Rabbi Calls Out From the Shtetl: "Raise Medicaid Reimbursement Rates"

Even for secularist me, Rosh Hashana packs surprising power. I use the season to resolve old debts and squabbles and note my recent accomplishments and failings.
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The other night, I watched Castaway with my daughter. In case you've been stuck on a Pacific Island, Tom Hanks plays Chuck Noland, a FedEx executive left by a plane crash in the same predicament.

Desperate for company, Chuck paints his likeness in blood on a Volleyball whom he names "Wilson." His new friend can't offer much practical help, but Chuck couldn't survive without him. They spend years together. One day, Chuck builds up the courage to leave the island on a makeshift raft. During a storm, Wilson falls from the boat and floats behind. Chuck tries to swim back, but he reaches the end of the tow line and realizes that he must abandon Wilson or he himself will drown. Chuck deeply mourns, but he moves on.

Minus the product placement, this is a divinely-inspired metaphor for our relationship with God.

Still, today is Rosh Hashana. Even for secularist me, it packs surprising power. I use the season to resolve old debts and squabbles, note my recent accomplishments and failings. My wife and I read aloud to our kids from the hokey but nice Treasury of Jewish Holidays. For Rosh Hashana, there is a nice children's story based on I.L. Peretz's tale, "If not higher." Here is a nice web summary :

The Rabbi of Nemirov had a strange habit. Every Friday morning he vanished.... Then suddenly, just in time for Shabbat, he would reappear. No one knew where he went. A whisper went among his disciples that the rabbi actually ascended to heaven for a few hours, communed with God, and returned.

One new student, a bit of a skeptic, could not stand the mystery and desperately wanted to know where the rabbi really went each Friday. One Thursday night in winter, the young man sneaked into the rabbi's house. He climbed under the rabbi's bed and waited there all night until the rabbi awoke just before daybreak. The rabbi dressed himself in old, dirty clothes, the clothes of a woodsman. Taking an axe and a large bag from a hook on the wall, out he went.

The young man followed as the rabbi went deep into the woods. At one point the rabbi stopped, and chopped and split as much fire wood as he could put into the bag. He then continued into the woods, the young man following quietly behind. Eventually the rabbi came upon a rundown shack, and knocked on the door. A strained woman's voice called from within, "who's there?" The rabbi replied, "The woodcutter. I see no smoke coming from your chimney. You need wood. You must be cold." "I am," the woman said. "But I am a poor, sick woman. I have no money to pay you." "Don't worry," the rabbi answered. "I'll lend you the money you need." "But I don't know when I can pay you back." Again, the rabbi said, "Don't worry yourself, you'll pay me when you can pay me."

The young man saw the rabbi enter the house, and heard the sound of wood being unloaded and stacked. A few minutes later a curl of smoke began to float upward from the chimney. The rabbi left the house, axe in hand, and headed for home.

The young man followed him back to town. He could, of course, tell no one of what he had seen. But from that Shabbat on, he prayed at the rabbi's synagogue and studied at the rabbi's table. And ever after, when some disciple would remark on the Rabbi of Nemirov's Friday habit of ascending to heaven, the young man would quietly respond, "Im lo ma'alah mizeh" - if not higher.

I love this story--which raises the neglected topic of long-term care. News flash: hundreds of thousands of Americans require nursing home care, and the system is pretty cruddy. Today's New York Times reports that 94 percent of such facilities were cited for violating health and safety standards last year. One in six facilities were judged bad enough to cause "actual harm or immediate jeopardy." Problems included infected bedsores, medication errors, bad nutrition, patient abuse and neglect. It's terrifying to imagine that a loved one might experience such shoddy treatment. Given what foolish deregulation has done for the economy these days, it's not surprising that the for-profit sector performs especially poorly.

Familiar reasons account for these problems. Many facilities are poorly managed. Staff-patient ratios are too low. Regulation and oversight are too lax. Most invisibly, Medicaid reimbursements are inadequate. Politicians skimp on this because it frees money for sexier stuff, and because they evade accountability for the inevitable results: underpaid, overworked staff cannot provide the care everyone knows they should.

We must address long-term care with the resources, the seriousness, and the dignity the subject demands. This requires that we bring this into the realm of social insurance. Our stressed state-federal Medicaid partnership is not carrying the load.

Conservatives don't like that Medicaid is becoming a common lifeline for millions of middle-class Americans who seek care, as one critic put it, in "welfare-financed nursing homes." We hear recycled stories of rich seniors who use Medicaid as an "inheritance protection plan." Hard as it is for free-market enthusiasts to accept, the private market isn't working for long-term care, and probably can't work. More stringent regulation, along with subsidies to high-risk consumers, would help but would probably not be enough. I won't rehash what Jacob Hacker and I have written elsewhere. Yet it's ironic that the party that rails against the "death tax" and touts private Social Security accounts seems so sanguine about the possibility of losing your nest egg if you contract Alzheimer's.

America spends trillions of dollars on medical care. We still don't provide the quality of care, the security, or the dignity that our loved ones and ultimately we ourselves deserve.

The Rabbi of Nemirov might not like my Castaway story. On the other stuff, I bet he would agree.

Shanah tovah.

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