Death spirals and other problems the Republican health plan doesn't solve

My grandmother spent the last years of her life in a nursing home, and I like to think that my grandfather would have been proud to know that she paid her own way until she died. In a long life of seven-day-a-week work, he held one principle above all the others: “Make sure Lettie is taken care of.” And he did. When she died at 101, she was one of the rare nursing home patients who manages a multi-year stay entirely on private pay.

That nursing home stay ate most of what he’d spent a lifetime piling up, of course. And most people do not accumulate those sort of assets; my grandparents combined some good luck with ferocious hard work, talent and extremely modest tastes, enabling a small-town small business to generate enough money to pay the bills for extended end-of-life care. With an average annual cost in the high tens of thousands, a single year in a nursing home will exhaust the financial assets of most families. That’s when those patients go on Medicaid.

So when I learned that Republicans had finally passed their very own Rube Goldberg health-care contraption, which includes changing the Medicaid payment formula to a fixed per-beneficiary sum rather than the open-ended entitlement it is now, I wondered: “What happens to nursing home reimbursements?”