Who Buys Long-Term Care Insurance? by Marc A. Cohen, Nanda Kumar, and Stanley S. Wallack

Transcription

1 DataWatch Who Buys Long-Term Care Insurance? by Marc A. Cohen, Nanda Kumar, and Stanley S. Wallack Long-term care costs-mostly for nursing home care-are likely to approach $62 billion in This is not surprising, considering that two in five elderly persons will require nursing home care during later life, and that the annual cost of such care often exceeds $30, Some 40 percent of this population s long-term care costs are paid for by the federal government and states through Medicaid programs. However, the recipients of care, or their families, pay over half of these costs. Most elderly will not incur a catastrophic long-term care expense, because a majority of those who enter nursing homes-the most costly long-term care service-are discharged within the first year of residence. This low financial risk makes nursing home costs suitable for risk pooling. The long-term care insurance market has grown considerably in the past five years, from fewer than 100,000 policies sold in 1986 to just under two million policies sold by About 5 percent of the elderly population has purchased a policy, and roughly 130,000 policies had been sold to employer groups as of Very little is known about the people who buy long-term care insurance. Here we present the results of a study of purchasers and nonpurchasers of long-term care insurance to identify who buys the insurance, to understand what motivates them to acquire policies, and to compare these findings to those on a sample of nonpurchasers. The important new information in this study will enable policymakers to determine the extent to which insurance is a viable solution to the problem of financing long-term care. Moreover, the study s findings may help to guide the insurance industry in developing products that consumers will buy. Also, the study s disclosure of purchasers attitudes may help to formulate strategies for consumer education and protection. Marc Cohen is a principal with LifePlans, Inc., in Waltham, Massachusetts, and a senior researcher at JDC-Brookdale Institute in Jerusalem. Nanda Kumar belongs to the Indian Administrative Services and is currently a research associate at LifePlans and a graduate student in the Department of Economics at Boston University. Stanley Wallack is chairman and chief executive officer of LifePlans and directs the Brandeis Health Policy Institute.

2 D ATAWATCH 209 Method and sample. Six companies (45 percent of total individual long-term care insurance sales in 1990) contributed a sample of purchasers and nonpurchasers age fifty-five and over. Each company randomly selected a sample of persons who had purchased policies in They sampled retroactively from December 1990, until they met the sample size, to assure that the sample captured relatively recent purchasers. A purchaser was defined as someone who had purchased a policy, paid premiums, and not returned the policy within thirty days. Purchasers of long-term care insurance are a select group of individuals, set apart by their attitudes, unique demographic profiles, and choice to buy policies. Thus our results can be generalized to the population who purchased policies in 1990, not to the entire population age fifty-five and over. A nonpurchaser was defined as someone who had received policy information from an agent but who chose not to purchase a policy. This definition reflects our interest in surveying individuals who made an active decision not to buy a policy. The sample of nonpurchasers represents this specific type of nonpurchaser. Because many others have been exposed to marketing information and have not chosen to purchase a policy, results cannot be generalized to the total population of people without long-term care insurance. During January and February 1991, mail surveys were sent to some 13,800 purchasers and 4,700 nonpurchasers. To assure a high response rate, companies were requested to telephone potential respondents in advance and also to send reminders to complete the survey. The response rate among purchasers was exceptionally high: about 8,400 completed surveys were returned slightly more than a 60 percent response rate. The response rate of nonpurchasers was lower: about 1,800 completed surveys were returned, representing a 43 percent response rate. Potential sources of sampling bias exist. For example, companies participating in the study represent slightly less than half of all sales in Although our analysis indicates that the policies they offer are relatively similar to the policies offered by nonparticipating companies, there is still a possibility that policyholders in the sample may be different from purchasers of insurance from other companies. Also, even though response rates were high, there may have been some degree of self-selection bias among the surveyed population, and of nonresponse bias among those not accepting the survey. Demographic information on nonrespondents was not obtainable. Demographic Profile Of The LongTerm Care Insurance Market The demographic profile of long-term care insurance purchasers differs greatly from that of other individuals over age fifty-five (Exhibit 1).

3 210 HEALTH AFFAIRS Spring 1992 Exhibit 1 Selected Sociodemographic Characteristics Of Purchasers, Nonpurchasers, And General Population Over Age 55, 1990 Characteristics Individual Individual General purchasers nonp urchasers population Average age % 20% 40% sex Male Female a Marital status Never married Married Divorced/separated Widowed Total household income Less than $10,000 $15,000-$19,999 $20,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000 or more b Total liquid assets c Less than $20, $20,000-$29, $30,000-$49, $50,000-$ $75,000-$99, $100,000 or more Education level Less than high school High school graduate Post high school College graduate Sources: LifePlans, Inc., Survey of Purchasers and Nonpurchasers; and data from various publications of the U.S. Bureau of the Census. a Differences between purchasers and nonpurchasers are statistically significant at the.001 level based on sample size of 8,363 purchasers and 1,750 nonpurchasers. b Differencesstatistically significant at the.05 level. c Refers to such liquid assets as savings, stocks and bonds, and annuities. Does not include home equity. Purchasers are wealthier than their peers in the general population; a greater proportion are below age seventy-five, female, married, and college-educated. Although purchasers and nonpurchasers resemble each other more closely than they resemble the general population, there are differences between the two groups. We also found that middle-income persons account for a growing proportion of the long-term care insurance market. This is important to note, because most of the literature on market size excludes individuals with incomes less than $20, This suggests that some products appeal to individuals of more

4 D ATAWATCH 211 modest means. On the other hand, one could argue that individuals with modest incomes should not purchase long-term care insurance because it is costly, because its primary purpose is to protect assets, and because these people would likely qualify for Medicaid if they needed nursing home care. During old age, this argument continues, when income typically declines, long-term care insurance should be regarded as a luxury product. Its purchase should therefore only be judged appropriate for individuals with significant resource levels to protect. While the latter is a valid argument, most purchasers including those of moderate means purchase insurance primarily to avoid reliance on family and friends for care and to assure that they can afford formal services. Also, most elderly individuals spend an average of $70 per month on Medigap insurance, even though the level of financial risk against which it insures is lower than that associated with long-term care use. 4 Our analysis of the long-term care policies chosen by purchasers of moderate means shows that they are spending about $80 per month for a policy covering four years of nursing home care, which pays a daily benefit of $61 with a twenty day deductible- reasonable degree of coverage by most standards. Most are able to afford such coverage by using some amount of savings or assets to help pay for premiums. It is also possible that these individuals are benefiting from transfers of funds from adult children to elderly parents to help pay for insurance premiums-something that we were not able to capture in the survey. Opinions About Long-Term Care Because purchasers and nonpurchasers have such similar demographic profiles, demographic distinctions are unlikely to be the most important variables explaining why some people approached by agents chose to buy policies and others did not. We hypothesized that attitudinal factors related to long-term care, the government, and insurance were most likely to explain purchase patterns. We thus attempted to differentiate purchasers and nonpurchasers according to their attitudinal profile. To do this, we asked general questions about long-term care, followed by more specific questions about risk, payment for services, reasons for buying, and the like. Our analysis of attitudinal differences focuses primarily on the differing proportions of purchasers and nonpurchasers who strongly agreed with a particular statement. One of the more important attitudinal differences relates to planning for the future (Exhibit 2). About 62 percent of purchasers strongly agreed with the statement that it is important that I plan now for possibly needing long-term care services in the future, compared with only 42 percent of nonpurchasers. Also, nonpurchasers were more than

5 212 HEALTH AFFAIRS Spring 1992 Exhibit 2 Opinions About Long-Term Care Among Individual Purchasers And Nonpurchasers Age 55 And Over, 1990 Opinion about long-term care (LTC) Individual purchasers I don t want to rely on children co pay for LTC if needed Strongly agree 86% 84%a Agree Disagree Strongly disagree 1 I worry about how I would pay for care if needed Strongly agree b Agree Disagree Strongly disagree 2 3 If I ever needed care, the government would pay most of the costs Strongly agree 6 14 b Agree 11 Disagree 44 Strongly disagree The insurance industry sells adequate coverage for LTC Strongly agree 9 7b Agree Disagree Strongly disagree 4 17 It is important that I plan now for possibly needing LTC services in the future Strongly agree b Agree Disagree 4 Strongly disagree 1 Individual nonpurchasers Source: LifePlans, Inc., Survey of Purchasers and Nonpurchasers. a Differences between purchasers and nonpurchasers are significant at the.001 level based on average sample item response of 8,009 purchasers and 1,680 nonpurchasers. b Differences statistically significant at the.05 level. twice as likely to believe that if they ever needed long-term care, the government would pay most of the costs. This could reflect continuing confusion about what is and is not covered by government programs (Medicare and Medicaid). Clearly, even most nonpurchasers would need to deplete their assets to become eligible for Medicaid coverage if they entered a nursing home. Finally, similar proportions of purchasers and nonpurchasers strongly agreed with the statement, The insurance industry sells adequate coverage for long-term care. When we also include those who simply agreed with the statement, however, differences increase dramatically. Both groups shared concerns about paying for long term care and avoiding dependence on children for financial help. Attitudes toward risk and payment. To further differentiate atti-

6 D ATAWATCH 213 tudes, we asked a series of questions about perceived future risk of needing and paying for care. The underlying theory of demand for insurance suggests that individuals compare alternative courses of action: purchasing insurance and thereby incurring a known and relatively small loss (the insurance premium), or facing a small possibility of an unknown but large loss or the large possibility that the event will not occur. 5 Other things being equal, purchasers are more likely to assess their risk of incurring a high expense to be greater than nonpurchasers. Respondents were asked how likely they might be to need nursing home care or home care for longer than six months. Consistent with our expectations, purchasers believed that they were at somewhat higher risk for needing nursing home care than did nonpurchasers (Exhibit 3). In contrast, both groups assessed their risk for needing home health care to be the same (Exhibit 4). Even if one assesses the personal risk of needing services as high, one is not necessarily at a high personal financial risk. Since this depends on how services are paid for, we asked purchasers to tell who would have paid for six months of long-term care costs in the absence of an insurance policy. Nonpurchasers were asked who would pay for most of the costs of six months of long-term care expenses. Roughly 60 percent of purchasers indicated that they would have had to pay for care out of pocket, compared with only 43 percent of nonpurchasers. Moreover, more nonpurchasers than purchasers believed that Medicare or their Medigap policy would pay (Exhibit 5). Both groups seemed to understand that they were unlikely to benefit from Medicaid. These findings further sharpen the attitudinal distinctions between purchasers and nonpurchasers. Nonpurchasers assessment of their risk shows them to be wrongly informed, given current perceptions of service Exhibit 3 Perception Of Risk For Needing Nursing Home Care Among Long-Term Care Insurance Purchasers And Nonpurchasers, 1990 Source: LifePlans, Inc., Survey of Purchasers and Nonpurchasers. Note: Differences significant at the.001 level.

7 214 HEALTH AFFAIRS Spring 1992 Exhibit 4 Perception Of Risk For Needing Home Health Care Among Long-Term Care Insurance Purchasers And Nonpurchasers, 1990 Source: LifePlans, Inc., Survey of Purchasers and Nonpurchasers. Note: Differences significant at the.001 level. use risk and payment risk. Yet, their decision not to buy a policy is as rational as is a purchaser s decision to buy a policy. A related and equally important finding is that one-third of purchasers believed that Medicare, their Medicare supplemental policy, or their retiree health plan would pay for most of the costs of a nursing home stay that exceeds six months. In the early to mid-1980s, about 80 percent of the elderly in one poll thought that Medicare would pay for most of the long-term care costs associated with nursing home care. 6 Thus, although understanding has improved greatly, a large degree of misinformation or misunderstanding about both public and private insurance coverage still Exhibit 5 Perceptions Of Purchasers And Nonpurchasers Regarding How Their Long-Term Care Costs Will Be Paid, 1990 Source: LifePlans. Inc., Survey of Purchasers and Nonpurchasers. Note: Differences significant at the.001 level. May not add to 100, because other category not shown.

8 D ATAWATCH 215 exists. It is reasonable to assume that both the agents and the marketing and sales literature stressed the fact that private long-term care insurance covers care that is not covered by Medicare or by Medigap policies. Thus, these individuals may be presumed to be among the more informed elderly on these issues. The relatively high level of misinformation suggests the need for further education. Reasons behind the insurance purchase decision. Very little research has been conducted to identify the reasons why people buy long-term care insurance. It is a common belief, however, that individuals purchase long-term care insurance primarily to protect their assets and estates. Yet it is also reasonable to assume that like any product, long-term care insurance has attributes that appeal to people for a variety of reasons. We therefore asked purchasers to indicate the importance of each of fifteen possible reasons for buying insurance (Exhibit 6). Again, our analysis focuses on the differing proportions of purchasers who cited a reason as being very important. The highest proportion of individuals indicated that a belief in the product or industry was a very important factor in their decision to purchase insurance. Most believed that the company providing their insurance policy is financially sound and has a good reputation. These findings may explain why someone chose to buy a particular policy, but not why someone chose to buy any policy at all. Reasons related to protecting family resources, enhancing independence and choice, protecting assets, and guaranteeing the affordability of services were cited next as being very important reasons for purchase, Respondents were then asked to choose the single most important reason behind their purchase decision. The reason cited most frequently (30 percent) was to avoid depending on others. The remaining reasons cited by at least 5 percent of purchasers concerned minimizing financial exposure and protecting family resources. While asset protection is certainly an important motivation for purchasing policies, contrary to expectations, it is not the most important reason. Together, assuring affordability of care and avoiding dependence on others were cited by half of all respondents as being the most important reasons behind the purchase decision. Diversity in purchase motivation is great; no single reason was cited by more than 30 percent of respondents as being the most important. Reasons for not purchasing policies. Most industry observers would agree that more people could afford to buy long-term care insurance than currently own policies. However, there is real disagreement about why this is so. One school of thought holds that long-term care insurance is out of the financial reach of most elderly. 7 An alternative view is that in addition to price, attitudes toward insurance companies, the

9 216 HEALTH AFFAIRS Spring 1992 Exhibit 6 Reasons Why Purchasers Age 55 And Over Bought Long-Term Care Policies, 1990 Reasons for insurance purchase To minimize financial exposure To protect my assets lmportant To guarantee that I will be able to afford needed LTC services To avoid losing lifetime savings by paying for nursing home or home health care, which happened to someone I know Not at all importanr The government will not cover the care chat I may need in the future I think that there is a good chance that I may need LTC services in the future To protect family resources To protect my family s standard of living if I ever need LTC services To have an estate for my heirs To enhance choice and independence To avoid depending on others for care and to preserve my independence To enable me to choose the LTC services that I want if I ever need them To avoid welfare To avoid depending on Medicaid Percent 72%

10 D ATAWATCH 217 Exhibit 6 Reasons Why Purchasers Age 55 And Over Bought Long.Term Care Policies (cont.) Belief in the product or industry The insurance company is financially sound The insurance company will pay benefits as stated in the policy The insurance company providing the plan has a good reputation The policy seemed like a good value for the money My insurance agent explained the importance of this type of coverage 89% Source: LifePlans, Inc., Survey of Purchasers and Nonpurchasers. Note: Based on average sample item response of 8,135 purchasers. relative newness and inadequacy of some products, denial of the possible future need for long-term care, confused signals from the public sector, and a lack of information are primary causes for the low demand. 8 Nonpurchasers in this sample represent individuals targeted by agents as potential purchasers, primarily on the basis of income. Thus, it is not surprising that purchasers and nonpurchasers had similar financial profiles. This suggests that wealth is not the primary factor for nonpurchase among the sample. Consequently, we can pursue other important attitudinal reasons behind the decision not to purchase insurance. We tested the hypothesis that the gap between the perceived value of policy benefits and the cost of the policy is the major reason why nonpurchasers in this sample chose not to buy policies, as well as other hypotheses related to how attitudes toward the industry, government, and payment for long-term care services affected the purchase decision. Nonpurchasers were asked to indicate the importance of each of seventeen possible reasons for their decision not to buy a policy (Exhibit 7). Again, we focus on the differing proportions of nonpurchasers who cited a reason as being very important. Cost was the reason cited most frequently (58 percent) for nonpur-

11 218 HEALTH AFFAIRS Spring 1992 Exhibit 7 Reasons Why Nonpurchasers Age 55 And Over Did Not Buy Policies, 1990 Reasons for not purchasing insurance Policy cost The policy costs too much I don t want to spend more on insurance I can t spend more on insurance important Policy design It is hard for me to know what a good policy is I don t think benefits will keep up with inflation Importanr I am waiting for better policies Financial exposure I plan to use my own money to pay for any care that I may need If I need LTC services, the government will pay Nor at all important I have other insurance that will pay for LTC services if I need them If I need LTC services, my family will take care of me Percent 58% I

12 D ATAWATCH 219 Exhibit 7 Reasons Why Nonpurchasers Age 55 And Over Did Not Buy Policies (cont.) Attitudes toward industry and government I am waiting to see if the government does more in this area I don t believe insurance companies will pay benefits as stated in the policy I believe that the government-and not insurance companies-should provide this type of coverage The insurance agent did not do a good job explaining the benefits of the policy I don t think insurance companies are financially sound Other reasons My spouse could not get coverage so I did not want to buy a policy I don t chink I will ever need LTC services 39% Source: Life Plans, Inc.. Survey of Purchasers and Nonpurchasers. Note: Based on average sample item response of 1,538 nonpurchasers. chase, followed by misgivings about policies. Moreover, 54 percent found it difficult to know how to choose a good policy. Although policies from five of six companies had optional inflation protection provisions, 47 percent of respondents had some doubt about the ability of benefits to keep pace with inflation. Finally, about two in five respondents said they were waiting for better policies. Respondents were then asked to indicate the single most important reason why they decided not to buy a policy. While 42 percent cited cost as the single most important barrier to purchase, the diversity of responses is reflected in the fact that no single reason for nonpurchase was

13 220 HEALTH AFFAIRS Spring 1992 cited as most important by more than 25 percent of respondents. Dissatisfaction with the policies currently on the market followed cost as a reason for nonpurchase, cited by 16 percent of respondents. Attitudes toward the role of government. Debate continues in Congress about the role of the government in long-term care. Key issues are the government s role in financing long-term care and in regulating the private long-term care insurance market. 9 Financing reform proposals can be laid out on a continuum. At one end are recommendations for a social insurance program covering all individuals; at the other end are more modest proposals designed to reform Medicaid and encourage the continued development of the private insurance market. Between these two end points are various financing approaches. For example, a shortterm, front-end governmental program to finance nursing home care for everyone was recommended in the 1990 Pepper Commission report and by Sen. Edward M. Kennedy (D-MA) in the 100th Congress. 10 In contrast, a governmental program covering all long-term care costs after a two-year deductible was introduced by Sen. George J. Mitchell (D-ME), also in the 100th Congress. 11 In our study, we hypothesized that purchasers would be more supportive of a government role in regulation, while nonpurchasers would prefer to see the government more involved in direct financing of long-term care. To begin to clarify the different perspectives on this issue, we asked purchasers and nonpurchasers whether or not they would favor a governmental long-term care program funded with new tax dollars for everyone or only for the most needy. Purchasers were less certain about the advisability of establishing a new governmental program than were nonpurchasers: 37 percent did not favor a new program at all or did not know how they felt about it, compared with 29 percent of nonpurchasers. Most nonpurchasers (56 percent) favored a universal governmental financing program. This may help explain why nonpurchasers have not chosen to buy policies: They believe the government should cover long-term care. Respondents were then asked how a new governmental financing program should be structured. They could choose a program that paid the first two years of long-term care costs (front-end), or one that paid all long-term care costs after two years of care had been received (backend). About one-third of both groups did not have a preference; onequarter preferred the front-end approach, and about 40 percent preferred the back-end approach. These findings suggest that both groups are uncertain about the desired structure of a new governmental program. What is perhaps most interesting about these results is that they reveal the total lack of agreement about the desirability of government s role in direct long-term care financing. The ambivalence among a

14 D ATAWATCH 221 relatively knowledgeable sector of the public, congressional experience with the repeal of the Medicare catastrophic provisions, and the relatively high costs of governmental long-term care financing alternatives may illuminate why most recent congressional efforts have focused on regulating the private insurance industry, not on new financing programs. The heightened interest in regulation can also be attributed in part to the publicity alleging illusory insurance benefits, the questionable sales practices of certain companies and their agents, and the confusion among consumers in judging whether or not a policy is of high quality or value. 12 Finally, confusion persists about what is covered by public programs as well as other private coverage (such as Medigap insurance), making it difficult for elders to know whether long-term care insurance is needed or how it should be integrated with other financial vehicles. 13 Purchasers were asked what specific actions not necessarily related to financing the federal government should take regarding long-term care. Nonpurchasers were not asked a directly comparable question but instead were asked whether a series of governmental actions would make them more likely to purchase a policy. Because the nature of the questions was quite similar, results are reported comparatively. Purchasers and nonpurchasers wanted the government to take a more active role in providing information to consumers (Exhibit 8). More specifically, they wanted the government to assist individuals in understanding the risks they face and the options for financing long-term care, Exhibit 8 Views On Potential Roles For Government Involvement In Long-Term Care Insurance Financing, Regulation, And Market Enhancement Area for government involvement Purchasers Nonpurchasers Information provision Provide consumers with information on ways to pay for LTC, including information on LTC insurance and government programs 52% -a Provide consumers with information on how to choose an LTC insurance policy 44 59% Provide consumers with information on the risks of needing LTC 38 -a Quality control Give a seal of approval to certain LTC insurance policies Government finance Provide a government LTC insurance plan for which purchasers would have to pay premiums Don t know a Source: LifePlans, Inc., Survey of Purchasers and Nonpurchasers. Note: Based on average sample item response of 8,069 purchasers and 1,632 nonpurchasers. a No data.

15 222 HEALTH AFFAIRS Spring 1992 as well as how to choose a policy. Nonpurchasers were more likely to want the government to sponsor a long-term care insurance program. Finally, nonpurchasers were 2.5 times more likely than purchasers to want the government to be involved in providing seals of approval for policies. The provision of information was considered the single most important action the government should take. Second most important was establishment of a governmental long-term care insurance program for which they would pay premiums. This may reflect the concern of nonpurchasers about the adequacy of products. It is more difficult to interpret this finding for purchasers. It may be that the closest comparison to a governmental long-term care insurance program is Medicare, for which the elderly pay premiums equivalent to about 30 percent of Medicare revenues. If purchasers thought that the premium level for a governmental long-term care program would have to cover the actuarial costs of the program much like private insurance it is less certain that they would have responded similarly. Conclusions The attitudes and opinions of consumers in 1990 provide insight both into roles the government may want to play in this expanding market and into the actions that insurers may want to take to assure continued growth during the coming decade. While the number of individuals insured by private insurance companies will continue to grow, it will probably remain below the percentage of the population that could afford to pay for insurance. Data from this study suggest that in addition to cost, attitudes toward insurance and risk, the relative newness and inadequacies of some products, confused signals from the public sector, and a lack of information contribute to low demand for private longterm care insurance. It is exceedingly important that the industry continue to generate new, innovative products. Insurers also must do more to educate consumers about products, thereby enhancing consumers confidence. The government also has an important role to play, particularly in providing information. Unless and until the government clearly defines its own role regarding long-term care, consumers may be reluctant to purchase private insurance. Thus, although the market is growing, further public acceptance of private long-term care insurance may be contingent on additional governmental action.

16 D ATAWATCH 223 The authors gratefully acknowledge the support and guidance of Susan Van Gelder and Diane Fulton. This research was supported by a contract from the Health Insurance Association of America. The views expressed in this paper are those of the authors, and any errors are theirs. NOTES 1. P. Kemper, C.M. Murtaugh, and B. Spilland, The Risk of Nursing Home Use in Later Life, Medical Care 28 (1990): ; and M. Cohen, E. Tell, and S. Wallack, The Lifetime Risks and Costs of Nursing Home Use among the Elderly, Medical Care 24 (1986): Health Insurance Association of America, press release, May R. Ball and T. Bethel, Because We re All in This Together (Washington, D.C.: Families USA Foundation, 1989); M. Cohen et a!., Financing Long-Term Care: A Practical Public Private Mix, Journal of Health Politics, Policy and Law (forthcoming); R. Friedland, Facing the Costs of Long-Term Care (Washington, DC.: Employee Benefit Research Institute, 1990); M. Meiners and A. Tave, Predicting the Determinants of Demand in Long-Term Care Insurance (Rockville, Md.: National Center for Health Services Research, December 1984); and A. Rivlin and J. Wiener, Caringfor the Disabled Elderly: Who Will Pay? (Washington, D.C.: The Brookings Institution, 1988). 4. J. Shikles, Director of Health Financing and Policy Issues, Human Resources Division, U.S. Genera! Accounting Office, testimony before the Senate Special Committee on Aging, 8 January P. Feldstein, Health Care Economics, 2d ed. (New York: John Wiley and Sons, 1983). 6. C. Brickfield, Long-Term Care Financing Solutions Are Needed Now, American Health Care Association Journal (October 1986). 7. Ball and Bethel, Because We re All in This Together; Friedland, Facing the Costs of Long-Term Care; and Rivlin and Wiener, Caring for the Disabled Elderly: Who Will Pay? 8. Cohen et a!., Financing Long-Term Care: A Practical Public Private Mix. 9. Hearings on long-term care insurance before the Ways and Means Subcommittee on Health, U.S. House of Representatives, 102d Congress, 11 April 1991; hearings before the Energy and Commerce Subcommittee on Oversight and Investigations, U.S. House of Representatives, 2 May 1990; and hearings on standards for private long-term care insurance before the Committee on Ways and Mleans, US. House of Representatives, 101st Congress, 1st Sess., 17 May Rep. Pete Stark (D-CA) introduced legislation in the 101st Congress to set standards for LTC insurance. The Long-Term Care Insurance Standards Act of 1989, H.R (introduced 17 March 1989). 10. Life-Care Long-Term Care Protection Act, S.2681, 100th Congress, 2d Sess. (1988); and U.S. Bipartisan Commission on Comprehensive Health Care, A Call for Action, Final Report (Washington, DC.: US. Government Printing Office, September 1990). 11. Long-Term Care Assistance Act of 1988, S. 2305, 100th Congress, 26 Sess. (1988). 12. Who Can Afford a Nursing Home? Consumer Reports (May 1988); Gotcha: The Traps in Long-Term Care Insurance, Consumer Reports (June 1991); and J. Wiener and K. Harris, High-Quality Long-Term Care Insurance: Can We Get There from Here? (Washington, D.C.: The Brookings Institution, 1989). 13. Departmental Work Group on Consumer Protection and Long-Term Care Insurance, The Federal Role in Consumer Protection and Regulation of Long-Term Care Insurance (Washington, D.C.: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, June 1991).