Health care costs

AS the federal government struggles to accommodate social needs in next year's trimmed-down budget, one issue to be faced is long-term care for the so-called ``disabled elderly.'' Thousands of people find the task of caring for such elderly relatives beyond the limits of their physical or financial resources. In these instances it should be government's responsibility to provide essential assistance to aid the care-givers and the elderly themselves.

One indication of dissatisfaction with the patchwork system of long-term care is a new study by the National Academy of Sciences, calling for a much stronger federal role in regulating nursing homes.

Researchers are exploring a number of ways to fund such long-term care, such as expansion of existing programs and tax credits for those caring for their elders, as well as a straightforward government insurance program, like medicare. Private-sector funding mechanisms under study include greater use of home-equity conversion and private insurance.

Whatever funding mechanisms are used, the whole issue needs to be seen not as an ``elderly issue'' or a ``health issue,'' but as a family issue. Congress, the administration, and the nation should examine the needs thoroughly but expeditiously to determine which approach to take, then move promptly.

Within 30 years, about one-third of Americans reaching age 65 will have a living parent. Increasingly, middle-aged people are already simultaneously putting children through college, saving for retirement, and providing for an elderly parent. Many middle-aged women, particularly, already juggling career, marriage, home, and children, are adding a fifth responsibility: an older relative.

Hints that the Reagan administration may eventually propose an insurance program to protect the elderly against ``catastrophic illness'' are welcome. But one proposal on the table -- the expansion of medicare, financed by additional premiums, to provide unlimited hospitalization -- should be seen as a limited approach to one part of a much larger problem.

For millions of older people and their families, ``catastrophic illness'' means not hospitalization but a stay in a nursing home. The gaping hole in the health-care safety net is that medicare pays for nursing-home care only if it follows a hospital stay. Uncle Sam pays for so-called ``custodial care'' in a nursing home only for those who qualify for medicaid. (Of course, many who start paying their own bills end up on medicaid as their assets are ``spent down.'')

Of the 7 to 8 million of the post-65 group who enter a hospital in a year, only some 200,000 stay more than 60 days, and of these, only about 70,000 stay more than 150 days. This is the group whose needs would be addressed by the expansion of medicare as has been proposed. The nursing-home population, meanwhile, is 1.4 milliion, about half of them receiving government support. Some 1.4 million more are receiving health-care services at home. Some 3.5 million disabled elderly receive no formal services.

Home health services have caught the public fancy as a humane alternative to nursing homes and as a potential cost-cutter. But planners worry about the potential ``woodwork problem'' if medicare is expanded to provide for these services: If the government started paying for home health services, the concern is, people would ``come out of the woodwork'' to apply for them. It is unclear just how many of those 3.5 million not getting services would want to sign on, and the uncertainty makes the planners anxious.

Of course, advancing years do not have to mean incapacity. The overwhelming majority of older people -- even above age 85 -- are not in nursing homes.

Meanwhile, a lot of people out there are going quietly about the heroic labors of caring for the frail elderly. These people need encouragement and appreciation -- both care-givers and those cared for.

It is often said that in the good old days happy families always cared for everyone under the same roof. Frequently they did. But often they did not, and could not. Similarly, many families today, after much soul-searching, have reached the decision that a nursing home is the best answer for a particular relative; from them, the burden of unbearable costs needs to be lifted.

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