Nothing like home

More than 80 percent of Americans say they want to die at home, according to the AARP. Yet since the advent of Medicaid, government funding for end-of-life care has traditionally favored nursing homes over in-home services.

Last year as a nation, the government spent $100 billion on nursing-home care — and $25 billion on home care.

Each state decides how it will administer its Medicaid program, and in recent years many have opted to shift priorities. Oregon, for instance, has rebalanced its system so that 70 percent of its Medicaid dollars are now spent on home care, versus 30 percent on nursing-home care.

In 2006, the New Jersey legislature expanded Medicaid benefits to include home care as well as assisted living and adult day-care options — an overhaul that proponents estimated would save the state $500 million.

In Virginia, Medicaid pays for limited home care — typically four to six hours a day — usually for the very poor. Funding guidelines are complex, but a typical home-care recipient on Medicaid has an income in the range of $700 to $800 a month, according to administrators of the Roanoke Department of Social Services.

Cheryl Jones bandages the legs of client Margaret Bass, 77, to help reduce swelling at the beginning of the day.

While Medicaid was conceived as a benefit for poor seniors, no one imagined that two out of every three nursing home residents would be on the program, as they are today.

Many recipients are not the extremely poor seniors the program was intended for, but rather middle- and upper-middle income seniors who have “spent down” their assets to qualify for the program. While many of them genuinely deplete their own savings to pay medical and nursing-home bills before they go on Medicaid, some transfer assets to their children well in advance of their need for nursing care.

The practice is legal but fraught with restrictions and complexities — and potential for abuse. It also makes it so there’s less cash in the coffers, money that could be funding home care for people of genuinely modest means.

“When you factor in the coming age wave and the fact that the current Medicaid model just isn’t going to work, what you’re looking at is a train wreck,” said Hobart Harvey, vice president of the Virginia Health Care Association, a nursing-home trade group.