Yesterday, I gave a talk at the Dutch Ministry of Health in the Hague (the political center of the Netherlands). I was asked to make a presentation about the U.S. long-term care insurance system. The problem is, we have no “system” to speak of. Rather, we have a confusing patchwork of public and private programs that together do – at best – a modest job of protecting individuals from the financial risks of long-term care.
Long-term care is a classic case of a risk that people ought to insure – it is highly uncertain whether you will need it, but if you do, there is a chance of it consuming enormous sums of money. A typical nursing home can cost you north of $6,000 per month, and having skilled RN care in the home can easily cost $30 or more per hour. These numbers can quickly exhaust the limited financial wealth of a majority of American households.
And yet, most people in the U.S. do not insure against this risk. In aggregate, people pay about 1/3 of all long-term care costs out of their own pocket, whereas only about 4% of expenses is paid by private insurance. Who covers the rest? Taxpayers – through Medicaid, and to a smaller extent through Medicare.
But Medicaid is pretty lousy insurance because it requires that you impoverish yourself before you qualify. Normally, we think of buying insurance so that a big financial shock does not ruin our future consumption possibilities – for example, if your house burns down (say, for example, you failed to pay the fire department your annual fee – see Nolan’s latest post!), you get enough money to rebuild so that you do not have to cut back on your other expenditures. With Medicaid, however, it helps you out only after you have spent virtually all your other money paying for care.
So why don’t people buy private insurance? There are many plausible reasons, but one of them – as shown in my work with Amy Finkelstein – is because Medicaid’s means-testing and secondary payer status means that it is in your interest *not* to buy insurance. Why? Because most of what you buy ends up duplicating what you could have gotten for “free” from Medicaid. And because many policies available in the private market fail to cover a large share of you possible expenditures, you may end up on Medicaid anyway.
This highlights a fundamental problem – and one that, I learned yesterday, is shared by the Netherlands and Germany (both countries about which others presented). Namely, once you decide that you are going to not let people die on the streets for lack of funds to pay for long-term care (and thus provide a government program to help), you cannot help but mess up the private market.
This leaves a dilemma. If the private market cannot function properly because of the government means-tested program, and if you are not willing to get rid of the means-tested program (which would almost certainly leave some people in need of care left without it), then the net result is that people will have significant exposure to uninsured risks. Of course, one solution is to drop means-testing altogether, and simply cover all long-term care under the universal Medicare program. But I confess that I really dislike the notion that just because we allow one form of government intervention (e.g., Medicaid), we must then provide even more government intervention n (e.g., covering all long-term care under Medicare) just because the market can no longer work! Not to mention that an expansion of our entitlement programs is the last thing we need given our long-term fiscal outlook.
Or do we just accept the status quo? Let Medicaid continue to help those who need it, but at the cost of crowding out potentially better private coverage and thus leaving many people exposed to the risk of impoverishment. It is a hard choice. Different countries have taken very different paths – and none of them are happy with it. The Netherlands covers all the care, but as a result they are facing large and growing government expenditures and are asking whether this is sustainable.
So, what are we to do? There is only one solution I can think of that a) relies on private markets rather than a taxpayer –financed government program, and b) ensures that everyone gets the coverage against financially-catastrophic long-term care expenditures. And that is to have the government mandate that everyone have coverage, but leave it up to the private market to provide it. Then, take the money we are currently using to pay for long-term care through Medicare and Medicaid, and use part of it to subsidize the premiums for those with low-incomes.
The problem, of course, is that an “individual mandate” to purchase long-term care insurance would be politically unpopular in the U.S. (even then-candidate Obama was against an individual mandate for regular health insurance during the campaign). It goes against our nation’s free market preference (which I am usually a huge advocate of!) But in this case, the irony is that a government mandate would probably result in less government control of long-term care, at least compared to the current system under which the government provides $3 out of every $5 spent.