Could You Afford Home Health Care? New Study Says Maybe Not

July 31, 2019

courtesy of Elder Law Answers:

By Dennis Thompson
HealthDay Reporter

THURSDAY, June 6, 2019 (HealthDay News) — The seniors most likely to need paid home care to maintain independent living are the least likely to be able to afford it long-term, a new study reports.

Only two out of five older adults with significant disabilities have the assets on hand to pay for at least a couple of years of extensive in-home care, researchers found.

Without some help, those elderly are much more likely to wind up in a nursing home, said lead researcher Richard Johnson. He is a senior fellow with the Urban Institute’s Income and Benefits Policy Center, in Washington, D.C.

“We have this perception that the risk of becoming frail is evenly distributed across the population, but it’s really not,” Johnson said. “It is more concentrated among people with less education, lower lifetime earnings and less wealth.”

Aging folks increasingly want to stay out of nursing homes as their health declines, maintaining their independence by living in their own houses, Johnson said.

But there hasn’t been a large increase in the number who are shelling out for paid home care, national statistics show.

To see why that might be, Johnson and his colleagues turned to data gathered by the University of Michigan’s Institute for Social Research.

The researchers broke paid home care down into three scenarios: limited care of 25 hours each month costing $475; moderate care of 90 hours a month costing $1,170; and extensive care of 250 hours per month costing $4,750 per month.

Initial results looked promising.

The investigators found that 74% of all seniors aged 65 and older could afford at least two years of moderate home care if they cashed in all their assets, and 58% could afford two years of extensive home care.

Then the researchers turned their attention to people most likely to need home care — those suffering from severe dementia or who require help with two or more activities of daily living. These activities can include eating, bathing, dressing, using the toilet, getting out of a chair or walking across a room, Johnson said.

Only 57% of those most frail seniors could afford two years of moderate home care, and only 40% could afford extensive home care for two years, the findings showed.

For these people, the burden will fall hardest on their family at first, Johnson said.

“Most people who become frail at older ages rely on unpaid family caregivers,” he said. “Those are the people who provide the vast majority of care.”

Paid home care provides relief for family caregivers, giving them a “respite from the grind of constantly being on call to help a frail loved one,” Johnson said.

Without that respite, family caregivers are more likely to wear down. That makes it even more likely that an elderly person who suffers a setback will wind up in a nursing home, Johnson said.

The findings are “disturbing,” said Eliot Fishman, senior director of health policy at Families USA, a consumer health care advocacy group. “But it’s not surprising to me,” he added.

“It’s an issue I worry gets lost in the health care reform discussion, because there tends to be a huge and understandable focus on health insurance and the affordability of health care,” Fishman said.

At the moment, paid home care tends to be expensive — an average $22 an hour — and isn’t typically covered by insurance, the study authors said in background notes.

Only 11% of seniors aged 65 and older have long-term care insurance, and Medicare doesn’t cover home care services, the researchers noted. Medicaid does cover home care, but there’s a waiting list and people have to be financially wiped out to qualify.

There’s also a looming shortage of home care workers, which the Trump administration’s immigration crackdown could make even worse, according to a Harvard Medical School study published this week in Health Affairs.

Immigrants account for one in every four people working in long-term care and direct care, that study showed. Reducing immigration will make the labor-starved field even less stable.

So what can be done?

Johnson points to a recent innovation by Washington state as one path forward.

Washington passed a law that imposes a 0.58% payroll tax on workers — a premium that pays into a fund to pay for home care, nursing home stay or family caregivers if they become disabled, Johnson said.

“We could think of some sort of public insurance like that as a way to deal with this problem,” he suggested.

Fishman said another option is to change Medicare and Medicaid to cover long-term care. Consideration of such a change probably should be pursued outside the larger health care reform discussion, he added.

Discussions of paying for long-term care have typically tied into other health care reform. “I wonder if that historically has been a mistake,” Fishman said.

The new study appears in the June issue of the journal Health Affairs.

More information

The U.S. Department of Health and Human Services has more about healthy aging.

 

Nursing Home Ratings: Who Can You Trust?

July 31, 2019

courtesy of Elder Law Answers:

By Richard Eisenberg

(An update on the following Next Avenue story, which appeared in March 2019)

On June 3, 2019, Sen. Bob Casey (D-Pa.) and Sen. Pat Toomey (R-Pa.) released a report called Families’ and Residents’ Right to Know: Uncovering Poor Care in America’s Nursing Homes. It included a list of nearly 400 nursing homes around the country where inspectors found serious ongoing health, safety or sanitary problems but whose names had not been publicly disclosed by the government. These nursing homes, with a “persistent record of poor care” do not appear on Medicare’s Nursing Home Compare site with a yellow triangle icon resembling a “caution” sign the way other homes, in the government’s Special Focus Facility program, do. The reason, according to the report by Senators Casey and Toomey:”a result of limited resources” at the Centers for Medicare and Medicaid Services.

You probably saw the viral Facebook post by the Texas man who said he planned to move into a Holiday Inn rather than a nursing home because it would cost  less. That’s a radical idea, and not an especially smart one. But with the average annual cost of a private room in a nursing home topping $100,000, according to Genworth, it pays to do diligent research to find a facility for your parent. And that means looking at nursing home ratings.

This type of detective work can be especially helpful if your mom or dad live in a rural part of the United States. As The New York Times reported this week, nursing homes in those places are increasingly shutting down. More than 400 rural nursing homes have closed or merged over the past decade, the Times said. That means families are being forced to expand their search for nursing homes just to find some.

What Is a Nursing Home?

Before I describe the Medicare and Yelp rating systems, a brief definition:

Nursing homes generally provide nursing care, meals, assistance with everyday activities and rehab services.

Assisted living facilities, by contrast, focus on helping residents with daily living activities and don’t offer as much medical care.

Medicare and Yelp Ratings of Nursing Homes

Both Medicare and Yelp rate nursing homes (sometimes called skilled nursing facilities) on a one-to-five-star scale. Medicare’s ratings of facilities it regulates are in the Nursing Home Compare part of the Medicare.gov site. The ones on Yelp show up if you do search for them with that online service.

But the two types of ratings are done very differently. So much so that Anna Rahman, an assistant professor at the USC Leonard Davis School of Gerontology who has studied them, recommends reading the Medicare reviews as well as the Yelp reviews to get a complete picture.

Rahman and her fellow researchers looked at 51 Yelp-rated nursing homes in California; they previously reviewed the Nursing Home Compare tool.

“We found the Yelp scores did not align well with the scores on Nursing Home Compare,” Rahman told me. “There are lots of possible reasons.”

Why the 2 Types of Nursing Home Ratings Are So Different

The biggest one: Medicare’s Nursing Home Compare star ratings measure facilities based on quantifiable data. Yelp’s reviews are more personal and qualitative. Rahman and her colleagues found that most Yelp reviews commented on “intangibles” like staff attitudes and responsiveness.

Put another way, Medicare can help show how well a nursing home is run and Yelp can show what nursing home residents, or their families, say it’s like to live there.

The Medicare Nursing Home Compare ratings are geographically comprehensive. When I looked for facilities near where I live in New Jersey, I received 160 ratings. (You can modify your search by number of miles, the name of a nursing home, star ratings and whether the facility accepts Medicare or Medicaid.)

By contrast, it’s harder to find many Yelp ratings for a particular area. And even if a nursing home is rated on Yelp, odds are there won’t be many reviews. When I did a Yelp search for nursing homes near me (I found 22), most had fewer than five consumer ratings. They rarely had more than eight.

How the Nursing Home Ratings Are Done

Nursing Home Compare gets its data from three sources: the federal government’s health inspection database; a national database of resident clinical data and Medicare claims data.

Medicare requires on-site inspections every 12 to 15 months. The nursing homes themselves typically report the staffing and quality measures. Critics believe some nursing homes game them.

To arrive at a star rating for a nursing home, Medicare starts with the health inspections rating, then adds a star for a good staffing rating or subtracts one for a one-star health inspections rating. Next, Medicare adds a star if the quality of resident care rating is five stars and subtracts one if that rating is just one star. And if the health inspections rating is just one star, the overall Nursing Home Compare rating can’t be upgraded by more than one star based on the staffing and quality of resident care ratings.

At Yelp, anyone can post a review based on any criteria he or she chooses to use.

When Rahman and her fellow researchers compared Medicare and Yelp nursing home ratings, they often found four or five stars on one but not the other. That’s not because one of the services is wrong; it’s that the raters rate different things.

An Expert’s Take on the Medicare and Yelp Ratings

Rahman is “frustrated” that Medicare has no consumer voice in its ratings system “even though we are supposedly moving to a patient-centric, family-directed health care system.”

Her advice when using its ratings: look for nursing homes that fare well in each of Medicare’s three broad measures: health inspections, quality of resident care and staffing.

“If I saw that a nursing home got five stars for quality measures, but two on staffing and two on health inspection, I’d move on,” she says. “I’d assume they were lying about quality. You can’t get great quality care when your staffing score sucks. You need staff to provide that care.”

Rahman also says the Yelp platform “has its own set of flaws,” although “they allow well-intended consumers to express an opinion about services they have been receiving.” But, she adds, family members often write these reviews. “And [loved ones who are] the residents, don’t necessarily agree. They often disagree.”

Merging Medicare’s Nursing Home Ratings With Yelp’s

She thinks “a nice solution” would be if Medicare and Yelp collaborated, because “people would like a Yelp-like score” on Nursing Home Compare.

“I don’t think it will happen,” says Rahman.

So for now, if not forever, check out nursing home ratings from Medicare and Yelp. Then be sure to visit facilities you’re considering to see for yourself. And don’t be shy about asking questions of administrators or staff (the Medicare Nursing Home Checklist can help).

With the steep cost of nursing homes, and often an urgency to locate a facility, you can’t afford to be.

Estate Planning with Cryptocurrency

July 31, 2019

courtesy of Elder Law Answers:

As cryptocurrencies like BitCoin, LiteCoin, and Ripple increase in circulation and longevity, estate planning attorneys are likely to see more clients acquiring these assets and incorporating them into their estate plans. As interest in cryptocurrencies has increased, the IRS is paying more attention to these kinds of assets. For example, just last year, a popular cryptocurrency exchange called Coinbase was court-ordered to release transaction information on approximately 13,000 of its users to the IRS, indicating that the IRS is beginning to monitor cryptocurrency transactions closely. Ryan Derousseau, The IRS Is Coming for Your Cryptocurrency Profits, Money Time (2018).

Although there is little authority on the tax treatment of cryptocurrency to date, attorneys should be aware of the ins and outs of this specialized property in order to create the best estate plans for clients holding cryptocurrency and properly administer the estates of deceased clients who owned cryptocurrency at their death.

What is Cryptocurrency?

Although over 1,000 different versions of cryptocurrencies exist, the essential hallmarks remain the same for nearly all of them. All Cryptocurrencies, Coinmarketcap.com (2018), https://bit.ly/2deiFHU. At its core, a cryptocurrency is a digital currency that uses blockchain technology to create a decentralized, immutable, public digital ledger. Cryptocurrencies are available only in digital form, which means that in order to use a cryptocurrency one must have access to a computer or smartphone device. The blockchain is a “digital ledger that is shared across a decentralized network of independent computers, which update and maintain it in a way that allows anyone to prove the record is complete and uncorrupted.” Michael J. Casey & Paul Vigna, The Truth Machine: The Blockchain and the Future of Everything (2018). Using this digital ledger, individuals can earn, purchase, and sell digital currency, or “cryptocurrency,” through a network of independent computers that track all of the payments through complex algorithms.

Transfers of cryptocurrency are accomplished through the blockchain technology. The transferor enters the transferee’s public address where the transferee will receive the cryptocurrency, along with the transfer amount and an optional note into the digital ledger. Once those pieces of information are entered, the transferor simply needs to press “send,” and the decentralized network of independent computers will validate the transfer. The transferee need not to do anything besides share his public address. Once the transfer is validated, the ledger is updated to reflect that the transfer has been made. No other documentation is required for the transfer to be complete.

Although cryptocurrency can be treated under various laws like conventional fiat currency (i.e., cash), the IRS’s current position is to treat cryptocurrency as property and not currency for tax purposes. US Dept. of the Treasury, Internal Revenue Service Notice 2014-21, Washington: GPO (2014), https://bit.ly/220DnKP. In a 2014 notice (Notice 2014-21), to date the most comprehensive guidance from the IRS on cryptocurrency tax issues, the IRS stated that “[f]or federal tax purposes, virtual currency is treated as property. General tax principles applicable to property transactions apply to transactions using virtual currency.” Id. As a result, when creating an estate plan or administering an estate, it is important to view any cryptocurrency in an estate as property rather than currency. Among other things, this means that the transfer of cryptocurrency can result in losses or gains. For example, cryptocurrency can be converted into fiat currency, which may result in a loss or gain. Unlike stock, however, cryptocurrency does not pay dividends, and unlike bonds or certificates of deposit, cryptocurrency does not accrue interest either. Rather, cryptocurrency increases (or decreases) in value like real estate. The market capitalization for all cryptocurrencies as of the date of this article is approximately $122 billion. Sam Ouimet, Bitcoin Pops Above $3,700 As Crypto Market Flashes Green, Coindesk (2019), https://bit.ly/2tbjlTX.

Why Are Some People Interested in Cryptocurrency?

Cryptocurrency has characteristics that are enticing to certain classes of risk-taking investors, traders, or speculators. Because of the semi-anonymous nature of the cryptocurrency market, there are typically few to no privacy concerns for individuals making transactions with cryptocurrency. Compared to bank accounts, there are few tax or other regulatory reporting requirements for account holders. This itself has attracted numerous holders. Advocates say that because cryptocurrency relies on the distributed ledger of blockchain technology, it protects holders from the risks associated with cyberattacks on banks and other traditional holders. This, too, is attractive to some.

People have started to use cryptocurrency as a flexible holder of value. For example, cryptocurrency can be used to secure loans. Will Yakowicz, Bitcoin Millionaires Have a New Way to Cash Out Without Ever Selling a Single Bitcoin, Inc.com (2018), https://bit.ly/2HMAjBd. Loans backed by cryptocurrency allow for cryptocurrency owners to put this asset to use without “cashing out” their cryptocurrency and therefore potentially incurring negative tax consequences as a result (discussed in detail below). Another method of investing cryptocurrency holdings and deterring taxes is through an individual retirement account (IRA) that owns 100 percent of an LLC invested in cryptocurrency. Jeff Vandrew Jr., How to Hold Cryptocurrency in a Retirement Account—Without Fees, Bravenewcoin (2018); see also Investing in Cryptocurrency using an IRA, NuView Trust Company, https://bit.ly/2V2zjfp.

To its backers, cryptocurrency is the money of the future and, just as platforms like Uber, Airbnb, and eBay have disrupted and replaced traditional middlemen, so too will cryptocurrency replace banks and other traditional financial intermediaries. In the meantime, cryptocurrency fans believe there are appreciation opportunities available to those who purchase at what they perceive to be the early stages in the life of this asset class.

What Are Some of the Downsides to Cryptocurrency?

Cryptocurrency is a relatively new type of asset that began when the Bitcoin network came into existence in January 2009. Benjamin Wallace, The Rise and Fall of Bitcoin, Wired (Nov. 23, 2011). As a result, there are many issues surrounding cryptocurrency that have yet to be settled. On May 30, 2018, the American Institute of Certified Public Accountants (AICPA) sent a letter to the IRS requesting additional guidance on the taxation of cryptocurrency, beyond its initial 2014 notice. Annette Nellen, Re: Updated Comments on Notice 2014-21: Virtual Currency Guidance (2018), https://bit.ly/2LWcRTL. This is the second letter of this nature AICPA has sent to the IRS, the first having been sent in 2016. The ABA’s Tax Section also sent a similar letter seeking advice from the IRS on the taxation of certain aspects of cryptocurrency on March 19, 2018. Karen L. Hawkins, Re: Tax Treatment of Cryptocurrency Hard Forks for Taxable Year 2017 (2018), https://bit.ly/2veucOg.

Some of the guidance sought in these letters includes what types of retirement accounts may hold cryptocurrency, whether a charitable contribution of cryptocurrency valued in excess of $5,000 will be treated the same as contributions of publicly traded stock, which do not require a qualified appraisal, and whether taxpayers may choose either the specific identification method or the first-in-first-out method as the accounting method for computing capital gains and losses. Id. To date, many of these issues remain unresolved.

One major taxation aspect that the IRS has addressed regarding cryptocurrency is capital gains and losses. Because the IRS treats cryptocurrency as property for tax purposes, an exchange or sale of cryptocurrency can lead to capital gains or losses. Failure to report these and other cryptocurrency transactions on a timely-filed income tax return can lead to fines and even possibly prison time, as taxpayers were warned by a letter released by the IRS in March 2018. Internal Revenue Service, IRS Reminds Taxpayers to Report Virtual Currency Transactions, IRS.gov (2018), https://bit.ly/2pGC34F. As a result, any trust holding cryptocurrency that wishes to liquidate cryptocurrency assets in order to make a distribution to a particular beneficiary should be aware of and properly report any capital gains or losses that ensue from the liquidation.

In addition, the SEC guidance on cryptocurrency is a work in progress. As of now, the SEC says that Bitcoin is not subject to regulation as a security, but it has noted that many cryptocurrencies are subject to regulation as securities, even as many of those issuers have not made the required regulatory filings. Louise Matsakis, Rest Easy, Cryptocurrency Fans: Ether and Bitcoin Aren’t Securities, Wired (June 14, 2018), https://bit.ly/2JQYPhZ. See also Bob Pisani, Bitcoin and Ether are not Securities, but Some Initial Coin Offerings May be, SEC Official Says, CNBC (June 14, 2018), https://cnb.cx/2sXrRGh.

Making Gifts with Cryptocurrency

Some individuals may be interested in making gifts of cryptocurrency in order to reduce income taxes accruing on their holdings. Even better, by donating appreciated cryptocurrency to qualified charities, the taxpayer can receive a charitable deduction on her income taxes for the gift and avoid paying capital gains taxes on the appreciation. Robert W. Wood, Tax-Free Ways to Transfer Bitcoin and Other Crypto: Expert Take, Cointelegraph (2018), https://bit.ly/2BCjzcm. In fact, charitable organizations sometimes welcome donations in the form of cryptocurrency, as the transfer of cryptocurrency requires less red tape than a typical wire transfer. 12 Nonprofits that Accept Cryptocurrency, [Blog] WeTrust (2018), https://bit.ly/2TH5kYO.

As noted earlier, the IRS’s current position treats cryptocurrency as property. See Notice 2014-21, supra.Therefore, gifts of cryptocurrency should be treated for tax purposes as gifts of property, in which the donee receives the donor’s cost basis in the property. As a result, when making a gift of cryptocurrency, it is important to properly track the basis of the gift. According to Notice 2014-21, a taxpayer’s basis in cryptocurrency that the taxpayer receives for goods and services is equal to the fair market value of the cryptocurrency on the date the taxpayer received it. Id.

For tax purposes, best practices for giving cryptocurrency include getting an appraisal of the fair market value of the cryptocurrency being gifted and executing a contemporaneous memorandum that includes details of the gift, such as the date of the transfer, the donor’s basis in the gift, and the fair market value of the gift at the time of the transfer, because blockchain transactions are anonymous. Although there is no authority on this issue, the memorandum should also include that the donor has given up control or dominion over the donee’s cryptocurrency address to verify that the gift is complete and, if the gift is being made to a charitable organization, that the gift meets the requirements of IRC § 170(f), to record that it qualifies for an income tax charitable deduction.

Cryptocurrency in Estates

Cryptocurrency has at least one procedural advantage over other financial assets in estate administration. Unlike a traditional bank or broker, which typically requires executors to produce an original death certificate and letters testamentary in order to take control of accounts in the deceased owner’s estate, cryptocurrency merely requires the fiduciary to have the decedent’s passcode to access and transfer the account for estate administration purposes. Sudhir Khatwani, Bitcoin Private Keys: Everything You Need to Know, CoinSutra—Bitcoin Community, (2018) https://bit.ly/2VHjbo7. The fiduciary then would hold the complex, multi-character passcode needed to access, invest and distribute the estate’s cryptocurrency assets to the beneficiaries as needed and as permitted by the relevant estate planning document. J.P. Buntinx, What Are Cryptocurrency Trusts, NullTX (2018), https://bit.ly/2Jo77l5. Because cryptocurrency offers ease of administration, there are fewer checks on a fiduciary who is handling a cryptocurrency account. Individuals who own cryptocurrency or have a trust that holds cryptocurrency should be exceptionally cautious when selecting an executor or trustee because the fiduciary could use the passcode to access and manage the cryptocurrency account, unlike a traditional bank account, which provides more oversight. In addition, should the fiduciary make a transfer of cryptocurrency that is not authorized by the relevant estate planning document, the transfer could be traced but would be nearly impossible to recover.

Although providing the passcode to the fiduciary may seem like the easiest method, it is important to ensure that doing so does not violate any federal or state privacy laws, terms of service agreements, or computer fraud and data protection laws. Such laws may include the Uniform Prudent Investor Act, the Uniform Prudent Management of Institutional Funds Act, the Federal Computer Fraud and Abuse Act, and the Revised Uniform Fiduciary Access to Digital Assets Act. In addition, by requiring only the passcode to access the cryptocurrency account, there is no way to ensure that a former fiduciary who has been replaced by a successor fiduciary does not access the account despite the lack of fiduciary authority to do so.

There are certain technological controls that can be employed to reduce this risk. “Cold storage” is a method used to keep cryptocurrency account information offline, adding an extra layer of security for cryptocurrency accounts. How to Setup Bitcoin Cold Storage, Bitcoin.com (2017), https://bit.ly/2A6I1ic. Through cold storage, a USB drive or similar device contains the account’s passcode concealed from users and privately transmits the passcode without the user knowing the passcode personally in order to access the account. In this way, a trust’s cold storage USB drive can be handed from a former fiduciary to the successor fiduciary without the former fiduciary retaining the passcode and without either fiduciary directly knowing the passcode themselves. Even with cold storage, fiduciaries should still take care to not run afoul of any terms of service that apply to the cryptocurrency account.

One downside to the cold storage method is that it is unclear whether the device or the cryptocurrency itself constitutes tangible personal property in an estate. Although Notice 2014-21 provides that cryptocurrency is “property” for tax purposes, it is silent on the nature of that property. As a result, until these issues have been more fully settled, it is important to carve out this exception when disposing of tangible personal property through an estate planning document.

In addition, because the IRS treats cryptocurrency as property rather than currency, it will most likely require an appraisal for estate tax purposes. Notice 2014-21 provides that the fair market value of cryptocurrency is based on the exchange rates at the relevant date for appraisal purposes. See Notice 2014-21, supra.

Estate Planning Techniques

When planning an estate, it is crucial to obtain information on any cryptocurrency held by the individual and to include language in the estate planning documents that permits fiduciaries to access, retain, and manage the cryptocurrency without extraneous liability. Fiduciaries should be made aware of the existence of cryptocurrency in the estate and should inquire with the decedent’s family members and financial advisors to determine whether the decedent owned cryptocurrency at death. Properly drafted estate planning documents will also permit fiduciaries to access the decedent’s digital assets, such as laptops and cell phones, which may have information about any cryptocurrencies owned by the decedent at death. It is important to provide these powers to the fiduciaries in an estate in order to allow the fiduciaries to access the decedent’s cryptocurrency after death. Even if the decedent provides the fiduciary with her cryptocurrency passcode during her life, the fiduciary’s use of the passcode after death without the proper permissions in the decedent’s estate planning documents and related laws could cause the fiduciary to violate federal or state privacy laws, terms of service agreements, or computer fraud and data protection laws. It is generally not recommended that an individual share her passcode with others for security reasons, but once a passcode is lost it is virtually impossible to recover, so individuals with cryptocurrency should consider writing down the passcode and storing it in a secure but accessible location (or multiple locations).

In theory, to fund a trust with cryptocurrency directly, one could simply provide the trustee with the passcode or the cold storage device for the cryptocurrency account to access and manage the account on behalf of the trust. As noted earlier, however, it is important to ensure that doing so does not violate any applicable laws or terms of service agreements. Because cryptocurrency’s history thus far is short—about ten years as of the date of this article—and volatile, it may be more prudent to hold cryptocurrency as a small part of a larger trust portfolio. Benjamin Wallace, The Rise and Fall of Bitcoin, Wired (Nov. 23, 2011). At a minimum, a cryptocurrency investor who wants to establish a trust holding solely cryptocurrency should release a trustee from any duty to diversify and provide the trustee with the necessary indemnification. If the trust’s cryptocurrency were held in a larger portfolio with a financial institution, the institution would simply change the trustees on its forms as needed.

Currently there is no authority preventing the funding of any trust with cryptocurrency or directing how such transfers should be memorialized for tax purposes. Ivan Taback & Nathaniel Birdsall, The Bitcoin GRAT, Wealth Management (2014), https://bit.ly/2w2lAu4. Therefore, it is important to prepare contemporaneous memoranda recording any transfer and to ensure that the donor has not retained any control over the transferred cryptocurrency (for example, by having access to the trust’s private cryptocurrency key). Id.

Leaving aside the all-important fact that the value of cryptocurrencies has to date proven extremely volatile, certain intermediaries have proven untrustworthy, and its regulatory framework is unclear, a believer in the future of one or more particular cryptocurrencies could find them well-suited in an irrevocable family trust that will pass the appreciated property to later generations. An individual who owns cryptocurrency could establish an irrevocable family trust with her children, grandchildren, and later generations as beneficiaries and fund it with a variety of assets, including her cryptocurrency holdings, as briefly described above. If cryptocurrencies increase in value over time, the appreciated value of the cryptocurrency in the trust would pass to the grantor’s descendants free of any estate taxes or further gift taxes. In this way, greater wealth can be passed down to later generations while avoiding unnecessary death taxes that would be incurred if the cryptocurrency had not been placed in a trust.

A grantor retained annuity trust (GRAT) may also be a useful vehicle for cryptocurrency because of its volatility. A GRAT funded with cryptocurrency is relatively easy for a trustee to administer. Id. A GRAT can be funded with cryptocurrency by employing the best practices for cryptocurrency transactions recommended above, including a qualified appraisal of the value of the cryptocurrency transferred to the GRAT upon which the annuity amount of the GRAT will be based. If the trustee also opens up a simple bank account for the GRAT at the time of funding, the trustee can use the power of substitution to exchange the cash in the bank account for cryptocurrency in the GRAT that has appreciated significantly, thus locking in the increased value of the cryptocurrency. Id.

An annuity payment is made with cryptocurrency by the trustee sending it to the grantor’s public cryptocurrency address as briefly described above. Once an actuary determines the annuity amount in regular currency, the trustee will need to determine how much cryptocurrency is necessary to satisfy the annuity payment. Because the IRS has deemed cryptocurrency to be property for tax purposes, the value of cryptocurrency for these purposes would be the price at which the property would change hands between a willing buyer and a willing seller on the date of the transfer. Treas. Reg. 25.2512-1 (2019). Best practices for determining the value of the cryptocurrency needed to satisfy the annuity include taking a weighted average of the mean between the highest and lowest cryptocurrency prices from multiple cryptocurrency exchanges. Taback & Birdsall, supra.

Conclusion

Cryptocurrency is a new asset class that estate planning attorneys are likely to see in their clients’ portfolios in the future. Although the IRS has not set forth clear guidance on every tax aspect of these assets, attorneys should take care to ensure that they are properly treated in the estate plan. It is important to include language in every will and trust that permits the fiduciaries to access the digital records necessary to properly administer any cryptocurrency in the estate. It is also important for clients to select trustworthy fiduciaries who will properly manage the cryptocurrency and follow the client’s intent. With proper planning and attention to the latest publications from the IRS regarding this asset, estate planning attorneys can help their clients who are interested in this new asset class.

By Parker F. Taylor, Vanessa A. Woods, and Jack Tanenbaum

Nursing home care cost significantly outpaces general inflation and medical care prices

July 30, 2019

NAELA eBulletin:

WASHINGTON — One of the largest studies on out-of-pocket costs for nursing home care finds prices are high and rising faster than other medical care and consumer prices, reports a team of health policy researchers.

Their study, published in Medical Care Research and Review, reviews nursing home prices in eight states between 2005-2010 and uncovers out-of-pocket prices that increase significantly beyond normal inflation and inflation in medical care prices.

For example, annual out-of-pocket costs for nursing home care increased as high as 30% in California during the study period.

The study also finds substantial price variation across states. In 2010, at an average of $131 a day (about $47,800 annually), Texas had the least expensive nursing home out-of-pocket cost, while New York State, at $334 daily ($121,910 a year) had the most expensive.

The study also finds different prices between nursing homes after adjusting for staffing levels and geographical difference.

The for-profit nursing home chains charged the lowest prices and nonprofit nursing home chains provided the most expensive care. The price differential between for-profit chains and nonprofit chains is about $4,160 annually, or equivalent to 6.2% of the average price of for-profit nursing homes. However, there is no statistically significant difference in prices between for-profit and nonprofit independently operated nursing homes.

The researchers also find that areas with higher market concentration of nursing homes leads to higher prices. Nursing homes that are near capacity limit also charge more than nursing homes that have more rooms available.

The study aims to provide more transparency of the out-of-pocket prices of nursing home care. “Not many people have those kind of resources, and so it is important to understand how fast prices grow and how they vary,” says the study’s lead author, Sean Huang, PhD, MA, assistant professor in the Department of Health Systems Administration at the School of Nursing & Health Studies at Georgetown University Medical Center.

Typically, individuals in need of nursing home care who do not have Medicaid, and usually pay out of pocket until they run out of money. Then they are eligible for Medicaid, Huang says. Only a small fraction of nursing home residents have private insurance, such as long-term care insurance, that helps cover the costs.

This study used a unique dataset on nursing home prices from 2005-2010 across eight states. “Very few people have studied this topic, so it required building the largest dataset on nursing home prices to date,” Huang says. “This kind of information is very valuable to potential consumers of this care.”

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Study co-authors include Richard A. Hirth, PhD, from the University of Michigan,

Jane Banaszak-Holl, PhD, from Monash University in Australia, and Stephanie Yuan, BA, from Georgetown University Medical Center.

The study was partly supported by a grant from the U.S. Social Security Administration, funded as part of the Retirement Research Consortium through the University of Michigan Retirement Research Center Award RRC08098401.

Living with Dementia – 51 Tips to Help You With Daily Living

July 30, 2019

In this in-depth infographic and article we share with you a whole range of tips of advice to help those living with dementia, whether that be you or a loved one.

We’d like to start this article by dispelling a few key myths about Dementia.

1. Dementia is not a disease

Contrary to popular belief, Dementia is not a singular illness. It’s a condition, caused by lots of different diseases. ‘Dementia’ is the collective term for the symptoms of these illnesses.  The most common forms of dementia are Vascular DementiaLewy Body Dementia and Frontotemporal Dementia.

2. Dementia is not ‘part of getting older’

Dementia isn’t a normal part of the ageing process. Although the likelihood of developing Dementia rises with age, it also affects many people under the age of 65.

Dementia is about more than just memory loss

Dementia affects people in a variety of ways – which all differ of course from person to person. Everybody experiences Dementia differently, and may have one symptom or many in varying degrees.

It’s still possible to live a healthy, happy, independent life with Dementia.

Dementia doesn’t stop you enjoying life

The fourth and final fact is what this infographic and article is all about. People with Dementia can – and do – continue to live their lives to the full, even as the condition progresses. But living well is only possible with the right tools, support and advice.

Below this infographic you will find a lot more written information regarding the tips.  We hope you find this useful. Please click on https://ukcareguide.co.uk/living-with-dementia/ for the infographic and for the remainder of the article.

Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities Arbitration Agreements (CMS-3342-F)

July 30, 2019

NAELA eBulletin:

Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule, “Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements” (CMS-3342-F). The final rule revises the requirements for arbitration agreements when they are used by long-term care (LTC) facilities to resolve disputes with their residents. Provisions in this rule establish substantial protections for residents and their representatives and ensure transparency in the arbitration process in LTC facilities, also known as “nursing homes”. The rule is part of the agency’s five-part approach to ensuring a high-quality nursing home system that focuses on strengthening requirements for nursing homes, working with states to enforce statutory and regulatory requirements, increasing transparency of nursing home performance, and promoting improved health outcomes for nursing home residents.

This final rule repeals the prohibition on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents, as proposed. However, this final rule includes protections of residents’’ rights by prohibiting LTC facilities from requiring residents to sign binding arbitration agreements as a condition of admission to, or as a requirement to continue to receive care at, that facility. It strengthens the transparency of arbitration agreements and the arbitration process with specific requirements for the LTC facility, such as the requirement that LTC facilities that resolve a dispute with a resident through arbitration retain copies of the signed arbitration agreement and the final arbitrator’s decision for five years and make such documents available for review by CMS or its designee. It also protects residents’ rights to make informed choices about their health care by ensuring that residents or their representatives have the right to understand what the arbitration agreement says and the consequences of signing the agreement.

Background

On October 4, 2016, CMS published in the Federal Register a final rule titled, “Reform of Requirements for Long-Term Care Facilities” (81 FR 68688) (2016 final rule). The rule banned binding pre-dispute arbitration agreements in LTC facilities. In 2016, the American Health Care Association (AHCA) and a group of affiliated nursing homes filed a complaint in the U.S. District court for the Northern District of Mississippi seeking a preliminary and permanent injunction enjoining CMS from enforcing the ban on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents. After the court preliminarily enjoined the enforcement of that regulation, the agency determined that further analysis of the rule was warranted. On December 9, 2016, CMS issued a nationwide instruction to State Survey Agency Directors, directing them not to enforce the 2016 final rule’s prohibition of pre-dispute, binding arbitration provisions.

On June 8, 2017, CMSCMS published a proposed rule, “Medicare and Medicaid Programs; Revisions of Requirements for Long-Term Care Facilities: Arbitration Agreements” (82 FR 26649) in the Federal Register. The agency received over 1,000 public comments on the proposed rule from a number of stakeholders, including nursing homes and beneficiary advocates. That proposed rule focused on the transparency surrounding the arbitration process and proposed the following:

  • The prohibition on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents would be repealed.
  • All agreements for binding arbitration must be in plain language.
  • If signing the agreement for binding arbitration is a condition of admission into the facility, the language of the agreement must be in plain writing and in the admissions contract.
  • The agreement must be explained to the resident and his or her representative in a form and manner they understand, including that it must be in a language they understand.
  • The resident must acknowledge that he or she understands the agreement.
  • The agreement must not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including federal and state surveyors, other federal or state health department employees, or representatives of the State Long-Term Care Ombudsman.
  • If the facility resolves a dispute with a resident through arbitration, it must retain a copy of the signed agreement for binding arbitration and the arbitrator’s final decision so it can be inspected by CMS or its designee.
  • The facility must post a notice regarding its use of binding arbitration in an area that is visible to both residents and visitors.

Final Rule Revisions to Arbitration Requirements

After careful consideration of the public comments, CMS is modifying our proposed changes.  We are not finalizing the requirements for plain language in the arbitration agreements and that the facility post a notice regarding its use of binding arbitration. We believe these proposed requirements are unnecessary due to other requirements finalized in this rule.  In addition, we are retaining some of the requirements finalized in the 2016 rule.  We are finalizing following provisions.  An LTC facility must:

  • Not require that a resident or his or her representative sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.  This must be explicitly stated in the agreement to ensure.  This ensures that no resident or his or her representative will have to choose between the resident obtaining the skilled nursing care he or she needs and signing an agreement for binding arbitration.
  • Ensure that the agreement is explained to the resident or his or her representative in a form and manner that he or she understands, including in a language that he or she understands, and that the resident or his or her representative acknowledges that he or she understands the agreement.  These two requirements ensure that the arbitration agreement is transparent and the resident or his or her representative understand what he or she is agreeing to.
  • Ensure that the agreement provides for the selection of a neutral arbitrator agreed upon by both parties and a venue that is convenient to both parties.  These requirements helps to ensure that the arbitration process is fair to both parties, especially the residents.
  • Ensure that the agreement does not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including Federal or state surveyors, other federal or state health department employees, or representative of the Office of the State Long-Term Care Ombudsman. This protects the resident and his or her representative from any undue influence by the LTC facility to not discuss the circumstances surrounding a concern, complaint or grievance.
  • Retain copies of the signed agreement for binding arbitration and the arbitrator’s final decision for 5 years after the resolution of any dispute resolved through arbitration with residents, and make these documents available for inspection upon request by CMS or its designee.  This will ensure that CMS will be able to obtain information on how the arbitration process is being used by LTC facilities, and on the outcomes of the arbitrations for residents.

For more information, please visit: https://www.federalregister.gov/documents/2019/07/18/2019-14945/medicare-and-medicaid-programs-revision-of-requirements-for-long-term-care-facilities-arbitration

 

A Final Retirement Account Distribution Must Still Be Made After Death

July 30, 2019

Federal law requires that beginning on April 1 of the year after you reach age 70 1/2, you must begin withdrawing a minimum amount from your non-Roth individual retirement account (IRA) or 401(k) accounts. These withdrawals are called required minimum distributions (RMDs).

But what if you die after age 70 1/2 and before all the account funds have been distributed? In the eyes of the law, death is no excuse not to take RMDs from an IRA or 401(k). Your heirs must take the final RMD before they can take control of the account.

Congress created the rules governing the minimum distribution of retirement plan funds to encourage saving for retirement and to allow retirement assets to build up tax-free during the plan owner’s working years. But lawmakers built in provisions so the money wouldn’t simply keep accumulating tax-free forever. The funds you withdraw are treated as taxable income in the year you take the distribution. If you don’t start taking the RMDs from your retirement accounts and pay taxes on the withdrawals, you will face a 50 percent penalty on what should have been withdrawn but wasn’t.

The rules for inheriting an IRA as a spouse are different than the rules for a non-spouse beneficiary, but regardless of who is inheriting the IRA, the heir must take the RMD for the year the account owner died. The full RMD must be taken by December 31 in the year the account owner died, even if he or she died at the beginning of the year. To take the RMD, beneficiaries must contact the custodian of the account and submit a death certificate. If the account owner died before he or she was required to begin distributions, then the beneficiaries do not need to take an RMD.

The money from the RMD will go directly to the beneficiary listed on the account, not the estate. That means it will be taxable income for the beneficiary. If there is more than one beneficiary, it will be split evenly.

To find out the best way to deal with an inherited IRA, contact your attorney.

How the Democratic Candidates Responded to a Health Care Policy Survey

July 2, 2019

When the 2020 Democrats were asked the best way to improve the health care system, a split in the field was revealed. Here are full responses from 19 candidates.  The New York Times asked all 23 Democratic presidential candidates for their views on the best ways to improve the health care system. We received responses from 19 of them.

[Read our analysis of the responses here.]

The first three questions asked whether the candidates supported three possible routes for
changing how Americans receive health insurance: by creating a “Medicare for all” system
that would eliminate private insurance; by providing a choice between a “public option”
health care plan run by the government and private insurance; or by making more modest
changes to the Affordable Care Act.
Candidates could indicate support for more than one option. But in the fourth question, we
asked which of the three options would be the best way to improve the health care system,
and that is where a split in the field was revealed.
The survey also included several other questions about health insurance and coverage, how
the candidates would finance their plans, and other matters like prescription drug prices.
Below are the responses from each of the 19 candidates. Many of the questions were posed
in a yes-or-no format but also allowed the candidates to add additional comments. Some of
the responses we received were written in the first person, while others were supplied by
campaign staff members. Aside from a few corrected typos and minor punctuation changes
for clarity, these are the full, unedited answers we received.

No.

We need to have universal coverage, lower costs, and improve quality — those are the three objectives we should be working toward. The best path to achieve those objectives is with Medicare-X, my plan to create a strong public option that provides people with the choice of buying into that option or keeping the insurance they receive through their employer or union.

In just four years, Medicare for All would take health insurance away from about 180 million Americans who receive their insurance through their employer or their union, the vast majority of whom like it. And it would take insurance away from another 20 million people who receive insurance through Medicare Advantage.

Yes.

All Americans.

The best path to covering all Americans with high-quality, affordable health insurance is with Medicare-X, my plan to create a strong public option that provides people with the choice of buying into that option or keeping their private insurance.

Medicare-X would start in rural areas where there is one or no insurer to increase competition and lower costs. It would then expand to every ZIP code, and become available as an option on the small business exchange. Medicare-X would also, for the first time, allow the federal government to negotiate lower drug prices on behalf of the American people. By using the existing Medicare framework, it does all of this without adding any bureaucracy.

No.

We should build upon the Affordable Care Act, including by extending premium assistance to more middle-class Americans who are above the A.C.A. cliff of 400 percent of the Federal Poverty Level. My Medicare-X plan would do that, in addition to increasing support to families under the 400 percent threshold who are currently receiving tax credits to help pay for insurance.

But we shouldn’t stop there. Medicare-X would also provide everyone with the choice of purchasing a public option, and it would allow the federal government to negotiate lower drug prices. We also need to reduce the cost of health care by increasing transparency and modernizing how we care for people.

Public option.

If you went into a living room anywhere in the country and told everyone about Medicare-X, my plan to create a true public option, I believe it’s a plan they could get behind. We don’t need to blow up our current health care system to provide everyone with high-quality, affordable care. And we don’t need to take insurance away from people who receive it through their employer and like it. Medicare-X starts in rural areas where the market is failing too many people. It covers essential health benefits and uses Medicare’s network of doctors and providers. It allows the federal government to negotiate lower drug prices. And it does all of this without creating any new bureaucracy.

Yes.

All Americans should be covered by high-quality, affordable health insurance. For people who are already eligible for Medicaid and other programs, our default should be for those programs to cover them. States that have yet to take advantage of the Medicaid expansion in Obamacare should do so in the best interests of their residents. Ultimately, by offering a strong public option through Medicare-X, we can accomplish universal coverage.

My Medicare-X plan would save taxpayer dollars relative to the current health care system, even as it covers millions more people. For example, a more modest public option has previously been projected by the nonpartisan, independent Congressional Budget Office to save $158 billion for taxpayers over a decade (source: bit.ly/2MH8b1V). That’s because a public option like Medicare-X requires premiums, but also cuts health care costs relative to private health insurance. We would then take those savings and reinvest them in improving upon Obamacare, so that more middle-class Americans are able to afford health insurance.

Notably, this differs dramatically from Medicare for All, which the nonpartisan Urban Institute has suggested would cost more than $32 trillion over the next 10 years (source: urbn.is/2WEIH9H). Regardless of whether people think this is the right approach, we have to acknowledge that nobody has shown how they would specifically pay for even a significant fraction of this total cost. According to Vox, when single-payer failed in Senator Sanders’s home state of Vermont, it failed when taxpayers were confronted with the fact that it would necessitate an increase in payroll taxes of 11.5 percent and income taxes by 9 percent (source: bit.ly/2VCeMOW).

My Medicare-X plan does not require a tax increase at all, because it saves taxpayer dollars relative to private health insurance. It allows the American people to choose this high-quality, affordable option instead of taking away their current health insurance.

Yes.

Undocumented immigrants should have the option of purchasing health insurance on the exchange.

Yes.

Americans are growing older, and we need to figure out how to provide them with long-term care.

Health coverage in long-term care is fragmented, insufficient, and inefficient. Americans shouldn’t be forced to spend down their life savings in order to be covered by Medicaid for long-term care. There are a number of ways to ensure that coverage is lifelong, and we should have that discussion.

No.

The United States government should negotiate drug prices through Medicare Part D and other federal programs on behalf of the American people. Medicare-X does that.

Importation from Canada is not a sustainable solution, because the reason drugs cost less in Canada is that the Canadian government uses its leverage to negotiate prices downward. Even if Canada allowed us to import all of its drugs (which it will not), we would still not be able to supply the demand in the United States, and it would have a limited effect on overall prices. We are nine times the size of Canada, and Canada would be left with drug shortages, which it would never allow.

After writing and passing legislation to secure our supply chain, I’m also concerned about counterfeit medications sold through supposedly Canadian online pharmacies, which are often not even based in Canada.

Yes.

I support allowing the United States government to negotiate drug prices through Medicare Part D and other federal programs. That’s the only way to get drug prices under control for the American people. Medicare-X does that.

Public option.

[The Biden campaign did not complete the survey, but indicated that Mr. Biden preferred a public option and referred to his statements on the campaign trail.]

Yes.

I support Medicare for All. There are different ways we can get there. Right now, there are several bills in the United States Senate that move our country closer to Medicare for All, and I’m a sponsor of them. The most important thing is to keep the ultimate goal in mind: affordable health care for every American, because health care is a human right.

Yes.

All Americans.

I am a co-sponsor of several bills in the Senate to create a public option, a powerful tool to introduce real competition into the market and drive down costs for consumers.

Yes.

I support strengthening the A.C.A., including by extending premium assistance to more middle-class Americans and undoing the Trump administration’s sabotage around enrollment, as one part of a broader effort to improve care and lower costs.

“Medicare for all.”

I believe our country needs to work towards Medicare for All and have co-sponsored several bills to help do just that, including through a public option and lowering the Medicare eligibility age.

Yes.

It is important that every American has health insurance not only to keep individuals and families healthy, but also to help keep health costs stable.

High out-of-pocket costs for people with insurance is one of the most concerning problems in our current system. On the path to Medicare for all, I support concrete steps to increase access and lower costs — including lowering the Medicare eligibility age and introducing a public option — all of which would be financed differently. Whatever the plan, we must do more to help low- and middle-income Americans, many of whom can’t afford to go to the doctor or get even basic preventative care due to prohibitive cost-sharing.

Our country already spends trillions of dollars on health care every year. By directing existing spending into a more efficient system, reducing the outrageous cost of many prescription drugs, and leveraging Medicare’s lower cost structure system, we can achieve savings that offset many of the costs of improving affordability and access. We can also raise taxes on the wealthiest Americans, while ensuring that most families are paying less for better care.

Yes.

Access to quality, affordable health care is a human right. We need to make our health care system more effective and efficient, and we must pass comprehensive immigration reform that creates a pathway to citizenship for those already living in the United States.

Yes.

Long-term care is an integral part of health care, especially for people with disabilities.

Yes.

I wrote and introduced the Affordable and Safe Prescription Drug Importation Act along with Senators Bernie Sanders and Bob Casey to allow for the safe importation of prescription drugs.

Yes.

I am an original co-sponsor of the Affordable Medications Act, which includes a number of provisions to bring transparency and competition to pharmaceutical companies responsible for outrageous drug prices. By allowing Medicare to directly negotiate with manufacturers, we can leverage the federal government’s buying power and cut costs for taxpayers and beneficiaries.

No.

Everyone should have access to health care — and it should be affordable to the individual and to the taxpayers. Access to health care shouldn’t depend on the size of your paycheck. It should be a right for all.

Through the A.C.A., we have been able to make great strides in ensuring coverage for more Americans, beginning to reduce the growth in health care costs, and providing better care inclusive of prevention, drug and alcohol treatment, screenings, and mental health care.

Yet even after the A.C.A., many people still can’t access care. And most of us are paying too much. More can be done.

About 156 million Americans are enrolled in employer-sponsored health insurance plans. Moving immediately to a Medicare for All system would both undermine existing employer sponsored health care, upset a significant portion of the economy, and result in significant payroll tax increases for working Americans to cover Medicare for All.

At the same time, 25 million Americans still lack coverage, and the Trump administration is only making things worse.

I believe that we can increase access and affordability by providing a public option for Americans who want to buy into government insurance which will also ensure competition in the private market; allowing the federal government to negotiate drug prices and bring down the costs of prescription drugs; automatically enrolling Medicaid eligible people in Medicaid; and ending surprise billing and out of network charges.

Yes.

All Americans.

Yes.

The Affordable Care Act began to put America on a path toward significantly improved health care coverage, better health prevention and results, and reduced expenses. The Trump administration has worked aggressively to block the important changes brought about by the Affordable Care Act resulting in reduced coverage, lower quality coverage options, and increased costs to consumers.

I believe by fully implementing the Affordable Care Act, providing a public option, allowing the federal government to negotiate drug prices, automatically enrolling people eligible for Medicaid, and ending surprise billing and out of network charges, we can significantly improve health care for all Americans.

Public option.

As a Governor, I am on the front lines of implementing health care solutions. I will never forget testifying in front of the U.S. Senate about implementation of the Affordable Care Act and Medicaid Expansion, and how they had meaningfully impacted health care in our states. At the same time, as we were testifying, Republicans were trying to repeal the A.C.A. and take our country backward. While some have the luxury of debating the ideal health care system, governors must implement effective systems that work for our constituents — and that’s what I have been doing in Montana.

Estimates indicate that a Medicare for All system would require between $2.5 and $3 trillion in new revenue each year. When you consider that the U.S. government is expected to bring in $3.6 trillion in 2020, an additional $2.5 to $3 trillion is a 69 percent to 83 percent tax increase.

The Affordable Care Act increased access to health care, behavioral health care, stabilized rural hospitals, improved health care in Indian country, provided preventative care, increased access to substance abuse treatment, and provided incredible improvements throughout Montana. Continuing to strengthen the Affordable Care Act while adding a public option and automatic enrollment for people eligible for Medicaid will go a long way toward full coverage, reduced costs, and improved health outcomes throughout the country.

No.

The vast majority of health insurance is provided by employers. We must make it both more affordable to employees, and for employers to offer health care. Those who are not covered by employer-based health care must be incentivized to have coverage through a public option — and we should help with the incentives. A mandate, however, is not an incentive.

The first thing we have to address is health care costs — for employers and families. Improving affordability will make it easier for everyone to access health care whether it is employer-based or publicly available.

Businesses that choose not to provide their employees with benefits, or businesses avoiding employee benefits through excessive use of contract employees, need to be examined.

No.

Comprehensive immigration reform that protects our border, helps the Dreamers who have known no other home than ours, and provides a path to citizenship for immigrants who have been part of the fabric of our country for many years is the best way to address health coverage for people who want to become American citizens.

No.

Long-term care is an increasingly important challenge for many families, and we should explore ways to make long-term care more affordable and accessible for all Americans without adding crushing costs to working families.

No.

Americans pay more for prescription drugs than nearly anyone else, yet we have nothing to show for it. Rather than focusing on importing drugs from other countries, we need to get our pharmaceutical companies to charge Americans less for vital medicines. If these efforts are unsuccessful, moving toward a safe drug reimportation program would remain an option.

Yes.

As Governor of Montana, I negotiated health care costs between our hospitals and the state employee insurance plan resulting in significant cost savings. It is long past time that the federal government did the same to lower pharmaceutical costs. With the purchasing power of the federal government and its many health care systems — Department of Veterans Affairs, Indian Health Service, Medicare, Medicaid, Federal Employee Health Benefits Program — we have significant leverage in these negotiations.

[This yes-or-no response was left blank, but the campaign left additional comments.]

I support universal health care and believe that a Medicare-type buy in provides the best glide path to a Medicare for All environment. Even then, private insurance can play a role, but only on a supplemental basis. Medicare for All is our goal because it represents a fairer, more efficient health care system that will spend less money on profits and bureaucracy and more on patient care.

Yes.

All Americans.

The path to Medicare for All that I believe makes Americans better off along the way is one that starts with a Medicare-like plan as a public option for people who want it. It will challenge private options to become more affordable and efficient; I am skeptical that they will be able to do so, and expect that this will lead to a Medicare for All environment in the future as more Americans opt in to the Medicare-like plan.

No.

I am in favor of strengthening the Affordable Care Act while we work to implement full reform.

Public option.

Yes.

New health spending should be financed by a combination of premiums and tax-based funding to ensure it is affordable.

Federal spending that makes health insurance affordable could be offset by taxes on the wealthy and on corporate profits.

Yes.

Undocumented immigrants should be able to buy coverage through the public option.

[This yes-or-no response was left blank, but the campaign left additional comments.]

America needs a comprehensive, universal insurance program for long-term care. This can either be done within a universal Medicare plan, or in parallel to it, but the United States must establish such a program so that families can count on long-term care.

Yes.

Such importation must be done in a way that ensures safety and quality.

Yes.

No.

I support Medicare for all with a role for private insurance for individuals that choose it.

Yes.

All Americans.

I support universal health care with Medicare as the foundation. Americans should have options to choose either a complementary or supplementary private insurance.

No.

[This multiple choice response was left blank, but the campaign left additional comments.]

The best way to improve the health care system is to provide Medicare for all, with an option to choose either a complimentary or supplementary private insurance.

Yes.

An expanded Medicare program should be financed mostly through a restructured tax code. Premiums and co-payments may still exist, but my proposal will prioritize keeping these payments low.

I would support repealing the Trump tax plan and replace it with one that asks corporations and the wealthiest elite to contribute their fair share.

Yes.

Undocumented immigrants pay taxes and are contributing members of our communities. I believe they should be eligible for government health care support and put on a pathway to citizenship. I look forward to putting forward a health care plan that addresses the health care gap for undocumented families.

Yes.

Yes.

Yes.

No.

I support the Universal Healthcare plan that I have crafted, which provides health care to every American as a right. It will allow Americans to have the option of having private insurance.

link: https://www.johndelaney.com/issues/health-care/

Yes.

All Americans.

No.

The first thing that the next President should do is fix the A.C.A. The A.C.A. was a good law and has been under attack from Republicans since the day it was signed. Our primary obligation should be to first stabilize our health care system before we begin overhauling it.

A.C.A. fixes.

Your question does not fully capture my views — I would first fix the A.C.A. and then work to create universal health care. The A.C.A. has been under attack from Republicans since the day it was signed. The best way to improve the A.C.A. is to stabilize premiums and bring down costs.

No.

Every American should have health care as a right via a federal program but have the option of purchasing health insurance.

A combination of revenues is the best path forward. Americans who are struggling financially should not have to pay co-payments that will restrict their ability to receive proper care whereas Americans with more resources would contribute. I also believe a government-only (single-payer) system would result in lower quality and more limited access.

My universal health care plan is fully paid for by eliminating the deductibility of employer-provided health care. https://www.johndelaney.com/issues/health-care/

No.

I support comprehensive immigration reform which provides a pathway to citizenship.

Yes.

Yes.

We should also tax big pharma when they charge other countries less than they charge Americans, thereby inflating the price of prescriptions drugs for Americans. https://www.johndelaney.com/issues/prescription-drugs/

Yes.

“Medicare for all.”

[The Gabbard campaign did not complete the full survey, but provided additional comments.]

I support Medicare-for-All. It is unacceptable that in our country we pay far more for health care than any other country in the world, yet we have far worse outcomes. No one in this country should be sick and in need of care and not able to get that care simply because they don’t have enough money.

We have to address the high cost of prescription drugs and hold pharmaceutical companies like Purdue accountable for deceptive sales practices. Right now, Medicare today still can’t negotiate with prescription drug companies to bring down the cost of health care. That has to change.

Like many other countries in the world that have universal health care, I believe there is a role for private insurance but we have to re-evaluate what that looks like — we need to create transparency in the system, break up what is essentially an oligarchy in the pharmaceutical and health care industries and ensure Americans aren’t being gouged for services they need to live.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Senator Gillibrand is a co-sponsor of the Senate Medicare for All bill and wrote the transition piece in the legislation. She supports the goals of that legislation and believes a single-payer system is the best way to achieve universal health care coverage, and to guarantee high quality and low-cost health care to all Americans.

Senator Gillibrand believes that a Medicare for All system will eventually displace the private insurance industry from providing health care. She believes that private insurers are welcome to compete with Medicare, but because Medicare is a nonprofit program, without shareholders or high C.E.O. pay, their prices will consistently be lower than private insurers, who will no longer have a role in health care.

Private insurers could still have a role in providing consumers additional elective medical services that they want to pay for individually, such as cosmetic plastic surgery.

Yes.

All Americans.

Senator Gillibrand’s overarching goal is to get Americans to universal coverage, and supports several pieces of legislation to that end. While she believes that Medicare for All is the ideal and best way to accomplish universal coverage, she also co-sponsors both Senator Stabenow’s Medicare at 50 Act, and Senator Schatz’s State Public Option Act.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Senator Gillibrand would of course support modifications to improve the cost and access to health care provided through the Affordable Care Act. But her main focus is achieving universal coverage and she believes the best way to do that is through a single-payer system like Medicare for All, with a critical public option as a transition.

“Medicare for all.”

Senator Gillibrand believes that a single-payer system like Medicare for All will get America to universal coverage quickest, while also providing the most affordable and highest quality health care. She believes that a nonprofit health care system that focuses solely on its patients’ health and well-being, and that does not have to worry about shareholder value or C.E.O. pay, will deliver the best care to the American people.

Yes.

Senator Gillibrand believes that extending health care coverage to all Americans is the most efficient way to ensure low prices. Moving to a single-payer system, where everyone is covered, will provide all Americans with health insurance they can afford.

Under Senator Gillibrand’s ideal system, health care would be financed through a combination of employer-matched co-payments and taxes.

Senator Gillibrand supports a financial transaction tax, repealing the corporate tax cuts, eliminating subsidies for excessive C.E.O. pay and for companies that ship jobs overseas, and restoring the estate tax.

[This yes-or-no response was left blank, but the campaign left additional comments.]

As is outlined in the Senate Medicare for All bill, Senator Gillibrand supports extending health care coverage to all U.S. residents as defined by H.H.S. Residents will receive coverage provided that they are paying into the health care system, and are on a pathway to citizenship.

Yes.

Yes.

Senator Gillibrand supports the importation of generic drugs and is a co-sponsor of the Affordable and Safe Prescription Drug Importation Act.

Yes.

Senator Gillibrand supports giving the federal government the ability to negotiate drug prices for Medicare. Medicare for All would empower the government to negotiate all prescription drug prices. She also co-sponsors the Medicare Drug Price Negotiation Act, which would allow the Secretary of Health and Human Services to negotiate drug prices in Medicare, and the Empowering Medicare Seniors to Negotiate Drug Prices Act, which would allow Medicare to negotiate for prescription drugs.

Yes.

Medicare for All will guarantee access to health care, with no premiums or co-pays, for every single American. Private supplemental insurance for procedures not covered under the Medicare for All plan would still be allowed, but it is time to stop letting big insurance companies put profit over people’s health care.

Yes.

All Americans.

Medicare for All is my preferred plan. I am also supportive of other measures to expand insurance to more Americans, which is why I am a co-sponsor of the State Public Option Act, the Choose Medicare Act, and the Medicare-X Choice Act.

No.

Protecting the A.C.A. from repeal is one of the proudest moments I’ve had in the Senate, and I am for strengthening it and building on its success. That’s why I support Medicare for All, so that we can ensure every American has access to health care.

“Medicare for all.”

Medicare for All will extend health insurance to every single American, with no co-pays or premiums. It will cover most procedures, as well as dental, vision and hearing aids, and will allow you to choose your doctor, without worrying about who’s in-network or not. We have to change a system that allows big insurance companies to put profit over people’s health.

Yes.

Republicans’ decision to repeal the Affordable Care Act’s individual mandate has destabilized our health care system, made costs go up for families, and increased the number of uninsured Americans.

I support the system set up under the Medicare for All bill I sponsor, where every American can have access to health care with no co-pays or premiums.

The U.S. spends more on health care than any country. In the next decade, we’ll spend $50 trillion on our current health care system. We simply can’t afford to do nothing. Budget estimates of Medicare for All show the system would save the system money.

Yes.

I support the process outlined in the Medicare for All bill, which ensures universal coverage.

Yes.

Too often, elderly Americans and people with disabilities are forced to leave their homes, live in poverty, or go without critical long-term care. It’s unacceptable. That’s why I’m proud to support Medicare for All, which would provide much-needed support for millions of Americans.

Yes.

I co-sponsor legislation to allow importation of prescription drugs from countries with safety standards as strong as the U.S., such as Canada. It will help lower costs for Americans who need access to medicine.

Yes.

I co-sponsor legislation to allow Medicare to negotiate drug prices, which would significantly reduce costs for our seniors.

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I believe that health care is a right for all Americans. As president, I am committed to achieving the goal of universal coverage. This week, I signed into law the nation’s first public health care option to create another pathway for delivering affordable coverage. I believe the public option should be a key first step toward delivering universal health care in our country. We must also lower the age of enrollment for Medicare, allow Americans to buy into or automatically enroll in Medicare, allow Medicare to import and negotiate the price of drugs, and end the Trump administration’s outrageous effort to strip millions of Americans of their health care. I am proud of my record as governor in expanding health care to 800,000 Washingtonians, passing the first public option in the country and passing the first long-term care insurance program in the country. As president I will build on this record of success to achieve universal health coverage for all Americans.

Yes.

All Americans.

Yes, and I believe the unprecedented accomplishments we have made in Washington State show that we are able to get this done. I believe that we must lower the age of enrollment for Medicare, including allowing all Americans to buy into Medicare or automatically enrolling in Medicare at birth. The Cascade Care public option plan that I have signed into law makes public health plans available to all Washingtonians, regardless of income, by 2021. It also requires establishing cost-sharing agreements that will reduce, by up to 10 percent, the cost of plans on the health care insurance exchange, which currently serves 266,000 Washingtonians.

No.

I am the only candidate in this race who has both voted for and implemented Obamacare, which now provides health insurance to over 800,000 Washingtonians. Because of Obamacare, we slashed our uninsured rate from 14 percent to 5.5 percent. I support efforts to shore up the Affordable Care Act, and when I am president, I will end the Trump administration’s persistent undermining of Obamacare that threatens the health care of millions of Americans. But we must also do more to build upon the progress we’ve made thanks to Obamacare with policies such as lowering the Medicare enrollment age, allowing Americans to buy into or automatically enroll in Medicare, and allowing Medicare to import and negotiate the price of drugs.

Public option.

Yes.

Health insurance should be financed through a combination of public subsidization for those who need assistance to obtain health insurance and premiums that are affordable. Our fundamental goal must be providing health insurance and health care to everyone in America.

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Our goal must be to ensure that everyone in America has health insurance and enjoys a right to health care. To help accomplish this, we must also quickly create a path to citizenship for undocumented immigrants, and I will do so as president.

Yes.

I signed into law the nation’s first publicly funded long-term care benefit, and I believe this is a model for national policy. Washington State’s Long-Term Care Trust Act leads the nation by providing support to care for an aging loved one, or for people of any age to receive long-term care for unexpected injuries or illnesses. It will provide dignity and peace of mind for people everywhere in our state, and it’s the right thing to do.

Yes, and I voted to do so repeatedly in Congress.

Yes, and I voted to do so in Congress.

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The Senator wants to see universal health care and there are many ways to get there. She believes the smartest transition right now would be to do a public option — which could be done by expanding Medicaid or Medicare — and that this will get us there more quickly.

Yes.

All Americans.

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The Senator supports a public option and she favors modifications to the Affordable Care Act, including extending premium assistance to more Americans.

Public option.

Yes.

Combination.

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[This response was left blank.]

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The Senator believes that all seniors should have access to high-quality long-term care.

Yes.

The Senator leads the bipartisan bill that allows for the importation of safe, less-expensive drugs from countries like Canada.

Yes.

The Senator leads the bill on lifting the ban on Medicare negotiating prices directly with drug companies on behalf of the 43 million seniors in the Part D program.

No.

Every American deserves excellent, affordable care. But as the only candidate in the race who receives single-payer health care today (through the V.A.), I’ve experienced such a system firsthand — and there are serious problems with it.

There are 150 million Americans who currently receive private health care, and they should be able to choose public health care if they want it — but they shouldn’t be forced onto a plan if they don’t. That’s why the right answer is a public option, exactly what President Obama had in the original plans for the Affordable Care Act, not Medicare-for-All.

Yes.

All Americans.

A public option would force public and private insurers to compete against each other for our business, which would give Americans the benefits they deserve: better coverage, cheaper prescriptions, lower costs, and health care that isn’t tied to a job.

Imagine having Congress and the next President force UPS and FedEx out of business, making everyone use the U.S. Postal Service whether they wanted to or not. Does anyone honestly believe that lack of competition would improve the U.S.P.S.? Just as we have choices for delivering packages, we should have choices for delivering health care. It’s a better, healthier, more efficient, and fundamentally more American system.

Yes.

I would be happy to sign premium assistance into law. It would extend benefits to the middle class, making health care more affordable for millions of Americans.

But we also need to go further; premium assistance is a great step forward, but it won’t drive costs down far enough, or for enough Americans. We need a public option to truly fix our system.

Public option.

I had private insurance growing up but now get my health care from the V.A. — one of the closest things we have to Medicare-for-All today — so I’ve seen the ups and downs of both systems firsthand. Neither one is good enough on its own.

The right answer is an aggressive public option, where all Americans can buy into a Medicare-like program if they want and keep their current insurance if they don’t. Competition between the private sector and a public option will drive improvements to both.

Yes.

For health care to be affordable, both healthy and sick folks need to be covered on our plans. Everyone does. That’s because if only sick or injured people received health care, the cost of health care would spiral out of control. And any of us can get sick or injured at any moment, so everyone needs coverage to drive down costs and keep everyone healthy. Having everyone enrolled in health care is also critical for preventative care, which saves lives and keeps down costs.

A combination of taxes, co-payments and premiums.

Our system is currently funded through a combination of taxes, co-payments, and premiums, all of which totaled 18 percent of G.D.P. in 2017. That’s twice as much as nearly every other wealthy country in the world. A well-designed system, including an aggressive public option, will address that problem and reduce the overall taxes needed to fund the system. For plans to compete, they will need to bring down the astronomically high bureaucratic costs in our current health care system.

Yes.

They would be allowed to buy into my public option. Under current law, hospitals in the U.S. cannot refuse to treat patients who need care. Therefore, our system already pays for health care for undocumented immigrants — usually through emergency rooms, which are the most expensive form of care.

By allowing everyone to buy into a public option, more folks will be covered, the risk pool will be younger and healthier, and fewer hospital bills will go unpaid. Everyone deserves good health care, and it makes the system stronger and more efficient overall.

No.

We should fund long-term care through government programs, as most other nations do. We should also invest more in home care and senior-adapted home technology to increase the quality and quantity of housing for seniors.

No.

Importing cheaper prescriptions from other countries is not the solution to our high drug costs. Prescriptions are cheaper in other nations because they negotiate drug prices. We should import their system, not their drugs. Importing their drugs has the potential to undermine safety, and more than that, it would risk exporting our drug prices to other nations — thus spreading the problem instead of solving it.

Yes.

Negotiating drug prices will make prescriptions more affordable for all Americans.

I made a commitment to continue receiving my health care through the V.A. even as a Member of Congress. Because the V.A. negotiates drug prices, any prescription I get is 40 percent less expensive than the same medications on private insurance. We should be doing that in all of our health systems to keep costs down for all Americans.

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Beto supports universal, guaranteed, high-quality health care. He believes the surest, quickest way to get there is a proposal like the Medicare for America bill, which says that everyone who does not have insurance today is enrolled in Medicare and that everyone who has insurance they cannot afford, premiums they cannot pay, a deductible they cannot bridge, is free to choose Medicare while letting Americans have the choice of keeping the employer-sponsored and private insurance plans that work for their family’s needs.

Yes.

All Americans.

No.

The Affordable Care Act allowed millions of people to get insurance, see a doctor, afford their medications, receive lifesaving procedures that allow them to live up to their full potential. Beto believes that we need to build on that success by getting to a place where there is guaranteed, universal, high-quality health care. He believes the surest and quickest way of getting there is through a plan like Medicare for America.

Public option.

Beto supports universal, guaranteed, high-quality health care. He believes the surest, quickest way to get there is a proposal like the Medicare for America bill.

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Beto supports a system like the one proposed under Medicare for America which would automatically enroll every uninsured individual and provide universal coverage. Those insured through their employer could choose to stay on that plan or enroll in the Medicare for America system.

Under the current system, the costs of health care are increasingly being shifted onto consumers. Beto is committed to reducing out of pocket costs. Beto supports a plan like Medicare for America which eliminates out of pocket costs for lower-income families, eliminates deductibles for all families, and limits out of pocket costs for middle income and upper income families to levels far below costs under the ACA or the current Medicare program. Such a plan would also set premiums based on a sliding scale as a percentage of income — with free care or subsidies for low- and middle-income Americans. Overall, we will reduce what America will pay on health care costs.

At a time when corporations and the wealthiest among us received a $2 trillion tax cut, we know we have the means to achieve universal, guaranteed, high-quality health care. By using existing allocations more wisely, controlling costs, and letting working families take the money they pay to private insurers and instead let them pay into a public option at a lower cost, we can ensure that every person can see a doctor, afford a prescription, and be well enough to live up to their full potential.

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This issue is one of many reasons Beto believes that comprehensive immigration reform must be a top priority. Because our laws rightly require hospitals to provide care to everyone, the cost of care for uninsured individuals is currently shifted onto other consumers. Therefore, it is in everyone’s interest to provide a pathway for obtaining insurance.

Yes.

Beto supports a plan like Medicare for America, which covers long-term care, including nursing homes as well as home and community-based services. By providing an option to every business and individual to buy into this system at an affordable cost, we ensure people can get the coverage they need.

Yes.

Beto has supported legislation that facilitates the import of safe, low-cost medicine from Canada and Europe where the same medications are available for cheaper.

Yes.

Yes.

Yes.

All Americans.

Yes.

“Medicare for all.”

We need to think big when it comes to making health care more accessible and affordable, which is why I am a long time supporter of Medicare for All. But as we move towards that ultimate goal, we need to be realistic on how we get there. That is why I also support making modifications to the Affordable Care Act and adding public option that would allow Americans to buy into Medicare without eliminating private health insurance options until we as a country can implement Medicare for All in a way that will move our country forward.

Yes.

A combination of taxes, co-payments and premiums.

A surcharge on very wealthy people. But we also need to reform these broken system so we are not throwing money at things that aren’t working. We need more revenue, but we also need to maximize what we have through deep reforms to how our government works.

No.

Yes.

Yes.

Yes.

Yes.

Bernie is running for president because the time is long overdue for the United States to join every other major country on Earth and guarantee health care to all people as a right, not a privilege, through a Medicare-for-all program. Health care is not a commodity. It is a human right. The goal of a sane health care system should be to keep people well, not to make stockholders rich. That is why we need Medicare for All. Bernie’s Medicare for All program would provide comprehensive health coverage to all with no premiums, deductibles, co-payments, or surprise bills.

No.

The question we face is whether we will guarantee health care as a human right. The only way to do that is to pass Bernie’s Medicare for All plan. The current system is completely dysfunctional, and in the current profit-driven health care system, we are at the mercy of the private insurance and pharmaceutical companies, whose greed dictates the cost of health care. The U.S. federal government has failed to rein in health care costs, which many of our peer nations have successfully done.

A public option or other buy-in plans fail to address the underlying problem in the U.S. health care system: corporate greed and profiteering off of the sick. The other proposals do not address skyrocketing prescription drug prices. They fail to simplify the current confusing and dysfunctional administrative system that makes up 17 percent of health care expenditures. Under Bernie’s Medicare for All plan, we slash administrative costs by relying on one payment and billing entity — the federal government — instead of hundreds.

Buy-in and other option plans still leave millions of Americans at the whim of their employers. 30% of employers change plans every year. On top of that, 66 million people separated from their job sometime last year, and by age 50, the average worker has held 12 different jobs. Medicare for All provides stability. After a four-year transition period, every man, woman, and child in the United States will have health care coverage from birth, with no changes or confusing “open enrollment,” no networks, and no surprise bills.

Medicare for All completely eliminates premiums, deductibles and co-payments for services. Under Medicare for All, health care is free at the point of service for all people in the U.S. regardless of income.

No.

Making only minor tweaks to the status quo is not enough. More than 30 million people do not have insurance. 41 million people are underinsured, meaning they have insurance but cannot afford to use it because the deductibles and other cost-sharing is too high. Keep in mind that 40 percent of Americans cannot afford a $400 emergency, yet deductibles routinely run into the thousands of dollars. Making small tweaks to the system may help a few of those tens of millions Americans, but small tweaks are not enough to solve the fundamental problems underlying our health care system.

[This response was left blank, but it was not applicable, since Mr. Sanders indicated support only for “Medicare for all.”]

Yes.

Bernie will guarantee health care as a human right, not a privilege or commodity. The United States must join the rest of the major countries in the world to guarantee health care to every person regardless of income. The only way to do that is to pass Bernie’s Medicare for All plan. Under Medicare for All, every American would be guaranteed care as a right and automatically enrolled in this new system.

Completely by taxes.

Let’s be clear, study after study shows that Medicare for All will save workers and average families thousands of dollars every year on health care, all while making sure corporations like Amazon and the ultra-wealthy pay their fair share.

Health care costs are a crushing tax for middle class families right now. If you count health care premiums as taxes, the United States is the second-highest taxed nation in the world. We can guarantee health coverage to all Americans while bringing down costs, just like every other developed country.

For decades, the American people have been told a lie: that we cannot afford to do what every other major country already does, and guarantee health care to all our people as a right, not a privilege. What the insurance industry’s lies fail to mention is that we already spend more per capita on health care than any other major country, with worse health outcomes, and that moving to a Medicare-for-all, single-payer system would actually end up saving the American people trillions of dollars.

By cutting unnecessary administrative costs, bringing down the outrageous prices of prescription medication, and ensuring large corporations and the wealthy pay their fair share in taxes, we can afford to bring the United States, the richest country in the world, in line with every single other industrialized nation and guarantee quality health care coverage to all Americans.

Yes.

Medicare for All means just that: all. Bernie’s plan would provide coverage to all U.S. residents, regardless of immigration status.

Yes.

Bernie believes that as a nation, we have a moral responsibility to ensure that all Americans have the supports and services they need. Under Medicare for All, health care will be guaranteed as a right and home and community based services and supports will be fully covered.

Yes.

We pay the highest prices in the world for prescription drugs. It does not have to be that way. Bernie introduced the Affordable and Safe Prescription Drug Importation Act, which would allow the importation from Canada and other major countries.

Yes.

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them. Bernie’s Medicare for All plan will allow drug prices to be negotiated by the Secretary of Health and Human Services under Medicare Part D. Bernie also introduced the Prescription Drug Price Relief Act, which will index the price of prescription drugs in the U.S. to the median price of the same drug in five other major countries.

No.

I support coverage for all, i.e., Medicare for all who want it. This would serve as a public option for any American, operating alongside and competing with private insurance plans, in order to drive prices down for everyone. If you’re sick you should be seen, and if you’re seen you shouldn’t go broke.

But we also should do what we do best as Americans: Find the unfindable, solve the unsolvable, and cure the incurable. We must invest in and commit to finding cures and more effective treatments in our lifetime, an initiative to publicly invest in genomics, targeted therapies, and data sharing. We’ll drive down the cost of care, increase our quality of life, and put a new generation of scientists to work while we’re at it.

Yes.

All Americans.

Americans should have a choice between coverage provided by private companies and that provided by the government. While I do not want to bring an end to private insurance, I support coverage for all, which would be a public option that would drive down the pressure on the private insurers and ultimately lead to more affordable plans for all Americans.

No.

It’s not the only solution, but we can and must protect, restore, and improve the protections that the Affordable Care Act gives all Americans regarding coverage for pre-existing conditions, coverage for maternity care, allowing people to remain on their parents’ plans through age 26, and so on.

Public option.

Public option, while restoring/protecting A.C.A. rules for private insurers.

Yes.

Requiring all Americans to have insurance, either public or private, means our health care system no longer has to bear the cost of treating uninsured patients.

A combination.

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Yes.

It is in society’s interest to have everyone be as healthy as possible, and that’s achieved through access to affordable health care for everyone.

Yes.

We have the opportunity to expand a care economy in which we invest in retraining mid- and end-of-career workers, including those displaced by technology, to work in providing long-term care — jobs for those who need them, care for those who need it.

Yes.

I support importing drugs if they meet safety standards and the manufacturers can be held liable.

Yes.

I will do anything that is safe for patients — from negotiating prices to better enforcement of antitrust laws — to make prescription drugs more affordable, because prices are simply too high now for too many Americans. When my son, Nelson, got sick recently, we took him to the doctor and then I went to a chain-store pharmacy to have a prescription filled. The pharmacist told me I was lucky to have insurance because what cost me $5 would cost an uninsured person $250. Later, I talked with one of my district’s few remaining independent pharmacists; he said the prescription’s actual wholesale cost is about $80, so he would have charged an uninsured person about $100. This is a broken system.

There are a variety of additional steps the government could take, such as increasing access to generic drugs and improving access and opportunity for clinical trials, to help lower costs. Whatever is done should reduce prices, maintain incentives for innovation, and ensure drugs continue to be safe and effective.

And our public investment in finding cures, and making those available and affordable, would bring costs down too.

Yes.

I support Medicare-for-All so that everyone is covered, no one goes broke because of a medical bill, and we start treating health care like the basic human right that it is.

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Every proposal on the table right now would layer coverage expansions that add up over time, but there’s no excuse for stopping at half-measures. The aim has to be very clear: make sure every single person in this country has guaranteed health care coverage.

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I have a bill to crack down on shady behavior by insurance companies and improve the quality and affordability of health insurance purchased on the A.C.A. exchanges or provided through employer coverage. We have to protect the A.C.A., but we can’t stop there.

“Medicare for all.”

Our aim should be to cover the most people at the lowest cost, and for me that means Medicare for All. Health care is a basic human right and no one should go broke to pay a medical bill.

Yes.

Massachusetts was a leader in health care reform, including by adopting a requirement that everyone have coverage. This requirement is one of several features that has made health care coverage in Massachusetts some of the very best in the nation.

Studies show that health care costs will decrease under Medicare for All. Families are going broke today from medical bills, and Medicare for All will ensure that co-pays, deductibles, emergency room visits, and prescription drugs don’t drown families with sky-high medical expenses.

Yes.

Health care is a basic human right.

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Medicare for All would guarantee long-term care coverage for everyone in this country. I also believe we must fight against Republican attacks on Medicaid, which is the backbone of our long-term care system for millions of Americans.

Yes.

Yes.

No.

I want to make Medicare available to everyone as an option, but not eliminate private insurance.

Yes.

All Americans.

Yes.

We should keep and strengthen the A.C.A.

Public option.

Medicare provides good quality care at affordable rates, and should be available to those who want it. But millions of people like their private insurance and should be able to keep it. So the best is including Medicare as an option on the health exchanges, a public choice along with the private choices.

Yes.

Through a combination of taxes, co-payments and premiums.

Repeal the 2017 tax breaks for big corporations and very wealthy, retain for middle class.

Yes.

No.

Yes.

Often the same drug is less expensive in other countries. However we need strict monitoring to ensure good quality.

Yes.

Medicare could negotiate lower drug prices for consumers.

Yes.

We pay more than any other major industrialized country for our health care to worse results. When Americans get sick, they’re focused more on how to pay for their care than how to get well. Our current system is dysfunctional and we need to move towards a Medicare for All system that provides coverage for all Americans from birth. I wouldn’t eliminate private health insurance, but I don’t imagine it being an economically viable business outside of supplemental plans since it’s competing against a no-cost alternative.

Yes.

All Americans.

A public option for all would be a major step in the right direction and can serve as a good option for people during the transition from our current system to Medicare For All.

No.

Our health care system today is fundamentally broken and we need to make bigger moves to fix it — not just incremental modifications.

“Medicare for all.”

While all these policies would move us in a better direction than our current system, I believe the best path forward is Medicare for All. This system will ensure coverage for all Americans while allowing us to keep costs under control.

Yes.

By ensuring everyone has coverage, we can promote preventative care and keep costs under control, while also making administrative costs lower for both the federal government and individual providers. And, most importantly, we can make sure that all Americans are taken care of when they’re ill or injured.

A combination of taxes and co-payments, not premiums.

Employer-sponsored health care already represents a huge percent of our spending in this area, and that money can be used to largely fund Medicare for All through a payroll tax. The Medicare for All system will be cheaper because of lowered administrative and other costs, a lack of profit motive, and a focus on preventative care.

Yes.

I believe in a pathway to citizenship for all undocumented immigrants. Anyone who applied for that pathway would be eligible to buy into the Medicare for All system.

Yes.

Long-term care, especially end-of-life care, is an important part of anyone’s lifetime health care needs, and as such should be a part of a Medicare for All plan.

Yes.

Many Americans are paying as much as 8-10 times the prices as Canadians for the very same prescription drugs. While we should start by trying to control prices in the domestic market through mechanisms such as international reference pricing, forced licensing, and public manufacturing of generics, if these efforts don’t work, then we should allow for the importation of prescription drugs.

Yes.

It’s ridiculous that this isn’t allowed already.

 

 

Dead people leave billions in their wills. How long do we have to listen to them?

July 1, 2019

If you’re into podcasts (who isn’t?), and you happen to make your living as a trusts and estates attorney, you’re going to love a recent episode of the Future Perfect podcast entitled Dead people leave billions in their wills. How long do we have to listen to them?Here’s an excerpt from the show notes:

We don’t let dead people vote.

We don’t let dead people run for political office.

But we do let dead people donate money that shapes the world, using charitable trusts.

And as we learn on this episode of the Future Perfect podcast, letting zombie donors pull the strings often doesn’t turn out all that well….

Ray Madoff, a professor at Boston College Law School, wrote a whole book about people donating from beyond the grave, called Immortality and the Law: The Rising Power of America’s Dead.

She says the all-powerful zombie donor is a relatively new American phenomenon.

For the first century or so after the American Revolution, the idea that the dead would have much control over the resources of the world seemed very undemocratic. But then came the Gilded Age, and the rise of a class of unprecedentedly rich people. Some of these robber barons were willing to spread their wealth around — in exchange for immortality. And that immortality came in the form of charitable trusts that lasted forever.

In the decades since, perpetual charitable trusts have become the norm.

The problem? Forever is a long time. And when donors write specific instructions in their trusts, they can’t predict the ways the world will change.

Click here for the podcast audio link. Great stuff, highly recommended.

NAELA Praises House Passage of Bill to Ensure Access to Home Care

July 1, 2019

courtesy of NAELA eBulletin:

The National Academy of Elder Law Attorneys (NAELA) praises House passage of H.R. 3253, the Empowering Beneficiaries, Ensuring Access, and Strengthening Accountability Act of 2019, introduced by Reps. Debbie Dingell (D-MI), Brett Guthrie (R-KY), Fred Upton (R-MI), Frank Pallone (D-NJ), Greg Walden (R-OR), Anna Eshoo (D-CA), Peter Welch (D-VT), Kurt Schrader (D-OR), Michael Burgess (R-TX), and Tim Walberg (R-MI).

The legislation extends, through March 2024, funds for the Medicaid Money Follows the Person Demonstration Project (MFP) and the guarantee that Medicaid’s spousal impoverishment protections will apply to home and community-based service (HCBS) waivers.

Medicaid provides the primary coverage for long-term services and supports (LTSS). Unfortunately, its strict means testing and bias toward restrictive institutional settings puts a severe strain on families. Providing spousal impoverishment protections in HCBS settings better ensures that families can stay together while reducing the risk that the spouse will end up poor due to his or her significant other’s disability.

Additionally, MFP allows individuals with disabilities of all ages to voluntarily transition from a nursing home back into the community. Since the program’s creation, more than 88,000 individuals have been able to move out of a nursing home to a less restrictive setting.

“Keeping families together at home in the face of a chronic illness sadly remains difficult in many cases. Unfortunately, too many individuals wind up in an institution against their wishes. That’s why we are extremely thankful for this bipartisan bill to extend Money Follows the Person, which covers transition services out of a nursing home, and the guarantee that Medicaid’s spousal impoverishment protections applies to home and community-based services,” said NAELA President Jennifer VanderVeen, CELA, CAP, NAELA Fellow.

About NAELA
Members of the National Academy of Elder Law Attorneys (NAELA) are attorneys who are experienced and trained in working with the legal problems of aging Americans and individuals of all ages with disabilities. Upon joining, NAELA member attorneys agree to adhere to the NAELA Aspirational Standards. Established in 1987, NAELA is a non-profit association that assists lawyers, bar organizations, and others. The mission of the National Academy of Elder Law Attorneys is to educate, inspire, serve, and provide community to attorneys with practices in elder and special needs law. NAELA currently has members across the United States, Canada, Australia, and the United Kingdom. For more information, visit NAELA.org, or to locate a NAELA member in your area, please visit NAELA.org/findlawyer.