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Imagine being on a boat headed straight at a jetty. You’re shouting to the captain and crew to change course but they’re shouting at each other. Everyone can see the crash coming but no one appears able to stop it.

That’s the situation with long-term care (LTC) policy in the U.S., albeit without the seaside scenery.

Consider these observations, published in an August 2012 Health Care Policy Snapshot Issue Brief from the Robert Wood Johnson Foundation:

“Long-term care expenditures are projected to increase to $346 billion in 2040. Medicaid accounts for 43 percent of all long-term care spending while Medicare accounts for 18 percent. Meanwhile, federal and state governments are reducing overall spending and states are cutting back on their Medicaid programs. The one piece of the [Patient Protection Affordable Care Act (PPACA)] that addressed long-term care financing—the CLASS Act—has been abandoned due to inability to assure its financial viability.”

According to Genworth’s 2011 Cost of Care Survey, the median annual cost of long term care in an assisted living facility is $39,135, an increase of 2.4 percent from 2010. The comparable cost for a private nursing home room rose 3.4 percent to $77,745. Costs vary significantly by region: a semi-private nursing home stay in the State of New York costs almost $119,000 per year versus $49,000 in Oklahoma. At $18 per hour for homemaker services and $19 an hour for home-health-aide services, the median hourly cost to receive care in the home remained flat over the past 12 months.

The Obama administration tabled the CLASS Act in October, 2011, citing funding problems.

Medicare isn’t designed to pay custodial LTC expenses. That leaves Medicaid as the federal government’s backstop program for those who qualify.

But the growing number of financially strapped persons requiring LTC—LTC services accounted for about one-third of Medicaid’s outlays in 2010—is straining that program’s resources and states’ budgets.

Overall, the outlook for remedial LTC-funding action on the federal level is not good, says Howard Gleckman, the author of “Caring for Our Parents” (St. Martin’s Press, 2009) and a resident fellow at the Urban Institute.

Howard Gleckman

“There is at the moment really no effort being made either by the Obama administration or in Congress to do anything about it,” Gleckman says. “The Romney campaign has said nothing about it. So, in terms of policy initiatives, at the moment there is nothing.”

Self-funding is not a viable option for most Americans.

That leaves a handful of potential funding mechanisms. Private LTC insurance gives insureds the most control over their benefit design, but sales remain sluggish.

Federal government civilian and military employees have access to competitively priced LTCI as part of their benefits package but market penetration remains low. The program attracts only about 5 percent of eligible buyers.

State partnership programs, which coordinate private LTCI benefits with Medicaid LTC benefits, could help many consumers, but fewer than 440,000 partnership policies were in-force at the end of 2011.

Jesse Slome

“The partnership has been one of the most disappointing busts in terms of an opportunity to really expand the marketplace,” says Jesse Slome, executive director of the American Association for Long Term Care Insurance. “It’s a great concept. It really comes down to a real lack of understanding. I mean, you’ve got to market it.”

The lack of a coherent policy from the federal and state governments hasn’t stopped industry observers from offering their own solutions.

William Galston, a senior fellow at the Brookings Institution, discussed several possible LTC-funding proposals in a recent issue of Democracy: A Journal of Ideas.

Galston suggests that the United States can come up with a private-insurance-based LTC funding system that mimics the structure of the PPACA health insurance program, or emulate the current Germany LTC funding system.

The PPACA-like LTC funding system would combine an LTCI ownership mandate, free LTC protection for low-income people, LTCI subsidies for people with incomes of 150 percent to 300 percent of the federal poverty level, and a bidding system that would spur private insurers to compete to offer solid, basic, five-year LTCI policies at affordable rates.

William Galston

For most consumers, Medicaid would then kick in only when the five years of basic LTCI benefits ran out, Galston says.

In a German-style system, workers over the age of 50 would stay in the current system.

Workers 50 and under would have to contribute 2 percent of their wages into an LTC fund or buy LTCI coverage with a term of five or more years that met federal standards from a private insurer that met federal standards.

The federal government would provide subsidies for low-income workers, to bring the minimum annual contribution to $1,000 per worker. An independent commission would evaluate the program every five years and recommend any changes needed to keep the program sustainable.

Given the confluence of budget deficits, policy disputes and political inertia, though, it seems unlikely that private-sector or government proposals will receive the attention needed anytime soon.

The reef looms large…

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Photo of Howard Gleckman courtesy of Susan Hornyak.


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