Why long-term care in America is a long-term problem 

As we gather around our holiday tables this year, we will be lucky if Grandma and Grandpa can join the festivities. 

What might go unsaid during the meal is how frightening and expensive it can be for the those growing old in America, wondering about how to pay for long-term-care services when independent living gets tough — and how tough it may get for the next generation to ensure that their parents are well cared for in America. 

This is the year to start debunking myths and facing new realities.  

Many Americans think their long-term care needs are covered by their health insurance or Medicare — this is not the case in America. The truth is that one-third of U.S. long-term care expenditures are paid for out of pocket, about 60 percent are paid for by the public sector (largely through Medicaid) but only if a person has less than $3,000 in assets, and only about 4 percent are paid for by private insurance. 

According to the American Association for Long term Care Insurance in 2020, 7.5 million Americans had long-term-care insurance. 

A person turning 65 today, according to the Department of Health and Human Services, has almost a 70 percent chance of needing some type of long-term care services and support in their remaining years. The gap between those needing services and those able to pay for or qualify for Medicaid or some Veterans Administration long-term care services is enormous. 

There are other new realities for our children to grasp.  

When President Franklin D. Roosevelt signed Social Security into law in 1935, the age to qualify for Old-Age, Survivors and Disability Insurance was 65. Back then, most of those who reached that age were poor and lacked health insurance. When benefits were first paid in 1940, 46 percent of adult males didn’t live to age 65, and for those who did, the average additional life expectancy was less than 13 years. For women, it was not a lot better. The system could handle the needs of these Americans. 

But today, the drain on Social Security is greater, with people living longer but not necessarily stronger. According to the National Academies of Sciences, Engineering and Medicine, “the experience of dying in the United States is often characterized by fragmented care, inadequate treatment of distressing symptoms, frequent transition among care settings, and enormous responsibilities for families.”  

So, what can be done to fix things? 

America spends 1 percent of its GDP on long-term care, making us 16^th on the list of wealthy countries, according to a New York Times review of global data that looked at comparably rich countries. It found that “Most spend more than the United States through government funding or insurance that individuals are legally required to obtain. Some protect individuals from exhausting all their income or wealth paying for long-term care.” 

We could model ourselves on a country like Japan, where long-term-care insurance is mandatory for Japanese citizens 40 and over. 

Or we could take a cue from the Netherlands, which spent over 4 percent of its gross domestic product on long-term care in 2021, more than any other country tracked by the Organization for Economic Cooperation and Development (OECD) and four times the amount the United States 

spent. 

We could re-examine federal programs like Social Security, Medicare and Medicaid, which make up 46 percent of the federal budget. If those programs were reined in, there might be more funds for long-term care.  

We can provide more demonstration programs at the state level, with alternatives to long-term-care facilities, and encourage paid leave for workers to be able to attend to the needs of aging relatives.  

The bottom line is that beyond a great Thanksgiving meal, we need a national conversation about aging in America to ensure that our children and grandchildren do not inherit a mess. It is the least we can do, given our share of the problem. 

Tara Sonenshine is the Edward R. Murrow professor of practice in public diplomacy at the Fletcher School of Law and Diplomacy at Tufts University 

Patrice Hirsch Feinstein is a grief support counselor. She was formerly the associate administrator of the Medicare and Medicaid Programs at the Department of Health and Human Services.