For many Americans over 65, gaining access to high-quality long-term care has proven to be a formidable challenge. The Robert Wood Johnson Foundation's efforts to improve access to and quality of long-term care includes programs to improve nursing homes; to expand home care, adult day care, and assisted living; to give elderly people more choice in the type of care they receive; to encourage volunteerism; and to better integrate the delivery of medical care and long-term care among other initiatives.
Then there is the problem of paying for long-term care. The cost of nursing home care routinely impoverishes older Americans, who are then forced to rely on Medicaid (or to spend down in order to qualify for Medicaid). Long-term care insurance, a way of protecting people against going broke in old age, is expensive and has appealed primarily to a narrow band of upper middle-class or wealthy individuals. To increase the appeal of long-term care insurance, the Robert Wood Johnson Foundation, in 1987, initiated an experimental program called the Program to Promote Long-Term Care Insurance for the Elderly. This program fostered a new and controversial type of long-term care insurance product that allowed nursing home patients with state-approved private long-term care insurance policies to be eligible for Medicaid with substantially higher levels of assets than are normally allowed. This would permit them to receive nursing care and still have enough to live on and to bequeath to their children.
In this chapter from "To Improve Health and Health Care," Joseph Alper, a freelance journalist and frequent contributor to The Robert Wood Johnson Foundation Anthology, describes the logic of the program and the hurdles that had to be overcome to field the demonstrations, including federal legislation limiting the program to the four states. The result of nearly 20 years' effort is mixed. The product has proven viable, but the number of policies sold to date—especially those sold to middle-class and lower middle-class individuals—is far smaller than was expected. The story ends on an upbeat note, however, with the passage of legislation in 2006 that will allow all 50 states to market the private-public policies.