Long-term services: Lots of ideas but who will pay for them?

There are plenty of ideas on how to meet the nation’s need for long-term services and supports, but a lack of will on how to pay for them.

That was the main theme of a session on LTSS federal policies and solutions during the 2025 Harkin Institute Retirement Security Symposium.

The “original sin” of federal LTSS policy was that when Medicare was created to serve the health needs of older adults, policymakers and lawmakers did not consider the future long-term care needs of that age segment, said Alison Barkoff of the Georgetown University Milkin Institute School of Public Health.

As a result, she said, “we do not have a system at all” to provide for LTSS.

Medicaid pays for LTSS care for those who have exhausted their resources, but is mainly focused on paying for nursing home care. Little support is available for family caregivers, who Barkoff said are 63 million strong and “are the backbone of our LTSS system not because they necessarily want to but because they have to.”

The economic impact of these millions of family caregivers is substantial, she said.

“We have trillions of dollars in wages that are being lost every year, as well as a loss of health benefits for those who must leave the workforce to become caregivers.”

Some states are paying family caregivers through Medicaid, she said, and some states are training family caregivers in the basics of what they are required to do to help their loved ones.

The paid caregiving workforce is in crisis right now, as fewer workers are available to help an increasing number of people who need care. The workforce crisis is exacerbated by immigration issues, Barkoff said. Providing training and support for family caregivers is one way to alleviate the workforce shortage.

“We not only need to fix the formal care system but we need to think across the systems with multisector plans that address the needs of everyone who needs and provides care,” she said.

Paid family leave would improve long-term services

The U.S. is one of the few nations that doesn’t mandate paid family leave, and that also impacts caregiving, said Dawn Huckelbridge, founding director of Paid Leave for All.

“This is creating a crisis in care,” she said. “Many people are retiring earlier than planned to become caregivers without support.”

However, she noted that 13 states and the District of Columbia have passed paid family leave legislation and provide job-protected paid time off to care for a family member.

The Family and Medical Leave Act provides unpaid leave “and is wildly insufficient,” she said. “It only covers about half of the workforce. Businesses under 50 employees are not covered and it is restricted to caring for spouses, parents and children.

“It’s creating a system of haves and have nots in this country.”

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at susan.rupe@innfeedback.com.