Vol. 18, No. 8
September 13, 2018

In This Issue: Obamacare marketplace stabilizes | Texas court weighs ACA’s future | GOP reacts to pre-existing condition coverage fears | Medicaid expansion looks for state voters’ approval | Medicaid work requirements undergo scrutiny | nursing home quality issues get a House subcommittee’s attention | sepsis looms as a major SNF challenge | researchers endorse killing off the long-term hospital payment system | CMS’ primary care payment system reform proposal accumulates concerns | AARP publishes major reports on statewide LTSS and paid family leave | home health aides’ “emotional labor” needs surface | dedicated hospital spaces for caregivers come into view | the nursing home care conference requires more robust family contributions | Innovative approach to caregiver respite in LA | earwax buildup seriously undermines seniors’ wellbeing | concerns arise over aggressive hypertension treatment among the elderly | oversight of brokers’ trading gets a wake-up call | the aging’s financial burdens spark increased bankruptcy filings | unexpected “balance bills” torment patients | and Drew Calver settles a $108 thousand hospital claim for $332 (with a little help from Kaiser Health News)
As the “lazy” days of summer gave way to a new fall season, the impending midterm elections, Brett Cavanaugh’s Supreme Court nomination, ACA litigation in Texas, and state Medicaid expansion ballot initiatives—to list just a few hot button issues—promised a season as contentious as any in recent years.
ACA Marketplaces Stabilize
September began with some good news about Obamacare. The ACA health insurance marketplaces, the Associated Press reported , “seem to be stabilizing after two years of sharp premium hikes. And the exodus of insurers from the program has halted, even reversed somewhat, with more consumer choices for 2019. In numbers crunched by the AP and Avalere Health, analysts found a 3.6% average increase in proposed or approved premiums across 47 states and Washington DC for next year. This year the average increase nationally was about 30%. The average total premium for the individual covered under the health laws is now close to $600 a month before subsidies. ‘Even so,’ observed Chris Sloan, an Avalere director, ‘this is still a market that’s unaffordable for many people who are not eligible for subsidies. Nearly 9 in 10 ACA customers get government subsidies based on income, shielding most from premium increases.’ But people with higher incomes, who don’t qualify for financial aid, have dropped out in droves.”
Texas Court Hearing on the ACA; Kavanaugh Testifies in DC
While reporting its findings on the 2019 ACA marketplace premiums, the AP simultaneously covered the proceedings in a US District Court in Texas where 20 GOP-led states urged Judge Reed O’Connor to declare the entire ACA unconstituional in the wake of Congress’ recent repeal of the “individual mandate” provision requiring Americans either to buy insurance or risk a tax penalty. Judge O’Connor made no immediate ruling following a four-hour hearing, AP’s Paul J. Weber reported . “The arguments in Texas unfolded as Democratic senators in Washington pressed Supreme Court nominee Brett Kavanaugh, whose confirmation could swing the next major challenge to the health care law. While Kavanaugh issued a 2011 opinion that some conservatives viewed as favorable to the individual mandate, Democrats worry he will provide a key vote on the court against the law.”
Senate Republicans’ Bill Limits Coverage of Pre-existing Conditions
At risk in the Texas ACA litigation is by all accounts the most popular provision of Obamacare, namely, coverage protection for pre-existing conditions. Senate Republicans facing the November election cycle and reading public opinion signals moved to quell anxieties over the demise of that and other ACA protections. Led by North Carolina’s Thom Tillis, 10 GOP senators introduced a bill that, as Modern Healthcare’s Susanna Luthi reported , aimed at “securing Obamacare’s guaranteed issue provision. Insurers would have to cover everyone in the individual market regardless of health status and could not revise premiums based on health. But the Senate bill doesn’t necessarily stop insurers from denying coverage for pre-existing conditions, because it doesn’t prohibit coverage exclusions, according to Larry Levitt of the Kaiser Family Foundation. ‘Insurers would have to guarantee access to coverage, so exclusions would be the primary way to limit coverage.’ Before the ACA, Levitt tweeted, ‘I saw examples of body parts or systems being excluded from coverage for people with pre-existing conditions. For example, an insurer might offer someone with asthma coverage, but exclude any services associated with the respiratory system.’ Tillis’s office pushed back against this characterization as misleading. ‘This 20-page bill is not comprehensive health care legislation,’ his spokesperson said. ‘It also does not strike down or change any provisions in the Affordable Care Act. This legislation protects Americans with pre-existing conditions so that they cannot be denied coverage or charged more based on health status.’”
Medicaid Expansion on the Ballot in Four States
Medicaid expansion efforts and Medicaid work requirements were both in late summer news. Four states are now awaiting the outcome of ballot initiatives that, if passed, will lead to the addition of thousands of new residents to those states’ Medicaid rolls. Idaho, Montana, Nebraska, and Utah have all certified ballot measures that will give voters the opportunity to weigh in on expansion. As Modern Healthcare’s Susanna Luthi reported , “‘the movement to protect and expand access to healthcare is one of the most powerful forces in American politics today,’ said Jonathan Schleifer, executive director of the Fairness Project—a group that supported the initiative campaigns in all four states. ‘Voters from across the political spectrum are revolting against politicians who are standing in the way of an America where the family can see a doctor without going bankrupt.’” The New York Times’ Robert Pear traveled to Utah to see first-hand how one Medicaid initiative is faring. “In this conservative state,” Pear observed , “which has not supported a Democratic presidential candidate for more than half a century, a grassroots campaign to expand Medicaid is building considerable momentum as election day approaches. If it wins approval here, it could happen almost anywhere. The Utah push is five years in the making now, and supporters of expansion are cautiously optimistic. Opinion polls suggest that 60% of Utah adults favor it. Advocates are energetic and well organized, knocking on doors and speaking frequently at public events. Opponents are lying low, but plan to make their case more forcefully before Election Day.”
Maine’s Ongoing Standoff Over Expansion
Lest anyone assume that ballot “yes” votes in November ensure Medicaid expansion, there remains the ongoing saga in Maine. The Republican Gov. Paul LePage, succumbing to a court order demanding action in the wake of the state’s voter-passed expansion initiative, “submitted a plan that would make the state the 34th to expand Medicaid,” reported Modern Healthcare’s Virgil Dickson. “But (the governor) hopes it doesn’t happen. ‘Not one dime of the hundreds of millions of dollars that will be needed to pay for the state’s share of the expansion has been appropriated,’ he said in a letter to CMS administrator Seema Verma. A spokesman for CMS confirmed that the agency received the request but would not comment on whether it would honor LePage’s request to not approve it.”
California Bill to Ban Medicaid Work Requirements
For Californians the issue is no longer about expansion. Awaiting Gov. Jerry Brown’s signature is a measure that, as Modern Healthcare’s Virgil Dickson reports, “will make California the first state to prohibit its health department from ever seeking a waiver that imposes work requirements on Medicaid enrollees. The bill’s language would not only bar work requirements, but also waivers that impose waiting periods, time limits and coverage lockouts for beneficiaries who don’t pay their premiums, according to an analysis by California’s Department of Health Care Services. ‘The measure will inappropriately restrict the ability and flexibility of the department to negotiate future waivers with the federal government,’ the agency said in a notice. ‘We believe this proposed prohibition in statute is both overly restrictive and unnecessary.’”
Outcomes of Work Requirements in Arkansas
As the ongoing debate over Medicaid work requirements continues unabated, some initial outcomes of its imposition in Arkansas are reviewed by Health Affairs blogger Jessica Greene. After interviewing a small but representative number of residents subject to the recently implemented requirement, Greene concludes that “of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing Medicaid rolls, rather than supporting people to get employment. A 39-year-old woman—who recently had to quit her job to get her niece whom she mothers, a birth certificate and other paperwork to start school—argues that ‘the policy does not take into account the complex lives of low income people. You are saying this should be possible, but you don’t know my circumstances. You haven’t been here.’”
Researchers Propose ‘Mitigating’ Interventions to Work Requirements
Several University of Michigan physician researchers tackle the “risk of Medicaid work requirements” and propose four “mitigating” interventions: 1) limit the initial implementation to adults under 50 years of age since they are less likely than older adults and those covered by traditional Medicaid to have chronic health conditions and functional limitations that will be adversely affected by the loss of Medicaid coverage; 2) provide clear guidance to physicians on health conditions, functional limitations, and caregiving responsibilities for household members with disabilities that will exempt enrollees from work requirements; 3) provide job training, employee referrals, and support for work-related transportation and childcare for enrollees subject to work requirements; and 4) make the reporting of compliance with work requirements less frequent and more flexible to account for fluctuating work hours, seasonal employment, and temporary gaps in employment.”
House Subcommittee Hearing on Nursing Home Safety
Recent revelations of serious lapses in nursing home staff and patient care took center stage in early September at a House subcommittee hearing. Representatives of HHS’ Office of Inspector General and the General Accountability office testified about their published findings, and a number of advocacy groups submitted written testimony. A video of the entire hearing, as well as witness statements are on the subcommittee’s website . Advocacy groups’ contributions included statements by the National Consumer Voice for Quality Long-Term Care and the Center for Medicare Advocacy.
Poor Nursing Home Staffing Levels Show Link to Sepsis
Punctuating the discussion on Capitol Hill was a disturbing Kaiser Health News/Chicago Tribune examination of “Avoidable sepsis infections that send thousands of seniors to gruesome deaths.” “Sepsis,” the article explained, “is a bloodstream infection that can develop in bedridden patients with pneumonia, urinary tract infections and other conditions, such as pressure sores. Mindful of the dangers, patient safety groups consider late-stage pressure sores to be a ‘never’ event because they largely can be prevented by turning people over every two hours and by taking other precautions. Federal regulators also require nursing homes to adopt strict infection control standards to minimize harm. Yet the failures that can produce sepsis persist and are widespread in America’s nursing homes, according to data on state inspections from CMS. Much of the blame, regulators and patient advocates say, lies in poor staffing levels. Too few nurses or medical aides raise the risk of a range of safety problems, from falls to bedsore infections that may progress to an even more serious condition, septic shock, which causes blood pressure to plummet and organs to shut down.” A special analysis conducted for Kaiser Health News by Definitive Healthcare, a private healthcare data firm, also suggested that the toll—human and financial—from such cases is huge. Examining data related to nursing home residents who were transferred to hospitals and later died, the firm found that 25,000 a year suffered from sepsis, among other conditions. That treatment cost Medicare more than $2 billion annually, according to Medicare billings from 2012 through 2016.”
Long-Term Hospital Payments Examined
In 1980, Modern Healthcare’s Tara Bannow writes , “long-term hospitals were created to protect 40 chronic disease hospitals from Medicare’s then newly implemented Perspective Payment System. At the time regulators feared that fixed DRG payments would not be enough to cover those hospitals’ costs. That small group has since grown to more than 400 hospitals with $5.4 billion in annual medical spending as of 2014, a new National Bureau of Economic Research study has found. According to the NBER report,” Bannow reports, “despite being reimbursed at much higher rates than skilled nursing facilities and home healthcare providers, long-term care hospitals don’t produce better outcomes in three important areas: they don’t reduce mortality, or length of stay, and they leave patients with higher out-of-pocket costs. CMS has taken a number of steps over the years to rein in long-term care hospital spending, including a dual payment system under which such facilities only received higher payments for patients meeting certain criteria. But said Liran Einav, one of the report’s authors and an economics professor at Stanford University, ‘while those restrictions probably cut the facilities growth in half, they still have been able to generate significant profit. When the government created long-term care hospitals in the early 1980s they created an unintended monster. Since then the government didn’t try to kill the monster, they tried to just stop it from growing arms and legs. They created freezes on new beds, new facilities. Part of our point is that maybe instead of trying to curb it from growing arms and legs, just kill the monster.’”
Primary Care Physicians Express Concern Over Medicare Payment Proposal by CMS
As Caregiving Policy Digest reported in August, CMS has proposed a major overhaul in how primary care physicians are compensated by Medicare for office visits. The current multi-tiered, multi-payment level system would be replaced by a generally single level system whereby physicians will be paid $98 for established patients and $135 for new patients. Harvard and Massachusetts General Hospital doctors have taken to the pages of the New England Journal of Medicine to voice their concerns about the proposal. While acknowledging CMS’s “admirable intention of reducing the Medicare paperwork burden,” the policy, the authors argue, “poses risk for Medicare beneficiaries with the most complex needs and may exacerbate workforce deficiencies. Collapsing fees for levels 2 to 5 office visits, which account for essentially all physician visits billed to Medicare, effectively removes physicians’ incentive to spend time with patients who have complex needs. The physician effort required for a level II visit is minimal. In contrast, working with patients who have multiple pre-existing coexisting conditions, psychosocial challenges, and language or other barriers requires additional effort that would no longer result in a larger payment. The incentive to conduct shorter, repeated visits would be high.”
Two New Reports from AARP’s PPI: LTSS ‘Across the States’ and Paid Family Leave Programs
AARP’s Public Policy Institute has published two major reports, one containing the latest information about individual state long-term services and supports (LTSS), the second examining the status and importance of paid family leave programs, as well as possible avenues to expanding their availability. The 2018 profiles , “Across The States,” encompass a four-page document for each state detailing such subjects as age demographics and projections, the cost of care, Medicaid long-term services and supports, family caregivers, home and community-based services, and nursing facilities. In an AARP blog post, the report’s authors highlight some of the profiles’ key trends and dynamics:

  • Family caregiver pool: The aging demographic trend will have a profound impact on family caregiving. In 2015 there were seven people ages 45 to 64 for each person age 68 and older. In 2030 it is estimated that the “family caregiver support ratio” will drop to four to one. Projections then show it falling to about three to one in 2050, when all baby boomers will be ages 85 or older.

  • Diversity among LTSS recipients: The older population is becoming more diverse. This growing diversity of the older population will impact how LTSS are provided in terms of meeting diverse personal and family caregiver preferences, arranging for language translation services, providing services with cultural sensitivity, and training healthcare providers in cultural competence.

  • Cost challenges: The cost of LTSS is not within reach of most families across all the states. The annual median cost for nursing facilities ($97,455 for a private room) is more than double the median income of older households.

  • Need for more home and community-based services (HCBS): Generally people prefer to live at home and in the community. Yet the system favors more costly nursing facility care for older adults and people with physical disabilities. Even though Medicaid spending is becoming balanced toward more HCBS, the level of balance varies dramatically among states and populations. While 40 states became more balanced between 2011 in 2016, 11 states became less balanced for older adults and people with physical disabilities.

In the second AARP-PPI publication, author Lynn Friss Feinberg presents a richly detailed progress report on the availability of paid family leave (PFL) and paid sick days under both federal and state laws. “In 2013,” Feinberg reports, “the AARP Public Policy Institute released a report that found only two states offered a paid family leave program, and only one state and the District of Columbia had enacted a paid sick days days law. As of June 2018, six states and the District of Columbia have PFL programs, and 10 states and the District of Columbia have paid sick days laws that cover family caregivers. And a number of additional states have legislation moving forward. Because most family caregivers now have paying jobs too, employed caregivers need access to workplace benefits that enable them to fulfill both their caregiving and paid work responsibilities. Workers should not have to choose between keeping jobs and providing care to a seriously ill family member when they need it the most. Without a paycheck to cover the basic costs of living while providing care, low-wage workers are particularly vulnerable. They tend to have the least access to paid time off for caregiving needs and cannot afford to take unpaid family leave. Given the aging of the population and the workforce, caregiver family policies are important for maintaining both economic growth and workers’ own economic security. Workplace leave policies are a sound investment for employers and for America’s working families with caregiving responsibilities.”
Research on Effects of ‘Emotional Labor’ on Home Health Workers
A study by New York City researchers takes caregiving to the most personal level in examining the effects of “emotional labor” on home health aides well-being. “All healthcare involves some level of emotional labor, the relational work required to build trust with patients and ensure their comfort,” the researchers write . “Emotional labor is critical to high-quality care, but can also cause workers stress by requiring them to perform or regulate emotions while masking their true feelings. These demands are of particular concern in home care. Personal care assistants and home health aides deliver the majority of direct home care services and shoulder the bulk of emotional labor that patients require. This can include ‘surface’ acting or ‘performing’ caring expressions or gestures, as well as deeper work where aides make an effort to build genuine emotional bonds with clients. Our study suggests that aides’ emotional well being is an important, often overlooked factor in supporting flourishing workers. We found that clients’ families and agency supervisors have a strong effect on aides’ emotional well-being, and these factors interact with other structural domains (such as scheduling or training needs) to affect a sense of confidence, control, happiness, and the ability to balance work and home life.”
Hospital Caregiver Centers: Why They Make Sense
Dedicated spaces for family caregivers are an idea whose time has not yet come, except in a few acute care hospitals, reports Modern Healthcare’s Tara Bannow. In one such facility, Burke Rehabilitation Hospital in White Plains, New York, “a new family caregiver resource center—a quiet spa-like space on the hospital’s first floor where loved ones caring for Burke’s patients can rest, recharge and meet with volunteers trained to address their questions and concerns—is proving very popular. Burke’s caregiver center saw as many as 250 people in its first month, said its director, Carla Assenza, and the number has grown since then. Because the training takes between two to three months, Assenza is currently working with the caregivers by herself, but soon hopes to deploy her team of volunteers, many of whom are former healthcare providers themselves. The team of about 15 people currently goes throughout the hospital to tell family members about the caregiver center.” The big barrier to expansion of the concept: health facility budgets. “Hospital administrators don’t always see the value in caregiver centers because they can’t draw a straight line between supporting caregivers and important outcomes like, say, reducing preventable emergency room visits,” observed Leah Eskenazi, operations director for FCA’s National Center on Caregiving. “It’s a difficult message to drive home when you can’t use the same cost-benefit ratio that’s used to judge adding other services to a hospital. That’s the particular challenge to these types of programs. They’re not like heart services or surgery of various types. They’re not bringing in money.”
Addressing Caregiver Participation in Care Conferences to Align With Person-Centered Care
A study emanating from the University of British Columbia’s School of Nursing takes a look at a critical event in the life of a nursing home resident: the nursing home care conference. More specifically, the study’s authors zero in on one aspect of the conference, namely, how family members are “positioned” during the event and how conference dynamics enhance or diminish family caregivers’ contribution. “Our findings,” the study’s authors write, “reveal some of the barriers to the inclusion of family in care conferences through the highly scripted process, the scripted nature of content, as well as through the privileging of a particular kind of knowledge—that is, the ‘professional/clinical’ knowledge held by certain care providers. As such, our findings suggest that the physical presence of families at the care conferences does not necessarily guarantee the active solicitation of their perspective or open communication, and their participation in care conferences could be seen as a tokenistic gesture. Moreover, when family members do insert themselves into the discussion in care conferences, they are ‘positioned’ as ‘resistors.’ These findings have significant implications for promoting the resident’s perspective at the care conference. Considering the advocacy role played by families, their disempowerment potentially leaves residents without an advocate, the effects of which may be even more pronounced in residents with dementia. In addition, these findings have important implications for reimagining care conferences as a valuable component in person-centered care.”
The Youth Movement Against Alzheimer’s YouthCare Offers Innovative Caregiver Respite in Los Angeles
Los Angeles is about to welcome an innovative approach to respite care for family caregivers of Alzheimer’s patients. Care will be offered free by the Youth Movement Against Alzheimer’s YouthCare, utilizing trained undergraduate and master students. The program’s venue will be downtown Los Angeles and it will be offered on Fridays and Sundays from 1 to 4 PM starting September 14 through December 2. Interested family caregivers should visit the YouthCare’s website for more details and sign-up information.
California’s Paid Family Leave Law: A Story of Caregiving With Financial Security
Health Affairs contributor Dr. Gail Wagner adds a poignant personal note to AARP’s discussion of paid family leave (see above) as she  recounts how one of her emergency room mentors reappeared years later in her oncology consultation office suffering from terminal cancer—and how the mentor’s only child, herself now a nurse, was able to provide uplifting caregiving as a result of California’s expansive paid family leave law. “California’s statewide paid family leave policy,” Wagner writes, “was the first in the nation and a vast improvement over the unpaid leave that federal and—until then—state law provided. Yet for millions of people, paid leave progress has been too slow, and both the human toll and the economic cost of inaction are too high. As an oncologist, I am greatly concerned that only 51% of cancer patients and survivors and 43% of their caregivers report having access to paid family or paid medical leave during treatment, according to national surveys conducted on behalf of the American Cancer Society. Roughly half of cancer patients and their caregivers reported experiencing financial distress as a result of being unable to work or reducing hours because of their or their family member’s illness. At some point every person will face a personal illness or the illness of a loved one. When people are able to provide or receive care without losing their paychecks and jobs, businesses thrive and society benefits. No one doubts that allowing people time to care for their own illness or that of a loved one or to care for a new child, is desirable from a humanistic perspective. However, in the United States we have not fully understood that doing so makes economic sense too. Because of California’s paid family leave program, my mentor had the security and comfort of being cared for by her daughter when she needed it most, without worrying that she would put her daughter’s job or financial stability at risk.”
Earwax: An Under-Recognized Problem in Older Adults
While government officials and patient advocates continue to grapple with the quality gaps in long-term care, “of all the indignities that come with aging,” writes Kaiser Health News’ JoNel Aleccia, “excessive earwax may be the most insidious. Don’t laugh. That greasy build up occurs more often in older years than those of the young. And when it goes unrecognized, it can pose serious problems, especially for the 2.2 million people who live in US nursing homes and assisted-living centers. ‘An excessive amount of earwax can cause hearing loss or ringing in the ears, while some people experience vertigo, which increases the risk of falling,’ said Jackie Clark, president of the American Academy of Audiology. ‘Right now we see some correlation between hearing loss and cognitive decline.’ Earwax is normally produced by the body as a way to clean and protect the ears, and for most people, the self-cleaning process works fine. But in others, including more than 30% of the elderly and developmentally disabled people, the wax collects to the point where it can completely block the canal. Up to two thirds of people in nursing homes may suffer from that condition, known as impaction. It’s so bad that Janie York of Omaha, Nebraska, started Here Now Mobile Hearing Solutions, one of a growing number of businesses devoted to cleaning hearing aids and checking the ears of elderly people living in residential care settings.”
Hypertension Recommendations Raise Concerns
Recent years have seen recommendations for treating hypertension grow more aggressive. In 2017, writes the Washington Post’s Janice Neumann, “a 2015 study—showing that seniors at high risk for cardiovascular events, but without diabetes, had lower rates of such events when they aimed for a systolic blood pressure of less than 120 rather than 140—was used to change the ‘new normal’ to less than 120/80. For Neumann’s mother, 92 in 2017, a spike in her blood pressure led to her entering a period of significantly increased medication to bring her normally high 150 systolic pressure in line with the new guidelines. The result,” Neumann reports, “was very troubling. By early spring, my mother was apathetic and even weaker. During a visit to her geriatrician, her sodium level was so low that she needed to be hospitalized and infused with fluids. A conversation with Dr. Michael Rich, a geriatric cardiologist at Washington University School of Medicine in St. Louis, made me realize I should have insisted that doctors consider my mother’s age and quality of life. ‘Medication dosages become trickier to adjust and side effects may increase as people age because metabolism changes, and the absorption, the distribution in the body and the elimination of most drugs is affected by aging,’ Rich said. That predisposes older individuals to a higher risk for side effects from most medications. Therefore often doses need to be adjusted in older individuals, typically downward, in order to get an equivalent effect to younger individuals without increasing side effects.”
Reviewing Parents’ Investment Account Reveals Unauthorized Trades and Large Commissions
The New York Times’ Tara Siegel Bernard pens a strong cautionary piece concerning investment brokers’ management of aging parents’ assets. “To help pay for her mother’s care, Tracey Dewart relied on an investment account that her 89-year-old father had opened more than eight years ago at a large security firm. At the time of her mother’s move to an assisted living facility, Ms. Dewart noticed what looked like unusual activity in the account, which she and her older sister had overseen for about four years. A closer look revealed that it was down $100,000 in one month. After about six months, she learned that the account, worth roughly $1.3 million at the start of 2017, had been charged $128,000 in commissions that year—nearly 10% of its value, and about 10 times what many financial planners charge to manage accounts of that size. About five months after she questioned the broker’s handling of the account, his firm had canceled 681 of the 1499 transactions for 2017, crediting about $84,000 in commissions. That left 818 trades and commissions totaling about $44,000 for the year—about 3.8% of the account’s value, still triple what many financial planners charge.”
Large Increase in Bankruptcy Among Aging Americans
Financial fears loom ever larger in the lives of aging Americans. That, reports the New York Times’ Tara Siegel Bernard, is reflected in the fact that “the rate of people 65 and older filing for bankruptcy is three times what was in 1991, and the same group accounts for a far greater share of the filers, according to a new study conducted by the Consumer Bankruptcy Project (CBP). ‘You can manage okay until there’s a little stumble,’ said Deborah Thorne, an associate professor of sociology at the University of Idaho and an author of the study. ‘It doesn’t even take a big thing.’ In data collected by the Employee Benefit Research Institute, the median household led by someone 65 or older had liquid savings of $60,600 in 2016, whereas the bottom 25% of households had saved at most $3,260. That doesn’t provide much of a financial cushion for a catastrophic health problem. By 2013, the average Medicare beneficiary’s out-of-pocket spending on healthcare consumed 41% of the average Social Security check according to the Kaiser Family Foundation, which also estimated that the figure would rise. Bankruptcy can offer a fresh start for people who need one, the CBP observes, but for older Americans it is too little too late. By the time they file, their wealth is vanished and they simply do not have enough years to get back on their feet.”
Surprise Medical Bills Top List of Healthcare Cost Worries
A significant driver of financial anxiety for Americans of various generations comes in the form of surprise medical bills. Such bills, in fact, top the list of healthcare costs Americans are most afraid they will not be able to afford, with four in 10 people saying they had received a surprisingly large invoice within the past year, according to a new Kaiser Family Foundation poll reported by Kaiser Health News’ Jordan Rau. KFF found that 67% of people worry about unexpected medical bills, more than major insurance deductibles, prescription drug costs and the basic staples of life: rent, food and gas. A quarter of people who said they received a surprisingly large bill attributed it to a doctor, hospital or other provider that was not in their insurance network.
Hospital and Insurer Can’t Agree and the Patient Gets $ 108,951 Emergency Hospital Bill
Drew Calver, a 44-year-old Austin, Texas, high school history teacher and swim coach, did not need poll results to alert him to the problem of unexpected medical bills. Collapsing with a heart attack in his bedroom, Calver was rushed to a nearby, out-of-network emergency room where he was quickly sent to the hospital’s cardiac unit to have four stents placed in his clogged main artery, writes Kaiser Health News’ is Chad Terhune. “The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840. Despite the difference of more than a hundred thousand dollars, having received the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him. And then the bills came. The total: $164,941 for a four day hospital stay, including $42,944 for four stents and $10,920 in room charges. Calver was billed for an unpaid balance of $108,951.31. Outside medical bill analysts concluded that a reasonable price for hospitalization in Austin involving four heart stents should have totaled between $26,000 and $36,000. Calver’s shocking bill reflected the fact that although Aetna agreed to pay for emergency care at the closest hospital even though it was out of network, the hospital and insurer could not agree on a reasonable price. But, fortunately for Calver, the story did not end there; in addition to experiencing firsthand the terror of facing an overwhelming, unexpected medical expense, Drew Calver also became the beneficiary of Kaiser Health News’ expose. Only days after publication and broadcast of the story, the hospital said it would be willing to accept $782.29 to resolve the $108,951 balance because Calver qualified for its financial assistance discount. Calver disputed owing any additional money, and by the next day the hospital/slashed the bill to $332.29—which Calvert paid off over the phone.”
2018 Rosalinde Gilbert Innovations in Alzheimer’s Disease ‎Caregiving Legacy Awards
Family Caregiver Alliance—with The Rosalinde and Arthur Gilbert Foundation—are pleased to announce the Rosalinde Gilbert Innovations in Alzheimer’s Disease ‎Caregiving Legacy Awards for 2018 are now open and we are accepting applications.

There are three $20,000 awards in the following categories:

► Creative Expression
► Diverse/Multicultural Communities
► Public Policy

Visit our information page for directions and link to the online application. Previous applicants are encouraged to apply again. Please share this announcement with any nonprofit or public organizations who are potential candidates for an award.

Deadline: Friday, October 12, 2018, 5 p.m. (Pacific Time)
FCA Board Member Rajiv Mehta Recognized as 2018 Influencer in Aging
FCA Board Member Rajiv Mehta has been recognized as a 2018 Influencer in Aging by Next Avenue. Rajiv is the founder and CEO of Atlas of Caregiving , a nonprofit with the mission and vision to address caregiving challenges through a knowledge of the day-to-day experiences of family caregivers. FCA was pleased offer support to the Atlas of Caregiving pilot project in 2015 and continues as a proud partner.

FCA Executive Director Kathy Kelly stated, “I am so excited and pleased that Rajiv has been recognized for his outstanding and groundbreaking work in caregiving with the recognition by Next Avenue as a 2018 Influencer in Aging! Kudos on the recognition.”
Follow Family Caregiver Alliance / National Center on Caregiving @CaregiverAlly
and Executive Director Kathleen Kelly @KKellyFCA.
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Editor: Alan K. Kaplan, (attorney and health policy consultant)
Contributor: Kathleen Kelly (executive director)
Layout: Francesca Pera (communications specialist)

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