When multiple sclerosis finally left Jane Richards unable to care for herself, she went into a nursing home. At first, the 75-year-old retired interior designer paid her own way. But within a year, the $3,500-a-month bill and other expenses had ravaged her life savings.
That left her no choice.
She did the same thing millions of other middle-class Americans have done. She turned to Medicaid, the medical assistance program for the poor.
"I'm just very thankful for it. I don't know what else people would do," said Ms. Richards, who is confined to a wheelchair at the Keswick home in Baltimore.
Established in 1965 as a welfare program, Medicaid has by default become the only substantial long-term care plan for a nation that critics say has failed to deal with the problem of long-term care for its elderly. Roughly 40 percent of 220 patients who live at Keswick in upscale Roland Park depend on Medicaid. And the numbers are far higher at many other nursing homes in Maryland.
Medicaid not only provides long-term care for the poor or middle class who wipe out their assets, but also serves a growing number of Americans who are quite legally sheltering sometimes considerable assets to qualify for Medicaid.
While nursing home patients constituted only 6 percent (27,050) of the 442,000 people who received Medicaid benefits in Maryland last year, they consumed more than one-fourth, or $341 million, of the total cost.
The state and federal governments have substantially cut reimbursement rates, but long-term care represents the largest share, 45 percent, of the nation's $52.5 billion price tag for Medicaid.
"Medicaid is the cornerstone of social programs in this country," said Nelson J. Sabatini, Maryland's secretary of health and mental hygiene.
But the cornerstone is a vastly expensive and inflexible program that has hogtied state officials financially. Next year, the overall Medicaid program is expected to devour $1 out of every $6 in the state's general funds.
Still, without it there would be no long-term care for taxpayers such as Mary Wallace, a 59-year-old Perry Hall woman who was left a quadriplegic and dependent on a feeding tube six months ago when a blood vessel in her brain closed. So far, private insurance has refused to cover the estimated $10,000-a-month cost for a chronic, long-term care facility. Mrs. Wallace's family will have no choice but to turn to Medicaid.
"We never would have thought this would happen. My mother and father worked all their lives," said Lynn White, Mrs. Wallace's daughter.
In 1989, Congress enacted a measure, sponsored by Sen. Barbara A. Mikulski, D-Md., allowing a husband or wife to qualify for Medicaid in a nursing home without impoverishing a surviving spouse.
But Mr. Wallace died in November. So the family probably will have to sell Mrs. Wallace's $130,000 split-level home and spend all but $2,500 of her savings to qualify for Medicaid, leaving her with little more than burial expenses and $40 a month in income.
Last year, Medicaid covered 70 people in Maryland whose medical expenses exceeded $200,000 each.
And the financial dilemma of long-term care can only get worse.
Because of improved medical technology, even severely debilitated people such as Mrs. Wallace are living longer. Overall, the elderly now make up nearly 13 percent of the population.
At the same time, society has undergone major restructuring, with fewer families caring for the elderly in their homes. Children often live far away from older parents. And many people -- including working couples with college-age children -- can't care for the elderly in their own homes. Forty-three percent of all those over 65 wind up in nursing homes.
"There was a time not too many years ago that it was a terrible stigma to admit that one of your relatives had been sent to a nursing home," said Mr. Sabatini. "Now we're saying the state will take care of that responsibility."
No longer, however, can most people afford to think of Medicaid as a welfare program.
"How can you think of it as that? It's heartbreaking to think of it that way," said Anna Meyers, a Roland Park resident who will soon apply for Medicaid for her 86-year-old sister who lives at Keswick.
Suffering from arthritis and degenerative heart disease, Mrs. Meyers' sister went into the nursing home in August 1990. Only then did her family discover the significant amount she'd saved in four different bank accounts during the 50 years she worked at Hochschild's department store.
"We thought she had enough money to take care of her for a long, long time," Mrs. Meyers said. "And it's only lasting her less than two years. She wanted to leave her brothers and sisters something."
In the past 10 years, the cost of care at Keswick has risen from roughly $2,100 to $3,500 a month, said Mrs. Meyers. Even in 1980, care for her own husband there wiped out much of their savings, leaving Mrs. Meyers with the prospect of applying for Medicaid if she ever needs nursing home care.