Planning for the Future — Long-Term Care and the 2008 Election (New Eng Jour Med)

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The New England Journal of Medicine
Volume 358:1985-1987 May 8, 2008 Number 19


Planning for the Future — Long-Term Care and the 2008 Election
David G. Stevenson, Ph.D.

Long-term care has all the makings of a great campaign issue. It affects a large portion of the population, it is expensive (it currently accounts for about 10% of all health care costs), and it requires a unique partnership between government and citizens. Moreover, a range of constituencies perceive the current long-term care system as seriously broken. It exposes people who need services to considerable financial risk, and it too often relies on an institutional model of care that is at odds with consumer preferences.

Nonetheless, the candidates in the 2008 presidential race have been virtually silent about long-term care policy. Health care received substantial attention during the 35 Democratic and Republican debates (garnering more than 1000 mentions), but almost nothing has been said about long-term care. Not a single major debate question has focused specifically on the topic, and it has been mentioned by candidates in response to other questions only 11 times. Nor has long-term care received much attention on the campaign trail. Only one candidate, Senator Hillary Clinton, has delivered a speech on the topic and proposed a detailed agenda for the future. Candidates have backed broadly appealing goals such as improving the quality of care in nursing homes, reducing hassles with companies that offer insurance for long-term care, and more frequently providing long-term care at home or in the community. There has not, however, been a serious discussion about a reformed vision for long-term care in this country — in particular, how it will be financed.

Almost 10 million people in the United States — two thirds of whom are elderly — currently need assistance completing basic activities of daily living (e.g., eating, bathing, and dressing). Most of these people remain at home, receiving help from family and friends. The vast majority of those who require paid supportive services are not insured against these potentially catastrophic costs. Neither Medicare nor private health insurance generally covers long-term care, and only a small proportion of older people have purchased separate insurance for it. Instead, long-term care in this country is supported by the safety nets of family caregiving, out-of-pocket payments, and the Medicaid program for people with low incomes.

By all accounts, the safety net for long-term care is frayed. Family caregivers strain under considerable burdens, caring for relatives while fulfilling other obligations to work and children. Americans typically enter retirement with modest savings, uncertain of how they will afford the routine costs of living, let alone catastrophic health care costs. And state budgets increasingly struggle to maintain Medicaid's role as the primary payer for the long-term care of aging citizens. For professional providers of such care, recruitment and retention of qualified staff members can be enormously challenging and expensive; the adequacy of Medicaid payments to providers is a perennial concern; and quality-of-care problems recur with troubling regularity.

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