The Evolution of Long-Term Care and Health Policy in the United States

Long-term care policy has been neglected for decades in the United States because of high costs, leaving middle-class families struggling to afford care. Many rely on unpaid caregivers, who face significant financial and emotional burdens. Historically, long-term care was a family or community responsibility, but in 1965, with the creation of Medicare and Medicaid, Medicaid became the default payer for long-term care. However, Medicaid only supports low-income individuals and does so incompletely. Medicare pays for long-term care only incidentally and temporarily by providing postacute care in nursing homes and at home. Private insurance is rare because of affordability and policy constraints. Unpaid caregivers fill in the gaps. While the system has evolved over time, most notably shifting from institutional settings to home-based settings, significant gaps remain. The result is a fragmented system that does not work well for most people. It is possible to reform long-term care through options including expanding Medicaid coverage, incorporating long-term care into Medicare, or creating a new social insurance program. Each option requires significant government funding and political commitment. Without action, the current system will continue to fail aging individuals and their families.