1. The Future of Long-Term Care: What Is Its Place in the Health Reform Debate? Howard Gleckman Tax Policy Center June 16, 2009

2. Remember: This is About People

3. The Challenge Deliver the most appropriate care to a highly vulnerable population Design a financing system to support this care without busting the budget Make it work for today’s frail elderly and disabled—and for 77 million Boomers

4. What Is Long-Term Care? Personal Care for disabled and frail elderly 10 million need it 85% is delivered in the community We spend $230 billion for paid care And $375 Billion for informal “free” care Free= financial, emotional, physical burdens

5. WHO PAYS?

6. Medicaid A Vast improvement over pre-1965 Provides benefits for the low-income elderly and disabled Targets assistance to those in society who most need it

7. BUT… You Pay ‘til you’re broke, then Medicaid Wide variation in benefits by state In the bulls eye in economic downturns Obligated for SNF care only Home care is optional Underfunded, limited benefits, long waiting lists

8. Stein’s law

9. Everyone Into the (Risk) Pool Private Long-Term Care Insurance Valuable estate planning tool for some Not a policy solution

10. Why? Too Expensive Too complicated Why buy if you’ve got Medicaid?

11. The Real Crisis of the Uninsured Health Insurance: 250 million covered LTC insurance: 7 million covered

12. SOLUTIONS DELIVERY ….BUT HOW? FINANCING:TIME FOR A MANDATE?

13. DELIVERY COORDINATE CARE MAKE IT AVAILABLE AT HOME Infrastructure: Not just personal aides, also housing, transportation, food, good medical care But don’t break the bank

14. FINANCE DO WE REALLY NEED MEDICAID? THREE ALTERNATIVES: ENHANCE PRIVATE LTCi CREATE NEW SOCIAL INSURANCE PUBLIC/PRIVATE MIX

15. ENHANCED LTCi Sell like Medigap Expand tax incentives Expand Partnership Program More Government Marketing EACH MAY HELP, NOT THE ANSWER

16. Social insurance International Model: France, Germany, Japan, Korea Nearly everyone but the UK & US

17. Medicare Part E HOW DO YOU TAX? Income tax surcharge (Burman/Johnson) Payroll tax surcharge (ala Germany) VAT—probably with health reform BUT…WILL AMERICANS PAY A NEW TAX?

18. Public/Private Government as First Payer (CLASS Act) Government as Secondary/Catastrophic: Galston; Tumlinson & Lambrew; Bishop

19. CLASS Act In the HELP bill Benefit: Cash, $50+ daily for life Auto enroll w/ an opt-out A premium, not a tax $65, or is it? Plus Private Insurance

20. Catastrophic Personal responsibility w/ low-income subsidy True catastrophic coverage Mandatory insurance or savings?

21. MODELS FOR FINANCING REFORM

22. If not now, when? HELP bill Will include CLASS Act, home care, workforce Workforce will pass, limited support for others Waiting for Obama