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We Have a Short Time to Fix Long-Term Care

Policymakers urgently need to address the absence of insurance coverage for the long-term-care needs of our rapidly aging society

By Michael Pessman

In addition to reminding us of the high cost of long-term care, the COVID pandemic has exposed shortcomings in how we manage the care itself, including the quality of facilities, quantity of beds, scheduling of staff and a lack of commitment to improving the system.

Long-term care reform must be at the top of the federal government's policy agenda if we as a society are to allow people to age with dignity and well-being. Reform should emphasize expanding coverage and strengthening connections with the broader health care and public health systems in order to create equity. A 2021 report by four leading researchers details this, and other advocates of long-term care reform agree with it.

An older couple smiling. Next Avenue, long-term care
The government has forecast that more than half of the adults turning 65 today will eventually require long-term assistance.  |  Credit: Getty

Every day in the U.S., 10,000 people turn 65, and the number of older adults will more than double over the next several decades to top 88 million people and represent over 20% of the population by 2050. The government has forecast that more than half of the adults turning 65 today will eventually require long-term assistance with daily activities such as eating, dressing and bathing.

This essential care should not be a personal financial challenge for anyone. At the start of 2022, the Kaiser Family Foundation reported that long-term care facility residents and staff cared for more than 201,000 COVID-19 patients who died, accounting for at least 23% of all COVID-19 incidents in the U.S.

Why We Need to Act Now

Considering the recent data from the Centers for Disease Control on a national surge in cases, it is necessary to address the importance of affordable long-term care insurance in order to pay for the necessary treatment and care.

The national annual median cost of care ranges from more than $108,000 per year for a private room in a nursing home to $20,280 per year for five-days-a-week adult day health care services, according to the Genworth Financials' 2021 Cost of Care Survey.

A semi-private room costs $7,756 a month, or $93,075 per year. The average length of stay among all nursing home residents is 485 days, according to a February 2019 report from the National Center for Health Statistics.

Families Drain Their Savings

In my experience as a gerontologist at Rush University Medical Center's Alzheimer's Disease Center in Chicago, I have spoken to older adults who were worried about the costs involved at the end of their lives. Several families have told me they are taking out reverse mortgages, spending down their savings and tapping retirement accounts to pay for long-term care.

When an individual is part of a married couple, this can be tricky. If they must pay private health care for their sick spouse, the healthy spouse often expresses concern about maintaining his or her lifestyle.

Many people I speak with wish to be able to pass their wealth on to their children and not have to worry about paying for skyrocketing long-term care costs. A survey conducted by Genworth in 2021 found that 66% of caregivers used their personal savings or retirement accounts to pay for long-term care for a loved one.

The Medicare Misapprehension

Some Americans reportedly think Medicare covers long-term care. But it only covers up to 100 days of care in a skilled nursing facility for each "benefit period," which begins the day you check into a facility and ends 60 days after you check out.

If someone needs more than 100 days of such care in a benefit period, they will need to pay out of pocket. For patients whose coverage days are running out, they must either pay with private funds or have a Medicaid application pending to avoid being forced out. Nursing homes that do not accept Medicaid are an exception.

For qualifying, lower-income patients, Medicaid pays for skilled nursing care (but not assisted living). Medicaid coverage isn't available to middle-class older adults with a household income of $17,609 or more for an individual in 2020.


The Affordable Care Act, known informally as Obamacare, included a long-term care insurance program called Community Living Assistance Services and Supports. Critics and independent analysts said the premiums people would pay into the program would not cover the cost of providing care, so Congress repealed that part of the law.

Will Congress Act on Alternatives?

There are alternatives in play. Rep. Frank Pallone, a Democrat from New Jersey and chairman of the House Energy and Commerce Committee, released a discussion draft of a Medicare long-term care benefit on May 2, 2018. This bill is still pending and the Senate has not voted on it.

House Ways and Means Committee Chairman Richard Neal, a Democrat from Massachusetts, has stated that Medigap supplemental insurance should include long-term care coverage. He wrote to the National Association of Insurance Commissioners, requesting information on ways to expand long-term services and supports through Medigap for older Americans and individuals with disabilities, but to date there has been no response.

Rep. Thomas Suozzi, a Democrat from New York, recently introduced the Well-Being Insurance for Seniors to be at Home (WISH) Act, legislation that would address one of our nation's most pressing challenges: financing long-term care for elderly Americans.

The bill allows enrollees to claim long-term care benefits only after one to four years of family caregiving, state or local care, or private coverage. Beneficiaries' waiting periods would vary depending on their lifetime income, with higher-earners waiting longer than middle- and low-income folks. In order to fund the plan, Suozzi proposes an additional Medicare payroll tax of less than 1%.

Questions About Structuring a Program

Policy experts differ over how best to structure a federal long-term care insurance program. Considerations include whether the program would be totally public or a public-private hybrid, how much cost-sharing enrollees should shoulder, whether participation would be mandatory or voluntary, and if coverage would be universal.

Several states, including Illinois, Michigan, Minnesota and Washington, have experimented with long-term care insurance plans and could serve as models for a national program.

It will be tough to fund the program while avoiding the actuarial pitfalls that have driven so many private long-term care insurers out of the market.

In other countries such as Japan, Germany, the Netherlands, Denmark and France, social insurance programs have been expanded or universal long-term care coverage already exists.

Several states, including Illinois, Michigan, Minnesota and Washington, have experimented with long-term care insurance plans and could serve as models for a national program.

Alternatives to Institutional Care

As an alternative to institutional care, any federal long-term care insurance program needs to encourage the use of home and community care. Nursing home care is significantly more expensive than home and community-based care. Research shows older adults thrive in their homes and communities when they can interact with friends and family more frequently and live in familiar surroundings.

State governments can receive grants from Medicaid — the government's largest long-term insurer — in order to help older adults stay at home. In the past few years, more than 90,000 older adults have benefited from grants by obtaining in-home care instead of moving into nursing homes.

There is no easy solution to the nation's long-term care crisis, but policymakers must address it. America can no longer be a country where older adults are forced to sacrifice their dignity and health in order to survive because they can't afford the care they need.

Michael Pessman In addition to being an avid gardening enthusiast, Michael Pessman is a gerontologist and a Public Voices Fellow at The Op-Ed Project. Follow him on X at @agernation. Read More
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