Health Insurance and Public Policy: Risk, Allocation, and Equity

By Miriam K. Mills; Robert H. Blank | Go to book overview

7
Fulfilling the Promise of Medicare

William Brandon

The media and personal knowledge have made increasing numbers of ordinary Americans aware of the plight of retired middle-class individuals or couples faced with a Hobson's choice of either allowing the expenses of long-term care (LTC) to make them destitute or divesting themselves of assets and income in order to become sufficiently poor to qualify for Medicaid, the principal public program that pays for long-term care in institutions. For the policy analyst, this dilemma becomes an anomaly in social policy: significant numbers of the only major group that is covered by social insurance--Social Security and Medicare--are forced to rely on means tested welfare for extended medical care.

The anomaly is clearly malign, for it results in particularly egregious institutionalized two-class medical care. Long-term care institutions are notorious for separating into those that will accept new patients on Medicaid and those that select private payers and sometimes only those patients who are thought likely to remain self-paying. 1 Moreover, it is cruel to perpetuate a system that forces many of those to whom minimal financial security in old age has been promised as a right through Social Security and Medicare into the welfare programs that publicly define poverty in America.

The remarkable repudiation by the elderly of the Catastrophic Coverage Act of 1988 resulted in part from their belief that the act failed to give them new protection of much value. The act, which provided protection against financially catastrophic acute health care, failed to address the more common catastrophic costs associated with the need for nursing home care. A host of government studies at both the federal and state level, such as the

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