Ensuring access to long-term services and supports is a problem that worries almost everyone at one point or another in their lives. How do you pay for it without breaking the bank for taxpayers or placing an intolerable burden on the backs of individuals and families? The need for extended care has become a reality due to the longevity revolution with millions of people living longer and reaching an advanced age where infirmities are likely to rob them of independence.

Yet the health care system isn’t designed to cope with the need for LTSS. The insurance and government programs are designed to pay for acute care: the detection, treatment, and solution of a short-term illness subject to either combat from a surgeon’s scalpel or a pharmaceutical fix or both.

Contrary to popular belief, Medicare does not cover LTSS; rather, Medicare covers only post-acute care, such as skilled nursing facility care, focusing primarily on short-term needs. Medicaid serves as the primary public payer for nursing home care, covering roughly one-third to half of all spending, but it is available only on a means-tested, asset-tested basis for those at a certain threshold of financial and/or medical need. Many middle-income people “spend down” and use their assets to pay for care until they have very little left and qualify for Medicaid. Those who qualify for Medicaid (whether low or middle-income) must contribute most of their income to their care costs, losing financial independence, and may be forced to enter a nursing home because they cannot access sufficient home- and community-based services or afford to remain at home.

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