Moving Toward Universalism? The Future of Long-Term Care in the United States.

Policy Points America's long-term care system is largely poverty-based, requiring most older adults to spend down their assets to qualify for limited, Medicaid-funded support, which is biased toward institutional care and plagued by bureaucratic complexity and enrollment hurdles. There are now, however, some promising changes. First, though access to home care still is more difficult than access to institutional care, the use of Medicaid home care services has grown significantly since the 1980s. Most promising is Washington State's innovative new universal social long-term care insurance program. Broad-based, compulsory social insurance has proved effective in other countries-lessening poverty-induced eligibility hurdles, increasing access to care (especially in communities), and mitigating political vulnerabilities associated with targeted policies. CONTEXT: America's long-term care policy approach is poverty-based, requiring most older adults to spend down their assets to qualify for limited, Medicaid-funded support, which is biased toward institutional care and plagued by bureaucratic complexity and enrollment hurdles.

methodsI conduct a review of long-term care policy developments since the 1980s, as well as related research on the impacts of these varying policy approaches on access to services.

findingsWhile Medicaid-funding long-term care remains plagued by complexity and access issues, there have been promising changes. Use of home and community-based services has increased substantially for Medicaid beneficiaries since the early 1980s due in large part to activism on the part of disability rights movement. Though new and still relatively limited in scope, the most promising change has been the recent adoption of a universal long-term care policy in Washington State.

conclusionsAs the population ages and care needs grow more urgent, the United States faces a critical choice-cling to a piecemeal, confusing, and impoverishing long-term care system or embrace universalism to ensure meaningful access to needed community-based long-term care supports.