The slowly ticking time bomb all health care wonks have been thinking about for decades is inextricably speeding up as the population ages: long-term care and the utter lack of humane solutions we've been able to come up with as a society. One state, however, is figuring out how to do it. Absent inclusion of long-term care in an eventual top-to-bottom healthcare system reform, Washington state is providing the model.
There are essentially three ways that care for sick, elderly, and fundamentally disabled people is covered: personal wealth (which runs out fast); private insurance; and Medicaid. Private long-term coverage plans are often prohibitively expensive, with people paying for coverage they may never use. Unlike standard health insurance, which some people seem to have a hard enough time grasping as essential, no one can be certain they'll use that long-term care insurance, so it has a limited market. That means premiums have to be set high. The Medicaid alternative is the most common, forcing families to deliberately impoverish themselves to meet the income limits.
What Washington has done under Gov. Jay Inslee (a Democratic candidate for president), is to create the Long-Term Care Trust Act. Christopher F. Koller, president of the Milbank Memorial Fund and Terry Fulmer, president of the John A. Hartford Foundation, describe it: "It is old-fashioned social insurance, collecting funds from a broad population to pay for the future needs of those who need assistance. Workers will pay a mandatory payroll tax, but a small one: 58 cents per month for every $100 income starting in 2022. That works out to $18 a year for the average wage earner. These contributions will be banked in a trust fund."
Partial benefits will start being paid out in 2025, and after that will be fully implemented and available to workers who've paid into the system for 10 years, with a lifetime maximum of $36,500 in payouts, indexed to inflation. That money could go to in-home care, supplementing income for family care-givers, to adapt a home, or for adult daycare or residential care. A person who needs help with at least three basic daily life functions—eating, bathing, getting dressed—would qualify for the benefits. Providing more options (in the form of funding) for people to stay in their own homes is huge. But $36,500 won't go very far or last very long for residential care.
This is still a groundbreaking effort by the state of Washington, and one that could and should be adapted as part of overall health care reform.