The cost of caring for America's disabled elderly is soaring as their numbers grow and expensive new treatments multiply. Nursing home expenditures have quintupled since 1980, rising faster than hospital costs. Part of the increase in expenses is due to skewed government priorities: The federal aid system rewards hospitals for expensive care and denies government aid to family members who try to keep their relatives out of nursing homes. It's a fat target for reform.
There's a spark of good news--President Clinton's announcement this week that the biggest domestic item in his budget this year will be $5.5 billion set aside to provide a $1,000 yearly tax credit for people with severe disabilities and for the relatives who take care of them. In addition, he will ask for $625 million to help state and local governments set up programs to aid family members providing care. For middle-class families struggling to pay nursing home costs, which now average $47,000 a year on the private market, $1,000 isn't much. But the amount will go further for families providing home care.
This is not the first time Washington has recognized the problem. In the late 1980s, noting that home care is more economical and humane than institutionalization, the government allowed Medicare dollars to be used for the first time for nursing visits to people's homes. Because of the change, federal payments for home health care costs have mushroomed tenfold in the last decade, far more than necessary.
According to a 1997 Government Accounting Office report, more than one-third of government home health care payments in California were undocumented, duplicative or for services never delivered. Part of the problem will be solved in October, when Medicare tightens the way home health care providers are paid; in addition, the Clinton administration proposes doubling audits of home health care claims.
There is also too much slack in determining who is homebound enough to qualify for home care. And too often skilled nurses provide basic bathing and personal care assistance because it's easier to get a nurse paid than an less skilled aide.
But reducing the cost of home care is one thing and denying it altogether is another: Right now in California, a wife who tries to care for her elderly husband at home isn't eligible for Medicaid dollars until she reduces the family assets to $3,000. If she commits him to a nursing home instead, she can shelter $80,760 in assets. Oregon and Washington state successfully petitioned the federal Health Care Finance Administration to allow them to give Medicaid dollars to families for home care without requiring those families to first impoverish themselves. California should follow their lead.
The long-term solution lies in a bigger overhaul of the way aid is provided. The American College of Physicians and the American Geriatrics Society have put forth modest, practical proposals for easing the costs and stress of home care and increasing the usefulness of federal dollars.
These groups would basically require a medical evaluation of what each person needs--nursing visits, hospitalization, home health care, physical therapy, drug therapy. Services would be delivered competitively, by bid, through HMOs and other managed care providers, and regularly evaluated by a medical team. Preventive care, like blood pressure testing and heart function evaluations, would be included.
Their bottom line is that the money already available has to be better spent, on care with a clear therapeutic benefit, delivered by caretakers who have an incentive to do a good and efficient job. President Clinton has the right idea, but the whole home care system needs a stronger dose of common sense.