A Parent has Alzheimer’s and a Gun. What Do You Do?

Senior man and his gun

Ever since Gregg Schnepp retired, his favorite activity has been gathering with his friends at the shooting range. According to his wife, Joanne, who is a strong believer in the right to bear arms, “shooting is about his only interest in life.” However, as a 70-year old with both mental and physical decline, it is becoming unsafe for Gregg to carry a gun.

Joanne knows she has to talk to her husband, but she is hesitant to take away the one thing that gives him so much enjoyment. Luckily, in the Schnepp’s situation, Gregg is fully aware and although it‘s tough, he’s willing to do what has to be done for his own safety and the safety of others. According to Gregg, who professed his love of shooting and “breaking clays,” it (giving up the gun) will “be a tough thing to do. It’s something I wouldn’t want to hear or want to tell anybody, but if it’s necessary, it’s necessary.  ”Unfortunately, most people faced with the same situation aren’t as willing and cooperative as Gregg, which can make for a tough conversation.

The Prevalence of this Situation

Currently, around 40% of the country’s older population has a firearm in the home, according to the Pew Research Center, and about 11% of people 65 and older have Alzheimer’s. People with Alzheimer’s can become aggressive and hallucinate, sometimes lose peripheral vision, fail to recognize loved ones, and forget the purpose of an object. Therefore, a person who has Alzheimer’s or another form of dementia with a gun can make for dangerous, and sometimes deadly, consequences.

For instance, last month, Rolfe Pilati, 87, killed his wife, before shooting himself at their Virginia home. A son told investigators that Mr. Pilati had dementia. In September, a Minnesota man with Alzheimer’s, Kenneth Bowser, 90, fatally shot his son, telling investigators that he feared the son would kill him. In other recent cases, people with dementia have killed or injured friends and relatives in Oregon, Missouri, Texas, Oklahoma and Tennessee.

So, while homicides committed by people with Alzheimer’s or other types of dementia are not everyday occurrences, they can very well happen when loved ones suffering from the disease became disoriented, pull guns from hiding places, and then struggle to explain their actions. Therefore, for the safety of everyone, if your loved one has a gun and shouldn’t have one anymore due to mental or physical decline, it’s important to take action.

Families are Reluctant to Remove Guns after a Diagnosis

There are a few studies out there that examine gun ownership among people with dementia and other cognitive disorders. Unfortunately, in most cases, they suggest that families are not removing guns after a diagnosis. In one assessment, which examined 106 patients at a South Carolina clinic, 60% of them still had a firearm at home. In another, involving 495 people at a Cleveland clinic, 18% did.
Why is this happening? It could be in large part because many relatives do not know how to approach the subject. Also, while doctors are legally permitted to give advice about gun storage, they often do not, according to a paper published in May in Annals of Internal Medicine. “Some physicians believe it is against the law to discuss firearms,” the authors wrote. Others are unfamiliar with “what to say during firearm safety counseling and how to say it.”

Suggestions from the Alzheimer’s Association
The Alzheimer’s Association offers guidance on how to minimize risks associated with firearms in homes where a loved one has dementia, as follows:

Have you struggled to discuss firearms with an aging relative? As you can see, these conversations can be challenging, but are very important. Remember, law enforcement may be able to assist, and a doctor may provide advice. The Alzheimer’s Association also has counselors available 24/7 at 1-800-272-3900.

Medicaid Planning for Alzheimer’s and Other Types of Dementia

Do you have a loved one with Alzheimer’s or another form of dementia? Alzheimer’s is the biggest health and social care challenge of our generation, and a diagnosis of the disease is life-changing.  When it comes to planning for long-term care needs, generally, the earlier someone with dementia plans, the better.  But it is never too late to begin the process of Long-term Care Planning, also called Medicaid Planning, Lifecare Planning, and Medicaid Asset Protection Planning.

Medicaid planning can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if your loved one is already in a nursing home or receiving other long-term care.

Medicaid Planning

Persons with dementia and their families face special legal and financial needs. At The Law Firm of Evan H. Farr, P.C., we are dedicated to easing the financial and emotional burden on those suffering from dementia and their loved ones.  We help protect the family’s hard-earned assets while maintaining your loved one’s comfort, dignity, and quality of life by ensuring eligibility for critical government benefits such as Medicaid and Veterans Aid and Attendance. Please call us as soon as possible to make an appointment for a no-cost consultation:

Fairfax Alzheimer’s Planning: 703-691-1888
Fredericksburg Alzheimer’s Planning: 540-479-1435
Rockville Alzheimer’s Planning: 301-519-8041
DC Alzheimer’s Planning: 202-587-2797

P.S. If you or a loved one own firearms, keep in mind that certain items, including guns, cannot simply be left to others in the same way that you would leave other property. They may be subject to strict regulations, or you may have specific instructions that may not be accounted for in your Wills or Trusts. Luckily, there are gun trusts and other strategies available for these thingsRead more here.

Critter Corner: Should My Uncle With Dementia Still Be Driving?

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Dear Commander Bun Bun,

My dad broke the news to me that his brother has dementia. I have always been close with my uncle, so I was quite upset to hear about it. He told me that he will be driving to our house next weekend to visit. Driving? What if he loses his way, or becomes disoriented? Is it safe for someone with dementia to still be on the road?

Dee Mencha-Driver

—–

Dear Dee,

I am sorry to hear about your uncle’s diagnosis. In answering your question, I just stumbled upon a recent study on the subject of driving with dementia, that was published in the Journal of the American Geriatrics Society. Hopefully, the findings can shed some light on your situation!

Researchers conducting the study analyzed data from 28 studies examining cognitive tests and driving performance among people with dementia. Half of the studies used on-road tests to determine driving ability. Most of the rest relied on reports from caregivers.

The cognitive tests tended to focus on attention and concentration, ability to see objects, memory, language and general mental status. Some tests also looked at executive functioning, a measure of reasoning and problem-solving.

People who performed badly on tests of mental status, executive functioning and attention and concentration also did poorly on driving tests just over half of the time. The other cognitive skills were linked to safe driving less than half of the time, with memory and language proving to be least relevant to driving skills. “As it stands, apart from on-road tests, which can be quite expensive for the client, there is no consensus on an objective assessment that can be used as an alternative,” lead author Joanne Bennett, a doctoral candidate at Macquarie University in Sydney, Australia, said.

According to Bennett, “Simply having a diagnosis of dementia does not mean that the individual should have to give up their license, however due to the progressive nature of the disease, they will eventually need to stop driving.”

There are red flags that show when adults are unsafe to drive, as follows:

• Eye impairments are common in dementia, and can result in people being unable to read signs or see pedestrians.

• Lack of orientation (e.g. driving up the wrong side of the road or inability to maintain lane position) are also key indicators that driving has deteriorated to a point when it is unsafe.

• Forgetting how to locate familiar places, failing to observe traffic signs, making slow or poor decisions in traffic and driving at an inappropriate speed may also be important warning signs.

People with dementia have up to eight times the odds of being in a car accident compared with other seniors. This is one reason that elders with a diagnosis of dementia who are still driving should consider protecting their assets from lawsuits by putting them into our firm’s Living Trust Plus(TM) asset protection trust, which protects the client’s assets from probate PLUS lawsuit PLUS nursing home expenses.

But in the early stages of the condition, people with a dementia diagnosis can often drive safely. As a result, their driving will need to be constantly monitored and reviewed by both loved ones and health professionals.

Maybe you can suggest that you go visit your uncle instead of him driving to visit you? Also, you may want to suggest to loved ones that they should talk to his physician about his symptoms, to find out whether he should still be on the road.

Hop this helps!

Commander Bun Bun

Discriminated Against for Having the “Wrong Type of Illness”

Doctor and Patient

Long-term care services, whether provided in institutions or in the community, are essential to the well-being of many elderly and non-elderly people with limitations in performing daily activities. In the United States, in particular, long-term care is disastrously expensive. And, when it comes to benefits, some people are discriminated against simply because they have the “wrong type of illness.”

In part 1 of this special report, we looked at long-term care in the U.S. and other countries. We explored the median net worth of the citizens of eight countries, and how much long-term care that would cover if someone were to pay for it out-of-pocket. We examined how long-term care is paid for and similar challenges that are faced by most countries, when it comes to providing citizens with assistance to pay for it. We also looked at how the Medicaid program is our country’s largest health and long-term care insurer, covering one in six Americans, including two-thirds of nursing home residents and one in five persons under 65 with chronic disabilities, and the complexity involved in applying for Medicaid benefits.

In part 2, we will now cover how America and a few other countries effectively discriminate against people with the wrong type of illness.

Medicare in the United States

In the U.S., Medicare is the public health insurance system for seniors over 65 and disabled adults, and it only pays for medical care delivered by doctors and hospitals and, in certain cases, short-term rehabilitation which might take place in a nursing home. For decades, Medicare has effectively discriminated against older adults with psychological conditions, such as depression and anxiety, because these conditions have received unequal treatment under Medicare. Medicare has paid a smaller share of the bill for therapy from psychiatrists, psychologists or clinical social workers than it did for medical services and has imposed strict lifetime limits on psychiatric hospital stays.

In 2008, Medicare covered 50% of the cost of psychological treatment, while in 2013, it covered 65%. In 2014, Medicare began paying 80% of its approved amount for certain outpatient mental health services. Payment kicks in once someone exhausts an annual deductible of $147 per year.

Medicare will pay for the services of medical doctors (such as psychiatrists) who do not take Medicare (non-participating providers), but these doctors can charge you up to 15% above Medicare’s approved amount. Some states have stricter limits on how much doctors can charge. Find out more about Medicare’s Mental Health benefits on the Medicare.gov website.

Since its inception, Medicare has also discriminated against many older adults in that Medicare does not pay for the type of care that is needed by people suffering with certain diseases; specifically, Medicare (and, for that matter, private health insurance) does not pay for the care that is needed by people suffering from chronic illnesses such as Alzheimer’s disease or other types of dementia, or other brain diseases that cause a diminished ability to function without assistance from others. When a family has a loved one with one of these “wrong types of diseases,” that family must become officially “impoverished” under federal and state Medicaid rules in order to gain access to the basic care that is needed as a direct result of the individual’s illness.

The chart below shows dementia care and coverage in other countries that don’t seem to discriminate based on type of illness (from Alzheimer-europe.org and other sources):

Country

Dementia Care and Coverage
Italy
Care in Italy for those with dementia can consist of home care (community care); integrated home care services(a combination of integrated and coordinated health and social activities which seek to keep an elderly person at home as long as possible); day centers (semi-residential structures); or nursing homes.

Italian citizens must purchase a ticket in order to have access to services within the National Health Service. People who are over 65 years old and those suffering from an officially recognized chronic and disabling disease do not have to pay.

Japan
Japan’s dementia strategy, which was started in 2012 and updated in 2014, involves the health ministry and 11 other ministries and agencies. The strategy funds research, prioritizes early detection, trains front-line health workers, provides support for caregivers, and creates “dementia-friendly” communities.

The most important change Japan has made to improve dementia care, however, came in 2000, when the government introduced mandatory long-term care insurance.

A primary goal was to help seniors live more independently and reduce the burden on relatives — particularly women, who are often the caregivers. So unlike long-term care insurance in countries like Germany, which offer cash, Japan’s system offers services — and consumer choice.

The scheme works like this: at age 40, every Japanese resident pays a monthly insurance premium. When they turn 65 — or get sick with an aging-related disease — they become eligible for a range of services: everything from dementia daycare to lunch delivery and bathing assistance. Depending on income, users also pay a 10% or 20% service fee — a measure that discourages overuse.

United Kingdom (Scotland, in particular)
The Community Care and Health (Scotland) Act 2002 ensured that people with conditions, such as dementia, were granted:
•free nursing and personal care for people over the age of 65;
•increased access to direct payments for home care services;
•the right to be assessed by informal caregivers, and that they are made aware of that right;
•that the contribution and views of caregivers, as well as the person they care for, are taken into account by local authorities before deciding which services to provide.

This is not dependent on financial status, capital assets, marital status,or the amount of care provided by an unpaid caregiver.

It is a tremendous shame that our country’s social policies essentially discriminate against those who get the “wrong types” of illnesses, such as Alzheimer’s and other forms of dementia. It is extremely unfair for Medicare to provide full coverage for most diseases but force those with the “wrong type” of disease to go broke financially in order to gain access to the basic care needed – care which our society calls “long-term care” instead of “health care.”  It should be no surprise to anyone that most knowledgeable families seek legal methods to preserve the efforts of a lifetime in order to protect themselves from our country’s unfair social policy.

If you have a loved one who is nearing the need for long-term care or already receiving long-term care, please contact us as soon as to schedule your appointment for our no-cost initial consultation:

Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301-519-8041
DC Elder Law: 202-587-2797

Can a Non-Citizen of the U.S. Become a Guardian or Trustee?

By Fredrick P. Niemann, Esq. of Hanlon Niemann Wright, a Freehold, NJ Guardianship Attorney and NJ Trust Attorney

As to the question of whether a non-U.S. citizen can serve as a guardian, Rule 4:81-4 of the New Jersey Supreme Court today merely states that “as between persons equally entitled, the Surrogate’s Court in granting letters shall give preference to a resident of this State, unless the best interests of the minor will not thereby be served.”  However, the case of Caruso v. Caruso, 106 N.J.Eq. 130, 148 (E. A.1930) stated that “[i]If the guardian is without the jurisdiction, the appointing court would be… powerless to enforce its decree against him personally so as to render him amenable to an order to account, to contempt proceedings or to be dealt with summarily,” which rejected an application for an Italian citizen/resident to be a guardian for a child in New Jersey.  6 N.J. Prac., Wills And Administration § 734 (Rev.3d ed.).  This case is technically good law, though whether courts will apply it is still a question.  So based on the court rule alone, it is possible to be appointed, but if there was a challenge, the Caruso case could be cited to deny a person their application to be appointed as a guardian.

To the question of becoming a trustee, N.J.S.A. 3B:11-2 requires a letter of trusteeship to be issued by the Superior Court in order to be a testamentary trustee.  Rule 4:80-5 is the same as 4:81-4, merely giving preference to residents over nonresidents.  N.J.S.A. 46:3-18 allows “[a]ny alien who shall be domiciled and resident in the United States and licensed or permitted by the government of the United States to remain in and engage in business transactions in the United States, and who shall not be arrested or interned or his property taken by the United States” to have the same rights and privileges as native-born citizens, which includes being a trustee.  Unfortunately, the statute only allows those permitted to be in the country to have the same rights, so this would exclude an illegal alien.  It also excludes aliens from any country that we are at war with.  Caparell v. Goodbody, 132 N.J. Eq. 559, 29 A.2d 563 (Ch.1942).

In one case of ours a client of ours is an illegal resident of New Jersey. Tehnically, court rules could allow her to be appointed as a guardian or trustee, but there seems to be a low likelihood this will happen.  If she were here legally and formally a resident of the state, because she is subject to the jurisdiction of the United States and New Jersey, a court would be more willing to grant her the ability to be a trustee and/or guardian.  Because she isn’t, she is “without the jurisdiction” of the State, and a court is unlikely to grant her this ability.

To discuss your NJ guardianship or trust related matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com.  Please ask us about our video conferencing consultations if you are unable to come to our office.

 

Muhammad Ali’s Vision Was Realized

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For more than 20 years, Rachel’s father has had Parkinson’s Disease. When she first moved to the DC area in 1998, her father walked with a cane, and although his hands shook a little, he was still able to dance with her at her wedding. Rachel knew that this was only the beginning, and as she researched the debilitating disease, she realized the worst was yet to come.

As Rachel’s father’s mobility got worse, he became confined to a wheelchair. He underwent the deep brain stimulation pacemaker surgery, and in combination with his meds, it helped a lot. He no longer shook like he used to, but his speech was still severely slurred, and he had trouble swallowing. Through it all, he kept a positive attitude and his love for his children and grandchildren is what keeps him going. For motivation, he also keeps his prized possession on display. It is an autographed pair of boxing gloves from Muhammad Ali, his hero and a fighter who also battled with Parkinson’s.

Rachel and her father’s hearts sunk when they heard the news earlier this month that Muhammad Ali had died after a 30+ year struggle with Parkinson’s. Ali was given the diagnosis in 1984 when he was just 42. The world witnessed his gradual decline over the decades as tremors and stiffness set in, replacing his athletic stride with a shuffle, silencing his exuberant voice, and freezing his face, so it appeared expressionless.

Muhammad Ali’s Fight Against Parkinson’s

Similar to Michael J. Fox, Muhammad Ali was on a mission to fight Parkinson’s by raising money for research and spreading awareness. His determination led to the creation of the Muhammad Ali Parkinson Center at Barrow Neurological Institute in Phoenix. “Muhammad felt he had a mission,” said Dr. Abraham Lieberman, Ali’s personal physician and chair of Movement Disorders Research at Barrow. “Muhammad rose from a young boy in Louisville to the heavyweight champion of the world. This center was part of it. This was his mission.”

When Ali was first diagnosed with Parkinson’s in the 1980’s, he resisted numerous attempts to lend his name to campaigns to battle the disease. But that changed after Ali met Dr. Lieberman, who wrote a poem that persuaded the Champ to join with Lieberman and Phoenix philanthropist, Jimmy Walker, to establish the Muhammad Ali Parkinson Center in 1997.

“He took terrific pride in the Center,” Dr. Lieberman said. “His eyes would light up when he came here.”

Ali’s Vision Was Realized

A press conference last week was held in an exercise room at the center used every day by hundreds of patients stricken with the same disease as Ali. They receive the same care that “The Greatest” did.  “The care has been afforded not just to the Greatest, but the least,” said Brian Mortenson, president and CEO of St. Joseph’s Foundation and Barrow Neurological Foundation. “That was part of the vision of the Alis.”

“One of the beautiful things about Ali was that it made no difference what status in life you had,” Dr. Spetzler said. “He may no longer be physically with us, but his indomitable spirit of confronting bigotry and fighting the ravages of the disease will prevail.”

“Muhammad stood up to this disease for 34 years,” said Dr. Lieberman, who last saw Ali on the day he died. “The last few years were really tough.”

Caring for Loved Ones with Parkinson’s: Tips from Lonnie Ali

In many ways, minus the Ali family’s fame and financial wherewithal, the Ali’s faced what millions of caregivers endure every day in America: the guilt and loneliness, joy and exasperation, frustration and anxiety, and the challenge of learning how to accept what Lonnie calls a “new normal.”

Lonnie Ali used several coping mechanisms in her role as caregiver, as follows:

  • Care for yourself. One piece of advice she offers others filling that role: Learn to care for the caregiver — yourself. Three times a week, Lonnie attended Pilates classes. She made it a point never to miss her doctor’s appointments because she knows if something were to happen to her, it would’ve been bad for him.
  • Ask for assistance. She also recommends knowing when to ask for help. As her husband’s illness intensified, Lonnie realized she needed more aid. “As long as Muhammad was fairly independent, it wasn’t a big deal,” she said. “But when he required more attention, I would be stupid not to think I didn’t need some assistance. Frankly, I could not do this if my sister did not live with us.”
  • Research and education are paramount, as is being well-organized. “When you get up, you have to start planning their day,” she says. “What am I going to make for breakfast? What is he going to wear? What doctor appointments does he have? What are we going to do today?” To keep track of her husband’s cocktail of medications, Lonnie kept an app on her smartphone and regularly monitored his activities, appointments and any physical changes. “We had a daily sheet, because you forget things,” she says. “What time did he get up? How did he sleep? When did he last go to the bathroom?” Keeping up-to-date on medical needs is critical, too.

The beauty of Muhammad was that “he made this illness, as horrible as it was, as much as it took away from him, serve him in some way,” Lonnie says. “If there was ever anyone who always landed on his feet, and come out smelling like a rose, it was Muhammad. It was his remarkable attitude toward life. He never has let anything stand in his way.”

Planning for Parkinson’s Disease

A diagnosis of Parkinson’s disease means adjusting to decreased mobility and other burdens of the disease. To alleviate problems later, it is also important to plan now for the worst to ensure your wishes are carried out and your family protected.

The first and most essential legal document is a Power of Attorney.  As you can see from the Ali’s situation, Parkinson’s disease can be very disruptive, and there may come a time with the illness that you would prefer others make choices for you. Many married couples assume that they are allowed to make legally binding decisions on behalf of their spouses. Unfortunately, this is not the case unless you sign a Power of Attorney.

Part of planning is to ensure that you or your loved one gets the best possible care and maintains the highest possible quality of life, whether at home, in an assisted living facility, or in a nursing home. Life Care Planning and Medicaid Asset Protection can be started any time after a person enters the “long-term care continuum,” meaning that a person is starting to need assistance with Activities of Daily Living (eating, dressing, bathing, toileting, transferring, and walking) or Instrumental Activities of Daily Living (such as cooking, cleaning, caring for pets, paying bills and managing finances). This type of planning can be started while you are still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if you are already in a nursing home or receiving other long-term care assistance.  In fact, the majority of our Life Care Planning and Medicaid Asset Protection clients come to us when nursing home care is already in place or is imminent.  Read more about Life Care Planning and Medicaid Asset Protection.

At The Law Firm of Evan H. Farr, P.C., we are dedicated to easing the financial and emotional burden on those suffering from Parkinson’s Disease and their loved ones.  If you or a loved one are suffering from Parkinson’s disease, we can help you prepare for your future financial and long-term care needs.  We help protect your hard-earned assets while maintaining your comfort, dignity, and quality of life by ensuring your eligibility for critical government benefits. Please call us for a no-cost initial consultation:

Fairfax Parkinson’s Planning: 703-691-1888
Fredericksburg Parkinson’s Planning: 540-479-1435
Rockville Parkinson’s Planning: 301-519-8041
DC Parkinson’s Planning: 202-587-2797

Critter Corner: Should I Get Long-Term Care Insurance?

Dear Baxter,

My neighbor is an insurance agent who keeps bothering me about long-term care insurance. I try to avoid her, but lately it hasn’t been working. To help me make an educated decision, can you provide some reasons I can add to my pros and cons list?

Thanks!

Lee Vamealone

—-

Dear Lee,

With long-term care costs generally rising faster than inflation, many people, such as you, are looking into whether long-term care insurance is right for them. While there’s definitely a benefit for some people to purchasing long-term care insurance, there are certain issues to consider before you buy, including some very important facts about how long-term care insurance interacts with Medicaid.

On a positive note, when it comes to LTC insurance, there may be some tax deductibility for the insurance premiums you pay as an individual (if you itemize deductions) to the extent that the premiums paid exceed 7.5% of adjusted gross income. Many states also offer tax incentives (credits/deductions) to encourage the purchase of LTC insurance.

The biggest disadvantage to long-term care insurance is that your premiums might increase drastically as you get older, despite the fact that the company told you that you were “locking in” your premium at the time you purchased the policy. This is because the insurance company can go back to the State Bureau of Insurance and request premium increases across the board, which all long-term care insurance companies have done over the years because of greater-than expected claims. For many people who purchased long-term care insurance in the past, they found that premiums became so high that they ended up having to cancel their policies in later years, losing all the money already put into the policy. Or, they were forced to accept drastically reduced benefits in order to keep their premium from increasing.

Also, in most cases, when long-term care benefits are actually paid, they are usually far below the actual cost of care. For many of the longest-term residents, benefits were used up before the nursing facility stay ended. For more details, please read our blog post, Long-Term Care Insurance: Yes or No?

So, if you are considering long-term care insurance, I suggest that you first look at each policy very closely because each one is written differently. Also, look closely at the insurer’s claims payment history and whether they have been increasing premiums for existing policy holders. If you have done your research and decide that long-term care insurance might be right for you and your family, you should first meet with an experienced Elder Law Attorney such as me in order to understand all of your options, because there are dozens of long-term care asset protection strategies other than long-term care insurance. For example, the Living Trust Plus™ Medicaid Asset Protection Trust is just one of many long-term care asset protection strategies.

Hope this helps!

Baxter

Special Report: Long-Term Care Around the World

Part I: The Cost of Long-Term Care and How it’s Paid For

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Long-term care services, whether provided in institutions or in the community, are essential to the well-being of many elderly and non-elderly people with limitations in performing daily activities.

In the United States, long-term care is disastrously expensive. Medicare, the public health insurance system for seniors over 65 and disabled adults, only pays for medical care delivered by doctors and hospitals and, in certain cases, short-term rehabilitation which might take place in a nursing home. Medicare never pays one penny for long-term care. The Medicaid program is our country’s largest health and long-term care insurer, covering one in six Americans, including two-thirds of nursing home residents and one in five persons under 65 with chronic disabilities. Long Term Care Insurance is available, but only owned by approximately 10% of Americans due to certain issues, including rising costs, policies not being enough to cover care, and companies going out of business.

Is the U.S. approach like or unlike the systems put in place in other countries? What are other countries doing to provide — and pay for — long-term care for their aging populations? In Part 1 of this Special Report, we will look at long-term care in the U.S. and other countries. In Part 2, we will cover how America and a few other countries effectively discriminate against people with the wrong type of illness.

What Long Term Care Costs:

In a recent article, we looked at how much long-term care costs, using the latest Genworth Cost of Care Study. Nationally, in the U.S., the median cost of a semi-private nursing home room is up 2.27% to $6,844 per month. In the DC Metro area, the average cost is $10,114 per month.  That’s $121,363 per year on average! Unfortunately, according to the study’s findings, the cost of receiving care will continue to rise sharply year over year.  For the full report, see Genworth’s Website, and/or download Genworth’s Cost of Care App from iTunes.

To compare the cost of long-term care globally, let’s take a look at the median net worth of the citizens of eight countries (in U.S. dollars), how much long-term care that would cover if someone were to pay for it out-of-pocket, and how long-term care is paid for, as follows:

Country
Affordability of Care
How Long-Term Care is Paid For
United States
Median net worth: $44,911.
Months of nursing home care that the median net worth can cover: 3 to 4 (depending on location). Nationally, median annual private pay costs for nursing home services average 241% of an older person’s annual income. This ranges from 166% to 444% across states.
Long-term care services are financed primarily by public dollars, with the largest share financed through Medicaid, a federal/state health program available to individuals who qualify financially (generally meaning that they own almost no assets).  Long-term care services are also financed privately through out-of-pocket payments by individuals and their families, and through long-term care insurance.
Italy
Median net worth: $138,653. Months of nursing home care that the median net worth can cover: 68
Long-term care in Italy is delivered by both public and accredited private providers of health and personal social care. The health care services provided by the Italian National Health Service are free of charge, with national and local taxation as its main funding sources.
France
Median net worth: $141,850. Months of nursing home care that the median net worth can cover: 38
France provides universal tax-funded long-term care insurance, but benefits are closely tied to income. As a result, a very poor person might get the equivalent of $1,400-a-month to pay for care, while someone earning about $50,000-a-year might receive only a few hundred dollars. As a result, in France, 11% of those 65 and older have purchased private long-term care insurance to supplement their government benefit.
Canada
Median net worth: $90,252. Months of nursing home care that the median net worth can cover: 30
Due to universal health insurance, benefits to the impoverished elderly in Canada are considerably more generous than those offered by the United States.

Fees from nursing home patients, for example, generally represent about one-third of the actual cost in either private or government homes. The balance is paid by provincial governments and community service agencies.

In Canada, there are some financial tests for government aid, but families are not required to deplete their assets to qualify. Those who are better off may be required to pay more, but rich and poor live under the same roof, eat the same meals, and go to the same social functions.

Japan
Median net worth: $110,294. Months of nursing home care that the median net worth can cover: 15
In the face of massive pressure from women who were trying to hold down jobs while caring for their mothers and mothers-in-law, Japan created a national long-term care insurance program. Funded by both taxes and income-based premiums, Japanese insurance covers about 90% of the cost of care, though principally for those 65 and older.
Germany
Median net worth: $49,370. Months of nursing home care that the median net worth can cover: 13
Germany adopted a universal, national long-term care insurance system that aims to pay about half the cost of long-term care.
China
Median net worth: $8,023. Months of nursing home care that the median net worth can cover: less than 2
In China, there is no government provided long-term care. Essentially, all facilities for long term care are private pay. The cost (around $3,000 a month) is very high for the average worker, but within the reach of the middle and upper middle class.

With a greater number of adult women participating in the workforce, family support for older people is diminishing. Faced with this situation, cost-effective solutions for community and home-based care that enable older persons to stay at home for as long as possible are urgently needed in China.

The Chinese government is currently exploring the establishment of a government-led LTC insurance program.

United Kingdom
Median net worth: $111,524. Months of nursing home care that the median net worth can cover: 31
Unlike the rest of Europe, the U.K. has failed to reform its financing system in any significant way, and remains stuck in its failing welfare model, which is similar to the U.S. model.

While the elderly (and everyone else) get universal medical care through its National Health System, only the poor get government long-term care benefits. And, because this assistance varies dramatically from one local jurisdiction to another, the system is widely disparaged as the “postcode lottery.”

The U.K. has struggled to fix their system for well over a decade. High-powered commissions have recommended major reforms, but little has been done.

Similarities Among Different Countries

In each country listed above, long-term care policy develops from a specific background of history, politics, resources, culture, community standards, emphasis on personal and family responsibility, and the role of government in social welfare. As times change, and populations grow, most of these countries will likely face similar challenges when it comes to providing citizens with assistance to pay for long-term care in the future.

Paying for Long-Term Care in the United States

In the U.S., Medicaid eligibility rules are extremely complex and confusing, and impossible to understand without highly experienced legal assistance. At the Farr Law Firm, we help clients find, get, and pay for the best possible long-term care while preserving and protecting their assets, including their homes, from the forced liquidation that is typically required in connection with entry into a nursing home. When needed, we complete the complex documents required for entry into a nursing home and for Medicaid.

Medicaid Planning can be started while you are still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if you are already in a nursing home or receiving other long-term care assistance.  In fact, the majority of our Life Care Planning and Medicaid Asset Protection clients come to us when nursing home care is already in place or is imminent.

If you are still healthy and not yet on the “long-term care continuum,” then instead of Life Care Planning and Medicaid Asset Protection Planning you should consider our Living Trust Plus™ Asset Protection Trust, which is a simpler and less expensive method of asset protection for clients who will most likely not need any long-term care for at least five years. For most Americans, the Living Trust Plus™ is the preferable form of asset protection trust because, for purposes of Medicaid eligibility, this type of trust is the only type of self-settled asset protection trust that allows a settlor to retain an interest in the trust while also protecting the assets from being counted by state Medicaid agencies.

As always, if you have not done Long-Term Care Planning, Estate Planning or Incapacity Planning (or had your Planning documents reviewed in the past several years), please call us to make an appointment for a no-cost initial consultation:

Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301-519-8041
DC Elder Law: 202-587-2797

Home Health Aides Are Quitting Their Jobs

Quit my job decision

The in-home care industry has been anticipated to be the largest job creator between 2012 and 2022, with an estimated 1 million new caregivers required during that time. Now some are questioning whether there will be enough people willing to fill those positions and that need.

Elizabeth drives 100 miles a day, to several different locations all over town. She cares for Mary, Donny, and Steve, and then typically has a meeting at her workplace. She doesn’t get a gas allowance or mileage, or benefits (she works hourly). She loves her clients, but is so tired when she gets home that she cannot spend enough time with her boyfriend, or do the things she loves, such as reading and cooking nice dinners. She is 29 years old and she is drained. She is a home health aide, and she is beginning to think she should quit.

Mark, on the other hand, is also stressed. He doesn’t travel quite as much as Elizabeth, because his company doesn’t give him enough hours. He gets no health insurance, and can hardly afford to support his family. His back hurts from lifting patients. He is considering leaving the profession altogether and going back to school.

Elizabeth and Mark are not alone. Based on a national survey of home health and hospice aides published in March 2016 by the Journal of the Gerentological Society of America, having too few work hours or injuries, low pay and lack of benefits, and experiencing burnout, were all associated with a desire to leave the profession.

To assess the current situation regarding home health care workers, surveyors used data from the National Home and Hospice Care Survey in 2007, a sample of more than 1,000 Medicare and/or Medicaid certified home health and hospice agencies and more than 3,300 aides working for those agencies. In phone surveys, the participants answered questions on job satisfaction, stressors, and demands, intent to leave the job, and compensation, among other factors. These are some of the findings:

  • About one quarter of workers said they were very likely to leave their job in the next year or were currently looking for a different job.
  • More than 80% said they were assigned to the same patients each week and
  • 13% said they had suffered an injury on the job in the past year. Most injuries are back injuries and other strains that come from lifting.
  • In-home care providers working for for-profit agencies are twice as likely to leave their job as those working for non-profit organizations.
  • Preventing on-the-job injuries and providing enough work to those who want it are good first steps to retain valuable home health care aides.
  • Higher job satisfaction and feeling valued by the organization often meant less intent to leave the job, as did employer-provided health insurance, but hourly wages did not correlate with intent to leave.

According to study coauthor, Natasha S. Bryant of the LeadingAge Center for Applied Research in Washington, D.C., “It can be difficult to attract and retain high quality home health aides due to low wages, inadequate training, physical and demanding work, and schedules that are often part time and unpredictable.” She suggested that aides need education and ongoing support as well as advancement opportunities to help them grow professionally and earn better wages. She also recommended that families respect the boundaries and the scope of the aide’s responsibilities and learn how to communicate with workers and to treat them with respect and dignity.

Sandra Butler of the School of Social Work at the University of Maine, agrees with Bryant. She adds, “The work is not suited to everyone, but many who do it really love it, but find the conditions sometimes force them to leave the jobs they love.”

The Desire to Age-in-Place versus the Lack of Assistance

In the coming decades, increasing life expectancy, a declining birth rate, and the aging of the baby boom generation will dramatically increase the number and proportion of the U.S. population over the age of 65. This aging of the population presents a number of challenges and unanswered questions, including where people will live and how they will obtain the support and care they will need as they age, while retaining as much independence as possible.

Most older adults have a strong desire to live in their own homes and communities. In an AARP survey, nearly 90% of people over age 65 indicate they want to stay in their home as long as possible, and four of five in that age bracket believe their current home is where they will always live. Unfortunately, a shortage of home health aides, and other factors such as unaffordable and inaccessible housing, and a lack of access to needed services can thwart this desire.

What Are Some Other Options?

As you can see, as much as most of us would like to age in place, it isn’t always possible, and you should therefore plan for contingencies. Research shows that 70% of the population will need long-term care in the future. With an average cost of a nursing home in Metro DC is $10,000-$14,000 a month—an amount that can be devastating to most families—it is definitely prudent to plan ahead. The Living Trust PlusTM maintains much of the flexibility of a Revocable Living Trust, but protects your assets from the expenses and difficulties of probate PLUS the expenses of long-term care while you’re alive, PLUS lawsuits and a multitude of other financial risks during your lifetime. Read more on our website.

Life Care Planning and Medicaid Asset Protection is the process of protecting your assets from having to be spent down in connection with entry into a nursing home, while also helping ensure that you or your loved one get the best possible care and maintain the highest possible quality of life, whether at home, in an assisted living facility, or in a nursing home. Call one of our offices to make an appointment for a no-cost initial consultation:

Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301- 519-8041
DC Elder Law: 202-587-2797


 

Critter Corner: Keeping My Estate Planning Documents Current

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Special Alert to Existing Clients and Potential Clients

YOUR LIVING TRUST MAY HAVE OUT OF DATE PROVISIONS AND NEED TO BE REVISED AS SOON AS POSSIBLE.

Closeup of male hand signing a contract, employment papers, legal document or testament. Isolated over black background.A once-popular estate planning tool, called a “Credit Shelter Trust” or – also called a “Bypass Trust” or a “Family Trust” — may now cost families more than it saves. If your estate plan includes one, it could be doing more harm than good, and you need to consider updating your documents as soon as possible.

Attorneys for many years had a method to double the exemption to $1,200,000, saving a married couple up to $300,000 in Federal Estate Taxes, plus additional savings at the state level. The idea was that when the first spouse died, that spouse’s Will did NOT leave all the assets outright to the surviving spouse. Instead, part of the estate was placed into a Bypass Trust — hey trust in which the surviving spouse maintained an interest, but it was a limited interest. The transfer to the Bypass Trust was not a taxable event because of the unlimited marital deduction between spouses, which allows an unlimited amount to be transferred to a spouse, or to a trust for the benefit of the spouse, so long as that spouse is an American citizen, without incurring any estate tax. On the death of the second spouse, the funds in the Bypass Trust could then pass free of estate taxes so long as that amount was less than $600,000, because the surviving spouse was entitled to an additional $600,000 exemption upon death.

Even though the tax motive for the Credit Shelter Trust is gone, for many clients with all their documents, the Trust still exists as an outdated ticking time bomb ready to go off upon the death of the first spouse. For most married couples, it is unnecessary, burdensome, and expensive. This is why many couples need to modify their estate planning documents to eliminate the Credit Shelter Trust, because it won’t go away on its own. If you leave it in place, instead of saving money, it will add time, expense, and burden to the administration of your estates.

If any of these changes have happened to you or if you haven’t updated your estate plan in the last few years, the time is now.

Even if no changes are necessary, you should ideally annually sign updated Powers of Attorney. Some financial institutions won’t accept a Power of Attorney more than a year old. Similarly, the older an Advance Medical Directive is, the less likely it is that it will be honored by a doctor or hospital.

If you’re not already a member, ask about The Farr Law Firm’s Lifetime Protection Program, which ensures that your documents are properly reviewed and updated as needed, so that they will have the proper effect under the law. If members of your family have not done Incapacity Planning or Estate Planning, or if a loved one is beginning to need more care than you can handle, please contact us as soon as possible to make an appointment for a no-cost initial consultation:

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