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

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

experts emphasize the importance of care outside of institutions. The proposed plan could be expanded to cover such services without much difficulty; therefore, critics should not dismiss the proposal on this account alone. The author does believe that the optimal way to inaugurate social insurance for long-term care is to restrict Medicare Part C reimbursement to care provided in skilled nursing and intermediate care facilities. Adequate explanation for this choice, however, would require another study.


NOTES

The study of this subject was begun by the author in a symposium published in Policy Studies Review ( Brandon, 1989), which reviewed the three approaches to comprehensive reform in financing long-term care. That article's overview of the issue leads to this chapter, which argues for social insurance of long-term care and proposes a specific plan to finance it. The author wishes to thank Seton Hall University for the sabbatical-year support that allowed him to work on this chapter.

1.
Outside of the long-term care field, the ideal of rich and poor, black and white receiving health care from the same sources has long been espoused even if the practice sometimes falls short. Support for the claim that nursing homes discriminate, if any is needed, can be found in Smith ( 1990), Feder and Scanlon ( 1980:58, 75), and Rango ( 1982). White admissions to nursing homes significantly exceeded those of blacks among those dying in 1986, even when longevity and sex were controlled ( Kemper and Murtaugh, 1991:596).
2.
Although traditional use restricts the term "social insurance" to public programs that are financed by premium-like payments that make one eligible to become a beneficiary, this chapter accepts the common extension of "social insurance" to include universal programs financed by general tax revenues. As Stephen Long and John Palmer ( 1982) point out, sometimes what they call "universal" programs may be designed with means-tested cost sharing. Because Medicaid pays Medicare copayments and deductibles for the elderly poor, Medicare is a "universal program with income-tested cost-sharing."
3.
For example, the loss of Medicaid coverage at a specific level of income discourages the economically rational welfare recipient from work. Some aspects of social insurance may also have notch effects. A cap limits earnings by Social Security beneficiaries who wish to receive full benefits.
4.
It is also a mistake to think that individual action on the basis of our increasing understanding of health risks offers protection. Healthy living, which may postpone both death and the need for nursing home care, is unlikely to reduce greatly one's chances of institutionalization over a lifetime. Indeed, it may increase the probability that an individual will be confined to a nursing home by prolonging survival to advanced ages when the incidence of institutionalization is highest ( Kemper and Murtaugh, 1991). The issue, which is complex and controversial, cannot be addressed in these few pages.
5.
Even the liberal Medicare reformers responsible for the Harvard Medicare Project advocated a deductible equal to the cost of the first month in a nursing home for nonrehabilitative care and a "residential copayment" calculated as a proportion of the beneficiary's Social Security income to partially cover the nonmedical costs

-119-

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