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“Finding a way to better finance long-term services and supports (LTSS) is high on the list of the nation’s health policy and political challenges, even though it is not high on today’s political agenda. Current policy underserves people who need care, overburdens families who care for them, and strains state budgets supporting Medicaid services when personal resources fall short. These already significant shortcomings will only increase as the population ages and more people need care.

“The fundamental LTSS financing problem is the absence of an effective accessible insurance mechanism to protect people against the costs of extensive LTSS they may require over the course of their lives, which often far exceed most people’s ability to pay. LTSS presents exactly the kind of unpredictable, potentially catastrophic risk and expense, with a high degree of variability, that insurance is designed to address. Most people now turning age 65 cannot know in advance whether they will be among the roughly half of their age cohort who are expected to die without suffering significant levels of impairment – that is, having two or more limitations in Activities of Daily Living (ADLs) or having severe cognitive impairment – or be among the 12 percent expected to need more than five years of substantial care.¹ When LTSS needs last for at least two years, average LTSS spending is about five times higher than for older people whose LTSS needs do not last that long. Most of the nation’s LTSS costs are incurred by people with long-lasting needs.²“

Source: Marc Cohen, PhD, Judith Feder, PhD, and Melissa Favreault, PhD. A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance. January 2018.

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“The proportion of the US population over 65 years old is increasing dramatically, and the group over 85 years old, the “oldest old,” is the most rapidly growing segment. People who survive into higher ages in America, which itself is an aging society, face a suite of competing forces that will yield healthy life extension for some and life extension accompanied by notable increases in frailty and disability for many. We spend more, for worse outcomes, than many if not all other developed countries, including care for older persons. Looking forward, our health care system is unprepared to provide the medical and support services needed for previously unimagined numbers of sick older persons, and we are not investing in keeping people healthy into their highest ages.”

Source: Rowe, J. W., L. Berkman, L. Fried, T. Fulmer, J. Jackson, M. Naylor, W. Novelli, J. Olshansky, and R. Stone. 2016. Preparing for Better Health and Health Care for an Aging Population: A Vital Direction for Health and Health Care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: 10.31478/201609n

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“Changing family structures and shifting roles for women in the United States population will also have significant effects on the supply of LTSS. Informal caregivers are an essential provider of uncompensated LTSS. In 2009, informal caregivers, typically women, provided up to three-quarters of these services, amounting to an estimated $450 billion in unpaid care (Feinberg, Reinhard, Houser & Choula, 2011). Along with the growth of the population age 65 and older, however, is the likely decrease in the availability of the population that typically fills the role of informal caregivers. Transformations in societal norms, such as more women working full time, decreasing birth rates and smaller family size, and an increase in the number of people who never marry, contribute to additional gaps in the supply of informal care. In addition, informal caregivers are increasingly tasked with more complex and demanding care activities, such as medication management, wound care, and incontinence care, yet they often do not have adequate support or training (Thomas & Applebaum, 2015).”

Source: Nga T. Thach, BS, and Joshua M. Wiener, PhD. An Overview of Long-Term Services and Supports and Medicaid: Final Report. RTI International for the US Dept. of Health and Human Services. May 2018.

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“The moderate spending growth seen in 2022 is likely to be a fleeting phenomenon. The significant reimbursement increases that health care providers sought in their contract negotiations with health insurers following the period of high inflation in late 2021 through 2022 are likely to play out in the form of high spending growth in both 2023 and 2024. We have already seen premium jumps for commercial health insurance coverage nationally, with some states experiencing premium increases of more than 10.0 percent in 2024, even as wages have only grown 3.9 percent.

“As states across the nation move forward with efforts to improve affordability by reining in health care spending growth, they face stiff resistance from the pharmaceutical and hospital industries. For example, in Oregon, where the state agency overseeing the spending growth target program has the authority to financially penalize providers that repeatedly exceed the target, the hospital association has sought to weaken the state’s accountability mechanisms by suggesting maximums for these penalties. In Connecticut, when the Office of Strategy called on three pharmaceutical manufacturers (Abbvie, Amgen, and Vertex) to appear at its public hearing in June, all three refused.”

Source: “In States With Health Care Spending Targets, Spending Growth Moderated In 2022 But Still Exceeded Targets”, Health Affairs Forefront, August 8, 2024. DOI: 10.1377/forefront.20240807.238694

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“In the world’s most advanced health care markets, calls are growing to move away from fee-for-service care and toward value-based care. Such a transition includes a number of structural changes involving new payment models such as increased use of bundles, thoughtfully collecting, analyzing, and sharing patient-reported outcome measures (PROMs), and re-organizing health care delivery infrastructure into integrated practice units.

“Although payment models in the US have evolved since HITECH (for example, as seen in both private and public initiatives to encourage the use of bundles), EHRs are typically linked to revenue cycle management and traditional, fee-for-service billing. Consequently, some technology remains at odds with—or at least partially misaligned with—target payment models. Ideally, databases designed for the delivery of value-based care would go beyond “standard” medical data to include data on social determinants of health and other factors.

“The potential mismatches between the design of digital tools and the goals of the health care system are worth keeping in mind: Software systems designed around fee-for-service health care delivery will perpetuate existing waste and shortcomings, while design that builds in opportunities for broader data collection, user-friendly personal health records, and the evidence-based deployment of personalized digital tools will support the transition to value-based care. In this respect, both the US and Germany have a long way to go. Germany, in particular, has a great opportunity to thoughtfully roll out such tools over the years ahead.

“Furthermore, to take full advantage of digitized health care delivery data, systems must develop algorithms based on large and diverse population data to ensure that risk adjustment for individuals can be done on the basis of representative data from an appropriately comparable group. Algorithms need access to unprecedented amounts of anonymized data, which in turn need to be “cleaned”—not only for errors and incompleteness, but also for inherent biases.”

Source: “On The Brink Of A Digital Health Care Transformation: What Germany Can Learn From The United States, “ Health Affairs Blog, October 20, 2021. DOI: 10.1377/hblog20211018.865750

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World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated April 2, 2025 by Doug McVay, Editor.