets other than their homes. Over half had less than $10,000 of cash available. In other words, the typical nursing home admittee is able to pay for less than six months of nursing home care (and less than two months in many communities, with sharply higher nursing home costs) in any event. It is unrealistic to expect any substantial cost savings for the Medicaid program from further restrictions on transfer rules.
Furthermore, historical data indicates that seniors infrequently give away their assets to become eligible for nursing home assistance. Between 1988 and 1992, Congress substantially liberalized the rules for married couples to become eligible for Medicaid, while simultaneously clarifying the transfer rules. During that time, the portion of nursing home residents covered by Medicaid increased by only two percentage points. Wiener notes that the increase should be almost entirely attributable to the change in married couple rules, suggesting that the number of people making gifts to become eligible must be almost insignificant.
Finally, Wiener notes that the administrative costs attendant on any plan to reduce transfers must be considered. In the case of Congress’ ill-conceived plan to criminalize gifts, for example, the costs of administrative rule-making, prosecution and incarceration might exceed any reduction in Medicaid costs.
On a related issue, Wiener also assesses the effect of new, stronger federal rules on estate recovery. As a practical matter, estate recovery programs rely on Medicaid recipients retaining an interest in their homes throughout their nursing home stay; research suggests that only 14% of Medicaid recipients own their homes at the time of institutionalization, so the possibilities for recovery are not high. In Oregon, the state with the best record of estate recovery, about 2.5% of Medicaid costs are recovered.
Discussions about the future of long-term care in the United States are obviously dependent on the current and projected extent of the need for care. While many working in the field have an intuitive feel for the frequency of use of nursing homes, the statistics can nonetheless be surprising.
Admission Rates
According to a 1991 article in the New England Journal of Medicine, 33% of men turning 65 in the prior year would spend at least some time in a nursing home. For women, that number grew to 52%.
While total admissions for women are significantly higher, short-term admissions are much less sex-dependent. Of that same 65-year-old group, 21% of women and 19% of men will be admitted for stays of less than one year. But for longer stays, women begin to dramatically outnumber men.
10% of men and 18% of women will spend between one and five years in the nursing home. Only 4% of the 65-year-old men will spend more than five years in the nursing home, while 13% of their female counterparts will do so.
Nursing Home Financing
According to the American Association of Retired Persons, over half of the cost of nursing home care is paid by the federal-state Medicaid program (ALTCS in Arizona). The actual figure is 51.7% of all nursing home costs, compared to 8.8% for the Medicare program and 2.2% for other public programs.
Long-term care insurance and medical insurance account for 2.4% of nursing home costs, with private programs (such as charities) provide 2.2%.
The remaining 33% of nursing home costs are paid by patients from their income and savings. It is not clear, however, whether the patients’ “share of cost” contributions to Medicaid coverage are included in this statistic.
1996 Medicare and Social Security Rates
Although numbers may change as the budget compromise takes final shape, 1996 numbers for Medicare and Social Security are currently in place. Until further changes, the following figures apply:
Medicare Part A
Hospital Deductible $736/illness
Daily Coinsurance (Hospital)
Days 1-60 $0
Days 61-90 $184
Lifetime Reserve $368
Daily Coinsurance (Skilled Nursing)
Days 1-20 $0
Days 21-100 $92
Premium (for those not otherwise qualified) $289/month
Medicare Part B
Premium $42.50/month
Deductible $100/year
Coinsurance
20% of approved charge
Balance Billing
15% of approved charge
Social Security
Cost of Living Adjustment 2.6%
Retirement Earnings Limits
Age 65-69 $11,520/year ($960/month)
($1 in benefits withheld for every $3 of earnings over the limit)
Under 65 $8,280/year ($690/month)
($1 in benefits withheld for every $2 of earnings over the limit)
Maximum SSI Benefit
Individuals $470/month
Couples $705/month
Two recent U.S. Supreme Court cases, though each dealing with a limited population, may have an effect on clients. In one, the Court dealt with group homes and boarding homes; in the other, the Court addressed long-standing state tax inequities.
Group Home Regulation
Oxford House, a Washington drug and alcohol treatment program, tried to open a group home in the city of Edmonds. Local planners objected, citing a city ordinance which prohibited more than five unrelated individuals from living together.
Oxford House appealed the denial through the federal court system, losing in the District Court but winning in the Ninth Circuit Court of Appeals. Now the Supreme Court has agreed that Edmonds’ rule is too restrictive.
The American Association of Retired People (AARP) joined Oxford House in opposing the rule. Though the proposed use in this case was a drug and alcohol rehabilitation program, AARP noted that it would restrict the ability of boarding homes, foster homes and similar facilities to care for elderly clients in residential areas. The Supreme Court agreed.
The Oxford House decision relies on the federal Fair Housing Amendments Act of 1988, which prohibits zoning ordinances restricting occupancy limits unless they are reasonable. The Supreme Court noted that the Edmonds ordinance did not restrict the number of family members who could live in one residence, so deduced that the limitation was based on something other than a desire to control the size of households. Since the limit was different for unrelated housemates, it was inherently unreasonable. Edmonds v. Oxford House, 115 S. Ct. 1776 (1995).
[Note: Tucson had a similar zoning provision until the mid-1980s]
Taxes on Federal Retirees
In the 1980s, Georgia (along with Arizona) was one of about 20 states that tried to impose state income taxes on federal pensions while exempting state pension income. Those tax efforts were struck down after only a few years of collections.
Georgia (like Arizona) initially argued that refunds for the illegally collected tax should be limited to those taxpayers who protested the tax at the time of payment. Since few had protested, this rule would have saved Georgia an estimated $100 million in refunds to 50,000 retirees. The Supreme Court, in its 1994 term, ruled Georgia’s proposal unacceptable, and ordered the state to adopt “meaningful backward-looking relief” for taxpayers who were illegally taxed. Reich v. Collins, 115 S.Ct. 547 (1994).
[Note: Arizona has grappled with the same problem, and has now adopted legislation to permit taxes to be recovered. Many of the taxpayers have now died, and the claims for repayment must be pursued by heirs.]
The American Association of Retired Persons is warning its members about mail-order scams. According to the AARP, mail-order con artists have begun to aggressively target elderly people.
Mail solicitations, sometimes involving bogus offers, “sweepstakes” and questionable health remedies and safety items, are showing up with accelerating frequency in the mail boxes of the elderly. Elderly recipients are particularly vulnerable to such tactics, says the AARP, because they tend to be more trusting, they often live alone and they have fewer ways of checking out the validity of the offers or representations.
A study funded by AARP categorized one-third of those over 75 as “highly vulnerable” to fraud. That compares to 24% with the same classification among those age 65 to 75, and 7% of those younger than 65. In addition, elderly consumers tend to be more passive after they have been duped. Twenty percent of those over age 65 say they have never demanded a refund, filed a complaint or taken similar action against a company. Among younger consumers, only 8% have been so consistently forgiving.
Hispanics Singled Out
At the same time, another group indicates that telemarketing scams have particularly focused on hispanics. Since many hispanics lack English proficiency, and since they tend not to report fraud, hispanics have been frequent victims.
The National Council of La Raza has announced a new campaign aimed at teaching hispanic consumers how to spot, stop and report telemarketing fraud. The program includes counsellors who speak Spanish and public service information. La Raza’s hotline can be reached at (800) 876-7060.
Take Stock/Take Charge
A new program aimed at health promotion and disease prevention among the elderly has been announced by Jewish Family and Children’s Service, with funding from United Way. The program involves interactive educational seminars entitled “Take Stock/Take Charge ” aimed at those age 55 or older.
The seminars will utilize what is billed as a holistic approach, focusing on disease prevention topics with activities designed to promote independent functioning and decision-making capacity. Particular emphasis will be given to the importance of early detection, regular examinations, nutrition, exercise, immunizations, rest and relaxation, home and auto safety and medication management. Seminars can be arranged for senior groups by contacting Gina Gills through JFCS at 795-0300.
The average older American will spend $2,803 out-of-pocket on health costs this year, according to a study by the American Association of Retired Persons and the Urban Institute. That amounts to 23 percent of the income of the same “average” elder.
In 1987, a similar study found that the health care bill was half the current figure, and it amounted to only 17 percent of income of the elderly. Out-of-pocket expenses include Medicare co-payments, drugs and insurance premiums.
For those under 65, health care costs are dramatically lower. Younger Americans spend an average of $679 a year, which is 8 percent of income.
The elderly use far more medical services. They go to the doctor twice as much, are hospitalized three times as much and purchase four times as many prescription drugs, according to the study.
More Elderly Arizonans
According to new Census Bureau projections, Arizona should become one of the “oldest” states in the country by 2020. Only Florida is expected to have a higher percentage of over-65 residents.
13% of Arizona’s population is now over age 65, which places the state 18th in the nation. The number of elderly Arizonans is expected to double in the next 25 years, which will mean that 20% of the population is over 65.
The same projections suggest that Arizona will become more ethnic in the next quarter-century. Asian, Indian and Hispanic populations are expected to grow faster than the rest of the state. Arizona should have the largest Indian population in the country by the end of this century.
Alzheimer’s Research
A new study suggests that the protein long known to be present in advanced Alzheimer’s patients may cause memory loss very early in the disease progression. The study, published in Sciencemagazine last month, shows that tiny amounts of the protein, beta amyloid, can interfere with potassium use in healthy cells. The results suggest that calcium is not the major culprit that it was thought to be.
Alzheimer’s is thought to affect as many as 4 million Americans. !00,000 deaths are attributed to the disease each year.
Racism and Dementia
From Wall Street Journal, 4/29/94
“The average nursing home combines mostly elderly white patients raised long before the civil rights movement and a staff of many nonwhites and immigrants. A New York nursing home is trying to protect those caregivers from the disturbing racist behavior of some Alzheimer’s patients.
At a recent weekly support meeting at the Hebrew Home for the Aged at Riverdale, whose staff is 73% nonwhite, nurses and nurses’ aides wondered aloud at how some befuddled patients can lucidly fall back on racial attitudes from the Depression. ‘There are memories that are riveted to the things of the past. They will remember their parents’ names…and that you are a nigger,’ says a nurse from Jamaica. The problem is particularly troublesome because the nurses’ 50 patients are in the early stages of dementia and sometimes seem to be responsible for their outbursts, says social worker Robin Bouru.
Despite the offensive incidents, the staffers have high morale and say they often develop close relationships with their patients. Training coordinator Myra Bryce Richardson advises the nurses to overcome the urge to retaliate by seeing the verbal attacks as symptoms of illness, not character. Preliminary results of a study at 15 New York-area nursing homes suggest that regular in-service training makes nurses less likely to take it personally, reducing stress on the job.
Half of all Americans who turn 65 this year are expected to spend some time in a nursing home. One percent of all Americans aged 65 to 74 reside in nursing facilities, and the proportion increases to seven percent of those 75 to 84, and twenty percent of those over 85.
Payment for Nursing Home
Almost half of those nursing home residents are paying for their long-term care from some combination of savings, family contributions and private insurance; most of the balance are paid for or subsidized by Medicaid, Medicare or other federal and state programs.
There is a tremendous market for insurance which could provide for the long-term care needs of such a large (and growing) population. The long-term care insurance industry has grown dramatically in recent years as a direct result.
What to Look For
When purchasing long-term care insurance, it is important to look for a number of benefit options:
Daily benefit rates. An inadequate rate will not provide sufficient coverage, and may make the patient ineligible for government assistance.
Home care. Policies with some home care provisions may permit the patient to remain at home longer.
“ADLs”. A policy should provide coverage when you are unable to perform a certain number of the “activities of daily living.”
Rating. Be sure the insurance company is likely to be around longer than you are.
The American Association of Retired Persons (AARP) offers a free brochure for prospective long-term care insurance buyers. “Before you buy: A guide to long-term care insurance” is available by writing to AARP Fulfillment, 601 E Street NW, Washington, D.C. 20049.
Elders Prefer Home
According to an article in the Wall Street Journal of November 16, 1993, the 1980s boom in construction of seniors housing developments may have misjudged the market. The article cites the results of a poll conducted by the American Seniors Housing Association as showing that elderly homeowners prefer to remain in their homes until death of a spouse, serious illness or frailty requires a move.
As a result, seniors housing tends to have older and frailer residents than expected, and many facilities have added emergency-response services (96%), housekeeping (85%) and nursing care (63%). The average senior housing resident is 82 years old, and three-quarters of residents are women.
