The Challenge of Long-Term Care

Over the next several years we will have to confront some critical issues regarding the way we provide and pay for long-term care in the United States. What we do in response to these issues will affect the fate of millions of older and younger disabled people. Our response will also have a defining impact on our moral culture and whether we divide or unite around a commitment to helping those who have little capacity to meet their need for care on their own.

With the possible exception of the United Kingdom, the United States has the most fragmented and underdeveloped long-term care system among developed countries with the lowest level of public financing for long-term care services.

Other developed countries have been preparing for big increases in their older populations and the associated growth in the need for long-term care for many years. The United States and most state governments have either failed or barely begun to develop the kind of system that we will need if care is to be provided in a morally responsible and cost-effective manner.

Over the coming years the nation’s long-term care challenge is set to explode. Today, about 10 million Americans need long-term care services. Nearly 2 million of them are 85 or older, which equals 38 percent of people in that age group. With the aging of the baby boomers who began turning 65 this year, these numbers are projected to double over the next 30 years. 

Medicaid now spends about $125 million annually for long-term care services for impoverished older and younger disabled people. This figure is expected to triple by 2040 with the growth of the older population and the increasing longevity of younger, physically disabled and intellectually disabled people. Whether these resources will be available as the need for long-term care grows, however, has been put into question with the emphasis among policymakers on austerity in federal fiscal policy and the continuing pressure on state budgets.
 

Efforts by conservative politicians to privatize Medicare and reduce financing for Medicaid are part of a larger ideological initiative. The rationale for sweeping privitization is based on a conservative economic theory that's often referred to as neoliberalism.

Instead of cutting and replacing successful social insurance programs with market-based approaches, we should be preparing to extend them by providing more public support for long-term care. That includes much more money to support what’s known as “informal” caregiving, which is unpaid assistance provided by family members and friends.

We cannot expect informal caregivers to continue bearing most of the burden of caring for a growing population of dependent elders if we are not willing to support them by subsidizing the work they do, implementing a paid family leave program, and creating a more seamless nexus between the formal (public) and informal (private) care systems.

The growth of the older population and the need for caregiving assistance over the next several decades could have a salutary effect on our moral culture and related political priorities.

For more than 20 years, shallow, materialistic values — most vividly expressed in the greedy, unaccountable behavior of our corporate elites with their outrageous compensation packages and reckless financial practices — seem to have become as dominant in American culture as they were in the 1920s. This narrow focus on private gain has eroded the kind of communal values (such as generosity and compassion) required to ensure a sufficient supply of long-term care services and other essential public goods.

This may change as many more people are affected by the caregiving experience — as they come to understand the existential meaning of caregiver loneliness and the fundamental vulnerability everyone faces. More of us are also likely to perceive the injustice of caregiver abandonment, which has already become all too common.

As caregiving becomes more common, it has the potential to play a major role in transforming America’s moral culture and politics. We’ll come to recognize the illusions of self-sufficiency and the realities of mutual dependence in a world of greater risks than the vast majority of us can bear alone.

This is, I think, precisely the point of an extraordinary report prepared by President George W. Bush’s Biomedical Ethics Commission in 2005. The commission stated that the nation is facing a crisis of care — “the danger that some old people will be abandoned or impoverished, with no one to care for them, no advocate to stand with them, and inadequate resources to provide for themselves.”

Polling over the last several months shows that the public opposes cutting Medicare, Social Security and Medicaid; a majority actually supports increasing their benefits and financing. This represents an opportunity for leaders and organizations to step forward and begin to occupy the moral and intellectual vacuum created by the failure of our elites to serve the public interest and fulfill their moral and fiduciary responsibilities.