Democratic presidential hopeful Pete Buttigieg has proposed an ambitious plan to reform long-term care finance and delivery in the US. It includes a public catastrophic long-term care benefit, enhancements to the private long-term care insurance market, reform to Medicaid long-term services and supports (LTSS), and higher wages and benefits for direct care workers.

Buttigieg, who says he learned about the failures of the existing system when trying to plan for the care of his late father, paired his long-term care package with major Social Security and retirement reforms, which I’ll write about separately.

He calls his plan Long-Term Care America. It is built around a universal, public $90-a-day catastrophic insurance plan for people over age 65 with physical or cognitive limitations. (Buttigieg has separate proposals for younger people with disabilities) Public catastrophic insurance has been recommended by the Long-Term Care Finance Collaborative (which I helped convened) and the Bipartisan Policy Center.

Public catastrophic insurance

While Buttigieg leaves out many specifics, his plan appears to be modeled on a refinement of those proposals developed by Marc Cohen of the University of Massachusetts, Boston and Judy Feder of Georgetown University. They’d trigger coverage based on an income-related waiting period. Thus, those with the lowest incomes might be eligible for benefits after one year while those with the highest incomes might have to wait four years.

Buttigieg’s catastrophic benefit is different from the plan adopted earlier this year by Washington State. The Washington plan is a front-end benefit of a maximum of $36,500. It would be triggered as soon as a resident is eligible based on physical or cognitive limitations, but it would be capped. In contrast, Buttigieg would require the waiting period but provide a lifetime benefit.

In effect, Washington State would cover more people sooner. Buttigieg would cover fewer people but focus public dollars on those who need help for the most time.

Private insurance

Buttigieg contemplates that middle- and upper-income people might buy private insurance to help pick up costs during their waiting period. Thus, he’s included several proposals to make private coverage less costly and more attractive.

He’d simplify and standardize policies, create an online marketplace (similar to Medicare Supplement (Medigap) or Medicare Part D drug insurance), and encourage employers to offer private long-term care insurance, including as an opt-out employee benefit.

For low income people, he’s proposed several reforms to Medicaid LTSS. Among them, he’d :

  • Expand eligibility for individuals with monthly incomes of up to $2,313 (up from $771 today) and financial assets of $10,000 (up from $2,000 today).
  • Enhance Medicaid home and community-based services.
  • Expand consumer-directed home-based programs.

He’d substantially increase funding for the Older Americans Act, the umbrella federal law that supports a wide range of services including home-delivered meals, transportation, and caregiver support; and fully fund adult protective services and the long-term care ombudsman program.

Helping care workers

More broadly, he’d enhance long-term care services provided under Medicare, mostly through Medicare Advantage. And he’d expand a program called CAPABLE, where a nurse, an occupational therapist, and a handyman work together to help older adults stay as healthy as possible at home.

Finally, Buttigieg proposes a wide range of reforms aimed at direct care workers, such as home health aides, personal care assistants, and staff at nursing homes and assisted living facilities. He’d set a federal minimum wage of $15 an hour, require 12 weeks of paid family leave, expand training programs, set minimum federal training and certification standards, and create state-based registries or job boards to match care workers with families that need assistance.

While important to care workers, these added benefits would significantly increase costs for families and for Medicaid. They’d also reduce the amount of hours of care families could purchase with his public benefit.

He’d also create a “community renewal visa” that would match immigrant workers with specific communities. Care workers who stay in that community for three years would be eligible for an expedited green card.  This is a creative solution to the need to support immigrant workers, who are critical to the delivery of personal supports.

Missing details

Both paid care workers and family caregivers would receive credits toward Social Security benefits for the time they spend assisting older adults or others relatives with disabilities.

Buttigieg’s plan has some gaps. He leaves out many details, especially for his catastrophic insurance program.  And he does not say how he’d pay for what would be a very expensive new package of benefits.

Yet, his ambitious plan would fundamentally redesign the way we deliver and finance long-term care. And it would vastly improve the lives of frail older adults and their families who, as Buttigieg discovered himself, currently face immense–and unnecessary—challenges when they or their loved one’s need care.

Full disclosure: At the request of the Buttigieg campaign, I provided some non-exclusive technical assistance as they developed their plan.