Health Care Policy
With regard to the differences between Medicare and Medicaid, the most fundamental is that Medicare is a federal program in place to assist all United States senior citizens over the age of 65. It is akin to Social Security in that the concept and practice rely upon seniors having paid into the program during their working lives (Medicare.gov., 2013). Consequently, Medicare is not based on individual income. The Medicaid scenario is different in that it is a program designed to address those in need of financial assistance due to low income, as it is both a federal and state venture. As eligibility for Medicaid is determined by income, how much the individual pays is assessed case by case. In some instances, and unlike Medicare, the senior may be relieved of all medical expenses. For the majority, some co-pay is usually required (Medicaid.gov., 2013). These differences emphasize what may be termed the fundamental difference between the programs, in that Medicare is a federal insurance plan and Medicaid is a relief measure for those is particular need.
Narrowing the basic differences down to coverage, Medicare encompasses four parts: A covers hospital bills, B addresses medical insurance, C is concerned with Health Maintenance Organizations (HMOs), and D deals with prescription drugs. While Part A usually requires no co-pay from the senior, the others typically do and at varying rates. Coverage also goes to another fundamental difference between the programs, in that Medicaid is not restricted to seniors. The coverage is broader in terms of populations, including children and the disabled, as it also is set by state parameters operating within federal guidelines. Depending upon the cases and policies, federal funds match those provided by the state, and in regard to all medical procedures.
If anything marks the changes to Medicare made in the past ten years, it may be said to be an increasing concern for excessive costs, combined with the more recent initiative for universal health care. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was signed by President Bush and geared to provide a greater prescription benefit for outpatient seniors. In 2005, federal efforts went to improving preventative care, with pre-signing physical screenings, along with a greater emphasis on discounted medications for low-income patients (Carey, 2013). More recently, President Obama’s fiscal plan for 2013-2014 involves shifting budget concerns and redirecting existing funds to curtail Medicare costs to the federal government. Obama’s agenda would rely on higher-income and future beneficiaries paying more, as it would also end the recent 2 percent payment cut to providers. This would ease the sequestration, or across-the-board cuts faced by providers, initiated several months ago (Carey, 2013). The sequestering itself, however, has more far-reaching implications. As it essentially refers to budget cuts, sequestering thus far has placed greater burdens on providers to meet costs. Most particularly, there is increasing concern over the impact of sequestration on cancer treatment facilities, which will be impeded from carrying on clinical trials (Boadi, 2013). As of this writing, and as with the course of the president’s health care system in general, legislators are involved in intense conflict, with Medicare essentially being used as a partisan instrument in a wider social and political contest.
In terms of the actual effects on seniors depending upon Medicare, it seems likely that the proposed agenda will not significantly improve health care. The reality is inescapable here, in that a tightened federal budget translates to, at best, shifts in available funds and a potential expectation for more from the wealthy. Restructuring an insufficient Medicare budget or framework may be necessary, but it cannot begin to adequately address so massive -and growing – a need as that of senior health. Ultimately, it seems that the proposed measures are further efforts to forestall the need to either completely revise the system or allocate greater funding to it.
It is generally believed that European health care systems are more accommodating to the needs of seniors and the populations as a whole, and the impression is not without foundation. A type of socialized medicine appears to be in place in major European countries, as may be seen in Germany’s policies. Moreover, the German system, as with others in Europe, is “universal” in the sense that the elderly are not treated within it as a separate population. The law requires that all working people contribute from their salaries to a “sickness fund,” and nearly 80 percent of Germans are completely covered by this. The remaining 20 percent are those at income levels which allow for privatized coverage. Seniors continue to contribute from their pension funds, which further blurs distinctions between the elderly and other populations (Glaser, 2013). Somewhat echoing Medicaid, the German provincial sickness funds work in concert with the parliamentary, or federal. With particular regard to the elderly, the absence of deductibles translates to German seniors typically availing themselves of medical services more readily, which promotes preventative care. In France, the system is nearly identical to the German, if only even more “socialized.” More of the entire population contributes to the sickness fund, doctors and hospitals are similarly reimbursed by these funds, and the elderly experience no diminution in services, as they also continue to contribute through retirement benefits. (Glaser, 2013).
If a drawback may be seen in these two European models, it is that the extent of the coverage is beginning to place strains on the sickness funds in both. Seniors stay longer in hospitals, and this alone has periodically generated disparities between physicians fees and reimbursement (Glaser, 2013). In Germany, this occasions political challenges and minor changes, while in France nothing is permitted to alter the inherent socialization of the system, and this latter aspect provides the most striking contrast between the European models and that of the U.S. If Germany and France depend upon a vast framework wherein most citizens pay in substantial percentages of income throughout life, there is nonetheless an essential focus placed on the most critical element of a society: the well-being of its people.
This is a basic and ideological difference, and one not placing the U.S. in a favorable light. More exactly, and as with so many other governmental and social mechanisms in place, the U.S. emphasizes economic class as the defining point in health care. Those who earn more receive better care, just as those who are poor must rely on various programs to provide them with minimal medical attention. As has been seen in the U.S., this commercially-driven approach to health care is precarious at best in a population increasingly elderly. More to the point, it seems that there is no realistic way to address the medical needs of seniors in the U.S. without significantly revising the entire structure of the health care system. So long based on individual income and varying ability to afford insurance of varying quality, there is no reasonable means to address those with diminished income: seniors. This being the case, the U.S. has two alternatives. Either the system in its entirety must be altered to resemble socialized systems that work efficiently in European nations, or the country must accept that the government is obligated to more substantially fund senior care. In both cases, there remains the incontrovertible fact that the nation may not in any way “lessen” the care of its aging population, and the regrettable reality is that current policies are likely to do so, operating as they do on limited budgets and an unethical ideology.
Long Term Care Policy
If anything more directly influences policy in regard to institutional or community-based care for seniors, it is the not unexpected component of finances. Both Medicare and Medicaid address community care, and increasingly so, but in limited ways. Medicare, for example, is more designed to accommodate the needs of acute illness and hospitalization. It is essentially about recovery, which fails to address the ongoing needs of seniors removed from care facilities. Home or community care in Medicare is severely restricted, reinforcing the emphasis on the more emergent cases; it will, for instance, help to finance home care, but only when the patient is unable to actually leave the home, and when a physician mandates the care as necessary (Hieda, 2012, p. 153). As noted, the economically-based platform of Medicare equates to its emphasis on the institutional, and preferably of short-term durations. It is, in plain terms, a hospital-based program, and one not created to consider the variables of home or community care.
Medicaid is, by virtue of its presence as addressing the needs of the poor, more flexible. Given the high cost of senior care, Medicaid then serves those populations beyond the low-income. States have, for example, the option to determine if seniors may benefit in regard to nursing home care; as many middle class seniors cannot afford nursing homes, they become eligible for Medicaid as soon as their assets are gone (Hieda, 2012, p. 153). Medicaid is also called into play for home and community care, as Medicare is not. Title XIX of the Social Security Act calls for Medicaid to apply most funding to institutional care, but states retain the option of allocating Medicaid funds for community and home services. The problem, which dictates the influences shaping policy, remains economic. More exactly, and in regard to seniors, the same state prerogatives that may fund senior community care assess the disabled and other populations requiring assistance. The budgets are limited, and influencing this further is public sentiment, which translates to legislative response. That sentiment appears to support institutional care for the elderly, a factor supported by the reality that even Medicaid cannot fund home care without a medical waiver (Ball, 2012, p. 12). The trajectory of influence and policy seems explicable; those Americans not yet senior in age are likely as concerned about taxation and budget restraints as governmental interests, and an aging population is then left with fewer alternatives in regard to home or community care.
The Affordable Care Act (ACA) is in fact two pieces of legislation: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. Both may be viewed as vast extensions of existing Medicaid policies, in that they are constructed to expand choices for patients, more stringently oversee insurance companies, and reduce costs. Essentially, the ACA broadens the parameters of Medicaid eligibility to include Americans under 65, without children, and on a sliding scale in regard to the federal poverty level. There are multiple provisions within the Act, dealing with prescription drug pricing, employer tax incentives on providing coverage, and expanding community care services (Medicaid.gov., 2013). The Community Living Assisted Services and Supports (CLASS) Act, built within Affordable Care, was intended to provide for those living with illnesses or disabilities who will require more specific care in their senior years. The Act was designed to allow the disabled to remain within the community, rather than avail themselves of institutional facilities likely required if the additional care is lacking. This was to be a program receiving no federal subsidy, funded only by workers’ contributions and/or payroll deductions, and with eligibility for benefit available after five years. However, the Congressional Budget Office has determined that the plan cannot be financially solvent over a 75-year period, and this was a statutory requirement (Blue Cross, 2011). The CLASS Act, then, has been withdrawn.
It very much appears that the CLASS Act was sacrificed to appease those interests opposed to the ACA, if perhaps obliquely so. In plain terms, that a statutory regulation could halt such an effort seems unconscionable, particularly as federal support was not an issue. While the government is nonetheless obligated to maintain the fiscal integrity of the Act, its removal then all the more indicates legislative fears that a potential lack of solvency would translate to eventual government spending. What is most regrettable here is that, in implementing the CLASS Act, the U.S. would have been engaging in a proactive and vastly important measure to address an inevitable social concern. That those who are disabled now will require greater care in the future, and that such care would be more advantageous for all concerned by assisting that population to remain within their communities, are realities difficult to ignore. Consequently,
there is the impression that the Act was withdrawn because, like the ACA, it too strongly defies the existing systems, and could be sacrificed as the ACA could not.
Among the barriers to a coordinated and successful approach to long-term senior care, it is necessary to note the ideological and cultural issues so ingrained within the U.S. In plain terms, and somewhat notoriously, this is not a culture altogether accepting of aging in any healthy way. It has long been observed that Americans prize youth, which equates to a societal dismissal of the aging. Seniors are generally perceived as burdens rather than as assets to the society, just as cultural stereotypes of seniors abound. This is, moreover, no minor consideration in how actual policy is generated. The people influence their legislators, and the latter can survive only by accommodating the most pressing public concerns. With the elderly seen as lacking in value, there is then minimal impetus to ensure quality of life, and budgets are directed elsewhere. That this American mentality exists in the face of the reality of, not merely everyone aging, but of most people living longer, the barrier is bitterly ironic as well.
Regarding how state or localized resources may enable senior community living that promotes wellness, the town of Kendallville, Indiana, provides interesting insights. As one of many Indiana towns targeted as potential senior centers, the demographics of Kendallville accommodated virtually all considerations, and in a novel way. More exactly, the city and state agencies perceived an opportunity to address two issues simultaneously: the erosion of an old-fashion downtown and the needs of seniors both native and retiring to the Midwest. In Kendallville, downtown businesses were failing, but it was suggested that creating an elder-centric village could resolve the problem. Extensive marketing and assessing was conducted in 2009 and 2010, and it was determined that such an urban model answered a variety of senior needs. Independent living quarters for seniors were constructed on the available land downtown, and the proximity eased transportation problems in that most seniors could walk to meet their consumer and social needs. As the seniors polled typically revealed desires to work part-time, start-up businesses in the downtown were given incentives to hire them (Ball, 2012, pp. 263-266). Since then, the Kendallville senior population has expanded, and successfully.
This expansion has admittedly relied upon concessions not considered originally, as in a greater need for assisted living residences than had been foreseen. Then, the community as an elder-centric entity remains new, so there is some doubt as to its ultimate achievement. Nonetheless, this effort marks an extraordinary development, in that it both addresses senior needs and departs from traditional perceptions regarding the elderly. Historically, the U.S. prefers to “herd” its seniors into isolated pockets removed from the mainstream living; in Kendallville, the idea was to infuse the seniors into a once vibrant area and draw on the advantages of a limited downtown space to both meet senior needs and revitalize an area. Logistics and tangible success factors aside, the success of this venture lies in the novelty of its approach, in that it empowers seniors and anticipates their being a vital part of a community.
Policy in Everyday Life: Legal Issues for Seniors
When the subject of legal issues as related to seniors arises, it is ordinary that one factor dominant the thinking, if not the actual discussion: the ability of seniors to properly administer their own affairs. While most seniors, like most adults, do not possess extensive estates or holdings requiring complex administration, the reality remains that any property is some property, and the general perception of seniors as less than capable influences the policies in place. This is a regrettable case of principles developing from conceptions and biases which reflect the social view of seniors. On one level, society does seek to fulfill its obligation and care for seniors when families take onto themselves power of attorney; there is the desire to protect the senior from financial predators and preserve as much as possible what has been achieved in a lifetime. This same impulse, however, is nonetheless prompted by convictions that with seniority comes incapacitation, or diminished mental faculties and judgment. In some cases, this is certainly true. In most, however, policies that remove the authority of seniors over their own possessions are based on little more than expectations of “senility.”
This societal bias is not put forth to assert that seniors are without rights, nor that all those aged 65 and older are inherently victimized. All states have detailed criteria to be met in regard to guardianship suits, wherein another party – usually a younger family member – seeks to attain custody of the senior and be empowered to direct their affairs. Interestingly, Florida is alone in requiring guardianship course instruction before a petitioner can file to be appointed a guardian, a fact likely related to the large senior population in the state (Gallo, 2008, p. 104). This factor is, in fact, evidence of how seniors themselves may shape policy, as the Florida mandate must reflect the influences of that larger population’s voting power. The bias, however, is nonetheless revealed in the fact that all states have a two-part criteria for judging competence, and the senior bias is evident in that which the senior is eligible to be determined competent or incompetent by virtue of nothing more than being a senior. All that is needed to meet the one criterion is the age, which indicates the ideological anticipation of diminished capacity with age. The other criterion is based on assessing the individual’s ability to care for themselves (Gallo, 2008, p. 102), which may then act as a failsafe in preventing undue guardianships being granted.
It is agreeable to think of guardianships as loving actions engaged in by families eager to protect and care for aging parents, and this is likely true in many instances. The most optimistic view, however, cannot ignore the reality that guardianship relies on policies that seem to trust to much to familial good intentions, and thus deny seniors opportunities to exercise their own rights. For example, and probably reflecting a cultural belief in the family’s worthiness to care completely for the senior, court monitoring of guardianships is notoriously lax. This is, in all states, a condition of guardianship, as the laws were written to ensure that no senior would be vulnerable to less than helpful intent. According to a 2006 report from the American Bar Association (ABA) in concert with the American Association of Retired Persons (AARP), however, reviews of cases are infrequent at best (Uekert, Dibble, 2011, pp. 10-11). This relates to issues at least partially addressed by the state of Florida, in that it is similarly observed that many judges adjudicate guardianship matters with little or no education as to the demands of the process. Perhaps more disturbing is the admission by the ABA that there is very little data at all regarding the numbers and states of guardianship cases in the U.S. in which incapacitated seniors are involved. Policies are in place to oversee the cases and collect the information, but the lack of the latter as put forth by the ABA is reinforced by the U.S. Government Accountability Office (GAO) (Uekert, Dibble, 2011, p. 11). It then becomes all too easy to perceive seniors as being automatic targets for unwarranted guardianship, and the critical aspect here is that law and policy appears to give way to a likely reluctance on the part of the courts to interfere in family matters.
It is usual for Americans to perceive other nations as more concerned with caring for seniors, and invested in policies that reflect ancient traditions of respecting the elderly largely absent in the U.S. To some extent, this is true. Yet it also appears that, as Asian nations become industrialized and under the sway of Western influences, that reverence is precarious. In South Korea, for example, physical abuse of the elderly is becoming something of a national crisis. This is likely linked to the lessening of the extended family unit as urbanization has taken hold. Increasing numbers of Korean seniors no longer live with their children, and are consequently more vulnerable. There has been a national response to the crisis, however, and one that does indeed reflect Asian ideologies respecting seniors. More exactly, if the families may no longer be relied upon to care for the aging parents, the government has stepped in to fill the void, and with legal measures that protect elder rights. The Elderly Welfare Act, generally designed to promote health and well-being, offers tangible resources to that end. Two types of facilities, Admission and Use, are in place to address the respective needs of seniors who require full-time care or are visitors to the services. The Admission facilities are divided into the medical and the residential, and the Use encompasses varying conditions as well, with more of an emphasis on providing recreational outlets for Korean seniors (Wykle, Gueldner, 2011, p. 542). In all, the variety of government sponsored modes of care is impressive, and seems to indicate a firm commitment to attending to senior concerns in respectful and healthful ways.
More in regard to the legal rights of seniors as inadequately seen to in the U.S., South Korea has as well a range of resources to assure seniors of sufficient living income. The National Pension Policy translates for seniors to the Old Age Pension, which in 2006 was in place for 1,227,155 Korean senior citizens with reduced incomes. Then, since July of 2008, the Elderly Long-Term Care Insurance offers medical attention and in-home care as a part of the National Health Plan. Those able to pay give between five and 20 percent of the costs, but those unable to pay receive care of comparable quality in community hospitals and service centers (Wykle, Gueldner, 2011, pp. 546-548). What is most apparent in this complex system is how Korea regards the legal status of its seniors. The variety of protections, pensions, and services stands in marked contrast to U.S. policies, and indicates a conception of the senior as a viable adult absent in the sea of U.S. guardianship affairs.
It is, of course, as unrealistic to assert that other nations address senior legal issues infallibly as it is to uniformly condemn U.S. practices. It is inevitable that different cultures will create policies which reflect their own cultural perceptions of the elderly, and it cannot be forgotten that elder abuse is a serious issue in Korea. At the same time, and with regard to changes in U.S. actions and processes, the examples of other nations reveal a profoundly important point, in that U.S. policy is inadequate because Americans generally do not, in a very real sense, come to terms with aging well. As has been amply seen in the failure of the courts to monitor guardianship cases as proscribed by law, all the statutes in the world are of little good if the society is not committed to caring properly for its seniors. This is, ultimately, the unfortunate foundation of U.S. response to seniors. In the most simplistic terms, the U.S. addresses seniors poorly because it is less than willing to accept the reality of them. Hence, a kind of invisible status is attached to the elderly, and the consequences range from grossly unacceptable care to violations of legal rights.
This admittedly dismal reality notwithstanding, however, there is a mode of redress. A parallel may in fact be made with another instance of a marginalized population achieving its recognition, in the Civil Rights movements of the 1950s and 1960s. In that case, and despite vocal factions of support, the society was largely opposed to changing the existing laws allowing for discrimination, and the ethical burden fell on the courts and the legislation processes. Society then “catches up,” as it were, and cultural perceptions shift to embrace the legal mandates. It seems that this is the course that must be adopted in regard to the legal rights of seniors. If the U.S. is as yet hindered by ideological conflict in regard to again, and the irony of that conflict within a population aging in unprecedented numbers aside, the law may enjoy no such privilege of inaction. It must address the reality that even the incapacitated senior is an individual with full constitutional rights, act to legislate accordingly, and consequently prompt the society to follow its ethically correct lead.
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