Solutions on the slow track.

There are approximately 146 million adult Americans under the age of 65 years. Fewer than 6 million Americans total are covered by private long-term care insurance. These numbers mean that perhaps 50 million young and middle-aged adults now living in the United States might reach their 65th birthday with a 50% chance of entering a nursing home and no means to pay for it.

To appreciate the scope of this pending crisis, imagine that everyone in California lost all their healthcare coverage on the eve of an epidemic that would infect half of the people with a debilitating fatal disease. Those are roughly equivalent numbers.

In his State of the Union address, President Clinton stated, "[w]e now know that with aging, inevitably, come the infirmities of age.... We cannot expect that every older American will be able to fend for himself or herself. And the real question is, what are our obligations to help every American get the care that is appropriate for each individual case?"

Washington's consensus answer to this "real question" has been the same throughout the past three administrations: Americans should pay for private long-term care insurance. According to Senator Charles E. Grassley (R-Iowa), chair of the Special Senate Committee on Aging, the objective of federal policy is to "encourage Americans to be proactive and prepare for their own long-term care needs by making insurance more widely available and affordable." Grassley and President Clinton agree that the keystone of federal efforts on long-term care insurance should be granting permission for government employees to purchase group rate long-term care plans through payroll deductions.

But months after the State of the Union address, Congress and the White House have been mired in debates on the details of the modest proposals to accomplish this. It's an unusual situation in which almost everyone agrees on federal policy but cannot come to closure on how the policy should translate into regulations, dollars and practice.

The two sticking points on long-term care insurance for federal employees are: (1) who decides which insurance policies should be made available for group rate purchases by federal employees, and (2) what type of federal employee should be eligible for the group rate? The Clinton administration wants the federal Office of Personnel Management (OPM) - heir to the old Civil Service Commission - to select one or two insurers to offer long-term care plans to federal workers, much as private sector benefits managers dictate the selection of vendors to corporate employees. H.R. 110, a bill introduced by Congressman Elijah Cummings (D-Md.), would budget $15 million for OPM to cover the cost of negotiating the minimum benefit package and the group rate premiums with the insurance industry. H.R. 1111, introduced in March by Connie Morella (R-Md.), would give OPM similar powers, but use a surcharge on premiums to pay for the administrative costs.

Traditional Republicans scorn both bills. Congressman John Mica (R-Fla.), for one, complains that OPM is "taking a simple idea and making it into a potential bureaucratic nightmare." Mica's solution is to limit OPM's role to approving legitimate insurers, leaving the federal employees free to choose among six or seven of them.

The debate over employee eligibility for federal group rates crosses party lines, with the administration taking a relatively stingy approach compared to more generous Republican and Democratic lawmakers. The White House proposal limits the benefit to federal civilian employees under the jurisdiction of OPM. However, Senator Max Cleland (D-Ga.) introduced S.894 at the end of April to expand the proposed benefit to millions of additional Americans, including federal retirees, members of the Armed Services and military retirees, and Foreign Services employees and designated relatives, such as parents of federal employees. Cleland's proposal would not change the cost of the insurance program to taxpayers because all of the additional categories of potentially insured people would continue to be responsible for the full cost of the group rate premiums.

Senator Grassley is not limiting his long-term care solution to the marketing of group rates to federal employees. In January, he introduced S.35, the Long Term Care and Affordability and Availability Act which, despite its grandiose title, merely allows deductions of the cost of long-term care premiums from taxable income. Grassley says the provision "will encourage planning and personal responsibility while helping to make long-term care insurance more affordable for middle-class taxpayers." The Republican tax-cut proposals passed by Congress this summer, and threatened at press time by presidential veto, contain similar long-term care insurance write-offs sponsored by congresspersons of both parties.

Missing from this year's frantic flurry of legislation, though, is debate over whether any of these provisions can stave off the impending coverage crisis. Senator Cleland, for example, admits that his relatively generous plan for access to group rate long-term care insurance is likely to result in no more than an additional 500,000 insured Americans, an increase of fewer than 10% over current enrollment. The tax deductions proposed by Senator Grassley and others would save a 50-year-old man earning $30,000 per year a maximum of slightly more than $100 from his income tax, as against premiums ranging typically around $30 per month. Modest savings of this sort don't seem to generate much market interest; similar tax deductions offered in the Health Insurance Portability and Accountability Act of 1996 did not produce a customer stampede for long-term care insurance.

Recent medical news could cast a further pall on the insurance solution. It is at least possible that a vaccine to prevent, or even partially reverse, Alzheimer's will be available within the next decade, according to some accounts. Baby boomers who might have been motivated to purchase long-term care coverage by the fear of this terrible condition might decide to place their bets on scientific progress instead of paying insurance premiums. Of course, even a cure for Alzheimer's would leave millions of Americans in need of nursing home care for other conditions. The crisis of uninsured and underinsured long-term care residents isn't really going away.

Seen from this perspective, Washington's squabbles over the details of long-term care solutions begin to resemble two men in front of an approaching tornado disputing who gets to hold the umbrella.