Wednesday, January 26, 2011

Aged care dilemma: tap homes, or let taxpayers pay

There's a lot more to life than money. But it's money - how much things cost and who will pay for them - that causes many of the arguments in families and most of the arguments in politics. Nowhere is that truer than in aged care.

We all agree that old people must be adequately cared for in their declining years and that governments must ensure this happens. But where does private responsibility end and public responsibility begin? More to the point, how should the cost of care be shared between the individuals involved, their heirs and successors, and the taxpayer?

The scope for duck-shoving - the temptation to push costs off on to someone else, particularly the anonymous taxpayer - is enormous. Trouble is, governments represent the taxpayer. Elected politicians know that if the demands they make on taxpayers get too high or grow too rapidly, they're in trouble.

Unless we're careful, we end up with government paralysis: politicians who aren't game to push more of the costs back on to individuals and their families, but aren't prepared to impose a lot more cost on the taxpayer.

The result is an aged care system that isn't working properly. Where some old people who need care aren't getting it because the government has imposed arbitrary limits on how much it's prepared to spend; where some individuals are getting a much bigger public subsidy than is fair, while others are paying a lot more than is fair, and where institutions are underfunded and the people who work for them are underpaid.

As last week's draft report from the Productivity Commission reminds us, that's where our aged care system is now and where it will stay until we find federal leaders with the courage to stand up to both the duck-shovers and the reluctant taxpayers.

But, actually, the system won't stay as it is for long. The ageing of the population means a lot more people will be requiring aged care in coming years, particularly when the bulge of baby boomers reaches old age.

The commission says there's no way the cost of aged care to federal taxpayers will fail to grow significantly over the years. So, barring the unlikely event of offsetting cuts in other government spending, we will have to pay higher taxes.

We can, however, limit the growth in cost to the taxpayer - as well as alleviating other deficiencies in the present system - by making the system more efficient and requiring greater contributions to aged care costs from those individuals in a position to make them.

What would be fair? The commission starts by dividing the total costs faced by old people requiring care into four categories.

First is the cost of accommodation, which is equivalent to rent or mortgage payments and home maintenance. Next are everyday living expenses, such as for food, clothing, laundry, heating and social activities.

Third is the cost of healthcare, such as nursing, therapies and palliative care. And fourth is "personal care" - the additional costs of being looked after because of frailty or disability.

The commission argues that accommodation and everyday living expenses should be the responsibility of individuals, but with a safety net for people of limited means. (Remember, this is why people receive the age pension. Those ineligible for the pension - or for a full pension - have other, private means to call on.)

The commission argues that health services should attract a universal (that is, non-means-tested) subsidy, as is a key principle of Medicare.

On the cost of personal care, the commission says individuals should be required to contribute according to their capacity to pay, but shouldn't be exposed to catastrophic costs of care. It suggests maximum lifetime payments be capped at $60,000.

We tend to think of the elderly as among the poorest in the community, but that's because we focus on their usually modest incomes. But it's a different story when the focus is on their assets.

The distribution of wealth has been shifting towards older Australians since the mid-1980s, and this trend is likely to continue. It's estimated that, in 2000, the 12 per cent of the population aged 65 and over held about 22 per cent of the total net wealth of households. It's projected that by 2030, the aged's share of the population will rise by 7 percentage points, but their share of net wealth will more than double to 47 per cent.

Where's all this wealth coming from? From the rising value of the family home. The rate of home ownership among the elderly is very much higher than among the rest of us. Yet the value of people's homes is largely ignored when calculating their aged-care charges and subsidies - until the house is sold, when everything changes.

This is what the commission says must change to make the cost-sharing fairer to those oldies who've never owned their homes or have recently sold their home, not to mention working taxpayers who may be far less well placed in the housing market.

Taking account of the value of people's homes in assessing their ability to contribute to the cost of their care - which the commission says should vary between 5 per cent to 25 per cent - would increase the pressure on people to sell their home or at least borrow against it.

It proposes widening the use of accommodation bonds - where money is lent to the care institution interest-free - but with the proviso that the size of bonds reflects the actual cost of accommodation.

Many old people and their inheritance-conscious children will hate the sound of all this. But since even John Howard lacked the courage to impose these reforms, it's doubtful whether Julia Gillard will be game to touch them.

The only trouble is, our treatment of people receiving and providing aged care will continue to worsen until we as a nation are prepared to call a halt to the duck-shoving.