Emigrating From the U.S. May Be the Only Way To Afford Eldercare

A nursing home for my mother in Germany would cost less than half of what she pays in Sacramento.

Elizabeth Zach January 23, 2019

Illustration by Erin McCluskey

In April 2017, my 84-year-old moth­er suf­fered a severe stroke.

If my mother were to need around-the-clock care, her costs could balloon to $120,000 a year.

For my moth­er, who moved to the Unit­ed States from her native Philip­pines in the 1950s when she was just 25, held a job for four decades, took care of my dying father for three years and then lived inde­pen­dent­ly for five years after­ward, the stroke was a cru­el and dev­as­tat­ing tran­si­tion into elder­ly depen­dent care — and it came with a shock­ing­ly high price tag.

Fol­low­ing her stroke, I moved my moth­er into a senior care facil­i­ty in Sacra­men­to, where I live. The facil­i­ty cost $80,400 last year, and the fee will increase by 6.4 per­cent in 2019.

Lat­er this year, my part­ner and I plan to mar­ry and move to Cologne, Ger­many, where he lives, and we agreed to bring my moth­er with us. So, last Sep­tem­ber, I vis­it­ed the Res­i­denz am Dom, a senior care facil­i­ty in Cologne, and met with Marie-Luise Wrage, a social work­er who coun­sels fam­i­ly mem­bers of poten­tial residents.

When it came time to dis­cuss costs, Wrage appeared slight­ly flus­tered, con­cerned that the amounts would be off-putting. First she explained to me that the Ger­man health­care sys­tem uni­form­ly clas­si­fies stages of dis­abil­i­ty and that costs are strict­ly reg­u­lat­ed based on a patient’s needs. The month­ly fees for my moth­er to be housed, fed and cared for at the Res­i­denz, she final­ly revealed, would come to about $3,200 — at which point I revealed that my moth­er pays more than twice that in Sacramento.

We laughed, but jok­ing aside, agreed: Grow­ing old — or falling ill — in the Unit­ed States is not for the poor.

The nation­al medi­an cost in the Unit­ed States for a one-bed­room unit in an assist­ed liv­ing com­mu­ni­ty is now $4,000 per month, or $48,000 per year. Alzheimer’s or demen­tia care increas­es that cost by an addi­tion­al $1,200 per month. Seniors must also often plan for out-of-pock­et expens­es, in some cas­es up to $2,000 in copays, coin­sur­ance and pre­scrip­tion drugs, as well as ameni­ties not pro­vid­ed by care facil­i­ties, such as toi­letries and non­pre­scrip­tion medicines.

Why the dis­par­i­ty between Ger­many and the Unit­ed States? Ben­jamin Veg­hte, research direc­tor at the advo­ca­cy group Car­ing Across Gen­er­a­tions (CAG) — who, like me, lived for 15 years in Ger­many — explains, There is no orga­nized sys­tem for elder­care in the Unit­ed States, while Ger­many has a social insur­ance pro­gram. Also, health­care in the Unit­ed States is most­ly pri­vate providers, and since indi­vid­u­als have no lever­age to bar­gain, costs are high­er. In Ger­many, there is a bud­get for health­care, where­by the gov­ern­ment nego­ti­ates prices with providers. Every­one pays in, cre­at­ing a whole nation of clients and a viable busi­ness model.”

He notes, too, that, unlike the Unit­ed States, oth­er indus­tri­al­ized coun­tries like Ger­many designed their health­care sys­tems a cen­tu­ry ago — long before there were vest­ed inter­ests rep­re­sent­ed by health­care lob­by­ists with license to influ­ence policy.

The Unit­ed States is unique,” he says. Health­care here is near­ly 20 per­cent of the econ­o­my and the indus­try wants to pro­tect its income.”

The ben­e­fits of the Ger­man sys­tem were famil­iar to me. In 2012, when I was liv­ing in Ger­many, I was diag­nosed with can­cer. Hav­ing nev­er dealt with seri­ous ill­ness, my first thought was, How am I going to work dur­ing treat­ments so I can afford this?” As an Amer­i­can, the words med­ical bank­rupt­cy” kept parad­ing across my mind. I’ve giv­en to sev­er­al GoFundMe cam­paigns of friends in the Unit­ed States who found them­selves unable to work because of treat­ments like chemother­a­py and radi­a­tion that phys­i­cal­ly exhaust­ed them, and they’d mean­while used up all of their allot­ted vaca­tion days and sick leave.

I, on the oth­er hand, nev­er saw a sin­gle invoice for any­thing relat­ed to my care in Ger­many. Whether one is pri­vate­ly or pub­licly insured, health­care there is com­pre­hen­sive and reli­able. I was allowed a year off of work with full pay and also a six-week stay at a health­care resort, none of which is unusu­al by Ger­man stan­dards. I can still remem­ber how per­plexed my Ger­man col­leagues were at my ini­tial anx­i­ety sur­round­ing my insur­ance and whether my job would be in jeop­ardy if I couldn’t work. For them, it was a giv­en that I would be treat­ed so well — as if I were, you know, recov­er­ing from a life-threat­en­ing disease.

All of this was cov­ered by my pub­lic insur­ance through my employ­er (a non­prof­it can­cer research soci­ety), for which I paid twice as much in month­ly pre­mi­ums as I pay now at my job in Cal­i­for­nia. Polit­i­cal con­ser­v­a­tives might well balk at this. I am grate­ful for the care and time off to recover.

I was required, by Ger­man law, to have health insur­ance. In the Unit­ed States, how­ev­er, the Sen­ate vot­ed in 2017 to elim­i­nate the Indi­vid­ual Man­date Clause of the Afford­able Care Act, which required indi­vid­u­als to pur­chase health insur­ance or pay a penal­ty. More than 12 per­cent of Amer­i­cans did not have health insur­ance in 2017, a per­cent­age that experts believe will increase when the indi­vid­ual man­date is sus­pend­ed in 2019.

But that’s not the only way that Germany’s sys­tem is more social­ized than the Unit­ed States’. While no pub­lic option for health­care cov­er­age exists here, the vast major­i­ty of Ger­man res­i­dents are insured by pub­lic sick­ness funds,” or Krankenkassen. In Ger­many, about half the hos­pi­tals are pub­lic and about a third are pri­vate but not-for-prof­it, with the rest pri­vate for-prof­it. There are both pub­lic and pri­vate insur­ers, but all insur­ers are required by law to cov­er every­one and to cov­er a stan­dard set of ben­e­fits, which includes most pro­ce­dures and med­ica­tions. Every Ger­man can access these funds because their insur­ance rates are adjust­ed based on their income. Mean­while, mil­lions of Amer­i­cans fall into what’s called the Med­ic­aid gap,” earn­ing too much to qual­i­fy for Med­ic­aid but too lit­tle to qual­i­fy for the Afford­able Care Act’s subsidies.

The dif­fer­ence in qual­i­ty of care is notable as well. In Sacra­men­to, my moth­er has to share a room and is unhap­pi­ly con­fined in her facility’s mem­o­ry care neigh­bor­hood,” which is essen­tial­ly a sequestered wing of the build­ing; at the Res­i­denz, how­ev­er, she would have her own room and more free­dom to roam the premis­es, which are built around a cor­ri­dor and court­yard, with shops and an adja­cent hotel.

In tak­ing over my par­ents’ estate, I saw how care­ful­ly they had planned for their retire­ment and health­care. Both were pen­ni­less when they immi­grat­ed to the Unit­ed States (my father fled Hun­gary in 1956), but they saved dili­gent­ly and paid off their mort­gage and also my col­lege edu­ca­tion. Yet, despite all this plan­ning, my mother’s safe­ty net could break with just one emer­gency; if she were to have anoth­er stroke and need around-the-clock care, her costs in Sacra­men­to could bal­loon to $120,000 a year.

All of which has left me absolute­ly baf­fled at the Repub­li­can Party’s sub­terfuge against health­care reform. We need a trans­par­ent, fair and reg­u­lat­ed sys­tem. A major­i­ty of Amer­i­cans already sup­port one solu­tion: sin­gle-pay­er health­care, a sys­tem in which a pub­lic enti­ty (i.e., the gov­ern­ment) would cov­er the costs of all med­ical­ly nec­es­sary ser­vices, includ­ing long-term care. Pub­licly fund­ed insur­ance has a proven track record: Accord­ing to the 2015 Glob­al Age Watch Index, the top five coun­tries for elder­ly well­ness (Switzer­land, Nor­way, Swe­den, Ger­many and Cana­da) all have pub­licly fund­ed insur­ance for long-term care.

Thank­ful­ly, groups such as Car­ing Across Gen­er­a­tions — a nation­al cam­paign to improve elder­care in the Unit­ed States — are push­ing for changes to our elder­care sys­tem. CAG calls for the cre­ation of a fed­er­al com­pul­so­ry long-term care insur­ance pro­gram,” paid fam­i­ly leave to ease the bur­den on those car­ing for elder­ly fam­i­ly mem­bers and an ini­tia­tive to incen­tivize and recruit fam­i­ly care­givers into the paid work­force.” These rec­om­men­da­tions would fix gaps in cur­rent elder­care cov­er­age and reduce the costs of car­ing for an aging relative.

For now, how­ev­er, when I think of my mother’s expen­sive dai­ly care, my own past ill­ness and the med­ical chal­lenges that my old age could bring, it’s sober­ing — and dis­ap­point­ing — to acknowl­edge that Amer­i­ca has failed to offer us a more secure life.

Eliz­a­beth Zach is the staff writer at the non­prof­it Rur­al Com­mu­ni­ty Assis­tance Cor­po­ra­tion, where she cov­ers rur­al pover­ty and economies, the envi­ron­ment, and trib­al issues across the 13 states of the Amer­i­can West, includ­ing Alas­ka and Hawaii. In 2018, she report­ed on per­sis­tent pover­ty as a Mar­guerite Casey Foun­da­tion Equal Voic­es Jour­nal­ism Fel­low. In 2016, she was a fel­low at the Uni­ver­si­ty of South­ern Cal­i­for­ni­a’s Annen­berg School of Jour­nal­ism, writ­ing on rur­al health­care in Cal­i­for­nia. In 2015, she was a media fel­low at Stan­ford Uni­ver­si­ty’s Bill Lane Cen­ter for the Amer­i­can West, for which she researched and wrote about women farm­ers and ranchers.
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