This article provides a comprehensive solution to the financing of long-term care for older Americans that balances government and family responsibility, while recognizing the different settings in which long-term care is provided. The article begins by examining the spectrum of long-term care in the United States from home health care to assisted living to nursing homes, as well as hybrids such as continuing care retirement communities. Successive sections of the article then analyze the federal government's health care program for older persons (Medicare), the joint state and federal program for poor people of any age (Medicaid), and private long-term care insurance in terms of how these mechanisms treat long-term care in each setting.

Finding serious deficiencies and inconsistencies in all three mechanisms, the article then offers a co-ordinated alternative: expand Medicare to cover long-term care in nursing homes but maintain responsibility for other long-term care settings with the affected individuals and their families. This approach recognizes that nursing home care substitutes for hospital care that Medicare would otherwise cover, while other long-term care settings substitute for family-provided care. Long-term care insurance would then be used as a means of financing long-term care in settings other than nursing homes, thereby making it more appealing. In addition, such insurance would be less expensive than presently, because it would no longer be priced to cover costly nursing home care. The article also recommends that such insurance be improved by standardizing policy options and features into a fixed set of packages that would be uniform among carriers. Other recommendations include ensuring price stability of issued policies and providing independent reviews of gatekeeper claim denials. The article concludes with some observations regarding financing of these proposals.


Law and Economics

Date of this Version

May 2004