A National Strategy for Long-term Care

A new health insurance proposal addresses the oncoming crisis of baby boomers entering old age.

This illustration can only be used with the Molly Mirhashem piece that originally ran in the 6/6/2015 issue of National Journal magazine. (National Journal)

Judith Feder, a professor of public policy at Georgetown University, has an idea that she hopes will address the oncoming crisis of baby boomers entering old age, with many needing long-term care. Feder and her colleagues propose a public long-term care insurance program that would become available to those who need it after a waiting period. I recently discussed this with Feder, who has focused on health policy for more than 30 years, both as a researcher and in government. Our exchange has been edited and condensed. 

(Richard Mia)

Can you explain your idea?

Right now there are 12 million people in the U.S. who need help with basic assistance in daily life—like eating, bathing, and dressing. We rely overwhelmingly on families to help people who need this long-term care. And this is not just an older person problem: 40 percent of the people who need long-term care are under 65. Medicaid helps people pay for services when they need them, but only after they have become impoverished and given up all their resources. My proposal is to create a public program that helps people when they need extensive, expensive long-term care.

What specific problem does this solve? What do the current options look like? 

Sometimes people claim that we can just plan for this and that it's going to happen to everyone—it doesn't happen to everyone! It's unpredictable and catastrophic. Even for people who are now age 65, half are going to die without needing any long-term care. A very small portion are going to have to spend a fortune in order to buy services on their own. Usually, when we have an unpredictable, catastrophic event, we rely on insurance, such as homeowner's insurance or health insurance. But we really don't have insurance for long-term care. Private insurance has not worked, Medicare doesn't cover it, and Medicaid is only there after you experience financial catastrophe.

What is new about your proposal?

We've talked for a long time about the need for better protections for people who require long-term care. But politics has made the development of a public mechanism very challenging. And private long-term care insurance hasn't proved a viable product. The barriers are both political and market-related, and on the political side there has long been controversy about whether this should be a public or private responsibility. My colleagues and I are trying to make clearer what should be a public role and what should be a private role.

Our proposal is to establish a public insurance program that's available to people after a waiting period, which would begin once they are identified as a person in need of long-term care. The length of the waiting period would be based on income: You'd have a longer waiting period if you're wealthier and a shorter waiting period if you're less affluent. In this structure, public insurance would protect people against catastrophic costs (a risk private insurers currently are not willing to take), and the private insurance market could fill in during the waiting period. So it creates a definable space that a private market might be able to fill. And because the waiting period would vary according to income, premiums would be affordable for modest as well as high-income consumers. People would contribute to the cost of these benefits while they work, as we do with Social Security.

Are their potential drawbacks to your proposal?

It is a challenge to get people to agree that we need a public commitment to some kind of social insurance program in order to really address this problem. And it does cost money, but those expenses can be broadly shared across the population rather than falling on the individuals and families of individuals who need the services. So I think the challenge is the political environment. And also in that environment, there's the challenge of making the resources sufficiently available, the eligibility clear, and the program strongly operational in all 50 states.

What can be done to bring this idea into the mainstream conversation about health policy?

There needs to be a greater public awareness of this hole in our safety net. We also need to summon support from constituencies and mobilize constituencies who are affected: mostly aging baby boomers as well as caregivers and direct-care workers, who are both presently underpaid and under-rewarded for this very difficult task.