In November, Washington State voters defeated a ballot measure that would have significantly undermined the nation’s first social insurance program for long-term care by a surprisingly comfortable 55 percent to 45 percent margin. The result means that the program, the WA Cares Fund, will continue toward full implementation in 2026.
WA Cares has succeeded where many other plans for addressing long-term care in the U.S. at the national level have failed. While WA Cares is much smaller in scope, it nonetheless offers a critical foothold and opportunity to demonstrate the viability of the social insurance model for addressing a problem that is overwhelming individuals, families, and government budgets. In tackling long-term care at the state level, WA Cares illustrates an alternative approach for making progress on a particularly vexing policy problem and offers a roadmap for other states. With a new Republican administration and Congress in Washington, D.C., this state-level strategy may be the only way to make meaningful progress on long-term care in the foreseeable future.
A Policy Area Marked by Failure
In 2019, lawmakers in Washington State waded into territory that had stymied Congress and given long-term care a reputation as an intractable policy problem. Several times over several decades, Congress toyed with the possibility of creating a national long-term care program; twice it even managed to enact one, though both episodes ended in embarrassing repeals.
Devising a viable social insurance program for long-term care has never been the central problem. As WA Cares director Ben Veghte says, “Designing a social insurance program is not rocket science. The Dutch did it in 1968. The Germans did it in 1994. The Japanese did it in 2000; South Korea in 2008. The blueprint is there . . . the policy is not hard.”
Rather, the persistent challenge has been navigating the politics of long-term care. Public misunderstanding and lack of awareness have been consistent roadblocks. Many experts note that, relative to other countries, Americans are uniquely resistant to thinking about the aging process. Extensive public opinion research shows that many Americans expect Medicare to cover any long-term care needs they may have. It does not, leaving the means-tested Medicaid program as the key player. These blind spots have made it harder for reformers to galvanize support for a national program. Long-term care policymaking also has been hobbled by infighting. Meanwhile, structural aspects of America’s political institutions, such as the separation of powers and the Senate filibuster, make it relatively hard to pass expansive social legislation in the U.S. In the case of the ill-fated CLASS Act — the long-term care program passed as part of the Affordable Care Act but later deemed unworkable and repealed — this meant sacrificing a sound policy design to accommodate political necessities.
An Elusive (if Limited) Success
Given this troubled policy history, WA Cares represents a rare success. The program has its limitations. It is only a partial fix in a single state for a problem that requires a more comprehensive solution. Yet it is an important first step. Under WA Cares, all Washington workers pay a 0.58 percent tax via automatic paycheck deduction. After 10 years of paying into the program, they become eligible for up to $36,500 in lifetime benefits (adjusted for inflation) if they require assistance with three or more activities of daily living (e.g., bathing, dressing, eating).
In the scope of long-term care, that benefit doesn’t go very far. Costs vary considerably, but regular assistance from a home health aide can easily exceed $60,000 annually, while a shared room in a nursing home can run well over $100,000 a year. For a family with an aging relative facing those kinds of needs — potentially for years — costs will far exceed what WA Cares offers.
Making the benefit more generous, however, carried risks. “We actually looked at a whole bunch of different models,” recounts Cathy MacCaul, advocacy director at AARP Washington and a central figure behind WA Cares. The policymakers wanted a sweet spot that offered “a reasonable benefit that would be meaningful but was still affordable.” They knew that how the legislature and the public perceived the program would be essential for its political viability. A higher benefit would be useful but would come with a higher price tag. As Seattle-area State Senator Karen Keiser (D) explains, as you approach the 1 percent threshold for the payroll tax, “you hit a barrier with the public and the media. It sounds like much more money, [where] 0.58 doesn’t sound like that much.” In a policy area littered with failed efforts, it is best to err on the side of caution.
The program’s supporters also note that even at the relatively modest $36,500 benefit level, WA Cares will still meaningfully improve the status quo for Washington workers. Research has shown a 65-year-old faces the following probabilities for their lifetime long-term care needs: none (17%), up to one year (24%), one to three years (32%), or three or more years (28%). The intensity of need varies but, roughly speaking, WA Cares can be expected to cover most of the costs incurred by the 24 percent of the population that requires less than one year of assistance. “The bottom line,” Veghte says, “is WA Cares solves 20 percent to 30 percent of the problem.” Even for those who will eventually face the kind of extensive needs and catastrophic costs many dread, WA Cares can serve as a critical bridge from crisis to stability. Having that first year covered, Veghte says, “gives the family time to catch their breath [and] put together a plan.”
At the national level, the challenges that have plagued long-term care policymaking aren’t going away. WA Cares has demonstrated a new approach. If it proves successful once fully operational, it could spur other states — and eventually even the country — to take similar or even more aggressive steps to address an issue taking an increasing toll on our society.
