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Alzheimer’s Takes a Financial Toll Long Before Diagnosis, Study Finds

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New research shows that people who develop dementia often begin falling behind on bills years earlier.Long before people develop dementia, they often begin falling behind on mortgage payments, credit card bills and other financial obligations, new research shows.A team of economists and medical experts at the Federal Reserve Bank of New York and Georgetown University combined Medicare records with data from Equifax, the credit bureau, to study how people’s borrowing behavior changed in the years before and after a diagnosis of Alzheimer’s or a similar disorder.What they found was striking: Credit scores among people who later develop dementia begin falling sharply long before their disease is formally identified. A year before diagnosis, these people were 17.2 percent more likely to be delinquent on their mortgage payments than before the onset of the disease, and 34.3 percent more likely to be delinquent on their credit card bills. The issues start even earlier: The study finds evidence of people falling behind on their debts five years before diagnosis.“The results are striking in both their clarity and their consistency,” said Carole Roan Gresenz, a Georgetown University economist who was one of the study’s authors. Credit scores and delinquencies, she said, “consistently worsen over time as diagnosis approaches, and so it literally mirrors the changes in cognitive decline that we’re observing.”The research adds to a growing body of work documenting what many Alzheimer’s patients and their families already know: Decision-making, including on financial matters, can begin to deteriorate long before a diagnosis is made or even suspected. People who are starting to experience cognitive decline may miss payments, make impulsive purchases or put money into risky investments they would not have considered before the disease.“There’s not just getting forgetful, but our risk tolerance changes,” said Lauren Hersch Nicholas, a professor at the University of Colorado School of Medicine who has studied dementia’s impact on people’s finances. “It might seem suddenly like a good move to move a diversified financial portfolio into some stock that someone recommended.”Tell us about your family’s challenges with money management and Alzheimer’s. More

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    An Uptick in Elder Poverty: A Blip, or a Sign of Things to Come?

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    In the 1960s, more than a third of older Americans lived in poverty. With the aid of federal programs like Medicare to help the elderly, the situation improved significantly. But last year, the poverty rate for those 65 or older increased, even as it sank for everyone else.The uptick offers new evidence that elderly people haven’t fared as well as younger generations in recent years, and some experts worry that it may signal a broader setback in the financial security of those past their prime working years.While 9.5 percent of the elderly population lived in poverty in 2020, that figure rose to 10.7 percent last year, the Census Bureau reported. The coronavirus pandemic was a central driver, disproportionately disrupting the employment and income of older people.They usually weren’t eligible for as much pandemic relief as families with children. And older workers left the labor force at higher rates than others as Covid-19 spread, and can have difficulty returning.That’s the situation that Walter Cox, 64, may find himself in. As an automotive technician at a car dealership in Tulsa, Okla., he never made more than $9.50 an hour, and wasn’t able to save money while raising two children. Nevertheless, he retired in 2020, as the physical labor — and rude customers — took a toll. He also got married, and he and his wife had about $2,000 in combined monthly income for most of 2021, which made for a comfortable if modest living.But when his wife had to leave for New Mexico to take care of her mother, the couple divorced, leaving Mr. Cox with a $765 Social Security check to cover all of his bills. That will leave him below the official poverty threshold of $12,996 for a person 65 or older living alone. He has been mowing yards for some extra income, but can’t do anything he had imagined doing in retirement, like a road trip to Yellowstone National Park.“I literally cannot afford to do anything but put gas in my car, buy groceries and pay my utility bills,” Mr. Cox said. “Because of the divorce, it’s looking pretty grim. But I’m hopeful that things improve.”For many older Americans, an inflation adjustment to Social Security payments — an 8.7 percent increase for 2023 was announced last week — will help next year. But people hitting retirement today often depend on Social Security as their only source of income, which wasn’t the program’s original intention.Poverty Rates by Age GroupIn 2021, even as the poverty rate sank for everyone else, it increased among seniors — rising above younger age groups for the first time in 15 years.

    Source: Census Bureau and Columbia Center on Poverty and Social PolicyBy The New York TimesOlder workers’ wages have grown more slowly compared with other groups over the past few years, and many didn’t have 401(k) accounts, or didn’t contribute enough to them, as companies closed their defined-benefit pension plans over the last couple of decades.“We’re getting more and more older people who lived through this experiment with do-it-yourself pensions, and they’re coming into this age group without the same kind of incomes that older people have,” said Teresa Ghilarducci, an economics professor at the New School who specializes in retirement policy. “I don’t think it’s a blip.”More on Social Security and RetirementMedicare Costs: Low-income Americans on Medicare can get assistance paying their premiums and other expenses. This is how to apply.Downsizing in Retirement: People selling their homes often have to shell out more to spend less. Here’s what to consider.Claiming Social Security: Looking to make the most of this benefit? These online tools can help you figure out your income needs and when to file.Even though the share of elderly people officially below the poverty line is low by historical standards in the United States, it remains among the highest in the developed world, according to the Organization for Economic Cooperation and Development. The average poverty rate for older Americans also masks far higher shares among more vulnerable groups, with nearly one in five Black and Hispanic women 65 or older falling below the official poverty threshold in 2021. It’s higher for single people, too — a reality forced on hundreds of thousands of older Americans whose spouses died of Covid-19.The poverty rate is also not a bright line when it comes to financial hardship. It doesn’t take into account debt, which more seniors have accumulated since the Great Recession. Moreover, nearly one in four people 65 or older make less than 150 percent of the federal poverty line, or $19,494 on average for those living alone. Another measure, developed by the Gerontology Institute at the University of Massachusetts Boston and called the Elder Index, finds that it takes $22,476 for a single older person in good health with no mortgage to cover basic needs, with the cost escalating for renters and those with health problems.“To some extent we’re splitting hairs when we talk about people who fall just above and just below, because they’re all struggling,” said Jan Mutchler, a demographer at the University of Massachusetts at Boston who helped devise the Elder Index. “The assumptions that go into what we’re calling hardship are just flawed.”That’s true for Juanita Brown, 77, who lives on her own in Galax, a small town in Virginia’s Blue Ridge Mountains. A farmer’s daughter, she worked as a nanny, and then a certified nursing assistant, and then a preschool teacher. Her husband worked in the local textile industry, and after raising two children, they had built a substantial nest egg.But then Ms. Brown’s mother developed Alzheimer’s disease and couldn’t support herself. Ms. Brown stopped working to take care of her, which cost another $500 per month in expenses. Her husband got prostate cancer, which required extended trips to the hospital in Winston-Salem, N.C.“That depleted us,” Ms. Brown said. After her husband died in 2019, she was left with a car payment and more bills that went unpaid during his illness. She took out another mortgage on her home to help cover them, along with the $1,465 she gets from Social Security on the fourth Wednesday of every month.Family photos on display in Ms. Brown’s home in Galax, Va.“When you sit down and look at your income, and what you got to pay for every month, you got to cut corners,” Ms. Brown said.That technically puts her above the poverty line. But that hasn’t left enough money to replace the dentures she lost three years ago, or to replenish her heating oil, which now costs up to $250 a tank. She uses her wood stove as much as she can, but it gets too cold at night, which aggravates her arthritis. She records every expense in a little booklet.“When you sit down and look at your income, and what you got to pay for every month, you got to cut corners,” Ms. Brown said. Sometimes, one of her sons will visit and leave her with $50, even though she knows they can’t afford it either.Many times before, Ms. Brown has leaned on the support of District Three Governmental Cooperative, a local agency that provides transportation, help navigating government benefits, opportunities to socialize and other services for older residents. Debbie Spencer, the agency’s director of aging and disability services, has seen more clients struggle over the last year to pay for groceries. Covid-19 also made it more difficult to reach her more isolated clients, who often lack internet connections.“We’re seeing people who don’t know whether to pay their utility bills, to buy food, or to buy medicine,” Ms. Spencer said. “They’re having to make decisions about what they’re going to do. We helped people last year, but we see more and more people calling us this year for help.”The agency also runs a training program for older workers, popular with people who’ve found their Social Security income inadequate to live on.To prevent the poverty rate from rising further, advocates for the elderly recommend three types of actions: shoring up employer-sponsored retirement programs, helping older people earn more by working longer if they need to, and basing eligibility for public benefits on a more realistic definition of economic hardship.In 2022, the Labor Department reported that while 72 percent of civilian workers had access to an employer-sponsored retirement plan, only about 56 percent took part in one. That, in part, is why the lowest one-fifth of the income distribution in households headed by seniors gets 80 percent of its income from Social Security.For those retiring today who do have a 401(k), a swooning stock market is forcing them to recalibrate what income they can expect going forward. And the millennial generation is likely to retire less prepared than its predecessors, because of higher loads of student debt.Those without adequate retirement savings often have to keep working late into their 60s and 70s. Emily Allen, interim president of the AARP Foundation, says too many seniors overestimate their ability to take a break — or are pushed out of jobs — and end up in a difficult situation.Becky Freeman, an employee of District Three Governmental Cooperative, a local agency that provides services to seniors, made a home delivery in Meadowview, Va.Ms. Freeman, right, reviewing bills with Mildred Sneed during a home visit.“Older workers who stepped away and want to get back into the work force often have to take jobs at a lower wage than they earned in the past,” Ms. Allen said. “It’s easier to get a job when you have a job. So often we encourage individuals just to get back into the work force, but then work to advance their skills.”To supplement low wages, the American Rescue Plan of 2021 temporarily made people over 65 eligible for the earned-income tax credit, for which they otherwise don’t qualify. Advocates for the elderly have pushed to make that change permanent, since the wage supplement is often enough to lift people out of poverty.Older people low on financial resources can also look forward to the drug pricing provisions of the Inflation Reduction Act, which will reduce the cost of medications in the coming years and provide subsidies for those living close to the poverty line.Meanwhile, though, most aid programs that had been created or strengthened in 2020 and 2021 are gone. Gail Gorlen, 77, started leaning more on her credit card after the Supplemental Nutrition Assistance Program went from sending her $170 each month — an amount increased during the pandemic — to $115. She feels lucky to have found an apartment in a subsidized senior housing complex in Joplin, Mo., when she and her longtime partner split up last year, and is hoping that her Medicare Advantage program will provide some extra help with food.But for now, even cooking all her food at home, the days before her benefit card arrives on the 20th of the month are stressful.“I’ve gotten to the point where I can only pay a percentage of my Visa — I can’t pay the whole thing off, I don’t have enough money in the month,” Ms. Gorlen said. “I keep charging, charging, charging.” More

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    2023 COLA Could Strain Social Security Program

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    The Social Security Old-Age and Survivors Insurance Trust Fund could be depleted a year or two earlier than expected as a result of larger payouts.The 8.7 percent Social Security cost-of-living increase that was announced on Thursday is welcome news for retirees who are struggling to cope with surging inflation. But it could bring the social safety net program a step closer to insolvency.Annual government reports in June showed that the Social Security Old-Age and Survivors Insurance Trust Fund, which pays out retiree benefits, would be depleted in 2034. At that time, the fund’s reserves will run out, leaving the system reliant on incoming tax revenue. Those funds will provide enough money to cover only 77 percent of scheduled benefits unless Congress intervenes.Social Security is largely funded through payroll taxes, taxes levied on Social Security benefits and interest on money that the trust funds invest.Now that the program will be paying out more to help retirees keep up with rising prices, the program will be under even more pressure to sustain itself. Budget experts warn that the reserves could run out before 2034 as a result of the larger benefits.“This very large COLA increase is likely to bring the year of insolvency forward by a full year,” said Maya MacGuineas, president of the Committee for a Responsible Federal Budget, referring to the cost-of-living adjustment. “It is just another reminder that procrastinating on addressing these imbalances leaves the people who depend on Social Security particularly vulnerable to a further deterioration in its finances.”The increased outlays for retirees will be partly offset by higher taxes on Americans. Along with the bigger benefits, the maximum amount of earnings subject to the Social Security payroll tax will increase to $160,200 from $147,000. Employers and employees each contribute 6.2 percent of wages up to that salary threshold, which is adjusted every year based on average wage growth.Because wages are rising, the amount of earnings subject to the tax is rising as well.Ms. MacGuineas estimated that the Social Security Trust Fund could have been depleted as much as two years earlier without the offsetting effect of the higher tax threshold.Kathleen Romig, director of Social Security and disability policy at the Center on Budget and Policy Priorities, said the depletion date could be accelerated by as much as two years. But she added that a couple of years of high inflation probably would not fundamentally change Social Security’s long-term financing outlook.“It’s normal for Social Security’s trustees to update the expected reserve depletion date as circumstances change,” Ms. Romig said.Ms. Romig noted that more than 65 million retirees count on Social Security for most of their income and that the cost-of-living increase would ensure that older Americans did not fall into poverty as they aged.The June projections actually showed the depletion date of the fund being delayed by a year, from an earlier projection of 2033, the result of a stronger-than-expected economic recovery in 2021.Anqi Chen, assistant director of savings research at the Center for Retirement Research at Boston College, said the impact of the cost-of-living adjustment on the Social Security Trust Fund would depend on a combination of wage growth and labor force participation in the U.S. economy.“Higher wage growth would mean higher revenue for Social Security and a higher labor force participation would mean more workers contributing to the program, which also means higher revenue,” said Ms. Chen, who is also a senior research economist at the center.The future of Social Security has emerged as a major issue in the midterm elections this year. Republicans have argued that their proposals are intended to protect the long-term viability of Social Security, but Democrats and President Biden have warned that if Republicans take control of Congress they will scale back the program and curb benefits for retirees.“MAGA Republicans in Congress continue to threaten Social Security and Medicare — proposing to put them on the chopping block every five years, threatening benefits, and to change eligibility,” Karine Jean-Pierre, White House press secretary, said in a statement on Wednesday. “If Republicans in Congress have their way, seniors will pay more for prescription drugs and their Social Security benefits will never be secure.” More

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    Social Security is projected to be insolvent a year earlier than previously forecast.

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    The financial outlook for Social Security is eroding more quickly than previously expected, as the coronavirus pandemic has drained government revenues and put additional strain on one of the nation’s most important social safety net programs. The overall finances for Medicare, however, are expected to hold steady, though the health program is still forecast to face financial pressure in the coming years.Annual government reports released on Tuesday on the solvency of the programs underscored the questions about their long-term viability at a time when a wave of baby boomers are retiring and the economy faces ongoing uncertainty as variants of the coronavirus surge. The United States economy already faces soaring federal debt levels in the coming decades, but both Democrats and Republicans have been wary of making significant structural reforms to the popular programs.“Having strong Social Security and Medicare programs is essential in order to ensure a secure retirement for all Americans, especially for our most vulnerable populations,” Treasury Secretary Janet L. Yellen said in a statement. “The Biden-Harris administration is committed to safeguarding these programs and ensuring they continue to deliver economic security and health care to older Americans.”Senior administration officials said that the long-term effects of the pandemic on the programs are unclear. The actuaries were forced to make assumptions about how long Covid would continue to cause unusual patterns of hospitalizations and deaths and whether it would contribute to long-term disabilities among survivors.The Social Security Old-Age and Survivors Insurance Trust Fund will now be depleted in 2033, a year earlier than previously projected, according to the report. At that time, the trust fund will run out of reserves and the program will be insolvent, with new tax revenues failing to cover scheduled payments. The report estimated that 76 percent of scheduled benefits will be able to be paid out unless Congress changes the rules to allow full payouts..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}The Disability Insurance Trust Fund is now expected to be depleted by 2057, which is eight years earlier than previously thought, at which time 91 percent of benefits will be paid.Medicare’s finances are effectively holding steady. While tax revenue for the Medicare program did decline as a result of the Covid-related recession, Medicare also ended up spending less money than usual last year, as people avoided elective care.Medicare’s hospital trust fund is projected to be unable to pay all of its bills beginning in 2026. This estimate is similar to those from Medicare’s trustees in recent years. Fixing that gap now could be achieved by increasing the Medicare payroll tax rate from 2.9 percent to 3.67 percent or by reducing Medicare spending by 16 percent each year, the report notes.But the report highlighted that the official estimate may be unrealistically optimistic. If certain policies set to expire in the next 10 years are extended, or if other expected policy changes occur, the projections would look substantially more worrying.Long term, the actuaries said they did not think Covid-19 itself would have substantial influence on Medicare spending on hospital care. On the one hand, the death of many vulnerable, older Americans from the virus may reduce future spending they would otherwise have received. On the other, the actuaries expect that some people may have additional health care needs from the syndrome known as long Covid..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}The actuaries declined to make any estimates on the effect of Aduhelm, a very expensive Alzheimer’s treatment that was recently approved by the Food and Drug Administration. The report said that officials were waiting for Medicare to issue guidance on how the drug will be covered before making any calculations. The drug could represent tens of billions of dollars in spending each year.Democrats in Congress are considering a host of changes to the Medicare program, such as adding new benefits, including coverage for dental, hearing and vision care. While these changes are expected to influence Medicare’s overall finances, none of them are likely to have major effects on the trust fund, which covers only hospital care.“Medicare trust fund solvency is an incredibly important, longstanding issue, and we are committed to working with Congress to continue building a vibrant, equitable, and sustainable Medicare program,” said Chiquita Brooks-LaSure, the administrator for the Centers for Medicare and Medicaid Services. More

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    Biden Takes On Sagging Safety Net With Plan to Fix Long-Term Care

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    The proposal to spend $400 billion over eight years faces political challenges and a funding system not designed for the burden it has come to bear.President Biden’s $400 billion proposal to improve long-term care for older adults and those with disabilities was received as either a long overdue expansion of the social safety net or an example of misguided government overreach.Republicans ridiculed including elder care in a program dedicated to infrastructure. Others derided it as a gift to the Service Employees International Union, which wants to organize care workers. It was also faulted for omitting child care.For Ai-jen Poo, co-director of Caring Across Generations, a coalition of advocacy groups working to strengthen the long-term care system, it was an answer to years of hard work.“Even though I have been fighting for this for years,” she said, “if you would have told me 10 years ago that the president of the United States would make a speech committing $400 billion to increase access to these services and strengthen this work force, I wouldn’t have believed it would happen.”What the debate over the president’s proposal has missed is that despite the big number, its ambitions remain singularly narrow when compared with the vast and growing demands imposed by an aging population.Mr. Biden’s proposal, part of his $2 trillion American Jobs Plan, is aimed only at bolstering Medicaid, which pays for somewhat over half the bill for long-term care in the country. And it is targeted only at home care and at community-based care in places like adult day care centers — not at nursing homes, which take just over 40 percent of Medicaid’s care budget.Still, the money would be consumed very fast.Consider a key goal: increasing the wages of care workers. In 2019, the typical wage of the 3.5 million home health aides and personal care aides was $12.15 an hour. They make less than janitors and telemarketers, less than workers in food processing plants or on farms. Many — typically women of color, often immigrants — live in poverty.The aides are employed by care agencies, which bill Medicaid for their hours at work in beneficiaries’ homes. The agencies consistently report labor shortages, which is perhaps unsurprising given the low pay.Raising wages may be essential to meet the booming demand. The Labor Department estimates that these occupations will require 1.6 million additional workers over 10 years.It won’t be cheap, though. Bringing aides’ hourly pay to $20 — still short of the country’s median wage — would more than consume the eight-year outlay of $400 billion. That would leave little money for other priorities, like addressing the demand for care — 820,000 people were on states’ waiting lists in 2018, with an average wait of more than three years — or providing more comprehensive services.The battle over resources is likely to strain the coalition of unions and groups that promote the interests of older and disabled Americans, which have been pushing together for Mr. Biden’s plan. And that’s even before nursing homes complain about being left out.The president “must figure out the right balance between reducing the waiting list and increasing wages,” said Paul Osterman, a professor at the Massachusetts Institute of Technology’s Sloan School of Management who has written about the nation’s care structures. “There’s tension there.”Elder care has long been at the center of political battles over social insurance. President Lyndon B. Johnson considered providing the benefit as part of the creation of Medicare in the 1960s, said Howard Gleckman, an expert on long-term care at the Urban Institute. But the chairman of the House Ways and Means Committee, Wilbur Mills, warned how expensive that approach would become when baby boomers started retiring. Better, he argued, to make it part of Medicaid and let the states bear a large chunk of the burden.This compromise produced a patchwork of services that has left millions of seniors and their families in the lurch while still consuming roughly a third of Medicaid spending — about $197 billion in 2018, according to the Kaiser Family Foundation. By Kaiser’s calculations, Medicaid pays for roughly half of long-term care services; out-of-pocket payments and private insurance together pay a little over a quarter of the tab. (Other sources, like programs for veterans, cover the rest.)Unlike institutional care, which state Medicaid programs are required to cover, home and community-based care services are optional. That explains the waiting lists. It also means there is a wide divergence in the quality of services and the rules governing who gets them.Although the federal government pays at least half of states’ Medicaid budgets, states have great leeway in how to run the program. In Pennsylvania, Medicaid pays $50,300 a year per recipient of home or community-based care, on average. In New York, it pays $65,600. In contrast, Medicaid pays $15,500 per recipient in Mississippi, and $21,300 in Iowa.A home health aide accompanies a patient to a vaccine appointment. Elder care has long been at the center of political battles over social insurance.James Estrin/The New York TimesThis arrangement has also left the middle class in the lurch. The private insurance market is shrinking, unable to cope with the high cost of care toward the end of life: It is too expensive for most Americans, and it is too risky for most insurers.As a result, middle-class Americans who need long-term care either fall back on relatives — typically daughters, knocking millions of women out of the labor force — or deplete their resources until they qualify for Medicaid.Whatever the limits of the Biden proposal, advocates for its main constituencies — those needing care, and those providing it — are solidly behind it. This would be, after all, the biggest expansion of long-term care support since the 1960s.“The two big issues, waiting lists and work force, are interrelated,” said Nicole Jorwic, senior director of public policy at the Arc, which promotes the interests of people with disabilities. “We are confident we can turn this in a way that we get over the conflicts that have stopped progress in past.”And yet the tussle over resources could reopen past conflicts. For instance, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to home care workers, which would cover them with minimum-wage and overtime rules, advocates for beneficiaries and their families objected because they feared that states with budget pressures would cut off services at 40 hours a week.“We have a long road ahead of passing this into law and to implementation,” Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, said of the Biden proposal. Along the way, she said, supporters must stick together.Given the magnitude of the need, some wonder whether there might be a better approach to shoring up long-term care than giving more money to Medicaid. The program is perennially challenged for funds, forced to compete with education and other priorities in state budgets. And Republicans have repeatedly tried to curtail its scope.“It’s hard to imagine Medicaid is the right funding vehicle,” said Robert Espinoza, vice president for policy at PHI, a nonprofit research group tracking the home care sector.Some experts have suggested, instead, the creation of a new line of social insurance, perhaps funded through payroll taxes as Social Security is, to provide a minimum level of service available to everyone.A couple of years ago, the Long-Term Care Financing Collaborative, a group formed to think through how to pay for long-term elder care, reported that half of adults would need “a high level of personal assistance” at some point, typically for two years, at an average cost of $140,000. Today, some six million people need these sorts of services, a number the group expects to swell to 16 million in less than 50 years.In 2019, the National Academy of Social Insurance published a report suggesting statewide insurance programs, paid for by a dedicated tax, to cover a bundle of services, from early child care to family leave and long-term care and support for older adults and the disabled.This could be structured in a variety of ways. One option for seniors, a catastrophic insurance plan that would cover expenses up to $110 a day (in 2014 dollars) after a waiting period determined by the beneficiary’s income, could be funded by raising the Medicare tax one percentage point.Mr. Biden’s plan doesn’t include much detail. Mr. Gleckman of the Urban Institute notes that it has grown vaguer since Mr. Biden proposed it on the campaign trail — perhaps because he realized the tensions it would raise. In any event, a deeper overhaul of the system may eventually be needed.“This is a significant, historic investment,” Mr. Espinoza said. “But when you take into account the magnitude of the crisis in front of us, it’s clear that this is only a first step.” More