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System Failures: Policing, Public Health, Education, Housing, Long-Term Care

By Harry S. Margolis


System Failures in the United States

The coronavirus pandemic and murder of George Floyd have laid bare the failures of public health and policing in the United States. Those failures are not news. We’ve known that we spend much more per capita on health care than any other nation with uneven results and a system where a health event can bankrupt a family.

We’ve known that Blacks are at great risk when they interact with the police, especially young Black men; that the police has become over-militarized, especially since 9/11; and that American police kill more than 1,000 fellow citizens a year, a rate that is 30 times that of Germany.

These failures of these systems are shared by others. Our system of higher education is the most expensive in the world, pushing many students and their families into unsustainable debt. My nieces who live in Switzerland received free university educations.

Our transportation system is based on the car which spews carbon into the atmosphere causing climate change. For most Americans, trains, subways, or bicycles are not a safe or convenient option.

We have millions of homeless people and millions more who are housing insecure, scrapping together money to pay the rent each month. Just think of the stress this creates.

The Long-Term Care Complexity

And then there’s our long-term care system. Both the provision of care and its financing are a patchwork. In some ways, this is the result of the strength of American entrepreneurialism. Both for-profit and non-profit companies and organizations have seen the need for care and stepped up to provide home care, adult day health, many different types of assisted living facilities, and nursing homes. Companies retrofit homes and assist seniors in downsizing. Geriatric care managers provide advice and oversight. Elder law attorneys help with planning and qualifying for Medicaid coverage.

This is complicated and confusing for any family trying to help a senior needing assistance. It is made more difficult by the nature of aging itself—there’s very rarely a long period of stability. What works for care today, probably won’t work tomorrow. Whatever system of care a family puts together today will have to be rebuilt several times over as dementia or physical fragility progresses.

Long-Term Care Financing

And then there’s the issue of paying for long-term care. Medicare pays for acute illness and some rehabilitation, not long-term care. Few people have long-term care insurance. This means that most care that’s not provided by family members free-of-charge is paid for out of pocket or by Medicaid—our nation’s safety net program for health insurance. To qualify for Medicaid (MassHealth in Massachusetts), you have to be poor. But the definition of what it means to be poor is very complicated, taking up reams of statutes, regulations, and court cases. Every rule has its grey areas and exceptions.

That’s great news for elder law attorneys—it makes our assistance necessary and keeps us in business. But it’s bad news for anyone trying to figure out what it will cost to provide care for a family member. To make matters worse, while Medicaid pays for anyone who qualifies and needs nursing home care, home care and assisted living care are only covered under certain circumstances.

So, planning for any family member’s care is triply complicated—combining the complexity of the various settings for receiving care, the uncertain progress of the disease, and the intricate Medicaid rules.

Rethinking Long-Term Care Financing

We ended up using Medicaid as our primary payment source for long-term care by haphazard circumstances. With no other source of coverage, as a nation, we fell into using Medicaid for this purpose.

As taxpayers, we’re already spending over $350 billion a year on long-term care, $150 billion of which comes from the Medicaid program (which all of the sudden looks cheap compared to the trillions we’re spending supporting the economy through the pandemic). There’s a call to “defund” policing which means different things to different people. At the very least, it means taking a fresh look about how we provide public safety in this nation and how the police should not be the answer to every 911 call.

While we’re rethinking public health, policing, transportation, higher education and housing, let’s take a fresh look at long-term care. Perhaps we need a Medicare Part E that covers all kinds of long-term care.



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