The United States has the best health care money can buy. But not everyone can afford to buy it. Annually we spend twice as much per capita on health care than Japan, yet the Japanese at eighty-two years are third in life expectancy--just behind Andorra and Macau--and we are forty-fourth at seventy-eight years--behind Bosnia and Herzegovina.
Of course, Japan is a scrupulously homogeneous society. Almost everyone is Japanese. We're an ethnic stew with wide variations in wealth and culture. But Cuba's impoverished status does not prevent it from doing quite a bit better than us on infant mortality and only slightly worse on life expectancy. So you don't necessarily get what you pay for. I have a pretty good health care plan, and despite the aggravating paperwork I get the good stuff--the top docs, overkill in diagnostics, payment for expensive cholesterol drugs. About fifteen years ago, I won a negative lottery and was diagnosed with a rare tumor, benign yet problematic-intertwined like a grapevine with the nerves in my left shoulder. I was sent to the "best surgeon in New Haven," and the best "radiologist in New Haven," and the "best rehab doctor in New Haven." But not everyone is so fortunate. Tens of millions have no coverage. They don't even get the worst doctor in New Haven.
Old age's dismal frailty is compounded by Medicaid's requirement that you impoverish yourself before they will pay for your nursing home stay. In Finland, Germany, and Japan, public money pays for you to stay in a nursing home as long as you live, and you can hold on to your assets. We try to game the system by passing on assets to our children--hoping they are Cordelias, not Gonerils or Regans--enough years in advance so that the government won't seize them. If you haven't transferred the deed to your house three years before the nursing home, the government moves in. Most people don't think ahead this way. It's usually the folks who have an estate worthy of estate planning. A Kaiser Family Foundation study found that 7 percent of Medicaid recipients in nursing homes were responsible for two-thirds of asset transfers. And the authors of the study take the hard view that you should give it to the government not your children: "The concern is that the individual's assets should be used to pay privately for nursing home care, instead of being transferred to relatives. Because Medicaid was designed to be a safety net only for the poor, asset transfer practices are thought to distort the intent of the Medicaid program and unnecessarily inflate public spending."
In other words, you have to become certifiably destitute in order to have welfare pay for your final days.
And what do the honestly poor get for their Medicaid money?
They get a highly medicalized environment, even if they don't need one.
Many of the people I meet in nursing homes, if not a majority, could be in assisted-living homes--if they could afford it. They need someone to organize their medication, help them take a bath, get in or out of bed, or remind them to use their walker. Few people need the intensive care of a nursing home.
Assisted-living centers are the halfway home between home and the nursing home. You could think of them as a reverse purgatory between the heaven of independence and the hell of total dependence.
It's a serious irrationality of our health care system that we are much more willing to pay for the cure than the prevention. In my outpatient psychotherapy days, I would have to approach insurance companies on bended knee to ask for more than six measly weeks of psychotherapy. When they failed to authorize more time, I'd think they're saying, "We ain't gonna pay for no twenty-five years of Woody Allen psychoanalysis." But what if the patient who is denied more outpatient therapy tries to kill himself and winds up in the hospital?
The denied additional psychotherapy sessions would have cost a few hundred dollars.
The hospital stay could run into tens of thousands. The denied outpatient therapy might have prevented the hospitalization. Where's the logic in that?
Outpatient psychotherapy is to psychiatric hospitalization as assisted-living centers are to nursing homes.
The average annual cost of an assisted-living center is $35,000; the average nursing home costs $75,000. Some can afford to pay the assisted-living costs out-of-pocket indefinitely. But if you live long enough, the money will run out, and you will need to go on the government dole. Medicaid will not pay for assisted living, but will gladly pay more than twice as much for the nursing home. The gold standard for care is to provide it in the least restrictive environment, but in the case of the elderly, the payment goes toward the most restrictive environment.
This dysfunctional safety net is only for the poor. If you're middle class, you have to become poor to fall into the net. So much for the American dream of working hard to get ahead.
The bottom line? Because you didn't support socialized medicine when you were young and acquisitive, you could lose everything in order to afford the poorhouse. The moral? Move to Finland.
