LTC Bullet: The Battle Lines Are Drawn

Friday, October 25, 2019


LTC Comment: Two sides advocate diametrically opposite solutions for the long-term care crisis. Who are they? What do they want? Which will win? Answers follow the ***news*** with details in our forthcoming report. Learn how to get a pre-publication copy now!

*** SOA TECH SUMMIT: On November 7, the Society of Actuaries, in partnership with Maddock Douglas, will host its first LTC Tech Summit at the Plug and Play Tech Center in the heart of innovation, Silicon Valley. Join leading innovators, payors, providers and investors to learn about emerging LTC technologies and participate in an intimate discussion to assemble the pieces that will address this crisis. Due to limited space, individuals wishing to attend the in-person event should register as soon as possible. Unable to attend in person? Select the live stream option during registration to take part in all the meeting sessions from the convenience of your computer. That’s what Steve Moses will do so he can report on this creative new program in an LTC Bullet soon after. ***

*** GENWORTH 2019 cost of care survey shows dramatic flip in rising costs from skilled nursing to home care. Read the press release here. Find the map and summary here. Dramatic new findings in the redesigned 2019 Genworth Cost of Care Survey will surely help sell new LTCI policies. This year, a single link takes you to one internet page with further links to both the national summary of costs by venue and a map of the U.S. where you can home in on individual states. The new design also has a slider that allows you to see estimated increases in costs for future decades. You can select hourly, daily, monthly and annual costs by venue and by state. I like this new design and believe you will too. Check it out now, but know you’ll be able to find it quickly in the future by accessing The Zone, our members-only website chock-a-bloc with all kinds of critical data and information. ***

*** FLIGHT OR FIGHT, that’s your choice. Either give up, go home, and let the opposition win. Or you can stand up to the perennial pessimists who say private long-term care insurance is a dead letter. You can read today’s LTC Bullet, get a pre-publication copy of our new report on “Medicaid and Long-Term Care,” and join the Resistance, AKA the Center for Long-Term Care Reform. Learn why the opposition’s concerted campaign to turn long-term care completely over to the government—the same government that ruined long-term care in the first place—is doomed either to fail or to make the system’s problems even worse. All current individual and corporate members of the Center should already have received your pre-publication copy of “Medicaid and Long-Term Care.” (If not, let us know at Everyone else: join the Center here, email to let us know you’re in, and the new report will be in your hands post haste. We can’t do this alone. We need your help. Carpe diem! ***



LTC Comment: On one side are the analysts and advocates who insist fixing long-term care is hopeless without greater government involvement. They want a new, compulsory social insurance program, like Medicare and Social Security, to sweep away problems of access, quality, low funding, and caregiver shortages. Their side is the Favorite.

On the other side are the lonely voices who favor a freer market approach. We want to redirect scarce public resources to the truly needy and create stronger incentives for everyone else to save, invest or insure for long-term care. Let people and the market choose the best way to provide and finance long-term care. Our side is the Underdog.

Around the end of the year, the Center for Long-Term Care Reform will publish a new report titled “Medicaid and Long-Term Care.” This study will explain what is wrong with the favored government takeover plan for long-term care. It will describe a far less onerous voluntary solution. For a pre-publication copy of “Medicaid and Long-Term Care,” join the Center here and contact the author at You’ll have your copy by email within minutes of joining our campaign to fix long-term care.

Here’s a preview of both sides of the long-term care debate, the Favorite vs. the Underdog, as developed in “Medicaid and Long-Term Care.”

Favorite: Long-term care is a mess. Access and quality are doubtful. Caregivers are in short supply. Free, family caregivers are over-stressed financially and emotionally. Medicaid pays too little. Private insurance failed. The coming age wave will explode costs. Institutional bias prevails; home care is inadequate. Woe is us. Please, Uncle Sam, take over and save the day.

Underdog: Whoa! All those symptoms are true. The existing system is terribly dysfunctional. But turning to government financing and control is not the place to start. Rather, the place to start is to ask why such problems exist. How did we get into this mess? What caused those symptoms of dysfunction in the first place? 

Favorite: Blank out. Nothing in the favorite’s literature, which we list and summarize in our new report, even attempts to explain why long-term care is failing so badly. Search their Health Affairs’ articles we cite and the SCAN, Leading Age, and LTC Collaborative reports those spawned and you will find nothing to account for the causes, as opposed to the symptoms, of long-term care problems.

Underdog: That’s why our new report briefly traces the history of long-term care services and financing from the 18th century until today. We show how increasing government regulation and financing of long-term care actually caused the problems that plague the long-term care system now. Given that history, you will see very clearly that adding more government regulation and financing, which caused the problems in the first place, can only make those problems worse.

Favorite: What do you mean government caused long-term care’s problems? How about some examples?

Underdog: OK, sure. Here’s a direct quote from our paper:  “At the root of all long-term care problems is Medicaid, the dominant payer. By providing only nursing home care—including room, board, and medical care—funded with virtually unlimited federal and state matching funds, Medicaid (1) exploded in cost, (2) created institutional bias, (3) caused access and quality problems by paying providers too little, (4) enriched plaintiff’s attorneys with the resulting tort liability cases, (5) crowded out private markets for home care and long-term care insurance, and (6) kept poor people poor with punishing spend down rules, while (7) letting the affluent save and benefit through eligibility loopholes.”

Favorite: Wait a minute? That can’t be true. Everyone knows Medicaid requires impoverishment and people all across America are spending down their life’s savings catastrophically to pay for long-term care. Medicaid only helps after they’ve been devastated financially. Our side’s articles and reports make that claim over and over again.

Underdog: True, and our report cites your claims and rebuts each one. There is no evidence of widespread catastrophic spend down for long-term care. In fact all the evidence proves the contrary as we explain and document in our report.

Favorite: But, but, but … sputter, sputter. How can that be?

Underdog: Our report explains, with citations to federal law and regulations, precisely why and how access to Medicaid long-term care benefits requires neither low income nor significantly depleted assets. Are you dubious? Then get and read our report. If you disagree, speak up. We challenge anyone willing to engage publicly to debate these issues in a forum of your choice.

Favorite: So, you’re saying people don’t plan for long-term care nor do they buy much private LTC insurance because they intend to rely on this mediocre welfare program? Hrumpf!

Underdog: No, not at all. People don’t know who pays for long-term care. They don’t think about it until they need expensive care at which point Medicaid is the path of least resistance. The simple fact that Medicaid has paid for most expensive LTC since 1965 enabled consumers’ denial of this risk and cost leaving generations dependent on questionable care mostly in welfare-financed nursing homes. Our report covers all that in detail.

Favorite: Well, if that’s true, where’s the proof?

Underdog: Our report cites an extensive popular and legal literature on how to qualify for Medicaid without spending down. We also explain how and why the other side—the advocates of expanded government interference—totally ignores that literature. Furthermore, we cite in detail a Government Accountability Office study that documents easy and commonplace Medicaid planning, but fails to draw the obvious conclusions, which we do draw and explain in our report. We propose a nationally generalizable study to establish once and for all the level and impact of unnecessary and counterproductive Medicaid long-term care dependency.

Favorite: We just don’t think Medicaid is that easy to get so we focus on other things.

Underdog: Right, that’s why our report has a whole section about your “Evasion of and Equivocation on Critical Concepts and Facts.” We explain how you misunderstand and misrepresent key ideas like “impoverishment,” “spend down,” “asset decumulation,” “median wealth,” “Medicaid planning,” and “out-of-pocket expenditures.” You also use and depend on highly dubious data sources which we identify and critique.

Favorite: “If Medicaid is not the catastrophic poverty-maker it is commonly made out to be, what is it?”

Underdog: That is exactly the question we ask and answer in the report’s “Ramifications” section. There we summarize how Medicaid caused institutional bias, impeded a private market for home care, exacerbated access and quality problems, created huge tort liability, impoverished poor people, enriched affluent people, and stultified private long-term care financing sources like home equity conversion and insurance.

Favorite: So, what would you do differently?

Underdog: That’s where our report shines in a section called “Policy Recommendations.” You just have to read it to believe how manageable our problems really are once you realize what caused them and how easy they will be to fix once we address their causes and not just their symptoms. In fact, we include a section called “Redefine the Problem,” which relies on the other sides’ studies and findings to prove the long-term care challenge is much more manageable than anyone previously believed, if and only if, correctly analyzed and addressed.

Favorite: So fixing what ails long-term care is a slam dunk if we just follow what you say?

Underdog: No, not at all, there is one huge obstacle that is beyond our ability to address by changing long-term care financing policy. It has to do again with government interference, but this time, interference in fiscal and monetary policy. Our report explains why our side made huge steps in the right direction, i.e. targeting Medicaid to the needy and encouraging private financing alternatives, in 1993 and again in 2005, but we’ve been stymied ever since. That will change by 2030 with catastrophic economic consequences, which we predict and summarize.

Favorite: So give up and go home?

Underdog: Not at all. Our message is “get ready.” Understand why we have the problems we have. Think clearly about what we have to change to fix them. When the crisis really hits, follow where the evidence and logic lead. Rebuild.

Favorite: We’re intrigued. Where can we get this report?

Underdog: Join the Center here and contact the author at You’ll have your copy by email (and all the other benefits of membership summarized here) within minutes of committing to join the Center for Long-Term Care Reform. Otherwise, you’ll need to wait for the report’s public release early in 2020.