Our family recently moved our 93-year-old mother, Renee, from her one-bedroom Manhattan apartment to an assisted living facility in Briarcliff Manor, New York. It has a beautiful view of the Hudson River. The river is a familiar and soothing sight for my mother. We grew up a block up from the Hudson in the Bronx, and my mother has gazed at it each morning for the past 27 years from her living room. Now, she has an even nicer view.
Navigating how best to care for aging parents is an expensive, complicated, and emotionally draining journey for all involved. My brother Rick has been spearheading my mother’s general care, her aide support staff, long-term care insurance, and pill management, among other responsibilities. He found the assisted living facility where Renee now resides and managed the move. Her favorite number is three, her February birthday, and like magic, Rick got her a room on the third floor.
I am lucky to have a brother like Rick, with his law degree, financial experience, and attention to detail, playing his lead role in her care while living 30 minutes from her facility. My other two brothers are lawyers with extensive business experience; one also lives close by. Not every family has siblings as well-equipped to analyze and manage the medical, emotional, and financial issues families face as parents age.
My modest assignment last week was to get my mother’s new place ready for her: coordinating furniture assembly, installing closet shelving, mounting artwork, getting internet service, and making sure cable was activated so she could watch the US Open – generally making the place as homey and comfortable as possible.
I spent so much time in the facility the week prior to my mother’s arrival that I felt like the Ted Danson character in the popular Netflix comedy A Man on the Inside, where an age-appropriate undercover agent embeds in an assisted living facility to solve a mystery. What I witnessed made me optimistic. The staff I observed was competent, helpful, and empathetic toward the residents and the family caregivers. A big hurdle is transitioning all her daily pill management to the nursing staff.
It was only recently that my mother embraced assisted living. After decades of living independently, moving into an assisted living facility is a major life change, and not easy. My mother has handled the transition well with all of its attendant emotional ups and downs.
The coming grey tsunami of elder-care facility demand will lengthen waiting lists and intensify competition to secure rooms. Prices will likely rise. This major demographic shift and demand curve has made the assisted living business a lucrative $55-100 billion industry.
My first exposure to assisted living came from Atul Gawande’s Book, Being Mortal: Medicine and What Matters in the End. Gawande described assisted living facilities, conceived in the 1980s, as a middle ground between living entirely independently and being institutionalized in a clinical nursing home. Conceptually, they allow residents to retain more dignity and personal control, with nursing support available as needed, helping them live more meaningful lives while avoiding the boredom, loneliness, and helplessness prevalent in hospitals and nursing homes.
Her facility, called The Club, allows residents to migrate from independent living to assisted living and then to memory care, as needed. Gawande fears senior living facilities will stray from their core values and become more institutionalized, but I didn’t see that during my time as the Inside Man. I thought the energy from those living more independently invigorated the assisted living population. In the elevator, The Club displays all the daily activities available, including concerts, game night, trips, lectures, and who doesn’t want to attend chair yoga at noon?
However, this all comes at a price. The annual cost for an assisted living facility varies from state to state, as states regulate the industry. The average annual cost in wealthy states like New York, Massachusetts, and Connecticut is upwards of $115,000 per year. States like Mississippi, Alabama, and Wyoming average about $58,000 annually. Costs vary based on how many people occupy an apartment (i.e., a couple) and the level of medical care required. Some high-end facilities require an upfront payment of almost $1 million dollars.
There is a huge disparity between the assisted living choices available to wealthy seniors and what is available to middle-class seniors and seniors living at the low end of the economic spectrum. Medicaid was designed as a social safety net for those who cannot afford care, forcing many, including middle-class seniors, to spend down or restructure their assets to qualify for Medicaid long-term care coverage. Applicants generally cannot have more than $2,000 in countable liquid assets (exceptions in NY, IL & CA) to qualify.
Imagine saving your whole life, only to have to give it up because it just isn’t enough. And you cannot just give money away to qualify. Medicaid enforces a strict 5-year look-back period. The government audits five years of bank statements, property deeds, and tax records. Giving cash, homes, or other assets to family for less than fair market value within that 5-year window triggers a penalty period of ineligibility, leaving the applicant potentially without Medicaid coverage for months or years, while still needing care.
Seniors can legally spend down assets by paying out of pocket for private care first, paying off debts, modifying a primary residence, purchasing a funeral trust, or working with an elder law attorney to establish Medicaid-compliant annuities or irrevocable trusts well in advance. Best to consult an elder law attorney, understand the rules, and set up trusts five or more years early.
Please note that even if you qualify for Medicaid support, a bed may not be available. There is a shortage. Note that Federal law requires Medicaid to cover skilled nursing home care for those who qualify financially and medically. Also, many private-pay assisted living facilities do not accept Medicaid at all, or accept it only after a resident has paid full price out of pocket for 1 to 2 years. As a result, middle-class seniors who exhaust their savings often have to move out of high-end assisted living facilities and into Medicaid-certified nursing homes or waiver-approved community homes once their money runs out.
The struggle to find the right care for aging loved ones will only get harder as family members disperse across the country, and people have fewer children to share the burden of managing their parent’s care. For now, I am happy that my mother feels safe, is watched over, is adjusting to her new home, and has a nice view of the Hudson River.
