The Financing of Long-Term Care: An American Conundrum

Americans do not, generally, plan for their own very likely future need for long-term care, and the federal government has yet to offer a program that meets these needs for most people. Family caregivers provide much of that care, at great cost to them, and long-term care insurance has shown limited success in uptake, as well as a dwindling presence in the insurance marketplace. What lies ahead for the burgeoning population of older adults that will need long-term care?

In “America’s Long-Term Care Conundrum,” Guest Editor Ruth Katz succinctly lays out the psychology behind not planning for our own needs in older adulthood, especially the need for long-term care, and describes what she learned in a listening tour of the United States, wherein she was schooled in what happens on the ground when people need and use long-term services and supports. Our current way of financing LTSS is unsustainable, Medicaid is not the solution, family caregivers are at a breaking point, and politics are standing in the way of a solution. But there is hope in learning from how other countries have solved their similar long-term-care quandaries.

Barbara Coulter Edwards and Aditi P. Sen, in their article, “High Demand and Fragmentation: The Current State of Long-Term Services and Supports in America,” explain the current challenges to financing long-term care, especially as people age into the frail elderly category; how increasing levels of cognitive decline will affect long-term-care costs; workforce shortages (which may be exacerbated by new immigration policies); and how policy makers and legislators might approach solutions through coordinated state and federal efforts.

In “Re-imagining the Delivery of Care for Older Adults with Chronic Conditions,” Howard Gleckman describes how the delivery of medical treatment and social supports in the United States is uncoordinated, and degrades the quality of life of older adults with chronic conditions, as well as possibly adding unnecessarily to costs. But now some public policy changes and market initiatives are resulting in the development of new models that better integrate care. What might they look like?

Robyn I. Stone, in her article, “Financing Long-Term Services and Supports—and the Challenge of Underlying Assumptions,” writes of the almost 30 years’ worth of options for financing long-term care that have been explored. Since 1990, policy makers, insurers, providers, consumer advocates, and researchers have struggled with underlying assumptions that affect the nature, scope, and political viability of any long-term services and supports program: Should a program be medical or functional? Is it a quality-of-life issue? Should such a program cover all people or just older adults? Should participation be mandated or not? Should the program be funded at the national or state level? The path ahead remains unclear.

Preparing for LTC Financing Reform: How Can Racial Disparities Be Addressed?”, by Barbara Gay, Ruth Katz, and James H. Johnson Jr., tackles the long history of racial discrimination that has resulted in racial disparities in long-term services and supports. Challenges in accumulating wealth have left older African Americans with fewer choices of services, providers, and settings for long-term care. Specific challenges older African Americans and their families face also are discussed, as are changes in public policy that are necessary to address racial disparities in the long-term-care field.

Alisha Sanders, in her article, “Housing Plus Services: A Model that Supports the ‘Whole’ Person,” explains trends indicating that elders, many with chronic conditions and functional limitations that increase their risk of needing expensive acute care services or of moving to a high level of care, will be economically insecure and struggle to find or to maintain affordable and accessible quality housing. New care delivery models linking affordable housing settings with services offer one promising approach for supporting such low-income older adults.

ASA is pleased to offer this latest issue of Generations, which will reach ASA members and subscribers in late April to mid May 2019. Single copies of the issue can also be purchased from our website.