Need a topic and case scenario for ethics paper

VickyRN, MSN, DNP, RN · Mar 11, 2011

What about the very controversial Medicaid "spend down" requirements to finance nursing home care?

Approximately one in four older adults will spend some time in a nursing home during the last years of their lives.

Another side product of the quandary caused by conflicting societal obligations is an ethical issue that has been gaining considerable attention. Related to financing, and therefore to access, it is the issue of “spending down” one’s resources to qualify for Medicaid coverage. This has produced one of the most urgent and pervasive ethical debates associated with long-term care.

Many of those who do not qualify for Medicaid still do not have enough assets to pay for long-term car themselves. They face a cruel choice: struggle to provide home-based care or do what is necessary to obtain Medicaid. To qualify for Medicaid, it is necessary to “spend down” lifetime accumulated assets to become impoverished and therefore eligible for assistance. Under regulations of the Medicaid law, spouses of those thus impoverished may obtain some protection, but children and grandchildren lose their share of accumulated life savings. One major problem with Medicaid financing of long-term care is that it introduces inequities across families, age groups, and social classes. For example, should people who become poor in old age be treated the same as those with a lifetime of poverty? Should families that contribute their own labor for caregiving have that contribution taken into account?

In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets.

The spouse of a nursing home resident--called the "community spouse" -- is limited to one half of the couple's joint assets up to $109,560 (in 2009) in "countable" assets. This figure changes each year to reflect inflation. In addition, the community spouse may keep the first $21,912 (in 2009), even if that is more than half of the couple's assets. This figure is higher in some states, even up to the full maximum of $109,560 (in 2009).

Most people who enter nursing homes as private-pay residents spend their assets by the end of 1 year and require government support for their care; one-third of the Medicaid budget is spent on long-term care. As the percentage of the advanced-age population grows, society will face an increasing demand for the provision of and payment for services to this group. In this era of budget deficits, shrinking revenue, and increased competition for funding of other special interests, questions may arise about the ongoing ability of the government to provide a wide range of services for older adults.

To what extent does the government owe each of us coverage for our care, regardless of our ability to pay for it? Consumers faced with spending down ask why, after they have been paying their taxes all these years, have to lose all that they have saved just to be eligible for long-term care? After all, is it not the same care that is covered for those who were not so farsighted and prudent? Should coverage not be an entitlement as so many other government benefits? People feel that the savings that they put away over many years were meant to be passed on to children and grandchildren. They believe it is unfair to take all of that way from them, in effect penalizing them for being frugal, and point to others who either spent all they had frivolously or never bothered to provide for themselves in the first place. Where is the incentive to save if it is to be taken away by the government?

Countering arguments, primarily coming from government entities that are hard-pressed to finance Medicaid programs, center on the unfairness of providing coverage to those who have their own resources.

Which is more or less ethical – to take away an individual’s savings or to force government to pay for someone who has those savings? The issues also affects the children and grandchildren of the individual consumers of long-term care. If asset transference is not allowed, they may not receive the inheritance that they, and their parents, had anticipated. On the other hand, if today’s elderly are allowed to collect Medicaid while transferring their assets to their children and grandchildren, these later generations may not have a public system on which to fall back.

According to public pinion surveys, 82% of the general public recognize that they cannot afford to pay the cost of long-term care either at home or in a nursing home. They also know that they cannot rely on the family alone; 86% want the government to help pay for long-term care instead of leaving it entirely up to the family. But despite such clear public sentiment, a universal public insurance program for long-term care is still not available in the US. On the contrary, Medicaid has become the public program of last resort to pay nursing home costs. In fact, it is the fastest-growing component of state budgets, and it is increasingly becoming an old-age program. Nearly 40% of all Medicaid benefits go to the elderly, chiefly for nursing home care.