Lucky you. Your number just hit big on Lotto, and you're getting a payout of $70,000 a year! Just in time. You're frail, and at age 65 you wonder how far your measly social security check will go.
Unlucky you. You dance for joy and fall and break your hip. You wind up in the hospital instead of on easy street, and the docs don't want to discharge you back home. They're worried you'll fall again, and they notice you're a bit dazed and confused.
Not to worry. You do have that $70,000 annual payment. Surely you'll land on your feet in a room with a view.
But would you like that room to be a hospital-style room with only a curtain for privacy? Would you like your door to be always open for strangers to walk in to poke and prod? Would you want it to be noisy with loudspeakers, loud talking, and beeping medical equipment?
In other words, the typical nursing home.
Seventy thousand dollars is the average annual nursing home fee, whether you are Brooke Astor and can afford to pay for it out of pocket, whether you have long-term care insurance, or whether you're on welfare and your stay is funded by Medicaid--which alone accounted for $54 billion of the $122 billion national expenditure in 2005.
Who plans for this? Few elders or their families make a deliberate, considered decision to move to a nursing home. Institutionalization more likely follows an accident or sudden illness. The slip, the fall, and the broken hip is a typical scenario. First the hospital, then the nursing home for rehab. If things go well, you get back home. If they don't, you may start hearing noises about your inability to be on your own.
There's little to argue against a nursing home for short-term rehab.
But could we imagine a better way to spend that $70,000 windfall for the long-term?
What about chucking the institution, staying home, and doing it a la carte? The average charge for a health aide is $18/hour. So a 24-7 health care aide would run your annual tab to $157,680, blowing through your $70,000. But a little economy of scale goes a long way. Three frail elders could share an apartment and a 24-hour aide and have almost $52,000 left over for food, clothing, shelter, physical therapy, and fun and frolic.
In most cases, a nursing home is way more than necessary--a sledgehammer for a thumb tack. Many people need just a little bit of help--someone to dispense their meds, prepare their meals, and help to get in and out of bed. Others might need 24-hour care, but not a nursing home. Assisted living--the halfway house between home-sweet-home and the nursing home--will fit the bill. But, oddly, Medicaid won't foot the assisted living bill. Medicaid will pay only for care in medical facilities, and assisted living doesn't qualify--even though the average annual cost is significantly lower, about $30,000. Add up the elderly millions who will eventually qualify for Medicaid, and think of the billions in savings.
This is only one of the irrationalities in our health care system. Insurance companies and government health financing agencies will pay tens of thousands of dollars for psychiatric hospitalization, but severely limit the hundreds of dollars for cost-effective outpatient psychotherapy. This despite abundant evidence that an ounce of prevention--outpatient therapy--is worth innumerable pounds of cures in hospitals.
The supposed gold standard for care is to provide services in the "least restrictive environment." Unnecessarily shuttling people into the most restrictive setting grossly violates this standard.
The idea of pooled resources and cooperative living arrangements is not new, nor does it originate in eldercare. In 1963, George Fairweather, a psychologist, proposed a model--the Community Lodge Program--that offered a way for psychiatric patients to live outside of hospitals. Groups of patients pool their government benefits, buy or rent lodging, start businesses, and hire professional staff to meet their special needs. Today, there are lodge programs across the nation.
When psychiatric patients or elders hire their own staff and run their own programs, they are transformed from dependent patients to empowered captains of their own fate.
The lodge program is but one of the good ideas to avoid hospital style institutionalization for the frail elderly. Aging in place is an idea that has an intrinsic appeal to my iconoclastic baby boomer generation. The problem is not a lack of ideas, but public policy that resists thinking outside the medical model box. But that box is bursting at the seams. Everyone is worrying about how the diminutive x, y, and z generations will pay for all of us boomers in our dotage. Financial shortfalls, rather than creative imagination, may force the diversion of funding into more cost-effective, less restrictive, more consumer controlled environments.
My graying Woodstock generation could come to look at cooperative care arrangements as a last chance to join the commune they only fantasized about a generation ago. It could be summers of love for the autumns of our days
(A version of this appeared as an op-ed in the New York Times (Jsnusty 17, 2007) as "Escape from the Nursing Home." Here I have the opportunity to publish it as I originally wrote it with a different ending.)
