The growing long-term care dilemma

Senate Democrats recently committed to tackling one of health care's most under-the-radar dilemmas: how to accommodate the long-term care needs of the fast-aging U.S. population.

Why it matters: The elder care infrastructure isn't ready for the demographic change heading its way.

Between the lines: This isn't the stuff that typically lights up a debate stage. But the math suggests that more and more American families are going to be confronted with a broken status quo and no easy solutions.

• "If the U.S. health care system is dysfunctional, then the long-term care situation is a complete and utter disaster," Penn Medical Ethics and Health Policy professor Zeke Emanuel wrote in a recent MarketWatch opinion piece with Benjamin Veghte, director of a new Washington state initiative.
• "With only the very poor or very rich having any way of paying for long-term care, that leaves the families of the broad middle class struggling financially and emotionally to keep mom and dad safe," they added.

The big picture: This is essentially about who is going to help seniors and people with disabilities with daily tasks, whether there's enough care available and how will it be paid for.

• And the kind of care we're talking about is very different from cutting-edge surgeries or groundbreaking new therapies that drive most health care affordability debates.
• It's labor-intensive tasks like feeding, bathing and medication management.

Where it stands: Though there are ideological differences over what to do, there's pretty universal agreement that the existing state of affairs can't continue.

The first fundamental problem is that most seniors can't afford many forms of long-term care out-of-pocket, yet an estimated 70% of them will need it before they die.

• The average person who turns 65 will eventually incur around $130,000 in long-term care costs, according to a Bipartisan Policy Center analysis.
• But the private market for long-term care insurance has largely collapsed, with only around 3% of people over 50 holding policies.
• The only public support for care is through Medicaid and requires seniors to deplete their assets before they become financially eligible.
• And while Medicaid is required to cover nursing home care, coverage for home- and community-based services — which seniors generally prefer — is much patchier.

The alternative to these formal arrangements is unpaid care provided by family and friends, which makes up an estimated three-quarters of total long-term care.

• As baby boomers age, the ratio of people needing care to available caregivers will head in the wrong direction. And there's also often a huge financial burden placed on the caregivers themselves.
• Caregiving can also force people out of the workforce. And in a population that also has a worsening ratio of workers to dependents, it's not a good idea to shrink the pool of productive workers.

The second basic problem is the workforce that's supposed to care for all of these baby boomers.

• There's already a shortage of long-term care workers, and the profession is generally low paying. Immigration crackdowns are taking a toll on the sector, which relies on a substantial number of foreign and undocumented workers.

• It's unrealistic to think that efforts to make care more affordable will actually make care more accessible if there aren't enough workers to provide it.

There's no shortage of ideas about how to fix the long-term care situation, but like nearly everything else in health care policy, they all come with trade-offs.

• The first question is whether to provide more government benefits or private solutions.
• A group of Senate Democrats recently made long-term care a plank on their health care affordability initiative, right after prescription drug prices and private insurance reforms.
• They would "invest in Medicaid home- and community-based services and establish a home care guarantee for people with Medicare."

Yes, but: The most obvious barrier to a new federal benefit is the huge cost.

• The Paragon Health Institute, an influential right-leaning think tank, focuses on encouraging people to privately save for long-term care that they'll need later in life.
• It argues that Medicaid eligibility is already too generous, and that if it wasn't as accessible, people would save more for themselves before they need care.

Washington state is about to start paying out long-term care benefits paid for by payroll taxes next month, providing a testing ground for whether such a model could work on a larger scale.

How it works: Similar conceptually to Medicare, workers pay 0.58% from each paycheck into the state long-term care fund, and then can later qualify for $36,500 in lifetime benefits from the program, called WA Cares.

• Of course, that covers less than a year of some of the forms of care we discussed above. But it's more than anyone else in the U.S. gets in public long-term care benefits.