Wednesday, March 28, 2007

Government care -Medicare and the VA

Less “Universal”Than Meets the Eye

Yesterday I visited a relative in a “skilled nursing facility,” The facility is a one story sprawling brick structure holding 120 patients. It has four wings, each staffed by four aides and one LPN for each 8 hour shift. Medicare covers most patients. You can stay for 100 days under certain conditions.

Otherwise you pay $9000 a month. I don’t quibble with the expense. Aides, nurses, physical therapists, pharmacists, and doctors work hard caring for mentally or physically disabled, often incontinent patients. Caring for these patients requires expensive equipment – monitoring devices, portable toilets wheel chairs, machines for lifting patients in and out of bed.

My Relative – a 73 Year Old Veteran

My relative is a 73 year old veteran. He receives disability from a back injury incurred while in the service. For the last 20 years, he has received care off and on from the VA. He suffers from Lewy Body disease, a variant of Parkinson’s disease that often ends with dementia. He has been hospitalized six times in the last year with aspiration pneumonia, has insulin-dependent diabetes, and suffers from chronic bronchitis and emphysema. He receives 40 pills daily, can’t walk and talk, and has trouble feeding himself.

Medicare Rules and VA Bureaucracy

Come next week, unless he shows progress, Medicare will force him to leave the nursing facility. His wife can’t afford the $9000 it will take to keep him there.. She has thought of the VA as an alternative. She has called the VA multiple times and listened to its lengthy telephone menu, but has yet to connect with a human voice. She has, she believes, hit a bureaucratic brickwall. She fears there’s no way through it or around it. But the Parkinson’s Foundation assures her, under the right circumstances, the VA will provide home care benefits. I’ve tried to help by googling the VA Office of Geriatrics and Extended Care. It has 250 Frequent Asked Questions, and a comment box where you can seek help.

The Question – What Lies Ahead Politically ?

My admittedly fleeting experience in the skilled nursing facility and the VA raises this question in my mind: What do existing government “universal” programs portend for future “universal coverage?’ I can’t help but reflect on what the present presidential candidates are promising.

On the Democratic side,

• Former senator John Edwards promises universal coverage and would pay for the estimated cost of $90 to $120 billion by raising taxes on the “wealthy.”
• Senator Barack Obama doesn’t have a detailed plan but says he “would create a political consensus around the need to solve the problem.”
• Gov. Bill Richardson would offer tax credits to help buy insurance and extend Medicare to cover those from 55 to 64.
• Senator Hillary Clinton would ”end price gouging, cost-shifting, and unconscionable profiteering..”
• Senator Christopher Dodd would forge a consensus to cover all Americans and raise taxes.

Most Democrats say they would raise taxes on “the rich” to pay for universal care. Other than public resistance, there’s one small nagging problem with raising taxes. As Presidents John F, Kennedy, Ronald Reagan, and the present president George Bush have shown, the surest way to raise government revenues to pay for social programs is to cut taxes. It works every time. Another problem is that existing government programs often produce waiting lists. My relative’s wife says she has been told she will have to wait for 2 years before her husband would qualify for a VA geriatric unit – which will of course be too late.

But let there be no doubt. Democrats “own” the health care issue, which accounts for their confidence in their rhetoric about universal coverage. You see, unlike the Republicans, they have this “plan” called “universal coverage.” Never mind the details about extraordinary costs of such programs (the Johnson administration said in 1965 Medicare would never exceed $9 billion, today it costs over $250 billion), the miserable service record , the inevitable waiting lists, the archaic VA facilities, and the endless impregnable bureaucracies. Besides, Democrats know universal coverage “polls fabulously” – who doesn’t want “free’ government coverage financed by the “rich?”

The Republicans? Well, the public doesn’t trust them on health care. Americans –frenetic, fearful, and furious -- over spiraling health costs, simply will not listen to complicated arguments about incremental change, or constant innovations, no matter how good these changes or innovations promise to be. Governors Arnold Schwartzenegger and Milt Romney have swaggered forth with “universal-lite” state plans heavy on regulation and taxes, targeted on health plans and providers, and payroll taxes. Polls favor these initiatives.

Troubles on the Horizon for State’s Universal Coverage

There are trouble signs on the horizon for these state plans. Health care and small business lobbies vigorously oppose being the “fall guys” for politically ambitious governors. State plans are already projected to cost much more than originally planned.

In Massachusetts, government spending will be $276 million rather than the $151 million promised. And premiums for uninsured workers will be $380 per month rather than the promised $200, amounting to as much as 6% of their income.

In California, the plan will cost $12 billion, in addition to the taxes on hospitals, doctors, and small businesses.

The biggest problem for Republicans is that they have no clear comprehensive Grand Plan for alleviating the cost and coverage crisis. Dr. Tom Coburn ( R.), the senator from Oklahoma, is said to have a bold plan, based on fundamental, bottom-up reforms cast in the language of markets, consumers in control, revamped tax codes favoring individuals, and health savings accounts, but his plan has yet to reach the level of widespread public consciousness.

A Sad Ending

Sadly, none of these future “universal plans,” as put forth by either political party, or the existing “universal coverage” systems of Medicare or the VA, will help my relative – or his wife -- pay for his end of life illness. Given his helpless condition, and his wife's inability to care for him there, he won’t be going home again. Where he goes, no one knows - and no one knows who pays.


1, Pear, Robert, Candidates Outline Ideas for Universal Health Care, New York Times, March 25, 2007.
2. Bellick, Pam, Massachusetts Sets Benefits in Universal Health Care Plans, New York Times, March 21. 2007/
3. Pipes, Sally, Intensive Care for RomneyCare, Wall Street Journal, February 26, 2007
4. Strassel, Kimberly, Republican Rx: GOP Alternatives to Hillary Care, Wall Street Jounral, March 23, 2007.
5. Finkelstein, Amy, The Cost of Coverage, Wall Street Journal, February 28, 2007.


Dr. Val said...

Well said, Dr. Reece. Such a sad story about your relative. This sort of problem is only going to become more common place as America ages... No easy answers here.

Anonymous said...

For people unfortunate enough to suffer from long term back pain i suggest a new mattress (or to be more specific – an orthopaedic, temperpedic, or memory foam mattress)
A whole range of specialist mattresses have been designed in order to try and correct posture and alleviate back and neck pains. The benefits are long-term and you don't need to regularly visit [and pay!] some heavy handed therapist to relieve the pain! I recently purchased an orthopaedic memory foam mattress online, and I can report, that after a fortnight sleeping on it, i wake up feeling much better than I did when I slept on my old mattress and i foresee a lack of future visits to my heavy handed chiropractor!!

Although one may jump to the conclusion that such specialist mattress prices are high, if you look hard enough you can find cheap mattresses out there, especially online. If you are dispirited by the expense, just think of the long term benefits for your health... a decent mattress can last up to 10 years!