The specific items included as ADLs and IADLs vary somewhat from study to study. For a report that cites two studies that used different lists of IADLs, see William D. Spector and John A. Fleishman, “The Characteristics of Long-Term Care Users,” U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality Research Report, January 2001, http://www.ahrq.gov/research/ltcusers/ (accessed May 10, 2012).
 The AARP estimates 88 percent of care was uncompensated in 2005. Wendy Fox-Grange and Donald Redfoot, “Medicaid: A Program of Last Resort for People Who Need Long-Term Services and Supports,” AARP Public Policy Institute Fact Sheet No. 223, May 2011, http://www.aarp.org/health/medicare-insurance/info-05-2011/fs223-medicaid.html (accessed May 10, 2012).
 See Genworth Financial, “Beyond Dollars: The True Impact of Long Term Caring,” September 30, 2010, https://www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/Beyond%20Dollars%20FINAL%20109048_093010_secure.pdf (accessed January 7, 2013).
 The disabled are often split into four categories: disabled children, the physically disabled but cognitively intact nonelderly adults, the developmentally disabled, and people with severe and persistent mental illness. See Bruce C. Vladeck, “Where the Action Really Is: Medicaid and the Disabled,” Health Affairs, Vol. 22, No. 1 (January 2003), pp. 90–100, http://content.healthaffairs.org/content/22/1/90.full (accessed May 10, 2012).
 See Americans with Disabilities Act of 1990, 42 U.S. Code § 12101 et seq.
 Vladeck, “Where the Action Really Is.”
 HHS estimates that Medicaid LTC spending was $113 billion in FY 2010 and will increase an average of 6.6 percent annually from 2011 to 2020, reaching more than $214 billion by 2020. Additional increases are expected in 2030 when the baby boomers reach 85 and will likely have their highest usage of long-term care. Centers for Medicare and Medicaid Services, Office of the Actuary, “2011 Actuarial Report on the Financial Outlook for Medicaid,” March 16, 2012, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf (accessed July 12, 2012).
 U.S. Census Bureau, “An Older and More Diverse Nation by Midcentury,” August 14, 2008, http://www.census.gov/newsroom/releases/archives/population/cb08-123.html (accessed January 7, 2013).
 U.S. Department of Health and Human Services, September 2008, cited in Genworth Financial, “Statistics,” http://www.genworth.com/content/lets_talk/united_states/english/planning_for_long/statistics.html (accessed May 10, 2012).
 Although current costs for healthy elders are lower, these healthier individuals will likely incur higher lifetime costs because they tend to live longer. Wei Sun, Anthony Webb, and Natalia Zhivan, “Does Staying Healthy Reduce Your Lifetime Health Care Costs?” Boston College, Center for Retirement Research Issue Brief No. 10-8, May 2010, http://crr.bc.edu/does_staying_healthy_reduce_your_lifetime_health_care_costs_.html (accessed May 10, 2012).
 Lynn Feinberg et al., “Valuing the Invaluable: 2011 Update: The Growing Contributions and Costs of Family Caregiving,” AARP Public Policy Institute, July 2011, http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf (accessed June 20, 2012).
 Rande Spiegelman, “Baby Boomer Reality Check,” Charles Schwab, May 23, 2012, http://www.schwab.com/public/schwab/resource_center/expert_insight/retirement_strategies/planning/baby_boomer_reality_check.html (accessed May 10, 2012).
 Genworth Financial, Genworth 2012 Cost of Care Survey, April 20, 2012, http://www.genworth.com/content/non_navigable/corporate/about_genworth/industry_expertise/cost_of_care.html (accessed May 10, 2012).
 Met Life Mature Market Institute, “Market Survey of Long-Term Care Costs: The 2012 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs,” November 2012, https://www.metlife.com/assets/cao/mmi/publications/studies/2012/studies/mmi-2012-market-survey-long-term-care-costs.pdf (accessed January 7, 2013).
 Henry J. Kaiser Family Foundation, “Medicaid and Long-Term Care Services and Supports,” March 2011, http://www.kff.org/medicaid/upload/2186-08.pdf (accessed June 20, 2012). When post-acute spending is not considered, the portions change to Medicaid, 62.2 percent; out-of-pocket spending, 21.9 percent; other private spending, 11.6 percent; and other public spending, 4.4 percent. National Health Policy Forum, “The Basics: National Spending for Long-Term Services and Supports (LTSS),” April 30, 2010, p. 3, Figure 1, http://www.nhpf.org/library/the-basics/Basics_ongTermServicesSupports_02-23-12.pdf (accessed June 20, 2012).
 This out-of-pocket spending includes any income of Medicaid recipients above the personal needs allowance that must be contributed toward the cost of their care. Social Security income alone has been estimated at almost half of out-of-pocket LTC spending. Nelda McCall, “Long Term Care: Definition, Demand, Cost, and Financing,” in Nelda McCall, ed., Who Will Pay for Long-Term Care (Chicago: Health Administration Press, 2001), p. 19.
 The extensive use of unpaid informal care is undeniable, but estimates of its economic value vary dramatically. The AARP estimates that about 42.1 million family caregivers in the United States provided care to an adult with ADL limitations at any given point in time in 2009 and about 61.6 million provided care at some time during the year. The estimated economic value of their unpaid contributions was approximately $450 billion in 2009, up from an estimated $375 billion in 2007. AARP Public Policy Institute, “Valuing the Invaluable: 2011 Update—The Economic Value of Family Caregiving in 2009,” Fact Sheet No. 229, June 2011, http://assets.aarp.org/rgcenter/ppi/ltc/fs229-ltc.pdf (accessed January 7, 2013). However, the Congressional Budget Office estimates the value at $76 billion. Douglas Holtz-Eakin, “The Cost and Financing of Long-Term Care Services,” statement before the Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives, April 27, 2006, http://www.cbo.gov/ftpdocs/63xx/doc6316/04-27-LongTermCare_testimony.pdf (accessed July 16, 2012).
 By comparison, other countries, such as Germany and Japan, separate the costs and sources of funding for LTC, distinguishing among medical, assistance, and room and board components. This distinction allows for more specifically targeted aid, such as allowing those receiving housing assistance to use that money to help with their LTC expenditures. See Mary Jo Gibson and Donald L. Redfoot, “Comparing Long-Term Care in Germany and the United States: What Can We Learn from Each Other,” AARP Public Policy Institute, October 2007, http://assets.aarp.org/rgcenter/il/2007_19_usgerman_ltc.pdf (accessed January 7, 2013).
 Bankers Life and Casualty Company, Center for a Secure Retirement, “Retirement Healthcare for Middle-Income Americans,” January 2012, http://www.centerforasecureretirement.com/media/150259/retirement-healthcare-report.pdf (accessed June 20, 2012).
 Henry J. Kaiser Family Foundation, “Medicaid and Long-Term Care Services and Supports.” However, because the services are not actually long-term, other studies exclude them from consideration as LTC expenses. National Health Policy Forum, “The Basics.”
 A recent settlement agreement in Jimmo v. Sebelius—which challenged the Medicare improvement standard, a de facto rule that required demonstrable improvement to receive rehabilitative services—expanded coverage to include rehabilitative services that will maintain the patient’s current condition or prevent further degradation.
 Asset exemptions vary from state to state and may include restrictions. For example, the primary residence was exempt up to $786,000 in 2012 as long as the Medicaid recipient intended to return or an eligible family member was living in the home.
 “Medicaid financing for long-term care is ‘not welfare, [that] people paid their taxes and deserve it,’” but “is an entitlement similar to Social Security.” Leslie Walker, Cynthia Gruman, and Julie Robison, “Medicaid Eligibility Workers Discuss Medicaid Estate Planning for Nursing Home Care,” The Gerontologist, Vol. 39, No. 2 (1999), p. 203. Another study noted some perceived stigma, concerns about loss of control, and morality concerns. However, these were trumped by beliefs that it was only unethical for the “wealthy” to receive Medicaid financing, “the government has a responsibility to us,” the family home should remain off limits as a source of funding, and Medicaid should focus on providing quality services to the middle class and eliminating the stigma and barriers to them getting into the best homes with Medicaid funds. Leslie Walker, Cynthia Gruman, and Julie Robison, “Medicaid Estate Planning: Perceptions of Morality and Necessity,” The Gerontologist, Vol. 41, No. 1 (February 2001), pp. 37–39.
 Actual payments under Medicaid are not a simple fixed rate, but instead are often the end result of a complicated formula plus other accounting tricks that provide additional funding to nursing homes while permitting the states to gain additional matching funds from the federal government. Thus, unlike other payment amounts under Medicaid, such as physician reimbursement rates, it is not possible to calculate the actual rate. Personal communication with Andrew Cohen, Pacific Health Policy Group, April 23, 2012.
 For example, see R. Tamara Konetzka, “Changing Economic Incentives in Long Term Care,” Syracuse University, Maxwell School of Citizenship and Public Affairs Working Paper No. 11, 2006, http://surface.syr.edu/cpr/11 (accessed May 10, 2012). Konetzka discusses the use of Medicare and private pay patients to cover shortfalls in Medicaid repayment rates, indicating that the private pay subsidies are reduced as many private pay patients move to more desirable assisted living facilities leaving Medicare to subsidize the costs. She ultimately argues for managed care as a better framework. This area of care coordination for dual eligibles has recently received substantial study and attention with advocacy from Judith Feder, who argues vigorously for using Medicare to provide coordination services to ensure appropriate care for Medicare patients with chronic conditions plus LTC needs. For example, see Judy Feder, testimony before the Special Committee on Aging, U.S. Senate, April 18, 2012, http://aging.senate.gov/events/hr244jf.pdf (accessed January 8, 2013).
 Who would be responsible for this care coordination and how it would be coordinated are still very contentious issues. However, the general need for coordination is largely accepted. See Henry J. Kaiser Family Foundation, “Medicaid and Long-Term Care Services and Supports,” and National Health Policy Forum, “The Basics,” April 30, 2010, p. 3, Figure 1.
 National Health Policy Forum, “The Basics,” April 30, 2010, p. 3, Figure 1.
 This figure includes individual and group policies as well as annuities and life insurance policies with accelerated LTC benefits. American Association for Long-Term Care Insurance, “2012 LTCi Sourcebook,” July 2012.
 For example, see Charles Duhigg, “Aged, Frail and Denied Care by Their Insurers,” The New York Times, March 26, 2007, http://www.nytimes.com/2007/03/26/business/26care.html (accessed May 10, 2012).
 “The detailed review of more than 1200 claims decisions suggests that when a third party independent audit is conducted, clinical benefit eligibility decisions are in line with the supporting documentation in the files and the contract provision of the policy…insurance companies tend to err slightly on the side of approving claims that may not meet policy contract benefit eligibility.” U.S. Department of Health and Human Services, “National Long-Term Care Insurance Claims Decision Study: An Empirical Analysis of the Appropriateness of Claims Adjudication Decisions and Payments,” April 2010, p. 12, http://aspe.hhs.gov/daltcp/reports/2010/claims.pdf (accessed January 8, 2013).
 Although the rates are guaranteed for the individual, rates can be increased for a group of policies. This can trigger confusion and anger by policyholders hit with large rate increases. Some analysts and insurers are now recommending that instead of lifetime guaranteed rates, policyholders should only expect rates to remain stable for five years followed by a cost-of-living adjustment. This increase is counter to the original concept of holding rates static to allow retirees to plan for a known expense while living on a fixed income. However, where insurance companies provide reasonable warning of potential rate increases, it can be reasonably argued the increases could be budgeted more successfully than the recent spikes.
 In addition to insurers’ bad actuarial assumptions, some of the cost problems stem from regulatory rules that mandated a loss ratio of 60 percent, a policy modified in the new National Association of Insurance Commissioners (NAIC) model regulations, which strive instead for rate stabilization. Although this sort of regulation is not solely to blame for the situation, it clearly played a role. For a more in-depth discussion, see Carol Cutter, testimony before the Special Committee on Aging, U.S. Senate, June 3, 2009, http://aging.senate.gov/events/hr210cc.pdf (accessed January 8, 2013). She urged that states be permitted and encouraged to undertake actuarial reviews to determine appropriate actions within their state. Alternately, others have cited the fact that the differences in state regulations coupled with different levels of willingness to allow rate increases create very different results depending on the state of residence and the state’s willingness to permit rate changes. See also U.S. Government Accountability Office, Long-Term Care Insurance: Oversight of Rate Setting and Claims Settlement Practices, GAO–08–712, June 2008, http://www.gao.gov/new.items/d08712.pdf (accessed January 8, 2013). The Government Accountability Office (GAO) found that rate increases are common throughout the industry, despite the declared intent to keep rates stable. Consumer protections and the results from similar review processes vary by state. Rate stability is becoming a frequent goal of state regulations, but the outcomes are still unclear and vary by company and state.
 This is particularly important to LTC insurance because a certain portion of float is mandated to be invested in low-risk investments, allowing it to remain available for payment of claims. These interest rates have caused a major hardship for companies anticipating a return on investments. The never materialized returns lead to lower amounts available to pay out on claims. Ron Liber, “When a Safety Net Is Yanked Away,” The New York Times, November 12, 2010, http://www.nytimes.com/2010/11/13/your-money/13money.html (accessed May 10, 2012). This was also emphasized in a personal conversation with Jesse Sloam, American Association for Long-Term Care Insurance, April 2012.
 Very few policyholders have actually dropped coverage altogether. For example, GAO Report to Congressional Requesters, Long-Term Care Insurance: Carrier Interest in the Federal Program, Changes to Its Actuarial Assumptions, and OPM Oversight, GAO–11–630, July 2011, p. 26, http://www.gao.gov/assets/330/322553.pdf (accessed January 8, 2013). The report noted that, when the Federal Long Term Care Insurance Program faced a rate increase, only 1.6 percent of enrollees lapsed their policies, with the remaining either paying higher premiums, opting for lower coverage amounts, or some combination of the two.
 Richard W. Johnson and Cori E. Uccello, “Is Private Long-Term Care Insurance the Answer?” Boston College, Center for Retirement Research, Issue in Brief No. 29, March 2005, http://www.urban.org/UploadedPDF/1000795.pdf (accessed January 8, 2013), and Life Plans, Inc., “Who Buys Long-Term Care Insurance? A 15-Year Study of Buyers and Non-Buyers, 1990–2005,” America’s Health Insurance Plans, April 2007, http://www.ahip.org/LTC-Buyers-Guide/ (accessed January 8, 2013).
 Pierre Pestieau and Gregory Ponthiere, “Long Term Care Insurance Puzzle,” Center for Operations Research and Econometrics, Discussion Paper, May 2010, http://www.uclouvain.be/cps/ucl/doc/core/documents/coredp2010_23web.pdf (accessed January 8, 2013).
 See Jeffrey R. Brown and Amy Finkelstein, “The Interaction of Public and Private Insurance: Medicaid and the Long-Term Care Insurance Market,” American Economic Review, Vol. 98, No. 3 (June 2008), pp. 1083–1102.
 This effect applies even when the publicly provided coverage of LTC expenses is incomplete.
 For example, some suggest that most should self-insure if they can or just go on Medicaid and accept that the providers will not be very good. See Alan Roth, “Why Long-Term Care Insurance May Become Extinct,” CBS News, April 9, 2012, http://www.cbsnews.com/8301-505146_162-57410258/why-long-term-care-insurance-may-become-extinct/ (accessed May 10, 2012), and Caroline Mayer, “Long-Term-Care Insurance Is More Expensive Than It’s Worth for Some People,” The Washington Post, January 23, 2012, http://www.washingtonpost.com/national/health-science/is-long-term-care-insurance-right-for-you/2012/01/12/gIQAoEomLQ_story.html (accessed May 10, 2012). Others argue that LTCi is an essential component of retirement planning. See Kimberly Lankford, “Navigate a Course for Long-Term Care,” Kiplinger’s Personal Finance, May 1, 2012, http://www.kiplinger.com/features/archives/krr-navigate-a-course-for-long-term-care.html (accessed May 10, 2012).
 Life Plans, “Who Buys Long-Term Care Insurance?”
 The Health Insurance Portability and Accountability Act sets compliance standards for a variety of plan details, such as renewability, consumer protection, and scope of coverage. The result of compliance with these qualifications is that plan premiums can be applied to the 7.5 percent spending on medical expenses to qualify for tax deductions. However, the majority of purchasers do not spend enough on health care to qualify for the tax deduction and as a result may be purchasing unnecessary coverage. Johnson and Uccello, “Is Private Long-Term Care Insurance the Answer?” and Life Plans, “Who Buys Long-Term Care Insurance?” An inability to compare products or understand the terms is often cited, and standardizing the products and making them easier to understand may move some toward purchasing. Bonnie Burns, “Comparing Long-Term Care Insurance Policies: Bewildering Choices for Consumers,” AARP Public Policy Institute, May 2006, http://assets.aarp.org/rgcenter/il/2006_13_ltci.pdf (accessed January 8, 2013). Regulators and insurers have countered this, citing standards adopted by state insurance regulatory agencies and companies that focus on providing accurate and sufficient information. Sean Dilweg, “Boon or Bane: Examining the Value of Long Term Care Insurance,” testimony before the Special Committee on Aging, U.S. Senate, June 3, 2009, http://aging.senate.gov/events/hr210sd.pdf (accessed January 8, 2013).
 Diane Rowland, “Filling in the Long-Term Care Gaps,” testimony before the Special Committee on Aging, U.S. Senate, June 3, 2009, p. 9, http://aging.senate.gov/events/hr210dr.pdf (accessed January 9, 2013). However, in the disappearing group market, underwriting is either eliminated or greatly reduced, making a potential situation in which high-risk individuals can be included. However, adverse selection in group markets could cause a death spiral.
 Nor do the underwriting statistics consider the disabled, who are likely to have lower income and wealth resulting in an inability to afford insurance.
 See Emily Oster et al., “Genetic Adverse Selection: Evidence from Long-Term Care Insurance and Huntington Disease,” Journal of Public Economics, Vol. 94, Nos. 11–12 (December 2010). The authors found that those with the genetic marker for Huntington disease were up to five times more likely to have LTCi than those without the marker or who were unaware of their status, even with individual risk factors for Huntington disease.
 “The average baby boomer (those people between 45 and 62 years of age) without a company-sponsored retirement plan has managed to set aside around $38,000. Those with a company-sponsored retirement plan aren’t doing much better—they’ve managed to squirrel away somewhere in the neighborhood of $88,000.” This according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Kelly Greene and Anne Tergesen, “More Elderly Find They Cannot Afford Not to Work,” The Wall Street Journal, January 21, 2012, http://online.wsj.com/article/SB10001424052970204331304577145002385012634.html (accessed May 10, 2012).
 Fidelity Investments, “Don’t Take a Lifestyle Cut in Retirement,” April 18, 2012, https://www.fidelity.com/viewpoints/retirement-readiness (accessed January 9, 2013).
 Genworth Financial, Genworth 2012 Cost of Care Survey.
 Of workers in retirement, 56 percent anticipate retirement income from a traditional pension, down from the high of 62 percent in 2005. Employee Benefit Research Institute, “Changing Expectations About Retirement,” RCS Fact Sheet, 2012, http://www.ebri.org/pdf/surveys/rcs/2012/fs-02-rcs-12-fs2-expect.pdf (accessed July 19, 2012).
 For a plan to increase individual savings for retirement, see David C. John, “Automatic Retirement Savings—Paving the Path to Personal Financial Security,” Heritage Foundation Backgrounder No. 2477, October 14, 2010, http://www.heritage.org/research/reports/2010/10/automatic-retirement-savings-paving-the-path-to-personal-financial-security, and David C. John, “Pursing Universal Retirement Security Through Automatic IRAs and Account Simplification,” testimony before the Committee on Ways and Means, U.S. House of Representatives, April 17, 2012, http://www.heritage.org/research/testimony/2012/04/pursuing-universal-retirement-security-through-automatic-iras-and-account-simplification.
 U.S. Census Bureau, “Current Housing Reports,” Series H150/07, in American Housing Survey for the United States: 2007 (Washington, D.C.: U.S. Government Printing Office, 2008).
 This indicates that a large portion of residents in independent living, assisted living, or combination facilities are covering their expenses personally from income and asset spend-down including “many individuals indicating they sold their houses and purchased additional annuities with the proceeds,” with less than 5 percent funding their care through a reverse mortgage. This is unsurprising because being outside the residence for one year causes the loan to come due. Only 8 percent reported that government programs were paying for their stays. Norma B. Coe and April Yanyuan Wu, “Residents in Senior Housing and Care Communities: Overview of the Residents Financial Survey,” Center for Retirement Research at Boston College, November 2011, http://www.alfa.org/Document.asp?DocID=227 (accessed January 9, 2013).
 Ibid. The concept of value may be worth additional study and may be useful to entice people to spend personal funds, including home equity, for their own care instead of turning freely to government assistance.
 In addition to being an unpopular option, a reverse mortgage would not provide an ideal funding source for institutional long-term care because the mortgage would come due following one year outside the home. Some consumers may be unwilling to risk losing their home in this manner, even if the long-term care needs do not extend to this period.
 Vickie Elmer, “Reverse Loans, Pre-Retirement,” The New York Times, April 12, 2012, http://www.nytimes.com/2012/04/15/realestate/mortgages-reverse-loans-at-a-younger-age.html (accessed January 9, 2013).
 Stephen A. Moses, “Private Long-Term Care Financing Alternatives,” Center for Long-Term Care Reform Briefing Paper No. 6, December 9, 2011, http://www.centerltc.com/bullets/archives2012/950.htm (accessed July 19, 2012).
 Kathryn Nix, “But Wait, It Gets Worse: The Medicare Actuary’s Realistic Outlook for the Program,” Heritage Foundation Issue Brief No. 3627, June 6, 2012, http://www.heritage.org/research/reports/2012/06/the-medicare-actuarys-realistic-outlook-for-the-program. See also John D. Shatto and M. Kent Clemens, “Projected Medicare Expenditures Under Illustrative Scenarios with Alternative Payment Updates to Medicare Providers,” Centers for Medicare and Medicaid Services, Office of the Actuary, May 18, 2012, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/2012TRAlternativeScenario.pdf (accessed June 4, 2012), and Suzanne Codespote, “Medicare Unfunded Obligations for 2012 Trustees Report,” letter to the Senate Budget Committee, April 23, 2012.
 One such reform attempt in 1996 criminalized Medicaid planning, a move ultimately repealed. This was followed by an unconstitutional attempt to criminalize attorney assistance in Medicaid planning.
 See Omnibus Budget Reconciliation Act of 1993 (OBRA-93).
 For a discussion of the need to expand existing estate recovery efforts, see Stephen A. Moses, “Long-Term Care Financing in New York: How to Save Money While Serving the Needy,” Empire Center for New York State Policy, Special Report No. 10, March 2011, http://www.empirecenter.org/Documents/PDF/LTC03.03.111.pdf (accessed July 20, 2012), and Stephen A. Moses, “Med-Cal Long-Term Care: Safety Net or Hammock?” Pacific Research Institute, January 2011, http://www.pacificresearch.org/press/medical-longterm-care-safety-net-or-hammock (accessed July 20, 2012). Seventeen years after it was mandated under OBRA-93 and with strong objection from the elder bar, Michigan became the final state to implement some form of estate recovery law in 2010. However, as with other states, the discussion continues on the application of estate recovery. For example, see Center for Elder Law, “Summary of New Medicaid Laws and Michigan’s New Estate Recovery Laws,” http://www.thecenterforelderlaw.com/lawyer-attorney-1394956.html (accessed January 9, 2013).
 Gretchen Jacobson, Tricia Neuman, and Anthony Damico, “Medicare’s Role for Dual Eligible Beneficiaries,” Henry J. Kaiser Family Foundation, April 2012, http://www.kff.org/medicare/upload/8138-02.pdf (accessed January 9, 2013).
 Others have called for more widespread action to move responsibility for dual eligibles to the states. For example, see Grace-Marie Turner and Robert Helms, “Providing Improved Care Management for Medicare/Medicaid Dual-Eligible Beneficiaries,” Galen Institute, May 7, 2012, http://www.galen.org/assets/MedicaidAdvantageBetterGovernmentCompetition.pdf (accessed January 9, 2013).
 Thomson Reuters and Univita Health, The Long-Term Care Partnership Program: 5 Years After Enactment under the Deficit Reduction Act, submitted to the Office of the Assistance Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, October 17, 2011.
 Ibid., p. 16.
 Ibid., p. 17.
 Mark R. Meiners, “Long-Term Care Insurance Partnerships: Considerations for Cost-Effectiveness,” Center for Health Care Strategies Issue Brief, March 2009. Meiners re-analyzes the results of a 2007 GAO report on the cost-effectiveness of partnership programs by reclassifying purchase decisions.
 “In fact, with over 300,555 partnerships qualified policies to date in the original four partnership states, only 315 individuals—less than 1 percent of individuals—have exhausted benefits and had to use Medicaid.” Thomas M. “Buck” Stinson, testimony before the Special Committee on Aging, U.S. Senate, June 3, 2009, p. 5, http://aging.senate.gov/events/hr210ts.pdf (accessed January 9, 2013).
 Thomson Reuters and Univita Health, The Long-Term Care Partnership Program.
 Multiple companies have recently withdrawn from the group market including major providers Unum and MetLife. Because of the potential for adverse selection, group policies are not always more economical than an individual policy. In fact, the premiums for group purchasers of partnership qualified policies are “significantly higher than the industry-wide premiums.” Ibid., p. 31.
 For example, Christine E. Bishop suggested a variation of the partnership program, a federal catastrophic coverage plan that would cover care after three years of care. The program would retain Medicaid as a safety net for the indigent, but would encourage the middle class to purchase coverage for needs below the catastrophic threshold. Catastrophic coverage would not cover room, board, or medical charges, which remain the responsibility of the individual unless Medicaid is used as a supplement. See Christine E. Bishop, “A Federal Catastrophic Long-Term Care Insurance Program,” Georgetown University Long-Term Care Financing Project Working Paper No. 5, June 2007, http://ltc.georgetown.edu/forum/5bishop061107.pdf (accessed January 9, 2013).
 This deduction applies to any medical expenses above 10 percent. The threshold increases to 10 percent from 7.5 percent as a part of the Affordable Care Act (ACA). This deduction is only available for taxpayers filing itemized deductions, which consequently makes them of greater benefit to higher-income individuals.
 See David G. Stevenson, Richard G. Frank, and Jocelyn Tau, “Private Long-Term Care Insurance and State Tax Incentives,” Inquiry, Vol. 46, No. 3 (September 2009), pp. 305–321. The authors found a small increase in the purchase of policies when tax credits are offered and no significant difference in purchases in states with tax deductions. See also Charles Courtemanche and Daifeng He, “Tax Incentives and the Decision to Purchase Long-Term Care Insurance,” Journal of Public Economics, Vol. 93, Nos. 1–2 (February 2009), pp. 296–310, http://wmpeople.wm.edu/asset/index/dhe/ltcifinal (accessed January 9, 2013).
 Gopi Shah Goda, “The Impact of State Tax Subsidies for Private Long-Term Care Insurance on Coverage and Medicaid Expenditures,” November 1, 2010, http://www.stanford.edu/~gopi/statetaxincentivesforltci.pdf (accessed January 9, 2013).
 David Baer and Ellen O’Brien, “Federal and State Income Tax Incentives for Private Long-Term Care Insurance,” AARP Public Policy Institute, November 2010, http://www.taxadmin.org/fta/rate/aarp_ltc_incentives.pdf (accessed October 22, 2012).
 Genworth Financial, Genworth 2012 Cost of Care Survey.
 Kathleen Sebelius, letter to Speaker of the House John A. Boehner, October 14, 2011, http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/10/boehner-.pdf (accessed January 9, 2013).
 Lori Montgomery, “Proposed Long-Term Health Insurance Program Raises Questions,” The Washington Post, October 27, 2009, http://www.washingtonpost.com/wp-dyn/content/article/2009/10/27/AR2009102701417.html (accessed July 21, 2010).
 Brian Blase, “No CLASS: How Congress Saddled Taxpayers with Another Costly Entitlement,” Heritage Foundation Backgrounder No. 2444, July 29, 2010, http://www.heritage.org/research/reports/2010/07/no-class-how-congress-saddled-taxpayers-with-another-costly-entitlement, and James C. Capretta and Brian M. Riedl, “The CLASS Act: Repeal Now, or Face Permanent Taxpayer Bailout Later,” Heritage Foundation Backgrounder No. 2441, July 22, 2010, http://www.heritage.org/research/reports/2010/07/the-class-act-repeal-now-or-face-permanent-taxpayer-bailout-later.
 Kathleen Sebelius, HHS Secretary, testimony before the Finance Committee, U.S. Senate, February 16, 2012.
 Howard Gleckman, Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America’s Most Urgent Health Crisis (New York: St. Martin’s Press, 2009).
 For a discussion of potential tax implications, see Michael Kitces, “The New Wave in LTC Hybrids,” Bank Investment Consultant, November 1, 2009, http://www.bankinvestmentconsultant.com/bic_issues/2009_11/the-new-wave-in-ltc-hybrids-2664417-1.html (accessed January 9, 2013). He also discusses tax changes, indicating one should be aware of potential changes in tax rules to modify these tax implications.
 For information on active and developing villages, see the Village to Village Network, website, http://www.vtvnetwork.org/ (accessed January 9, 2013).
 Bankers Life and Casualty Company, Center for a Secure Retirement, “Retirement Healthcare for Middle-Income Americans,” January 2012, http://www.centerforasecureretirement.com/media/150259/retirement-healthcare-report.pdf (accessed January 9, 2013).
 For an explanation of the program, see U.S. Department of Health and Human Services, Administration on Aging, “Long-Term Care Planning,” http://www.aoa.gov/AoA_programs/HCLTC/LTC/index.aspx (accessed January 9, 2013).
 For additional information, see 3 in 4 Need More, website, http://www.3in4needmore.com/ (accessed January 9, 2013).