The relationship between money and a dignified, peaceful death.

Along with my prior blog about choosing the right healthcare proxy, my dear friend also consented to share the following, intimate account of her father’s passing, as a service to readers of this blog.

I am conveying her story because it is the perfect example of the difference having ample money to pay for long-term care makes.

Money creates options. With money, comes access to higher quality long-term care. If you don’t have many millions of dollars saved, you must rely on long-term care insurance if you wish to access high quality long-term care.

As you read this story, imagine how different D’s father’s end of life would have been if he had not had ample money to pay for the independent living community plus the 12-hour a day home health care her father needed. Most families do not have the wealth to do this.

D’s father required rather extensive care for about seven years at a total cost of nearly one million dollars.  This would obviously be a financial catastrophe for the typical American family, in addition to causing physical and emotional sacrifices for most families. Fortunately, all three siblings agreed to spend as much wealth as necessary on their father’s care. This is not always the case. As you read D’s story, you will see that because her father had superb care from others, D did not have to provide daily  hands-on care for her father. However, D was actively involved in checking on her father’s care – which contributed significantly to its high quality. She also provided essential emotional support to her father on a daily basis. 

This combination of no financial stress plus D’s daily presence by phone or in person over a 7-year period undoubtedly extended his life and significantly added to its quality. 

LTCi ownership is about making sure you have access, dignity, options, and choices if you need long-term care, at minimal financial, physical, and psychological sacrifice to those you love most.


D’s story:

Dad moved into independent living with an aide. He had end-stage macular degeneration & hearing impairment.  Having an aide enabled him to have a better quality of life, interacting with others. He made new friends, lost others, but powered on. Managing Dad’s care was my full-time job during his final years.

I took Dad for his check-ups, especially his pulmonologist, a wonderful caring man. Dad had been on oxygen constantly, for the last 3 years as his lungs were failing. I was unhappy about Dad’s color, so I took him for a check-up. I received the news that the end was near and it was going to be bad. The doctor was right. Witnessing my father’s death was gut wrenching. I was determined to make Dad as comfortable as possible.

Dad’s last week was spent gasping for air, completely overheated, sweating profusely. When I called, he had kept hanging up the phone on me. I did not realize how close the end was because of this.

Dad’s 97th birthday came, he woke and asked if he was 97 yet. Then he said “Good!” and went back to sleep. Close family and friends spent his birthday sitting with him, talking to him, holding his hand.

Periodically, I would ask him if wanted to be held, he would nod yes. So I would get in bed with him and hold him. At one point, he started patting my tush and I reminded him that I was his daughter. He replied, “ I diapered that tushie, it’s mine,” laughed, and fell back to sleep.

Hospice had been called, but they were a bit late in arriving. By then, his whole body had quieted down, no more gasping for air like a fish out of water and profuse sweating. The RN said he was ready to go, based on his posture, appearance, and his not waking anymore. The purpose of Hospice was to give liquid Morphium to ease my father’s suffering.

Two days after Dad’s 97th birthday, on the last night of Passover, he died. He had fun, joy, laughter delighted in his family and grandchildren. He was always the best dressed man in the room. I can also say he was not always a joy. He could be oh so cranky, with the best of them, but witty. We had a standing date every Wednesday and he sang me good-night every night, in that croaky voice that couldn’t carry a tune with a bucket.


Choosing a Healthcare Proxy and Long-Term Care Planning

Planning for long-term care and choosing a healthcare proxy (HCP) must both be done as far in advance as possible, with as much honesty as humanly possible.

Be very sure that the people you choose as your HCP will carry out your wishes.

Both are done because people wish to have the highest possible caliber of care, dignity and options, even if they have limited, or no capacity to make decisions.

Choosing the right HCP also ties in to long-term care insurance (LTCi) purchase because both are done out of the utmost consideration and love of others.

Both actions are done to ensure the least amount of stress and discord for surviving family and friends.

The following is a true story, shared by a very close friend:

“Because my father did not want my sister to feel left out, he named her as his second health care proxy (HCP). That was a bad decision and the wrong reason to grant a HCP.

My Dad lived a long and very productive life, retiring at 87. As he approached 90, some medical issues that he had since his late 20’s became much worse.  But each was survivable.

With Dad’s consent, my siblings and I decided that there would be no surgeries or heroic measures taken to keep him alive. 

Despite his failing health, Dad was astute and very capable of managing and understanding his business affairs. He ably directed his wishes. He appointed our brother Power of Attorney. As Dad was filling out the HCP form with his attorney, he said to me, ‘You are number 1. You will make my medical decisions with and for me, as you have been doing for years. I have to give your sister something, or she will feel totally left out, so I am making her #2. I do not want her husband  involved in the decisions.’ Dad also had a Do Not Resuscitate (DNR) order, much to my sister’s surprise.

 For years, I took care of all of Dad’s medical care.  My sister only visited from time to time, when Dad was hospitalized, or to spell me for a day or two. She had a family, lived out of town and was busy with her life. The key thing Dad didn’t want was to die in a hospital with tubes sticking out of him, strangers around him, alone. He was very clear about this.

My sister chose to ignore our father’s DNR, along with his wishes. 

My sister was visiting.  Sitting in Dad’s living room, She heard Dad’s agonizing gasps but chose to overlook them. She did not call me. When I got there, she said to me cheerily, ‘what’s up?’ 

I dropped my things on the floor and immediately went to Dad; I knew this was it. That sound, that sound, that unmistakable sound was horrifying. I believe my father was in pain. Unnecessary pain. I do not understand how anyone could sit in a room obliviously over-hearing painful gasps. She did look in on him from time to time, but she was out of touch with reality. She continued texting, making calls, laughing, etc.

Once I got there and she acknowledged the severity of the situation, she said, ‘I am #2 HCP and my husband says Dad should be in the hospital with an IV drip for his dehydration and someone should work on a small bedsore that had appeared in the last few days and he should be intubated.’

 My father’s lungs had ceased to function. Her behavior was nuts. I replied, ‘Your husband is not the one with the HCP and you cannot delegate. You can refuse your responsibilities or do what Dad wants. This is the end. The RN has given you the facts. I can have the MD call you directly to tell you the same thing.’  My sister insisted on calling her husband. Our brother had to assertively remove our sister from Dad’s apartment.”

A very difficult situation was made much harder just by the bad choice of a HCP.

Make sure your wishes are known. My attorney has a copy of my last wishes to back up my HCP, just in case some stranger butts in to change your decisions.

My advice is make sure that those you select as HCP are chosen for the right reasons. They should be reliable, in the loop on medical status, doctors, meds. They must be capable of making decisions without consulting a spouse or someone else for every move, and they must be able to defend your wishes and act in your best interests, first and foremost.


Sign that I’m Getting Old: I See Actual Evidence of Income Inequality

In my prior blog,, I gave irrefutable proof that income inequality is here. Due to the human tendency to deny facts that are unpleasant, it is often difficult for even smart, educated people to acknowledge this.

The email below comes from an informed prospective client who works in the long-term care industry. Every day she sees families in crisis, largely because their loved one does not own long-term care insurance (LTCi).  She believes LTCi is the only solution for middle-class people who want to secure their dignity and options, should the probable need for long-term care arise. She sought my help upon the strong recommendation of her friend.  We had a good rapport, and I showed her reasonable LTCi premiums. At the point of placing her LTCi application, she froze in fear, like a deer in headlights :


Just wanted to touch base with you. I want to be respectful of your time. My week became crazy at work. Things went haywire with individuals quitting and getting laid off. I am going to hold up on my long term care insurance. I will pay the increase when I get the insurance. I may be getting laid off. I will know some time in Feb. I do not want to take on added expense until I know something. Thank you kindness and patience with me. 


When I began selling LTCi 23 years ago, I did not get many objections like the one above. True enough, there was horrid, incorrect, sometimes scathing media coverage of LTCi in those days. This is not as true nowadays. People were also convinced Medicare would pay for their long-term care or that their kids would care for them. Thankfully, both of these myths have been largely dispelled.

Now we have income inequality replacing the obstacles described above and throwing a wrench into what I believe would be an otherwise thriving LTCi industry.

This is sad to me. With the presence of income inequality, there is a stronger than ever need for LTCi ownership.



New study shines light on family long-term care providers

A new study by the AARP Public Policy Institute and the United Hospital Fund reports on just how much care, and what type of care employed family members (unpaid caregivers) provide. The findings are alarming. They show that despite their workplace obligations, nearly half of all employed family caregivers perform many of the tasks we normally associated with licensed health care professionals, including a range of medical/nursing tasks, such as medication management, wound care, using meters and monitors, and more.

An earlier report by the same authors found that nearly half of family caregivers (working and non-working, combined) nationally performed such medical and nursing tasks. This new report shows that family caregivers who also work, perform medical/nursing tasks at about the same rate non-working family caregivers do.

These findings surprised the researchers, who expected more of a difference between the extent to which employed and not-employed caregivers perform medical/nursing tasks.

The report also examines the characteristics and stress levels of working versus unemployed family caregivers. No surprise here: employed caregivers have more stress.

Much of the stress family caregivers face would be alleviated with the presence of long-term care insurance.

It’s always best to move ahead of life events

A long-time client, Carolyn Bowden, has been kind enough to share her thoughts about why she and her husband chose to downsize from a larger home to a significantly smaller rented apartment while they were both still very independent.

I strongly feel it’s far better to honestly consider and realistically prepare for possible health adversities far in advance. Life is more enjoyable this way. Buying long-term care insurance is an important part of doing this, and so is preemptively downsizing, as the Bowdens have done.

Carolyn told me that she and her husband made this move not only for themselves, but also for their entire family.

I admire Carolyn for making this considerate, preemptive move and am grateful to her for offering the share her experience with my readers.

What follows is a quote from her recent column she wrote, featured in the _____”

“My husband and I moved in November 2013 to a Senior “Independent” Living Residence for adults (only) over the age of 50.   Our 2 bedroom, 2 bath apartment is just 1026 square feet with a balcony.  This meant we could only take with us 1/4th of the contents of our home.  We do have a small, 3 by 8 foot storage room outside our apartment, and we selected to park our car in a car port instead of one of the small garages.  Our apartment is on the top floor, at the rear of the building on the north side.

The month before our move, I would walk our house and “grieve” over what I was leaving behind.  Our new home has amenities, such as, granite counter tops, an attached garage and a beautiful view of the adjacent park behind our home.  We lost items like our sterling, lenox china and crystal, which were sold in an estate sale, along with family treasures going back over 200 years.  The children have their own “treasures”. I consoled myself by envisioning what had been mine, would now be in “new” homes and my hope was that they would be appreciated and enjoyed.

I am excited with the intimate apartment and have discovered how much easier it is to maintain. Our is more carefree now. In some ways,  we have fewer decisions.  For example, I only have one set of tongs, 3 sauce pans, and 3 skillets, etc.  It is like living in a small cottage, except that I do not have the white picket fence with climbing roses.

We are renting now. How nice it is to just pick up the phone or email when maintenance and repairs are needed!  We bear no unexpected expenses. There’s no need to wait for repairmen to arrive.  There is no expiration of service warranties to deal with.  I am so very happy!

However, my husband is not as comfortable with the changes.  He misses his recliner, his view of the park where there was always something of interest to see.  He can no longer open the door to venture outside and check out the yard and trees.  But, he is trying.  He is pleased with no longer having major home repairs and expensive maintenance of the yard.

It is my thought that this time next year he will be more adapted.  Thoughts of what we left behind will be just memories.  We will be busy moving ahead.”


Studies Explain Why Americans Won’t Plan for Their Long-Term Care

My prior blog describes two recently published studies, commissioned from the Center for Long-Term Care Reform. For those of us who study long-term care financing, the studies are quite frightening. They quantify how economically vulnerable states are for long-term care (LTC) expenses. The studies were for GA and VA, and a forthcoming study will examine NJ. More information on these studies may be found at the Center for Long-Term Care Reform.

An op-ed piece for the Columbia County News-Times, by Steve Moses, president of the Center for Long-Term Care Reform, was published on December 11, 2013. In his piece, Steve describes how easy it is for a citizen with business savvy and means to get the government, through Medicaid, to pay for their long-term care. Even though publicly funded long-term care is of inferior quality, it is “free”, or rather, it is free only at the expense of taxpayers, while the citizen often preserves much of their wealth though clever legal strategies.

The fact that it is fairly easy to get the government to pay for long-term care anesthetizes the public and prevents it from responsibly planning for long-term care in advance, with long-term care insurance (LTCi). But the gimmicks for free LTC will certainly backfire as more states confront the dilemma of greater demand for Medicaid funds than they can possibly meet, and when the seniors who manage to get into Medicaid nursing homes become aware of the miserable environment in which they will spend the rest of their lives. In stark contrast, someone who needs LTC and owns LTCi will have many more options and access higher caliber care. Studies show LTCi owners also access care sooner, and with less panic and emergency than Medicaid (Welfare) recipients.

Here’s a link to the study done for Georgia:

Take responsibility, folks!

Thank you again, Dear Abby, for providing fodder for this blog.

When I read this recent column, written by a daughter whose mother is evidently in a Medicaid-paid nursing home and receiving less than respectful care,  I said to myself, “grow up; face the truth and don’t pawn off the blame onto others.” The daughter’s sugary sweet letter smacks of the misguided denial I often see. It is cloaked in the daughter’s dysfunctional view of reality. The daughter aims her complaints at her mother’s caregivers, who are simply the most visible, yet non-responsible, cause.

As usual, Abby  does not address the actual problem, which is the public’s widespread avoidance of conversation and responsible planning for long-term care, well in advance. However, she did give a correct answer to the letter writer, which is, “don’t blame the messenger”! Abby also correctly noted that the caregiver is the lowest ranked, lowest-paid, least respected, and in the most understaffed area at the nursing home. These caregivers do their best. They often work two or more jobs, and really must have heart and soul to want to do this type of work. Don’t blame the caregiver for the low quality care you are nearly certain to receive in Medicaid-funded nursing homes.

Understanding Rate Hikes

As far as I can tell, every reputable long-term care insurance (LTCi) carrier that’s sold LTCi for more than five years  has given its policyholders at least one rate hike. I will attempt to explain what causes LTCi rate hikes and what to do about them.

What causes rate hikes?

  1. LTC insurance policies have extraordinarily high persistency, which means that about 95% of all LTCi, industry-wide, remains on the books after it is sold. When LTCi is properly placed, hardly anyone ever drops their policy.  LTCi persistency is higher than actuaries anticipated
  2. LTCi policies also have incredibly long “tails”, meaning that an LTCi policy sold to a 55-year old might stay on the books 30 or more years before it is collected from
  3. Protracted, low, interest rates
  4. Claims that last longer than expected

These characteristics combine to cause a perfect actuarial storm for LTCi carriers and policyholders.

LTCi’s high persistency rate and long tail are unique. Because of both of these traits, when an LTCi policy is issued, the carrier must post very large amounts of reserve funds. The carrier invests the reserves in conservative, long-term assets. The majority of LTCi’s profitability is derived from interest earned on these posted reserve funds. When interest rates plummeted unexpectedly in recent years and stayed down for so long, when policies experienced higher than predicted persistency rates, longer “tails” and claim durations, prior actuarial assumptions became incorrect. Rate hikes are a means to adjust for these inaccurate assumptions and to ensure that all policies are paid in full when clients collect on them.

It’s a good thing LTCi carriers do this. They act in a responsible way. I would rather have LTCi carriers give rate hikes to be able to honor their obligations to policyholders, than behave like the federal government and make financial commitments that it cannot meet in the future.

If clients cannot increase their payments to cover the rate hikes, the majority of LTCi carriers allow policyholders to pare back their LTCi at time to get their premiums back down. Even if an LTCi policy needs to get pared back to keep its premiums affordable,  the policyholder will normally still have a high-performance policy.

What causes public alarm and outcry over LTCi rate hikes?

When I get client calls in response to news of their LTCi rate hike, reactions typically consist of fear, anger or a mixture of both.

I blame the media and the insurance industry for much of  these reactions.

The media is historically under-educated on the subject of LTCi. Today, with fewer journalists  and less freedom than ever to adequately research before tight deadlines, the media often gets the story of LTCi rate hikes all wrong. There are exceptions. Terry Savage is one. She’s one of a dying breed of true journalists with the luxury of being able to meticulously research her stories before they’re published. More often than not, media runs “if it bleeds, it leads” stories about LTCi. Such incorrect stories describing “intolerable” LTCi rate hikes, without providing adequate explanation, are the norm in mainstream media, not the exception.

The insurance industry must also accept some blame because of its high employee turnover. It is highly unusual for the selling agent to be still active, accountable and present when clients receive rate hikes.  And when policy holders inquiring about the increased premiums do not receive the proper explanations and information, their logical reaction is a combination of anger and fear. When this  results, lacking a competent agent’s insight, help and advice, policyholders too often make the wrong decision about their LTCi policies.

The truth is, even with rate hikes factored in, the original LTCi policy is normally still a steal of a deal. It is easy to prove this. All we need to do is take the rate hiked LTCi policy’s current monthly or daily benefit (if it has built-in automatic growth every year, its current values are usually significantly higher than what the policy started at). We then compare rates for a replacement LTCi policy at the policyholder’s current age, not their original buying age. When we compare the prices of equivalent new coverage with the present policy’s benefits, and at the client’s present age, the results are normally quite shocking. Even with the rate hike taken into account, the original LTCi policy is still very inexpensive, compared to what a new, comparable policy would cost.

In my experience, policyholders calm down when they understand the impact of insurers’ claims experience and low interest rates. When the circumstances causing LTCi rates hikes are explained to them in a businesslike, rational, professional manner, the majority of my clients choose to keep their LTCi policies and tolerate the rate hike.

I lament that so many LTCi policyholders have no one they can trust and turn to for advice when their rate hike letter arrives. This can cause unintended, bad headlines and publicity for LTCi. This in turn gives people and families additional excuses to put off having conversations about responsible and reasonable long-term care planning.

I have seen in excess of 300 of my clients’ LTCi policies pay out lavishly and with ease, exactly as planned. This has given my clients increased dignity and options. It has prevented much stress and strife, both emotional and financial, for my clients families. I have never had a single claim denied in the 23 years I’ve been in practice.

A single top income could buy housing for every homeless person in the US

Jim and I just saw a disturbing /engrossing/very important film called Inequity for All”. I encourage everyone to see this film! It had a huge effect on me. It takes complex, abstract economic concepts, adds humor and the human element, and makes these concepts very approachable and easy to understand.

From the film’s site:

  • In 1983 the poorest 47% of America had $15,000 per family, 2.5 percent of the nation’s wealth.
  • In 2009 the poorest 47% of America owned ZERO PERCENT of the nation’s wealth (their debt exceeded their assets).
  • At the other extreme, the 400 wealthiest Americans own as much wealth as 80 million families – 62% of America. The reason, once again, is the stock market. Since 1980 the American GDP has approximately doubled. Inflation-adjusted wages have gone down. But the stock market has increased by over ten times, and the richest quintile of Americans owns 93% of it.

How does income inequity pertain to responsible long-term care (LTC) planning?

When I began my long-term care insurance career in 1989, sales of long-term care insurance (LTCi) nationwide were slow. The biggest battle I fought was people’s ignorance, not fear. In those days, people insisted the government would pay for their long-term care, their kids would take care of them, or they would never need long-term care. The media, too, were very ill-informed. Most media coverage disparaged LTCi at every opportunity, and called it a non-essential rip-off. Even the insurance industry considered LTCi to be its illegitimate step-child in those days.

In 2013, the above issues have pretty much been dismissed. Studies today prove the majority of people now admit they might need LTC, and that they are financially unprepared to pay for it.

Interestingly, LTCi sales still languish

In today’s world, the ever-present stress of job insecurity, having to stay in a job you hate, toxic co-workers, working in order to have medical insurance, longer hours, job cutbacks, stagnant wages, higher tuition, overhead, and debts, with no visible way out of such predicaments, is common. Many are understandably scared.

When people live with these types of fears, they often suffer from emotional, irrational inertia and the inability to act affirmatively. We LTCi specialists can show them $50/month premiums they can easily afford. They might have nursed their own mother for years, at considerable physical and economic loss, yet they are paralyzed with fear and do not purchase reasonably priced LTCi. They cannot act.

Inequity for All describes the vicious cycles that result from income inequity. Slow LTCi sales, despite the fact that most now understand LTCi ownership is the only rational solution to big problems many of us will face, is one more dangerous by-product of this nation’s mounting income inequity.

Truthful info on LTCi claim payments

These statistics from Genworth, a leading long-term care insurance (LTCi) carrier, provide insights into the nature and complexion of LTCi claims:

If you missed Genworth’s webinar on their claims history over the past 38 years, here are some interesting facts: 

Youngest claimant: 27 years old

Oldest claimant: 103 years old

Longest claim: 19.6 years

Most expensive claim (still ongoing): $1,300,000

71% of all claimants are females 29% of all claimants are male

51% went on claim due to dementia & cognitive issues

15% of all claims lasted more than 5 years

Average length of claims, if on claim more than 1 year: 3.9 years

71% of claims started with home care 13% of claims started with assisted living facilities 16% of claims started with nursing homes

50% of claims lasted less than 1 year (conversely, 50% lasted more than 1 year)

The reason claims closed: 61% death 28% Recovery 11% exhausted benefits Average age of claimant: 79

Who goes on claim?

38% Single women 28% Married Women 10% Single men 24% Married men

Most expensive claims: Dementia & Parkinson’s