How Growing Inequality Is Altering The Long-Term Care Policy Battlefield, While Tightening The Financing Knot

For many years, long-term care (LTC) policy makers have tended to fall into two warring camps: those favoring expanded social insurance, and those wanting tighter Medicaid eligibility criteria to incentivize people to plan for and buy LTC insurance. Both sides have warned of looming financial catastrophe as the Baby Boomers move into retirement and more than double the population needing care. Disagreement has resulted in a policy stalemate. The vanguard of the Boomer generation is less than 10 years away from beginning to drive up demand for LTC, and the country is unprepared to pay for it. It’s time that the policymakers stepped out of the old trenches. The war they’ve been fighting is largely obsolete.

Both progressives who supported the Community Living Assistance Services and Supports (CLASS) Act (a federal LTC insurance program quickly repealed after passage due to its financial instability), and those more inclined to market-based solutions tend to share a middle-to-upper-middle class perspective that has not been sensitive to major shifts in the economic strata below them. Many assume there is a stable American middle class that could either be sufficiently taxed to expand government programs or incentivized to pre-finance LTC of a variety and a quality level above a typical nursing home—which is what is now universally available to Americans through Medicaid after exhausting virtually all their assets. Two developments now challenge this orthodoxy. The most obvious is the collapse of the market for LTC insurance, which Conservatives held out as the alternative for middle class reliance on Medicaid. More important, but until recently less understood, is the phenomenon economist Joseph Stiglitz calls the “hollowing out” of the American middle class. A growing body of research reveals trends including a long period of wage stagnation; significantly less likelihood of earning as much as one’s parents; and diminishing lifetime earnings for cohorts entering the workforce since the late 1960s.

Barring a miraculous and sustained spurt of economic growth with profits equitably distributed among the population, the reality is that as the Boomers begin consuming LTC, only about 15 to 20 percent will have enough income and assets to afford to pay for a variety of LTC services at home, in assisted living, and nursing homes. Half the population will not have enough in assets to finance LTC costs. The third of the population in between may or may not have enough to pay for some of their LTC needs, depending on circumstances, saving habits, and fortune. Adding to the challenge, the last Survey of Consumer Finances shows that between 2013 and 2016, the only age group in which family wealth declined was those aged 65 to 74 (down from a median of $239,000 to $223,000) (Exhibit 1). The Great Recession hit the tip of the Boomer generation at the end of their working lives when it is difficult to recover financially.

– Health Affairs

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