Love Is (Not) All You Need

In 2004, Roberta H. and her husband, Alex, both 64, were living a contented life in a small town in western Massachusetts. Married for 39 years, with two grown sons, they had saved for years and were looking forward to traveling in a year or two, once they retired from their respective jobs—Alex was a college English professor, and Roberta was director of communications for a consortium of local colleges.

Then disaster struck. Alex was diagnosed with early-stage dementia and took early retirement from his job. Determined to care for her husband at home, Roberta paid a variety of people—at a cost of about $1,000 a month—to take him for walks, drive him to the YMCA, and prepare his lunch. She filled in the gaps by telephoning him several times a day.

As his dementia worsened, though, Alex needed full-time care, so Roberta found an adult-daycare center that could take care of him while she worked. For 18 months, Roberta dropped off Alex in the mornings and picked him up after work, a routine that worked well until he had a medical emergency—painful urine retention—that landed him in the hospital. Medicare paid for Alex's stay, but after three days the hospital released him, even though he could barely walk. "It was such a stressful time," says Roberta, "and I had no time to figure out where Alex should go to get the therapy he needed."

A flurry of phone calls later, she found a skilled nursing home that didn't have a waiting list, but there was a catch: Medicare would cover a total of only 100 days of skilled care and rehab. After the coverage ended, Roberta began drawing on the couple's savings, paying the nursing home $7,500 a month, plus miscellaneous expenses. Eight months and $75,000 later, the stock market crashed and cut the value of the couple's savings in half.

"I was so scared," Roberta recalls. "Not only was my husband disappearing, but our savings were, too. All I could think was, if something happened to me, there'd be nothing left and I'd be out on the street." At the urging of a financial counselor, she made an appointment with a respected elder-law attorney in the area. When he laid out her options, only one—divorce—allowed her to get care for her husband and hang on to their remaining savings. By divorcing Alex, the love of her life, he would become indigent, thus becoming eligible for Medicaid.

"I felt terribly depressed and guilty," says Roberta, "but I felt I had no choice." She received the final divorce papers on August 15, 2008, the day before the couple's 44th wedding anniversary.

Roberta and Alex are not alone. Like many older Americans, they find they must make gut-wrenching choices—to divorce a spouse or to file papers refusing to pay for an institutionalized spouse (a practice known as "spousal refusal")—simply to become eligible for government-subsidized long-term care.

The two existing national health insurance programs—Medicare and Medicaid—have, in part, created the conditions that have led people to take these drastic measures. Medicare, the health insurance program for those 65 and over, was designed largely to treat acute medical conditions and does not pay for more than 100 days of skilled nursing and rehab therapy.

Medicaid, the health insurance program for the poor, does pay for nursing home care but only after an individual has "spent down" his or her assets—that is, he or she has depleted all cash assets, including stocks, except for a nominal amount, usually $2,000. Spending down assets by transferring them to your children is not a viable option because Medicaid looks for gifts the patient made within the five years prior to applying for Medicaid, and then denies coverage for the number of months the gifts could have paid for nursing home care.