Illustration: Aïda Amer/Axios

Taking care of the aging population is a crisis in the making, and no one — not families, not government programs and not the health care workforce — is prepared for it.

The big picture: Providing health care to aging Baby Boomers will strain Medicare’s finances, but the problem is even bigger than that.

Long-term care — the kind of services typically performed in a nursing home or by a home health aide — largely falls through the cracks of both public and private health insurance, saddling seniors and their families with financial and emotional burdens they often didn’t anticipate or plan for.

  • “It’s a problem nobody’s talking about,” said David Grabowski, a health policy professor at Harvard who studies long-term care. “Part of that’s just, these are hard issues to think about. Nobody wants to think about getting old and needing care. But part of it is that these are really hard problems.”

By the numbers: Estimates differ on the specifics, but they generally agree that somewhere between half and two-thirds of seniors will need at least some long-term care.

  • Today’s seniors will incur an average of $138,000 in long-term care bills, according to one federal study.
  • Even middle-class seniors are largely unable to cover those costs, according to a study published earlier this year, which Grabowski co-wrote.

How it works: Medicare doesn’t cover most long-term care services. The market for private long-term care insurance is tiny and fraught with failure.

  • That leaves three real options: Be rich enough to pay out of pocket, be poor enough to quality for Medicaid, or lean on family and volunteer caregivers.
  • In many cases, seniors must do all three: They begin paying out of pocket, then quickly spend everything they have, making them Medicaid-eligible, but still rely on family members for at least some additional help.

Medicaid is already the biggest line item in most states’ budgets — so as the need for long-term care grows, it will cost seniors, families, states and the federal government all at the same time.

The intrigue: A lot of long-term care has recently shifted away from nursing homes and toward home care or community-based options like assisted-living facilities.

  • That’s a good thing for seniors, but “the challenge with it is it sort of widens this gap between the haves and the have-nots,” Grabowski said.
  • Medicaid is still structurally tilted toward nursing homes, and when it does pay for home care, it doesn’t pay home care workers very well.

That leads to yet another problem — high turnover among nurses and caregivers, which isn’t great for patients.

  • Home care workers are also predominantly immigrants, tying this issue up with yet another charged political debate.

The bottom line: I asked Richard Johnson, who leads the Urban Institute’s program on retirement, why there isn’t a bigger political constituency to change this system.

  • “If you provided this benefit, lets say you made paid home care more affordable, there’s always a concern that it could lead to less family care,” he said.
  • “Look at child care,” he said. “We don’t have much of that, either.”

Go deeper: The unofficial health care system

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