Suppose Grandmother has a living will. It says that if she falls into a vegetative state, like Terri Schiavo did, she wants to be kept alive on a feeding tube. How long? “Until the good Lord takes me away.” One terrible day, she is thus stricken, and in goes the feeding tube. OK, who pays for her care?
Most of the fist-waving a year ago was over whether Michael Schiavo had the right to order the removal of his wife’s life support. Terri’s parents said that they wanted their daughter kept alive, and that if Michael did not wish to care for her, they would.
The parents’ view clashed with reality. The reality was that the nurses at a Florida hospice were taking care of Terri, and Medicaid was paying for them. Clearly, the taxpayers also had a stake in these painful decisions, though no one talked about it much.
The time has come for that conversation, and it ought to be frank. Medicaid, the health-insurance plan for the poor, is supported by federal and state taxpayers. Medical technology can keep people with no hope of recovery floating between life and death for decades. The taxpayers have a right to set limits on how much of this they will finance.
Medicare covers the elderly and disabled, but does not pay for nursing-home care. Medicaid will. It has become something of a game for middle-class families to transfer an ailing relative’s assets to, say, their children, in order to make the patient “poor” and therefore eligible for Medicaid. The Deficit Reduction Act – signed by the president but now held up by lawsuits – would make such transactions far harder to do, according to Lawrence Davidow, president of the National Academy of Elder Law Attorneys (www.naela.com).
A spouse may still easily transfer assets to a husband or wife for these purposes, Davidow notes, but she or he also has a legal obligation to pay for the partner’s medical necessities.
State laws vary on how much wealth a spouse can keep and still have a wife or husband qualify for Medicaid. In New York State, for example, a house is an untouchable asset, no matter how valuable. (As a result, a wife in New York could be living in a $2 million house, while her husband receives nursing-home care at taxpayer expense.) However, carrying out the wishes of a spouse can still cost the marital partner a great deal.
If the patient is widowed or otherwise single, that person’s entire estate could be wiped out on nursing-home costs. With nursing homes typically billing $70,000 a year (Terri Schiavo’s hospice charged an average $80,000 a year), it would not take long for assets worth even $250,000 to evaporate.
Such situations can cause anguish for families. It’s one thing to see that money used to keep Grandmother comfortable in her last years. It’s another to spend it on keeping her unconsciously tied to tubes month after month – especially when the family wealth could have been assigned to the children’s education. But if Grandmother’s living will says to keep her breathing no matter what (and there’s no long-term-care insurance), that’s where the money will go.
Once her assets are depleted, however, the taxpayers, through Medicaid, take over. But should they? There are arguments aplenty over the enormous sums being devoted to heroic end-of-life treatments, even when the ailing person is conscious. But the wisdom of using taxpayer dollars to keep people in irreversible comas or vegetative states is less debatable. Our society hasn’t even agreed to inoculate all its children. Should we feel obliged to spend $80,000 or more a year to provide 24-hour nursing for someone who will never wake up?
Most taxpayers would agree that the answer is no. And if the answer is no, then the time has come to question whether even airtight living wills should be the last word. In truth, the great majority of living wills are made by people who want to avoid futile treatment, not prolong it. But what about the people whose end-of-life wishes would drain hundreds of the thousands of dollars from Medicaid to no obvious good end?
Americans need to talk about this.
Froma Harrop is a Providence Journal columnist. Contact her by writing to fharrop@projo.com.
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