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By Louis H. Brownstone

The California Legislature and Governor Newsom recently proposed establishing a statewide public long-term care insurance program.  The central goals are to aid our citizens as they age and become sick and to reduce the billions of dollars of growing long-term care costs to Medi-Cal.

Citizens should make their voices heard regarding this program because as much as they would like to have long-term care protection, they would have to be taxed in order to cover the cost.  They will have to weigh the costs versus the benefits and in the end will probably have to vote their preference by ballot.

A Task Force was appointed and has met some twenty-four times over the past year.  At the end of 2023, an actuarial report assessing the cost and viability of such a program was submitted to the Legislature.  Will the Legislature pass a bill based on the Task Force recommendations?

Few doubt the significance of the growing cost of long-term care and its impact on whole families as their older members age.  According to the Genworth Cost of Care Survey, 2021 costs in California were $ 201/day for a home health aide, $ 173/day for an assisted living facility, $322/day for a semi-private room in a nursing facility, and $ 400/ day for a private room.  The average period of care in a nursing home varies from about two years for males to over three years for females.  Very few families can cover the cost of a long scenario.

Because most cannot afford to pay for outside help, most care today is provided by family members and friends, often at great personal sacrifice.  But families are shrinking in size and care by family members is becoming less available.

The United States is the only developed country where you have to be poor in order for the Government to cover your long-term care needs.  Bills to further fund long-term care are introduced often in Congress, but have not passed due to lack of funding.

The lack of Congressional action has led many states, including California, to consider their own program.  The first state program is now being implemented in Washington State, covering a minimal long-term care benefit, paid for by a payroll tax on employees of Washington companies.

The issues are similar in California and were considered by the California Task Force.  The California Task Force is made up of three disparate groups: (1) heads of caregiving organizations, (2) actuaries from insurance companies, and (3) members of the Department of Insurance.  Due to their different backgrounds, they wound up recommending five different plan designs, not one, which vary greatly in costs and benefits, giving the Legislature a maze of alternatives to consider.

In my opinion, the only design which has a chance of passing the Legislature is one of the least expensive ones and is an adaptation of the Act in Washington State.  Even with this minimal design, the tax could be about one percent of income, or $ 700 per year for a person with an income of $ 70,000.  This would only create a minimal public long-term care program.  Those who could afford it would want to augment their coverage with private long-term care insurance.

The Task Force assumed that employers could pay half the cost, but I believe there would be tremendous opposition by employers to being further taxed in California.  This new tax could encourage more employers to move their domiciles to a state, such as Arizona or Texas, where there is no corporate income tax, thus depriving California of needed revenue.

The Legislature only has a few weeks to introduce new legislation in the 2024 session.  If a new bill is not introduced by late February, nothing will be passed in 2024.  Then we’ll see what happens in 2025 to enable a bill to become law, possibly by early 2026.  That’s all assuming that there is wide public support for such a program.  Currently, most citizens are unaware of the considerable work that has been done and the many issues involved. The selling of a program will be a major undertaking and hasn’t yet been funded.

Nothing has happened yet, but watch what the Legislature does.  Stay tuned, as this issue could have a big effect on your future.

What is long-term care insurance good for?

Long-term care insurance is good for far more than simply paying for nursing homes. MASKOT/GETTY IMAGES

You have a nearly 70% chance of needing some form of long-term care by the time you turn 65, and that care can be expensive. If you’ve looked into how you’ll pay for it, you may have come across the option for long-term care insurance.

This unique type of insurance is designed to help cover the large and growing cost of long-term care. But what exactly does that mean? Does it mean you’ll need to be confined to a nursing home or assisted living community before your benefits kick in, or is long-term care insurance good for something else?

You might be surprised at the ways this type of insurance can help you as you age. Moreover, the benefit of this insurance may extend to your loved ones.

What is long-term care insurance good for?

In general, long-term care insurance is important for most people.

“Since those who reach age 65 have a 70% chance of needing care, planning is needed,” says John Hill, president of Gateway Retirement.

Long-term care insurance could help you with that planning process. But what exactly is long-term care insurance good for? Here are a few things coverage could help with:

To help cover the cost of aging in place

There’s a widespread misconception that long-term care insurance is only for people who plan on moving into a nursing home or assisted living facility. That’s not exactly true. It is true that some plans only provide coverage if you move into one of these facilities, but there are plenty of other plans that can help you age in place. These plans can come with coverage features like:

  • Home renovations: Some long-term care insurance policies may help with the cost of home renovations to make your home more accessible as you age. For example, these policies may help with the cost of installing a ramp to your front door or handles in your bathroom.
  • Equipment: Long-term care insurance policies may also help cover the cost of the equipment that makes it possible for you to age in place.
  • Care: Long-term care insurance can help cover the cost of home healthcare as well. It could even pay your family members to provide your care.

To pay for a skilled nursing home

Even if aging in place is your plan, there may be a time when a skilled nursing home is the more feasible option. After all, even if your family members have intentions of handling your care, medical conditions may lead to a need for around-the-clock skilled medical care. At this point, a nursing home is typically the best option.

On the other hand, nursing homes can be expensive. According to the American Council On Aging, the cost of a nursing home can easily exceed $100,000 per year. Long-term care insurance can help cover this expense, potentially preserving your privacy, your dignity and your ability to choose as you age.

To ease the burden of care on your loved ones

Long-term care insurance is especially important if you plan on aging in place with family caregivers. There are a few ways this type of insurance helps in this scenario:

  • Adult daycare: Your family members may not be able to provide 24-hour care. After all, they may have their careers to maintain or need time off every once in a while. Adult daycare facilities can provide the care you need during these times, but they can also be expensive. Long-term care insurance may help cover this expense.
  • Family caregivers: It’s important to try and provide compensation for your family caregivers. Sure, they’re willing to provide your care out of love, but offering payment makes it more rewarding for them to do so. Long-term care insurance may give you a way to pay your family caregivers. However, if that’s your plan, be sure that the policy you purchase covers both formal and informal caregivers.
  • Skilled care: At some point, you may need care that goes above and beyond the skills your family members have. At this point, you’ll likely need in-home skilled care or a skilled nursing facility. Your family may struggle to find a way to help you cover these costs if you haven’t already planned for them. Long-term care insurance can help ease this burden.

The bottom line

Long-term care insurance is a good way to plan for countless potential circumstances. The simple fact is that when you turn 65 the chance that you’ll need some form of care tends to increase. With that in mind, it’s a wise idea to plan for the cost of this care with long-term care insurance.

Facing Financial Ruin as Costs Soar for Elder Care

The United States has no coherent system for providing long-term care, leading many who are aging to struggle to stay independent or to rely on a patchwork of solutions.

Reed Abelson and 

Reed Abelson is a health care reporter for The Times and Jordan Rau is a reporter for KFF Health News. They interviewed dozens of families and experts for the Dying Broke series, a joint project on long-term care.

Margaret Newcomb, 69, a retired French teacher, is desperately trying to protect her retirement savings by caring for her 82-year-old husband, who has severe dementia, at home in Seattle. She used to fear his disease-induced paranoia, but now he’s so frail and confused that he wanders away with no idea of how to find his way home. He gets lost so often that she attaches a tag to his shoelace with her phone number.

Feylyn Lewis, 35, sacrificed a promising career as a research director in England to return home to Nashville after her mother had a debilitating stroke. They ran up $15,000 in medical and credit card debt while she took on the role of caretaker.

Sheila Littleton, 30, brought her grandfather with dementia to her family home in Houston, then spent months fruitlessly trying to place him in a nursing home with Medicaid coverage. She eventually abandoned him at a psychiatric hospital to force the system to act.

“That was terrible,” she said. “I had to do it.”

Millions of families are facing such daunting life choices — and potential financial ruin — as the escalating costs of in-home care, assisted-living facilities and nursing homes devour the savings and incomes of older Americans and their relatives.

“People are exposed to the possibility of depleting almost all their wealth,” said Richard W. Johnson, director of the program on retirement policy at the Urban Institute.

The prospect of dying broke looms as an imminent threat for the boomer generation, which vastly expanded the middle class and looked hopefully toward a comfortable retirement on the backbone of 401(k)s and pensions. Roughly 10,000 of them will turn 65 every day until 2030, expecting to live into their 80s and 90s as the price tag for long-term care explodes, outpacing inflation and reaching a half-trillion dollars a year, according to federal researchers.

The challenges will only grow. By 2050, the population of Americans 65 and older is projected to increase by more than 50 percent, to 86 million, according to census estimates. The number of people 85 or older will nearly triple to 19 million.

Among Americans who had $171,365 to $1.8 million in savings at age 65, those with greater long-term care needs were much more likely to deplete their savings than those who did not need long-term care.

Notes: The percent who died broke is the percent of each group of people who reported a net worth of less than $3,000 by the time they died. Groups of people were those who at age 65 reported to the Health and Retirement Study a net worth in the 50th to 95th percentile, or $171,365 to $1,827,765 in 2020 inflation adjusted dollars, and who subsequently either needed or did not need long-term care. Read the full methodology.

Source: New York Times/KFF Health News analysis of Health and Retirement Study data from 2000 to 2021.

By Albert Sun and Holly K. Hacker

The United States has no coherent system of long-term care, mostly a patchwork. The private market where a minuscule portion of families buy long-term care insurance has shriveled, reduced over years of giant rate hikes by insurers that had underestimated how much care people would actually use. Labor shortages have left families searching for workers willing to care for their elders in the home. And the cost of a spot in an assisted-living facility has soared to an unaffordable level for most middle-class Americans. They have to run out of money to qualify for nursing home care paid for by the government.

For an examination of the crisis in long-term care, The New York Times and KFF Health News interviewed families across the nation as they struggled to obtain care; examined companies that provide it; and analyzed data from the federally funded Health and Retirement Study, the most authoritative national survey of older people about their long-term care needs and financial resources.

ImageTwo dolls dressed in pink and yellow clothes sit on a windowsill next to several framed photos. Betty Mae Glenn’s legs are stretched out on her nursing home bed.
The nursing home room of Gay Glenn’s mother in Topeka, Kan. Her mother had to pay the home more than $10,000 a month until she qualified for Medicaid.Credit…Arin Yoon for The New York Times
Two dolls dressed in pink and yellow clothes sit on a windowsill next to several framed photos. Betty Mae Glenn’s legs are stretched out on her nursing home bed.


A snapshot of Annie Reid in a floral dress and her mother, Frances Sampogna, sitting on a bench outside. The photograph rests on a lace doily.
An old photo of Annie Reid and her mother, Frances Sampogna, at her mother’s house in Silver Spring, Md. Ms. Reid moved home to care for her mother, who had dementia.Credit…Shuran Huang for The New York Times


Framed photographs of Dottye Burt-Markowitz and her husband, Stan Markowitz, when they were younger.
Pictures of Dottye Burt and her husband, Stan Markowitz, in their home in Baltimore. Mr. Markowitz, who had Parkinson’s disease, eventually moved to a nursing home.Credit…Shuran Huang for The New York Times

About eight million people 65 and over reported that they had dementia or difficulty with basic daily tasks like bathing and feeding themselves — and nearly three million of them had no assistance at all, according to an analysis of the survey data. Most people relied on spouses, children, grandchildren or friends.

The United States devotes a smaller share of its gross domestic product to long-term care than do most other wealthy countries, including Britain, France, Canada, Germany, Sweden and Japan, according to the Organization for Economic Cooperation and Development. The United States lags its international peers in another way: It dedicates far less of its overall health spending toward long-term care.

“We just don’t value elders the way that other countries and other cultures do,” said Dr. Rachel M. Werner, the executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “We don’t have a financing and insurance system for long-term care,” she said. “There isn’t the political will to spend that much money.”

Many older adults struggled with basic tasks

Almost 20 percent of those 65 and older reported having difficulty with one or more basic daily tasks. Of those, many were not receiving help.

Source: New York Times/KFF Health News analysis of Health and Retirement Study data from 2020 and 2021

By Albert Sun and Holly K. Hacker

Despite medical advances that have added years to the average life span and allowed people to survive decades more after getting cancer or suffering from heart disease or strokes, federal long-term care for older people has not fundamentally changed in the decades since President Lyndon Johnson signed Medicare and Medicaid into law in 1965. From 1960 to 2021, the number of Americans age 85 and older increased at more than six times the rate of the general population, according to census records.

Medicare, the federal health insurance program for Americans 65 and older, covers the costs of medical care, but generally pays for a home aide or a stay in a nursing home only for a limited time during a recovery from a surgery or a fall or for short-term rehabilitation.

Medicaid, the federal-state program, covers long-term care, usually in a nursing home, but only for the poor. Middle-class people must exhaust their assets to qualify, forcing them to sell much of their property and to empty their bank accounts. If they go into a nursing home, they are permitted to keep a pittance of their retirement income: $50 or less a month in a majority of states. And spouses can hold onto only a modest amount of income and assets, often leaving their children and grandchildren to shoulder some of the financial burden.

“You basically want people to destitute themselves and then you take everything else that they have,” said Gay Glenn, whose mother lived in a nursing home in Kansas until she died in October at age 96.

Her mother, Betty Mae Glenn, had to spend down her savings, paying the home more than $10,000 a month, until she qualified for Medicaid. Ms. Glenn, 61, relocated from Chicago to Topeka more than four years ago, moving into one of her mother’s two rental properties and overseeing her care and finances.


In a camel-colored long coat and jeans, Gay Glenn sits on the steps on the porch of her mother’s two-story house in Kansas.
Ms. Glenn, outside her mother’s home in Topeka, moved to Kansas from Chicago more than four years ago to oversee her mother’s care and finances.Credit…Arin Yoon for The New York Times

Ms. Glenn visiting with her mother and brother in a skilled nursing facility in Kansas. Ms. Glenn sold her mother’s house, right, shortly before her mother died in October.

Under the state Medicaid program’s byzantine rules, she had to pay rent to her mother and that income went toward her mother’s care. Ms. Glenn sold the family’s house just before her mother’s death. Her lawyer told her the estate had to pay Medicaid back about $20,000 from the proceeds.

A play she wrote about her relationship with her mother, titled “If You See Panic in My Eyes,” was read this year at a theater festival.

At any given time, skilled nursing homes house roughly 630,000 older residents whose average age is about 77, according to recent estimates. A long-term resident’s care can easily cost more than $100,000 a year without Medicaid coverage at these institutions, which are supposed to provide round-the-clock nursing coverage.

Nine of 10 people said it would be impossible or very difficult to pay that much, according to a KFF public opinion poll conducted during the pandemic.

Efforts to create a national long-term care system have repeatedly collapsed. Democrats have argued that the federal government needs to take a much stronger hand in subsidizing care. The Biden administration sought to improve wages and working conditions for paid caregivers. But a $150 billion proposal in the Build Back Better Act for in-home and community-based services under Medicaid was dropped to lower the price tag of the final legislation.

“This is an issue that’s coming to the front door of members of Congress,” said Senator Bob Casey, Democrat of Pennsylvania and chairman of the Senate Special Committee on Aging. “No matter where you’re representing — if you’re representing a blue state or red state — families are not going to settle for just having one option,” he said, referring to nursing homes funded under Medicaid. “The federal government has got to do its part, which it hasn’t.”

But leading Republicans in Congress say the federal government cannot be expected to step in more than it already does. Americans need to save for when they will inevitably need care, said Senator Mike Braun of Indiana, the ranking Republican on the aging committee.

“So often people just think it’s just going to work out,” he said. “Too many people get to the point where they’re 65 and then say, ‘I don’t have that much there.’”

The boomer generation is jogging and cycling into retirement, equipped with hip and knee replacements that have slowed their aging. And they are loath to enter the institutional setting of a nursing home.

But they face major expenses for the in-between years: falling along a spectrum between good health and needing round-the-clock care in a nursing home.

That has led them to assisted-living centers run by for-profit companies and private equity funds enjoying robust profits in this growing market. Some 850,000 people age 65 or older now live in these facilities that are largely ineligible for federal funds and run the gamut, with some providing only basics like help getting dressed and taking medication and others offering luxury amenities like day trips, gourmet meals, yoga and spas.

The bills can be staggering.

Rising costs for long-term care

The median annual cost of all types of long-term care has risen faster than inflation over the last two decades.

Notes: Costs are adjusted for inflation and shown in 2021 dollars. Home health aide figures for 2005 to 2007 are omitted because of a change in methodology.

Source: Genworth Cost of Care Study

By Albert Sun

Half of the nation’s assisted-living facilities cost at least $54,000 a year, according to Genworth, a long-term care insurer. That rises substantially in many metropolitan areas with lofty real estate prices. Specialized settings, like locked memory care units for those with dementia, can cost twice as much.

Home care is costly, too. Agencies charge about $27 an hour for a home health aide, according to Genworth. Hiring someone who spends six or seven hours a day cleaning and helping an older person get out of bed or take medications can add up to $60,000 a year.

As Americans live longer, the number who develop dementia, a condition of aging, has soared, as have their needs. Five million to seven million Americans over age 65 have dementia, and their ranks are projected to grow to nearly 12 million by 2040. The condition robs people of their memories, mars the ability to speak and understand, and can alter their personalities.

In Seattle, Margaret and Tim Newcomb sleep on separate floors of their two-story cottage, with Ms. Newcomb ever-mindful that her husband, who has dementia, can hallucinate and become aggressive if medication fails to tame his symptoms.

“The anger has diminished from the early days,” she said last year.

But earlier on, she had resorted to calling the police when he acted erratically.

“He was hating me and angry, and I didn’t feel safe,” she said.


In a navy-and-white print blouse, Margaret Newcomb holds back a curtain while watching her husband Tim, in a ball cap and shirt.
Margaret Newcomb cares for her husband, Tim, who has dementia, at home, partly in an effort to protect their retirement savings.Credit…Ruth Fremson/The New York Times

She considered memory care units, but the least expensive option cost around $8,000 a month and some could reach nearly twice that amount. The couple’s monthly income, with his pension from Seattle City Light, the utility company, and their combined Social Security, is $6,000.

Placing her husband in such a place would have gutted the $500,000 they had saved before she retired from 35 years teaching art and French at a parochial school.

“I’ll let go of everything if I have to, but it’s a very unfair system,” she said. “If you didn’t see ahead or didn’t have the right type of job that provides for you, it’s tough luck.”

In the last year, medication has quelled Mr. Newcomb’s anger, but his health has also declined so much that he no longer poses a physical threat. Ms. Newcomb says she’s reconciled to caring for him as long as she can.

“When I see him sitting out on the porch and appreciating the sun coming on his face, it’s really sweet,” she said.

The financial threat posed by dementia also weighs heavily on adult children who have become guardians of aged parents and have watched their slow, expensive declines.

Claudia Morrell, 64, of Parkville, Md., estimated her mother, Regine Hayes, spent more than $1 million during the eight years she needed residential care for dementia. That was possible only because her mother had two pensions, one from her husband’s military service and another from his job at an insurance company, plus savings and Social Security.

Ms. Morrell paid legal fees required as her mother’s guardian, as well as $6,000 on a special bed so her mother wouldn’t fall out and more on private aides after she suffered repeated small strokes. Her mother died last December at age 87.

“I will never have those kinds of resources,” Ms. Morrell, an education consultant, said. “My children will never have those kinds of resources. We didn’t inherit enough or aren’t going to earn enough to have the quality of care she got. You certainly can’t live that way on Social Security.”


A portrait of Annie Reid, who sits on her childhood bedroom with her small dog Romeo. The walls are a light blue with gauzy curtains over a window and three small shelves with cards on them.
Annie Reid moved back into her childhood bedroom and lived there for years to take care of her mother, who had dementia.Credit…Shuran Huang for The New York Times

For seven years, Annie Reid abandoned her life in Colorado to sleep in her childhood bedroom in Maryland, living out of her suitcase and caring for her mother, Frances Sampogna, who had dementia. “No one else in my family was able to do this,” she said.

“It just dawned on me, I have to actually unpack and live here,” Ms. Reid, 61, remembered thinking. “And how long? There’s no timeline on it.”

After Mrs. Sampogna died at the end of September 2022, her daughter returned to Colorado and started a furniture redesign business, a craft she taught herself in her mother’s basement. Ms. Reid recently had her knee replaced, something she could not do in Maryland because her insurance didn’t cover doctors there.

“It’s amazing how much time went by,” she said. “I’m so grateful to be back in my life again.”

Most people were cared for by family, not professionals

Partners and daughters were the most common caregivers for people who needed help with daily activities.

Note: For those 65 and older who needed and received long-term care in 2020 and 2021.

Source: New York Times/KFF Health News analysis of Health and Retirement Study data for 2020 and 2021

By Albert Sun and Holly K. Hacker

Studies are now calculating the toll of caregiving on children, especially women. The median lost wages for women providing intensive care for their mothers is $24,500 over two years, according to a study led by Norma Coe, an associate professor at the Perelman School of Medicine at the University of Pennsylvania.

Ms. Lewis moved back from England to Nashville to care for her mother, a former nurse who had a stroke that put her in a wheelchair.

“I was thrust back into a caregiving role full time,” she said. She gave up a post as a research director for a nonprofit organization. She is also tending to her 87-year-old grandfather, ill with prostate cancer and kidney disease.

Making up for lost income seems daunting while she continues to support her mother.

But she is regaining hope: She was promoted to assistant dean for student affairs at Vanderbilt School of Nursing and was recently married. She and her husband plan to stay in the same apartment with her mother until they can save enough to move into a larger place.


In a kitchen where a stainless steel refrigerator and microwave serve as a backdrop, Feylyn Lewis pours tea from a gallon jug into a brown mug while her mother, sits in a wheelchair behind her.
Feylyn Lewis making a cup of tea for her mother, who needed a wheelchair after she had a stroke. “I was thrust back into a caregiving role full time,” she said.Credit…William DeShazer for The New York Times

Over the years, lawmakers in Congress and government officials have sought to ease the financial burdens on individuals, but little has been achieved.

The CLASS Act, part of the Obamacare legislation of 2010, was supposed to give people the option of paying into a long-term insurance program. It was repealed two years later amid compelling evidence that it would never be economically viable.

Two years ago, another proposal, called the WISH Act, outlined a long-term care trust fund, but it never gained traction.

On the home care front, the scarcity of workers has led to a flurry of attempts to improve wages and working conditions for paid caregivers. A provision in the Build Back Better Act to provide more funding for home care under Medicaid was not included in the final Inflation Reduction Act, a less costly version of the original bill that Democrats sought to pass last year.

The labor shortages are largely attributed to low wages for difficult work. In the Medicaid program, demand has clearly outstripped supply, according to a recent analysis. While the number of home aides in the Medicaid program has increased to 1.4 million in 2019 from 840,000 in 2008, the number of aides per 100 people who qualify for home or community care has declined nearly 12 percent.

In April, President Biden signed an executive order calling for changes to government programs that would improve conditions for workers and encourage initiatives that would relieve some of the burdens on families providing care.

The only true safety net for many Americans is Medicaid, which represents, by far, the largest single source of funding for long-term care.

More than four of five middle-class people over 65 who need long-term care for five years or more will eventually enroll, according to an analysis for the federal government by the Urban Institute. Almost half of upper-middle-class couples with lifetime earnings of more than $4.75 million will also end up on Medicaid.

But gaps in Medicaid coverage leave many people without care. Under federal law, the program is obliged to offer nursing home care in every state. In-home care, which is not guaranteed, is provided under state waivers, and the number of participants is limited. Many states have long waiting lists, and it can be extremely difficult to find aides willing to work at the low-paying Medicaid rate.

Qualifying for a slot in a nursing home paid by Medicaid can be formidable, with many families spending thousands of dollars on lawyers and consultants to navigate state rules. Homes may be sold or couples may contemplate divorce to become eligible.

Ms. Burt caring for her husband in October 2022, at the nursing home he moved into in Baltimore.


Dottye Burt sits on the edge of a bed in a darkened room, with a bedside table lamp behind her.
Mr. Markowitz had to contribute $2,700 a month to the nursing home, which ate up 45 percent of the couple’s retirement income. His wife rented a modest apartment near the home, all she could afford on what was left of their income.Credit…Shuran Huang for The New York Times

And recipients and their spouses may still have to contribute significant sums. After Stan Markowitz, a former history professor in Baltimore with Parkinson’s disease, and his wife, Dottye Burt, 78, exhausted their savings on his two-year stay in an assisted-living facility, he qualified for Medicaid and moved into a nursing home.

He was required to contribute $2,700 a month, which ate up 45 percent of the couple’s retirement income. Ms. Burt, who was a racial justice consultant for nonprofits, rented a modest apartment near the home, all she could afford on what was left of their income.

Mr. Markowitz died in September at age 86, easing the financial pressure on her. “I won’t be having to pay the nursing home,” she said.

Even finding a place willing to take someone can be a struggle. Harold Murray, Sheila Littleton’s grandfather, could no longer live safely in rural North Carolina because his worsening dementia led him to wander. She brought him to Houston in November 2020, then spent months trying to enroll him in the state’s Medicaid program so he could be in a locked unit at a nursing home.

She felt she was getting the runaround. Nursing home after nursing home told her there were no beds, or quibbled over when and how he would be eligible for a bed under Medicaid. In desperation, she left him at a psychiatric hospital so it would find him a spot.

“I had to refuse to take him back home,” she said. “They had no choice but to place him.”

He was finally approved for coverage in early 2022, at age 83.

A few months later, he died.

Reporting was contributed by Kirsten Noyes and Albert Sun, Holly K. Hacker of KFF Health News that is part of the organization formerly known as the Kaiser Family Foundation, and JoNel Aleccia, formerly of KFF Health News.

Audio produced by Tally Abecassis.

Act now on long-term care planning

November is Long Term Care Awareness month!  

There are various factors that you should consider if you delay planning for how to would handle a long-term care event:

  • Life’s unpredictable: No one can predict when or if a chronic illness will strike. Waiting to buy coverage could result in being ineligible or having limited options should you experience a change in health.
  • Increasing cost: The longer you wait to purchase long-term care coverage, the higher your premiums will be as you age.
  • Risk putting the burden on others: Without a plan, many families are left to make decisions in a time of crisis, frequently resulting in financial, physical and emotional burdens.
  • Protect against future costs: Locking in meaningful coverage now can help protect against future uncertainties. 

Dianne Feinstein’s ‘significant medical expenses’ before her death point to harsh reality for everyone

San Francisco Chronicle – Long Term Care planning article

Kellie Hwang

Sep. 28, 2023 Updated: Oct. 1, 2023 4:23 p.m.

Sen. Dianne Feinstein returns to Capitol Hill in Washington, D.C., after her hospitalization from shingles on May 11. The dispute involving the estate of her late husband illustrates the harsh reality of the costs of in-home health care, experts say.

In the weeks before Sen. Dianne Feinstein’s death, her health struggles after a bout with shingles and extended absence from the Senate highlighted an issue that has implications for many Americans.

A key argument by Feinstein in the dispute over the vast estate of her late husband — including a multimillion-dollar Stinson Beach home — was that she needed the money to pay for “significant medical expenses.”

That claim by Feinstein, a high-ranking politician whose late husband was a billionaire and who is independently extremely wealthy, illustrated the harsh reality of the costs of in-home care, experts say.

According to court filings, the California Democrat’s health issues necessitated more than $160,000 in medical expenses, much likely due to the high costs of home health care and any assistance with daily living after Feinstein’s March hospitalization from shingles.

In-home care generally encompasses medical or assistive care for individuals who need additional support to live at home. The Centers for Disease Control and Prevention estimates 4.9 million people received or ended home health care in 2017.

Feinstein was insured through Medicare and a marketplace policy enabled by the Affordable Care Act, but neither covers many of the costs of long-term home care. In fact, most public and private health and disability insurance policies offer little or no long-term in-home care benefits.

But while most people plan for their retirement, many don’t think about long-term home care expenses until they or a loved one ends up needing it.

“I think a lot of people live precariously, and a lot of people manage in ways that are not ideal,” said Katherine Possin, a professor at the UCSF Memory and Aging Center.

And they may be in for a rude awakening.

An Associated Press-NORC Center for Public Affairs Research survey found that 49% of people 40 and older expect to depend on Medicare to pay for their long-term care needs, even though such services typically are not covered. The survey also found that 69% of Americans have done little to no planning for their long-term needs, and only 16% are confident they will be financially prepared to pay for such care.

Add to that one more sobering statistic: “The federal government predicts 70% of people over the age of 65 will at some time in their life need long-term care,” said Bonnie Burns, a consultant with California Health Advocates — and the majority of them will start out needing that care at home.

Compounding the problem is the size of the aging Baby Boom population: The number of Americans 65 and older reached 55.8 million in 2020, growing nearly five times faster than the total population over 1920 to 2020, according to the 2020 census.

Most long-term care at home is provided informally at home by unpaid family members and friends, according to the National Institute on Aging. Professional paid caregivers are hired through home health care agencies and include nurses, home health care aides and therapists.

While long-term care can also include nursing homes, assisted living facilities or adult day care centers — each of which is a complex topic in its own right — Feinstein’s in-home care situation prompted this deeper dive, with health care and financial experts explaining how to avoid being blindsided.

How common is the need for in-home care?

An older person may have suffered an injury, is recovering after an operation, or is managing an acute or chronic condition. Staying at home can offer elderly people independence and increased comfort.

Most home-based services include personal care such as bathing and dressing, as well as taking medication and supervision to ensure safety. Effective in-home care can save money, improve health outcomes and reduce the need for hospitalization, experts say.

While the need varies based on a person’s situation, and will change over time, data shows 3.7 years of long-term care is required for women, and 2.2 years for men, according to the Administration for Community Living.

One-third of the population may never need the support, and 20% will need it for longer than five years. About 65% of people use in-home care for an average of two years.

How much does it cost?

The cost is dependent on a number of factors including individual needs, medical conditions, where you live and the level of care you’re seeking.

In the ultra-pricey Bay Area, in-home care is going to cost more compared with other metro areas, experts said.

“Premiums are going to be higher, and the rate to get a caregiver is going to be higher,” said Anne Rosenthal, a certified care manager in the Bay Area. “The cost of living here is going to be higher, wages are higher.”

For example, according to a long-term care calculator from life insurance company Genworth, the estimated 2023 costs for a home health aide in San Francisco is $7,585 a month for 44 hours a week, and $91,025 annually. For homemaker services such as meal preparation, grocery shopping, laundry and cleaning, it’s an estimated $7,282 monthly and $87,384 annually for 44 hours a week. Genworth follows industry guidance of 44 hours as the estimated hours per week for professional in-home caregivers.

There are several calculators available to estimate long-term care costs, including one from AARP and another from the American Institute of Certified Public Accountants.

How is in-home care usually paid for?

Long-term care insurance is one option, with 7.5 million Americans reporting some form of coverage as of 2020.  While it can help protect your nest egg, it is costly.

According to the American Association for Long-Term Care Insurance, a 55-year-old man could expect to pay an annual premium of $2,200 for $165,000 in benefits in 2022 that grow 3% yearly. That premium would be $3,700 for a 55-year-old woman, as women have longer life expectancies than men. The annual premium goes up as you age: For a 65-year-old, the same benefits would be $3,135 and $5,265, respectively.

“Insurance brokers get large commissions just for selling a policy, and many will offer low-cost policies that are not as useful as a policy offering more benefits,” said Brooke Salvini, a financial adviser and planner based in San Luis Obispo. “Premiums increase each year, sometimes as much as 40%.”

When shopping, she advised getting “the most comprehensive policy you can afford” with an inflationary rider, which offers protection against the increasing costs of long-term care services due to inflation.

A newer product is combination policies that offer both life insurance and long-term care. Generally you have the option to pay one lump-sum premium or a few large annual premiums, and your beneficiary receives a benefit upon your death if you don’t max out your long-term care benefits. The average single premium payment was $75,900-$77,000 in 2022.

Low-income individuals may qualify for public support programs such as Medi-Cal (California’s Medicaid program) that have income or asset eligibility requirements. Some people in particularly difficult circumstances may try to transfer or sell assets in order to qualify for programs, but Salvini said for most people it’s not a go-to strategy she would suggest, and she has not performed this type of planning for her clients.

Burns, the California Health Advocates consultant, said unpaid in-home care frequently falls on women, particularly daughters who often have to care for their own children and also work full-time jobs.

“My mission in life is to find a way to finance this type of care,” she said.

Washington state offers the WA Cares Fund, the only long-term care benefit program of its kind in the U.S., covering all full-time, part-time and temporary workers in the state. Starting in July 1, 2023, workers began contributing a portion (0.58%) of their paychecks automatically.

California has initiated a task force to “make recommendations to the state Legislature for a similar program,” Burns said — but she added that it would be difficult to craft in a way that meets the need for future care and would also be a tough political sell.

For some in the Bay Area, receiving care in their current setting may not prove economically feasible, according to Rosenthal, the certified care manager. They might need to consider options like moving to a less expensive area, or to a community setting or other shared housing arrangement, Rosenthal said.

How can I save for this expense?

Experts say you should start planning for in-home care expenses in your 30s to 40s.

“Saving early is better and easier,” Salvini said. “You can save a smaller amount each year and let time work the magic of compound growth.”

Salvini said potential health care costs are generally part of an overall retirement savings plan, and a U-shaped spending pattern — with peak expenditures at the beginning and end of the retirement period — will result in a solid financial plan.

“The early years of retirement spending is high for activities that were delayed, and put off during the busy work years,” she wrote in an email. “In the middle retirement years, spending may be less because big budget bucket list desires have been fulfilled. Then the later elder years of retirement can have medical expenses.”

Another way to save is by utilizing your health savings account if you’re covered by a high-deductible plan.

“HSAs are triple tax advantaged — a deduction at the time of contribution, tax free growth, and tax-free withdrawal when used for medical expenses,” Salvini said. “One often overlooked ‘super power’ of an HSA is no requirement to match expenses and withdrawals in the same year.”

She advises clients to save the maximum amount allowed in their HSA, and “let their account grow tax free as long as possible.” Pay for current medical expenses from other savings, and “save all medical receipts to document a future lump sum withdrawal from the HSA.”

Your HSA should allow investment of most or all amounts in the account, Salvini added.

If an HSA isn’t an option or the contribution limit is too low, Salvini said a company retirement plan, such as a 401(k), or a traditional or Roth IRA is a good choice.

“The decision to contribute after tax into a Roth or pre-tax into a traditional (IRA) is very much an individual family decision based on income level and tax brackets,” she said. “The most important strategy is simply to be saving as much as you can, as early as you can.”

These topics can be too difficult or unpleasant for many people, Salvini acknowledged, pointing to a survey from senior living referral service that found 67% of Americans don’t have an estate plan. In their case, hiring a financial adviser might be a good decision, she said.

“A good adviser will start the conversation with clients on this difficult topic and set aside a budget in the financial plan for the likelihood of future long-term care costs, whether that means respite support for family caregivers or full service assisted living,” she said.

Owning a long-term care insurance policy will also reduce the amount that must be saved for possible long-term care expenses.

While certain conditions will necessitate professional care, some older individuals are “thinking out of the box” when it comes to getting help with tasks and services, Rosenthal said.

Communities known as elder villages are staffed by multigenerational volunteers who help older people age in place, such as the San Francisco Village, a membership organization. Ashby Village in Berkeley is a reciprocal community that helps connect older people to each other and to resources and services.

Sarah Dulaney, a clinical nurse specialist at the UCSF Memory and Aging Center, said while these communities don’t replace caregivers, they can help build a social network and widen resources. Older people can also receive help with certain tasks such as being driven to appointments, or help finding a new doctor or someone to clean their home.

“The Baby Boomer generation is thinking about how to age in place, and people may be realizing that their kids live across the country or out of the country, and they have their own kids and jobs,” Dulaney said. “These are grassroots healthy aging communities.

“But if you already have dementia and need help,” she added, “this is probably not a place to get it.”

Reach Kellie Hwang:; Twitter: @KellieHwang

Written By Kellie Hwang





On March 10th, a superior court approved the proposed second-class action settlement which has now gone out to CalPERS policyholders to accept or reject by June 6th and with a final court approval hearing scheduled for July 26th.

The settlement amount has dropped to $800 million from $ 2.7 billion in the first proposed settlement.  This may be to bolster the finances of the CalPERS long-term care program in order to protect remaining policyholders.  However, this program has had a history of failure, and keeping a CalPERS policy may be problematic.

The CalPERS policy is a group long-term care insurance policy, and as such, is not subject to regulation by the California Department of Insurance and is financed solely by CalPERS.  Unfortunately, CalPERS investments have turned sour, and for that and other reasons, the program has been grossly underfunded.

The basic offer of the new settlement involves two choices: (1) refund of 80 % of premiums paid, and (2) keeping policies and getting $ 1,000 and a moratorium on rate increases through October, 2024.

Alternatively, policyholders can reject both choices by completely excluding themselves from the class action lawsuit and still maintain their policies.  There is also a process to object to the settlement.

If more than 1% of policyholders exclude themselves from the suit, then the settlement permits CalPERS to walk away from the deal.  CalPERS walked away from the first proposed settlement which failed to garner sufficient approval from policyholders.

With a settlement, as opposed to a trial, CalPERS representatives have not been compelled to speak publicly about what occurred and why.  As well, with this settlement, CalPERS denies all culpability and responsibility for causing harm or violating contracts.

Policyholders that accept either of the settlement offers will also give up all claims against CalPERS arising from or related to the 85% premium increase.  Whether such a release of claims would apply to CalPERS’ most recent 90% rate increase is unclear.

For those who decide to obtain the refund of 80% of premium paid, we may be able to provide another solution which would protect you against the costs of long-term care.  You could convert that cash refund into a plan which could take the cash you receive and multiply it several times to cover long-term care expenses in the future.  To do this, you would have to be less than 85 years old and in fairly reasonable health.  To find out whether you  would qualify, please either give us a call at 800 303-1527 or contact us at


A new, mandatory tax which would provide minimal long-term care benefits for California’s citizens has now been recommended by the California Task Force for Long Term Care.

Here’s the brief background.  The California Task Force for Long-Term Care was established “to explore the feasibility of developing and implementing a culturally competent statewide insurance program for long-term care services and supports.”  The Task force has a committee of fifteen members, consisting mostly of California Department of Insurance employees and representatives of caregiving organizations.

The Task Force has met many times over the past year and has submitted its recommendations to the Legislature and the Governor.  It has tried to improve the imperfections of the recently enacted Cares Act from the State of Washington.  The Cares Act will be funded beginning in July through a mandatory payroll tax of .58 %.  It will give workers a lifetime benefit of $ 36,500, adjusted annually by Washington’s Consumer Price Index.  Other states, including the large ones of New York and Pennsylvania, are also considering adapting the Washington Cares Act.

The concept here is to provide a small long-term care benefit and to encourage citizens to buy wrap-around private long-term care insurance.  This would protect citizens and save the state many millions of future Medi-Cal dollars.

In my view, this is a noble effort to provide a public program to solve the pressing and growing long-term care conundrum.  The Committee meetings showed how pervasive and threatening long-term care costs are and are growing.  But the more one examines the details of a public program, the more complex the issues.

The California Task Force has decided to provide the Legislature with five recommended designs, not just one, which are widely different from each other, both in cost and in benefit structure.  It has hired the actuarial firm of Oliver Wyman to provide the cost analysis no later than December 31, 2023.

The Committee favored the most expensive designs, which could increase payroll or income taxes by as much as 20 % over the huge 9.83 % that many Californians currently pay.  It hoped to get employers to pay up to half the cost, which is unlikely in my opinion.  In the end, there is going to have to be a more realistic cost proposal for the Legislature to consider.

Washington State had a very limited period for citizens to buy private long-term care insurance and by doing so, opt-out of the program.  One seventh of the eligible citizens did so.  The Task Force is recommending a similar program in California.  Individuals who own eligible private insurance before the program effective date would be permitted to opt-out of the program.

If this recommendation becomes law, as was the case in Washington, there will be a stampede in California in 2023 to buy private long-term care insurance, and by doing so, probably avoid the tax.

As long-term care insurance specialists, we are gearing up to keep abreast of developments and provide expert advice.  For many, the time to act is now.

By Louis H. Brownstone