Baby Boomers are in serious denial when it comes to their medical and long-term care costs in retirement. Yes, Medicare provides excellent health insurance (subsidized in large part by taxpayers). But it doesn’t come close to paying for a senior’s medical costs. And doesn’t pay for long-term supports and services at all.

Those holes in the Medicare system mean a couple turning 65 today will pay an average of $220,000 in out-of-pocket medical costs before they die, according to a new study by Fidelity Benefits Consulting. Those out-of-pocket costs include premiums, co-pays, and deductibles. On top of their medical care, two-thirds of those 65 and older will have some long-term care needs. And other studies estimate that each spouse can expect to pay an average of $50,000 on average for that care, on top of their health care costs.

That means a typical couple will need to put aside roughly $300,000 to pay for their care in old age. But Census Bureau reports the median net worth of an average couple at age 65 was only about half that in 2010. It is probably more now since the housing and stock markets have recovered from their lows, but it is still not close to $300,000.

Even more worrisome, Boomers think they’ll need only about $50,000 to pay for their health care in retirement.  And many think Medicare will not only pay for health care but also for long-term supports and services. Sadly, they are wrong and wrong.

Medicare does pay for health care. And, as my Urban Institute colleague Gene Steuerle has shown, it provides very generous benefits. He estimates that a two-earner couple that turned 65 in 2010 can expect  $387,000 in Medicare benefits, far more than the $122,000 they paid in Medicare taxes. A Boomer couple that turns 65 in 2020 will get $499,000 in Medicare benefits over their lifetimes.

But even with generous government benefits, they will still have to pay hundreds of thousands of dollars out of pocket.

Now, estimates of care costs in old age are all pretty rough. Other analysts come up with somewhat different projections for the lifetime health costs of seniors. For example, the Employee Benefit Research Institute calculated in 2012 that a couple would need to put aside about $165,000 at age 65 to have a 50 percent chance of paying for their lifetime medical (but not long-term care) costs. EBRI figured they’d need to put aside about $225,000 to have a 75 percent chance of paying all their medical costs in old age.

These estimated costs are falling a bit to reflect more generous Medicare benefits. They may decline further if the recent slowdown in the growth of overall medical costs has staying power. But even so, costs will be far beyond what many Boomers will be able to pay.

EBRIs presentation is especially valuable since it tries to reflect the uncertainties of predicting the future. Some of us will pay less than the average, but some of us will pay much more.

We know, for example, that a typical male over 65 will need a little less than 2 years of long-term supports and services over his lifetime, while a typical woman will need about 3 years of assistance. But those are just averages. A study completed several years ago found that one-third of those 65 and older will  need no assistance at all, but one in five will need help for five years or more.

A separate EBRI study shows that household wealth crashes when someone has a long stay in a nursing home or uses a home health aide for long time. For instance, it finds the median household wealth falls from $102,000 when someone enters a nursing facility to just $60,000 after six months.

That collapse in assets, driven by both medical and long-term care costs, may partially explain why so many nursing home residents end up on Medicaid. As Josh Wiener found in his recent study, the vast majority of those who became eligible for Medicaid long-term care benefits never had much to start with.

And that’s the real problem. Millions of Baby Boomers are totally unprepared for the medical care and personal care they are likely to need in retirement. All the denial in the world won’t make those needs go away. And the consequences of ignoring the problem can be catastrophic.

In the past few weeks, no fewer than three highly respected groups have proposed major health care reforms. They all promise greater use of patient-centered integrated care, but none include supports and services for frail elders or younger people with disabilities.

It took four decades to incorporate a drug benefit into Medicare. Now we seem to be in the same place with supports and services for people with chronic disease. If you were building a health system from scratch, you’d never leave out the non-medical assistance people need to help manage chronic illness—say, help with personal hygiene.

It makes no sense to include physical therapy as part of a plan of care if a patient has no way to get to the therapist. The greatest electronic medical record in the world can’t help someone who is malnourished because she can no longer shop or cook for herself.

Yet, none of these ambitious plans, which otherwise have a lot to offer, integrates such care into a new health system.

Maybe the authors are too focused on traditional medical treatment. Maybe they worry about what they fear will be the added cost—though done right, integrating health and personal care could save money. Maybe they don’t want to open the political can of worms that is long-term care.

But the health challenge for most seniors is chronic disease, and the aim of good care ought to be preventing chronic, manageable conditions from spiraling into acute episodes that result in costly and debilitating hospitalizations.  And a good way to do that may be to provide a modest suite of personal services and supports to these patients.

But none of these plans includes such a design.

All aim to improve care and save money.  All are built on better coordinating care. And all would reward both providers and patients for participating in health plans that provide high-quality care at low cost.

The first proposal comes from Cathy Schoen and Stuart Guterman of the Commonwealth Fund and Karen Davis, the long-time head of Commonwealth who is now at the Johns Hopkins Bloomberg School of Public Health. They propose a program called Medicare Essential which would combine the program’s hospital, physician, and drug coverage (Parts A, B, and D) into a single integrated benefit.

The second plan was designed by the Bipartisan Policy Center, a Washington think-tank, and is aimed at cost containment and quality improvement. It proposes broad system reforms, including a new Medicare design it calls as Medicare Networks. It too focuses largely on medical care. There is a role for nursing facilities and home health agencies, but only as post-acute care providers. These networks would provide some care coordination for those with chronic disease, but not delivery of long-term supports and services.

The third plan was sponsored by the Brookings Institution but designed by a group of health experts from across the policy spectrum including former Medicare and Medicaid administrators Mark McClellan and Mike Leavitt, former OMB directors Peter Orszag and Alice Rivlin and health policy analysts such as Katherine Baicker, Michael Chernew, and David Cutler of Harvard, and Mark Pauly of the Wharton School. Two members, Rivlin and former Senator Tom Daschle, also served on the BPC panel.

This model, like the BPC plan, would make major changes in both Medicare and Medicaid (as well as in the broader health delivery system). It contemplates some limited models of care integration for those who are dually eligible for both Medicare and Medicaid (something many states are already doing). However, its proposal to move Medicare to what it calls Medicare Comprehensive Care is a different story.

It too recognizes the needs of elders with multiple chronic disease, but seems to include only care coordination services, not the added personal care itself within its integrated care model.

Don’t get me wrong. All of these plans are ambitious and all seem to anticipate the political system’s drive towards better integrated care. But they ignore a critical piece of the puzzle for 12 million people now receiving long-term supports and services, a number than will double by 2030. Medical care alone, no matter how good it is, will not improve the quality of life for these people and their caregivers.

The smart people who designed these new reforms need to think a bit more creatively for that to happen.

There is a widespread belief that seniors, in cahoots with shady lawyers and greedy children, hide their assets so they can receive Medicaid long-term care benefits.  It turns out that this image—sort of the greedy geezer equivalent of Cadillac-driving welfare queens—is largely an urban myth.

While some seniors undoubtedly find ways to transfer assets (everyone, it seems, knows someone who has—or at least thinks they do), new research paints a very different picture:  Most frail seniors and younger people with disabilities who receive Medicaid benefits were poor long before they ended up on program. They did not hide their assets because, in large part, they didn’t have any to start with.

The study, by Josh Wiener and colleagues at the research firm RTI International, was based on a national survey that allowed them to follow thousands of people aged 50 and over for 10-12 years.

Although the study did not explicitly look at the issue of asset transfers, it paints a fascinating picture of people who turn to Medicaid as they age. Josh’s paper, funded by the SCAN Foundation, follows them as they age, develop health problems, and eventually become impoverished.

Josh and his colleagues were studying a phenomenon known as Medicaid spend-down, the process where someone runs through their money until they become eligible for the means-tested program.

Medicaid provides long-term supports and services for seniors and people with disabilities, but only if they meet strict income and asset tests. Though the limits vary by state, single individuals generally must have no more than about $2,000 in financial assets (they can also keep their home and some personal property).

Over the period 1996-2008, about 10 percent of people who had not previously been on Medicaid became impoverished and ended up on the program.  Among those who were 65 or older at the beginning of the study, about 13 percent spent down.  Younger people were half as likely to do so.

Keep in mind that the study may understate the percentage of those who ultimately go on to Medicaid since it followed them for only 10-12 years.  By the end of the survey period, the youngest people were still only in their sixties and had not yet begun to incur heavy medical and long-term care costs. Often, that doesn’t happen  until people reach their early or mid-80s.

Only about half of those who became Medicaid eligible had used any long-term supports and services. That suggests many Medicaid recipients became impoverished due to high medical costs or other factors.

But the key story is that those who did spend down started with far fewer assets and income than those who did not. They were disproportionately minorities, unmarried, and poorly educated. Among those who became Medicaid eligible by 2008, the median value of their total assets a decade earlier (including housing but excluding IRAs) was only $33,000—just one-fourth of the total wealth of those who did not spend down.

Of those who spent-down to Medicaid, 85 percent had less than $112,000 in total assets (including home equity) a decade earlier. The median net value of their primary residence was just $17,000, and 60 percent had household income of less than $16,000.

In other words, most of those who spend-down to Medicaid due to disability or old age were barely hanging on long before becoming eligible for the program. This population didn’t give much away because they never had much to give.

Finding an alternative to Medicaid is a huge challenge for policymakers looking for solutions to the long-term care financing problem. This population has very few financial resources to pay for their own long-term care. Tapping into housing assets won’t help because they have little home equity. Most would never be able to afford long-term care insurance.

Of course, there are millions of others who are more solidly middle-class, and it may be possible to build new financial solutions for their long-term care. But Josh’s research shows that those who end up on Medicaid in frail old age or because they are disabled may have few other options.

You’ve probably seen the headlines from President Obama’s 2014 budget: He’d slow the growth of Social Security benefits by changing the way payments are increased for inflation, trim Medicare by cutting payments to providers and making high-income retirees pay more out of pocket for their health care, and he’d protect Medicaid from budget cuts.

But you may not have seen some of the fine print. Behind those big numbers, Obama would cut or freeze spending on many key programs for seniors. For instance, he’d freeze funding for Meals on Wheels and other nutrition programs, as he has through most of his Administration. Same story with aging network services and family caregiver support.

He’d trim spending for community-based supportive services, while cutting funding from$16 million to $10 million for Aging and Disability Resource Centers, which provide information services to seniors, people with disabilities, and heir familie

Of course, this is just the first step in the budget process. Congress will have to act sometime this year on these funding requests and, in many cases, could well trim them further. Remember, House Republicans have vowed to balance the budget within 10 years, entirely through spending reductions.

This budget is just a glimpse of the future. With growing pressure to reduce the deficit and limited enthusiasm for tax hikes, spending of all kinds, including for senior services, will face ongoing pressures.

California has taken the idea of managed care for low-income seniors and people with disabilities to a whole new level. Under an agreement with the Obama Administration announced last week, the state will begin shifting both medical care and long-term supports and services to managed care companies in just seven months.

Watch this closely. You may be looking at the future.

For a fixed, per-patient monthly rate, those firms will be responsible for providing the full spectrum of care to people who have few assets and little income, but who often require extensive levels of care. The program, called Cal MediConnect, will cover people who receive benefits from both Medicare and Medicaid (called Medi-Cal in California)—thus often called dual eligibles.

Over the next 15 months, California expects to enroll 456,000 people in managed care in what will be the biggest program of its kind ever tried. As many as 200,000 will be enrolled in Los Angeles County alone, making the just LA effort bigger than any similar state program in the nation.

Managed care for the frail elderly and younger people with disabilities has tremendous potential, since  people with complex needs are likely to do better with fully-integrated care. For instance, a package of home care services and help with diet and transportation could greatly improve the quality of life for a senior with congestive heart failure and help her avoid the kind of health crisis that would result in a hospitalization.

Of course, using well integrated care to avoid acute medical crises also has the potential to save money. That promise of better care at less cost explains why the 2010 Affordable Care Act included new incentives for such a shift to managed care. California estimates only modest savings of about 1 percent in the first year, growing to about 4 percent by the third year.

However, states are anxious to take advantage of managed care because it allows them to share in any cost savings. Under today’s system, if a well-run Medicaid long-term care program reduces medical costs, it is the federal government—which pays 100 percent of Medicare costs—that benefits. The state gets nothing.

Four other states—Illinois, Ohio, Massachusetts, and Washington—have begun similar experiments. Other states, such as Florida, are moving low-income seniors to managed care under separate programs.

However, managed care carries significant risks. For starters, no insurance company has experience in managing fully integrated care for so many people with complex medical and long-term care needs. No one knows quite how to do this. The danger for patients is that managed care companies will find it difficult to provide a high level of care and still make a profit. As a result, they may scale back the care they provide or demand higher state payments.

Can states avoid these pitfalls? Perhaps these firms learned from past mistakes. In addition, California and the care companies will be required to meet tough quality standards that were not required in older models.

While the California program is described as a three-year demonstration, it is hard to imagine an initiative this big ever fading away, unless it proves an utter failure. Interestingly, the Obama Administration scaled back the original proposal from California Governor Jerry Brown, who wanted 800,000 dual eligibles moved to the new system.

Already, three quarters of Medicaid beneficiaries who receive only medical care (mostly low-income mothers and their kids) are in managed care plans. Many other states are looking at shifting their dual eligible populations to either the fully capitated system that California has adopted or managed fee-for-service plans.

Because it is California, and because of the size of its program, this experiment is bound to receive outsized attention overt the next few years. Perhaps it will be the first step towards fully integrating medical and long-term care for all Medicare beneficiaries. Or it may turn out to be a bust. But either way, it deserves close watching.

America’s system for financing long-term care is failing, and the window for creating a payment system that works is rapidly closing. That was the conclusion of a morning-long expert session sponsored last week by the SCAN Foundation.

While the participants differed on specific solutions, most agreed on four key issues:

• The existing system for funding paid long-term supports and services is built on a wobbly three-legged stool: low private savings, an underfunded Medicaid program, and a hobbled private long-term care insurance market.
• The solution must include an affordable way for Americans to prefund their long-term care costs. This could include tapping financial assets or home equity, or buying insurance (either government, private, or some combination of both). Low-income people would require some form of safety net protection.
• Any future system should finance high-quality long-term supports and services that are well-integrated with medical care. This is especially important since recipients of care services suffer from chronic disease or injury that often requires complex medical interventions.
• There is currently no political consensus on how to do any of this.

That is where everyone agreed. Here is where they did not:

Several panelists focused on ways to enhance private insurance, where the market for traditional long-term care coverage has effectively collapsed. A paper by Marc Cohen of Lifeplans, Inc. and professors Richard Frank and Neale Mahoney of Harvard described a broad package of design changes that might make policies more attractive.

Their ideas include simplifying and standardizing insurance products, indexing premiums annually instead of requiring carriers to ask for big rate increases every few years, allowing insurers to sell high-deductible plans (where buyers could be responsible for as much as two years of LTC costs), and better educating consumers about the price of long-term care and the limited government resources available to pay for it.

They also propose industry-funded reinsurance pools that would protect insurers against unanticipated risks. Another suggestion: Require that companies over a certain size offer LTC insurance and force workers to buy unless they make an active choice to reject insurance. They also recommend new highly-targeted government subsidies, such as tax credits, to encourage moderate-income consumers to purchase long-term care insurance.

Finally, they suggest linking long-term care and health insurance, an idea I raised last year.

Several of their proposals, such as catastrophic coverage and standardized plan designs, are aimed at substantially lowering rates.

Expanding the role of employers may be especially critical since 80 percent of workers currently have no access to coverage through their jobs, according to a separate paper by Jeremy Pincus and colleagues at the insurance industry consulting firm Forbes Consulting Group.  Like Cohen, Frank, and Mahoney; Pincus also believes an employer mandate would significantly boost the number of workers who would buy LTC insurance.

But all that may not be enough. Other conference participants felt that even with these broad-based changes, voluntary private insurance would remain unattractive for many people. As a result, some sort universal coverage is the only way to make LTC insurance truly affordable for middle-income households. Voluntary insurance, even with reforms, would remain out of reach for tens of millions of middle-income people.

Anne Tumlinson of the consulting firm Avalere Health, Josh Wiener of RTI International  and their co-authors found that mandatory insurance would be significantly less expensive than voluntary coverage. Tumlinson said that maintaining the voluntary system would do little more than preserve the unworkable status quo.

Insurance officials tell me privately that, even in the best case, perhaps 20 percent of Americans would buy voluntary LTC insurance. Perhaps another one-third have lifetime incomes so low that they can’t be expected to pay for their own care, either through savings or insurance, and will need some sort of public support.

That leaves perhaps half the country at risk. The challenge for policy makers and the market is to figure out what will work for them. The SCAN program was a great start, but much more needs to be done.

Long-Term Care insurance too expensive? How about short-term care insurance?

In an attempt to make increasingly-costly coverage affordable for middle-class buyers, some insurers are selling policies that offer bare-bones personal care benefits—sometimes as little as $50-a-day for three months. These policies are more affordable, but are they worth the money?

Bankers Life and Casualty Co. has been selling these low-cost, low-benefit dollar policies for a decade, but Brian E. Millsap, Vice President of Product Management for Long Term Care, says they’ve taken off in the past few years and now outsell traditional LTC insurance at Bankers.  

To understand how they work, first think about those traditional policies. Millsap says a Banker’s LTC policy typically covers $145-a-day for an average of 2.7 years. That’s a maximum of about $143,000 in benefits. About half of its buyers also get inflation protection to help offset future increases in the cost of care. For the average Banker’s customer, who is 63, such a policy costs about $2,100-a-year. 

If that’s out of your price range, you’ll need to compromise. You could, for instance, buy an average daily benefit of $50 for life (the design of the now-dead CLASS Act). However, few private carriers offer lifetime benefits any more.

Since about 70 percent of claimants die within two years of receiving benefits, you could try an alternative: a big daily benefit for just a few years. But those can be very expensive as well. A $250-a-day, two-year policy with inflation protection would cost a 63-year-old about $3,500, according to one carrier.  

So how about a very short-duration policy with a low daily benefit? Keep in mind that this insurance, like traditional LTC overage, is not health insurance. You are eligible for benefits only when you need help with activities of daily living such as bathing or eating, not just because you are sick.

Millsap says an average short-term care policy from Bankers provides $140-a-day for just 220 days, or about 7 months. That’s about $31,000 in total benefits. 85 percent of buyers get no inflation protection. For a 63-year-old, the average annual premium is less than $750.  

That’s much more affordable, of course. And if you think you’ll be able to get care at home and will have family members to help, such a policy might pay for some important extra assistance from a home health aide. They may also be easier to buy if you have pre-existing medical problems since underwriting is less strict. Combined with enough savings, it might even get you access to a high-quality nursing home that might not take Medicaid patients.

But these policies come with some big disadvantages.

$140-a-day would fall far short of the $200-$350 you’d need for a nursing home stay so you’d need to make up the difference through savings or gifts from family members. In addition, by not buying inflation protection, steadily increasing costs of care will eat away at what is already a modest benefit. For instance, assuming 4 percent inflation, that $140 daily benefit will be worth only about $60 in 20 years—enough to pay for only about 3 hours of home care. 

If you don’t have other savings, or will need more than limited care, you’ll almost certainly end up on Medicaid. These policies may delay Medicaid eligibility for a few months, however, making the government program the biggest beneficiary of this insurance.    

Note: Short-term policies are not eligible for the Long-term care Partnership program, which allows people to preserve additional assets and still receive Medicaid benefits.

Another way to think about it: If you buy at 63, you may pay premiums for 20 years before going to claim. At $750-a-year for a $140-a-day, 220-day policy, you’ll pay $15,000 to buy a maximum of $31,000 in insurance (assuming premiums don’t go up).

One financial planner who specializes in middle-market clients is skeptical. He says these policies are “like buying a stuffed bear.” They may make you feel better, but they won’t provide any real financial security.

That’s especially true for the very low-end policies. After all, $50-a-day for 60 days is a maximum benefit of just $3,000, and that won’t buy much personal assistance. Buying $140-a-day for a year makes more sense, but you still need to think hard about what will happen when the benefit runs out.  

Nearly two months ago, Congress created a commission to recommend reforms to the current long-term care system. So what has happened since? Not much.

Leaders of Congress have appointed members to serve on the panel but President Obama—who has three of 15 picks– has not yet made his choices. The commission can’t select a chairman, find a staff, or set an agenda until he does, so for now the effort remains on hold.

Sources say the delay is mostly bureaucratic—it often takes the White House time to review background checks and run candidates through the usual political traps. 

The commission members picked so far are an intriguing mix. They include health and long-term care policy experts, three representatives from the nursing home and the senior service industry, two physicians, a union official, a philanthropist focused on finding a cure for Alzheimer’s disease, and a Medicare consumer advocate. Somewhat surprisingly, it has no members explicitly representing the views of people with disabilities, family caregivers, or the insurance industry.

As I have written previously, this commission will operate under severe constraints. It is supposed to address three big issues–long-term care financing, delivery, and workforce challenges. It has no budget so its staff will be made up of people detailed from Congress or the Administration. It has only six months to submit a report (the clock starts ticking once Obama discloses his choices). After Obama makes his picks, the panel will have nine members appointed by Democrats but only six selected by Republicans–a ratio that already has the GOP planning to play defense. Most troubling, Congress is not required to act on the panel’s recommendations.

Some optimists believe the commission can achieve some modest goals—by framing the importance of long-term care reform and perhaps by agreeing to small reforms. But others have much lower expectations.  

Who are its members?

Democrats have picked:

Javaid Anwar, a Las Vegas internist who is vp for health services at a large casino/hotel company and served as chair of Nevada’s Committee on Access to Health Care.  

Laphonza Butler, president of the Service Employee’s International United Long Term Care Workers’ union.

Bruce Chernof, a physician who is president and CEO of the California-based SCAN Foundation, which focuses on senior issues.

Judy Feder, my colleague at the Urban Institute who served as a senior health aide in the Clinton Administration and staff director of the 1989-90 Pepper Commission.

Judith Stein, founder of the Center for Medicare Advocacy, which represents beneficiaries in their disputes with the Medicare program.

George Vradenburg, a former media executive and founder of USAgainstAlzheimer’s—a non-profit that advocates largely for research dollars aimed at finding a cure for dementia.

The GOP picks are:

Judith Brachman, who formerly served as a housing official in the Reagan Administration and director of the Ohio Department of Aging, now chairs the Jewish Federation of North America’s Aging and Family Caregiving Committee. JFNA represents long-term care providers.

Bruce Greenstein, Louisiana’s Secretary of Health and Hospitals, who was formerly a senior official at the federal Department of Health and Human Services and managing director for worldwide health at Microsoft.

Stephen Guillard was CEO of several large skilled nursing facility operators including HCR ManorCare and was chairman of the Alliance for Quality Nursing Home Care, a trade group that represents large for-profit nursing home companies.

Neil Pruitt is chairman and CEO of UHS-Pruitt Corp, an integrated health care company, and board chair of The American Health Care Assn., the largest trade group representing nursing homes and other senior service providers.

Grace-Marie Turner is president of the Galen Institute, a free-market oriented public policy organization that focuses on health care issues.

Mark Warshawsky is a pension expert who directs retirement research at the benefits firm Towers Watson and was a senior official at the Treasury Department from 2004-2006.  

There are some impressive people in this group and a few who seem to have little knowledge of long-term care. They represent a wide ideological spectrum which, depending on the panel’s dynamics, could be an opportunity to find bipartisan consensus or, more likely, a recipe for gridlock. But the commission won’t be anything at all until Obama picks the last three members.        

Pope Benedict delivered an important message today: There comes a time for most of us when our bodies and minds weaken and we must change the way we live our lives. As with the Pontiff, it may mean giving up a demanding job. But for others, it may mean much more: Getting help with those activities we once took for granted.

This does not mean giving up life, of course. For many elders, retiring from a day job makes time for new interests and challenges. In our culture, that’s a choice that is made more acceptable by age (if you leave your job at 40, you’re a deadbeat or going through a mid-life crisis. If you leave at 70, you’re retiring).

And entire industries have grown up around the idea of productive aging, the third age, or all the other marketing euphemisms out there. Dr. Bill Thomas has a nice perspective on the choices we can make as elders.

But for most of us, the time will come when we need more help with life than we’ve been used to. For those elders suffering from chronic diseases, independence slowly takes on a new, and more limited, meaning.

As with Benedict, who is 85, this often happens in our 80s. On average, men at about 80 will face a year and a half of severe disability. Women can expect about three years of severe disability starting at about 82.  

It is that period when many of us will need long-term services or supports. It may be help bathing or dressing, cooking or going to the doctor.  And it may require the assistance of a family member or a paid aide, or perhaps require a move to a residential care facility or even a nursing home.

Two-thirds of those 65 or older will need some assistance before they die, according to a landmark 2005 study by Peter Kemper, Harriet Komisar, and Lisa Alecxih. One-third will need it for a year or two, but one out of five will require care for five years or more. Half of those 65 or older will spend no money on personal care, though that is often thanks to the help they get from family members who may make substantial personal and financial sacrifices. But one in six will need to set aside more than $100,000 (present value of 2005 dollars) for long-term care.

Pope Benedict will get the help he needs. But many of us will not have the resources for this care. We don’t have the community surrounding us that the Pope enjoys. Increasingly, we don’t have children, or our children live at a distance or are estranged. Few of us have the money to purchase aid. Half of Americans age 65-74 have financial assets of less than $65,000, though they’ll need nearly twice that on average just to pay for medical care in old age.

We think that Medicare will pay for our long-term care, but it won’t. Medicaid, which does pay (if you are impoverished and very frail), is under enormous financial stress. And private long-term care insurance is expensive and increasingly difficult to buy.

Thanks to Pope Benedict for reminding us that while old age can bring great joy, it can also bring frailty. With good diet and exercise, we may be able to delay the day disability comes, but short of sudden death we can’t stop it.

We can prepare for it though. And Benedict’s story is a reminder that we need to–as individuals, families, communities, and as a society.

On New Year’s Day, as part of the law that kept the nation from toppling over the fiscal cliff for two months, Congress quietly repealed the Community Living Assistance Services & Support (CLASS) Act, and created a new commission to recommend broad long-term care reforms that could affect financing, delivery and care workers.

I was, and continue to be, very skeptical about the commission’s ability to accomplish much. But after spending this week talking to Washington insiders, I heard several express the hope that the panel could at least achieve two important goals: Defining the problem and broadly framing future solutions.

Just getting a bipartisan commission of Congress to acknowledge the importance of the challenges facing those receiving long-term supports and services and their caregivers would be a huge step forward. Acknowleging that our current system of financing and delivering  this care is terribly inadequate would be another big step. And defining the roles of government programs such as Medicaid as well as private insurance would be yet another significant achievement.

Still, that would be a long way from proposing specific reforms–an accomplishment that seems far out of reach for this group. Members of the panel, as I noted last week, must be appointed by the end of this month and the commission has only six months after that to make proposals to Congress. The panel has no budget and will have to rely on staffers from Congress and the executive branch. Its make-up–nine Democratic appointments and only six GOP selections–almost guarantees partisan squabbling.

 Worst of all, even if the group could reach a consensus, there is no requirement that Congress ever vote on its plan.

Yet, several veterans of past long-term care battles in Washington are hopeful that this group can at least frame a future debate. I agree that it would be very valuable. And I hope they are right and I am wrong. But I’m not holding my breath.