The California Department of Aging awarded a three-year, $4.3 million contract to the LeadingAge LTSS Center @UMass Boston—through the center’s partner, Community Catalyst—to study policy opportunities to address the affordability of long-term services and supports. The project, the largest single contract awarded to the LTSS Center since its creation in 2017, has the potential to address a challenge that reaches far beyond California: How to help the “overlooked middle”—Americans who have too much income to qualify for Medicaid’s safety net programs but not enough to afford long-term care—pay for eventual nursing home or in-home care.

“In the healthcare realm, public policy typically focuses on making sure that people who are uninsured and/or poor have access to healthcare and safety net programs. But long-term care is a very different challenge,” says LTSS Center Co-Director Marc Cohen. “Saving for long-term care and buying private long-term care insurance are out of reach for most middle-class Americans. Their alternatives are relying on family members or spending down their savings to pay for nursing home or in-home care until they qualify for safety-net coverage.”

Cohen and his team are partnering on the project with a variety of organizations including Community Catalyst, where Cohen also serves as research director for the organization’s Center for Community Engagement in Health Innovation, and Gretchen Alkema, PhD, whose Wolf Eagle Enterprises consultancy advises on aging, longevity, and care delivery innovation. 

California’s Medicaid program, referred to as Medi-Cal, provides free or low-cost medical services for children and adults with limited income and resources. Recognizing that many older adults and people with disabilities don’t meet Medi-Cal’s income minimums, the 2022-23 California State Budget authorized funding for the long-term care financing and affordability research initiative. “They want to learn who these people are, what their needs may be over time, and what programs may exist in other states that the legislators can learn from to find options for middle-class programs,” Cohen says. “The need for long-term care strikes people across all economic classes, and it’s a difficult situation to plan for.” 

The three-pronged project will include:

  • Exploring  potential opportunities through Medicare, including research and actuarial analysis from ATI Advisory and Milliman actuaries.  
  • Defining the “overlooked middle” population and projecting their needs over time in partnership with the Urban Institute and studying how to help people stay in their homes in partnership with Harvard’s Joint Center for Housing Studies.
  • Holding a series of listening sessions and focus groups in partnership with Community Catalyst and Collaborative Consulting to hear firsthand from people with lived experience about the target population’s challenges and worries. The researchers will also contract with NORC at the University of Chicago to conduct a quantitative survey in California about current challenges and issues facing this population. A second NORC survey will help determine which of the potential solutions resonate with Californians.

At the conclusion of the project, the research team will present to California state leaders and policymakers an analysis of their demographic projections of the overlooked middle-class population and its long-term care needs along with potential solutions to the challenges of affording the care.