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July 2015

ASPE ISSUE BRIEF

HHS OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION

OFFICE OF DISABILITY, AGING AND LONG-TERM CARE POLICY

FINDINGS FROM THE SURVEY OF

LONG-TERM CARE AWARENESS AND PLANNING

Using data from the 2014 Survey of Long-Term Care Awareness and Planning, a number of 

analyses were undertaken to better understand public knowledge about long-term care, 

concerns related to aging and disability, plans to address needs, and preferences about 

different aspects of long-term care insurance. The survey showed that knowledge of long-term 

care is low among the general population aged 40-70: most were not well-informed about longterm care costs, the role of Medicaid, or nursing home length of stay. Losing independence 

was the top concern followed by being a burden to one’s family. Respondents were willing to 

undertake a number of actions if faced with a chronic disability. Most respondents believed that 

long-term care financing is largely an individual rather than government responsibility, and 

have a strong preference for voluntary initiatives, including private long-term care insurance 

and voluntary public long-term care insurance. However, when asked about specific insurance 

preferences, price, the length of coverage, and the daily benefit amount were rated as the most 

important attributes of long-term care insurance policies.

Long-term care (LTC) is a range of services and supports to meet personal care needs. 

Most LTC is not medical care, but rather assistance with the basic personal tasks of 

everyday life, such as eating, dressing, and bathing (Congressional Budget Office, 

2013). In 2011, 5.7 million people--about 16 percent of the elderly Medicare population 

--needed assistance with LTC according to a widely-used definition established by the 

Health Insurance Portability and Accountability Act of 1996 (Drabek & Marton, 2015). 

LTC can be very expensive, and Medicare and most private health insurance plans do 

not cover these costs. In 2014, nationally, the median cost of a semi-private room in a 

nursing home was $77,380 per year and the median cost of home health aide care was 

$20 per hour (Genworth Financial, 2014).

With the aging of the population and growing demand for LTC, it is important that 

Americans take steps toward preparing for LTC, both individually and as a society. This 

Research Brief summarizes findings from the 2014 Survey of Long-Term Care 

Awareness and Planning with the goal of contributing to our understanding of the 

concerns of people, plans to address needs, and preferences about different aspects of 

LTC insurance and financing.
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Data and Methods

In 2014, the U.S. Department of Health and Human Services, Office of the Assistant 

Secretary for Planning and Evaluation contracted with RTI International and GfK 

Research to develop and field a Survey of Long-Term Care Awareness and Planning. 

A nationally representative sample of 15,298 non-institutionalized United States adults 

40-70 years old completed the survey. 

Respondents were asked to complete:

1. A survey containing questions on: (1) self-perceived longevity and the risk of 

needing LTC; (2) basic financial literacy and psychological characteristics such 

as risk tolerance; (3) LTC knowledge and LTC experience; (4) beliefs and 

concerns about LTC; (5) retirement and LTC planning; (6) LTC information 

gathering and decision making; (7) attitudes toward LTC financing options; and 

(8) core demographic and socioeconomic information.

2. A discrete choice experiment (DCE), a form of conjoint analysis, designed to 

elicit respondent preferences among various attributes of LTC insurance. 

Findings

Self-Reported Longevity Risk and Risk of Moving to a Nursing Home

• The majority of respondents had high expectations of their longevity, with 82.1 

percent believing that they had at least a 50 percent chance of surviving to age 

85 or older. More than one-fifth of respondents (21.8 percent) rated their chances 

of living to old age as 90-100 percent. Although there was not much difference by 

age, women were more likely to think that they would live to age 85 or older. 

• Despite high expectations of surviving to old age, not as many respondents 

expected to need nursing home services in the future. Although a significant 

proportion of respondents believed that there was a substantial risk of their using 

nursing home care, 42.9 percent assessed their chances of moving into a 

nursing home in the future as less than or equal to 20 percent. Only 3.8 percent 

believed they have a 90-100 percent chance of ever moving into a nursing home. 

Concerns about Becoming Disabled

• “Losing independence,” was the top concern expressed by almost all 

respondents (90.6 percent), followed by “being a burden to your family” 

(83.5 percent), and “losing control and choice over LTC you might need” 

(83.3 percent). Being unable to depend on family/friends for care was the least of 

the seven concerns, although two-thirds (65.3 percent) still reported worrying 

about this possibility. 
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Willingness to Take Long-Term Care Actions

• Respondents were asked about how willing they would be to take specific actions 

should they become disabled and need LTC (Figure 1). The highest proportions 

of respondents were willing to make modifications to their homes (82.3 percent); 

rely on a spouse, family member, or friend for care (75.0 percent); and have a 

family member or friend move in (69.7 percent). Fewer than half were willing to 

move in with children, family members, or a friend (48.5 percent), or use the 

value of their home to pay for LTC (43.6 percent). 

• Not surprisingly, moving into a nursing home was the least favored choice. Just 

over a quarter of respondents indicated that they would be willing to move into a 

nursing home if they became disabled (28.6 percent).

FIGURE 1. Willingness to Take Specific Actions in the Event of a Disability

(N=15,298)

SOURCE: RTI analysis of the 2014 ASPE Survey of Long-Term Care Awareness and Planning.

NOTES: Percentages are shares of respondents who reported being "very"/"somewhat" willing to 

take an individual action.

Experience, Knowledge, and Awareness of Long-Term Care

• Americans do not have a good grasp of the high costs of LTC. Only about onefifth of all respondents (20.2 percent) correctly estimated the average cost of a 

month of nursing home care in their state of residence, and 15.3 percent 

correctly estimated the average cost of one hour of home health aide care in their 

state. Aside from those who estimated nursing home and home health costs 

incorrectly, more than one-third (36 percent) did not know enough to choose a 

response (not shown). 
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• Respondents also did not understand how LTC is currently financed. Only a 

quarter of all respondents (25.3 percent) correctly identified Medicaid as the 

government program that pays the most for LTC services in the United States. 

Preferences for Long-Term Care Financing

• Table 1 displays a portion of respondents’ preferences for LTC financing options. 

Most supported individual responsibility and voluntary, largely private, options. 

Approximately three-fifths of respondents (58.7 percent) said they strongly 

agreed/agreed that it is the responsibility of individuals to finance their LTC; 

conversely, about a third of people (37.1 percent) stated that they strongly 

agreed/agreed that it is the responsibility of government to help pay for LTC.

• Respondents were generally supportive of the concept of LTC insurance, but 

many had competing demands for their money. Almost two-thirds of respondents 

(66.4 percent) either agreed or strongly agreed that “knowing that I have some 

LTC insurance will give me peace of mind,” but almost half (44.4 percent) 

reported that they had other priorities for their money than buying LTC insurance.

• Respondents were most supportive of the government allowing LTC insurance 

purchase through tax policy and other funding sources. Nearly 70 percent of 

respondents either agreed or strongly agreed that the government should allow 

the purchase of LTC insurance with Individual Retirement Accounts (IRAs) and 

401(k)s and over 60 percent felt that the government should promote the 

purchase of LTC insurance through taxes. 

• Overall, respondents favored voluntary programs, especially those that would 

promote private LTC insurance. Fully 62.9 percent of respondents supported a 

voluntary public LTC insurance program. In contrast, 18.4 percent of people 

supported a mandatory public LTC insurance program.

• Most respondents (62.7 percent) either agreed or strongly agreed that they did 

not want the government to “tell me what to do about LTC insurance.” 

• Although negative views were expressed of both private insurers and 

government, stronger negative views were expressed of the potential role for 

government. A slight majority of respondents (51.1 percent) strongly 

agreed/agreed that they do not trust the government to run a public LTC 

insurance program, while 32.3 percent did not trust private insurers. 
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TABLE 1. Preferences for LTC Financing

(N=15,298)

Survey Questions

Strongly Agree/

Agree

(percent)

Neutral

(percent)

Strongly Disagree/

Disagree

(percent)

It is important to plan now for the 

possibility of needing LTC services 

in the future.

71.2 26.0 2.8

Responsibility for LTC

Responsibility of individuals to finance 

their LTC 58.7 32.6 8.7

Responsibility of government to help 

pay for LTC 37.1 37.9 25.1

Government should:

Promote LTC insurance through taxes 62.4 28.9 8.7

Allow LTC purchase with IRAs and 

401(k)s 69.2 26.2 4.6

Require all people to purchase LTC 

insurance 15.7 35.2 49.1

Pay LTC costs when insurance 

benefits run out 40.9 40.0 19.1

Offer voluntary, public LTC insurance 

plan 62.9 26.7 10.4

Establish mandatory, public LTC 

program

18.4 34.4 47.3

Personal involvement with LTC financing

Everyone should have LTC insurance 

and a mandatory, public program is 

the way to accomplish that

19.5 34.4 46.1

Everyone should have LTC 

insurance, but private companies 

should provide the insurance

23.2 49.9 27.0

Requiring people to buy LTC 

insurance is OK, if price is not too 

high

40.5 25.5 34.1

Knowing that I have some LTC 

insurance will give me peace of mind 66.4 27.1 6.5

Paying for LTC is individual 

responsibility, not government 46.6 38.1 15.3

Government should not tell me what 

to do about LTC insurance 62.7 28.1 9.2

I have other priorities for my money 

than buying LTC insurance 44.4 41.9 13.8

I do not trust government to run a 

LTC insurance program 51.1 33.0 15.9

I do not trust private insurers 32.3 46.7 21.1

SOURCE: RTI analysis of the 2014 ASPE Survey of Long-Term Care Awareness and Planning.

NOTE: All results are presented weighted.

Relative Preferences for Long-Term Care Insurance Plan Features 

As part of the DCE portion of the survey, respondents were asked to choose between a 

series of hypothetical LTC insurance policies with various attribute levels. The 

attributes included Daily Benefit Amount, Benefit Period, Deductible Period, Medical 

Underwriting, Plan Cost, Sponsorship and Required Enrollment. 

The Deductible Period refers to the period during which you have to pay for care out of 

pocket before you are eligible to receive benefits from insurance. Sponsorship refers to 

what entity will offer the insurance--with the DCE, respondents were asked to choose 
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between policies offered by private companies or the Federal Government. Finally, for 

Required Enrollment, respondents were asked if they prefer insurance to be Voluntary, 

that is you may buy the policy if you like, but you do not have to, or Universal, where 

everyone is required by law to purchase the insurance.

Figure 2 displays respondents’ relative preferences for features of the hypothetical 

policies. The estimates in this table are scaled to show respondents’ relative 

preferences among the various insurance attributes, with 10 being the highest (most 

desired) and 0 being the lowest (least desired). Figure 2 also shows the relative 

importance of these attributes across their full range. Specifically, those with the largest 

range (i.e., premium cost) were the most important overall in determining choice 

behavior, and those with the smallest range (i.e., deductible levels or sponsorship) were 

least important. A 5 in this table represents an average of all the features, so larger 

deviations from 5 indicate more importance--desirable above 5 and undesirable

below 5.

FIGURE 2. Relative Preferences for LTC Insurance Plan Features

SOURCE: RTI International analysis of the 2014 ASPE Survey of Long-Term Care 

Awareness and Planning.

NOTE: Figure depicts results, rescaled in terms of relative importance to each other, 

0 = least preferred, 10 = most preferred.

• Respondents expressed strong preferences for voluntary, low-cost policies with 

long benefit periods and high benefit amounts. A $30 per month premium is the 

most desired attribute and a $400 per month premium was the least desired 

attribute. There was not much variation across deductible periods. Respondents 

exhibited strong preferences over the length of the benefit periods: one-year 
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policies were strongly undesirable, while lifetime benefits were highly desirable. 

People strongly favored $300 a day benefits versus $50 a day benefits. 

• Another way to look at these preferences is to compare a simulated hypothetical 

insurance plan with the same features ($100 daily benefit amount and three-year 

duration and holding all other attributes constant) across a series of premium 

costs ($25, $50, $75, $125, $150 and $250 per month) and against the option of 

"no insurance." In a voluntary setting, predicted demand exceeds 50 percent at 

approximately the $50 per month premium cost. In other words, above this cost, 

less than half are expected to voluntarily choose LTC insurance. 

Conclusions

Analysis of the Survey of Long-Term Care Awareness and Planning indicates that 

knowledge of LTC is low among the general population aged 40-70: most were not wellinformed about LTC costs, the role of Medicaid, or nursing home length of stay. 

Respondents expressed a wide variety of concerns related to aging and disability with 

losing independence being the top concern. When asked what they would be willing to 

do if disabled, many said make modifications to homes; rely on a spouse, family/friend; 

or have family or a friend move in with them. However, a majority said they would not 

move in with family/friends, use the value in their home to pay for LTC, or use nursing 

home care. Respondent’s opinion on the use of home equity may reflect the important 

role homes have in American culture and may reflect a desire either to leave an 

inheritance for their families or to preserve their major asset for some other adverse 

event.

In general, and when responding to the survey questionnaire, respondents favored 

individual responsibility over government responsibility for LTC financing. Moreover, 

respondents generally favored voluntary initiatives, both private and public, although 

they had a stronger preference for private LTC insurance. Mandatory public LTC 

insurance did not garner much support. Respondents also voiced substantial mistrust of 

how the government would manage a public LTC insurance program. However, when 

given an actual choice between hypothetical LTC insurance policies, respondents 

tended to focus almost exclusively on price, the length of coverage, and to a lesser 

extent, the daily benefit amount of the policies. Respondents had a preference for 

voluntary insurance, but not as highly as their preference for low price and extensive 

coverage. Compared to these preferences, respondents were much less concerned 

about the deductible period, medical underwriting, or sponsorship of the plan--whether 

by the government or private sector. Given the somewhat conflicting views of the 

public, the challenge for policymakers is to find a reform strategy that will both 

successfully address the problems of the LTC system and have broad political support.
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References

Congressional Budget Office (2013). Rising Demand for Long-Term Services and Supports for 

Elderly People. http://www.cbo.gov/sites/default/files/cbofiles/attachments/44363-LTC.pdf. 

Drabek J, & Marton W (2015). Measuring the Need for Long-Term Services and Supports 

Research Brief. ASPE unpublished data.

Genworth Financial (2014). Genworth 2014 Cost of Care Survey home care providers, adult day 

health care facilities, assisted living facilities and nursing homes. Richmond, VA: Genworth 

Financial. 

https://www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/130568_032514_Cost

ofCare_FINAL_nonsecure.pdf. 

This Research Brief was authored by Joshua M. Wiener, Galina Khatutsky, Nga Thach, Angela M. 

Greene and Benjamin Allaire (RTI International); Derek Brown (Washington University); and Helen 

Lamont, William Marton and Samuel Shipley (Department of Health and Human Services). It summarizes 

findings from the 2014 Survey of Long-Term Care Awareness and Planning with the goal of contributing 

to our understanding of the concerns of people related to aging and disability, plans to address needs, 

and preferences about different aspects of long-term care insurance and financing. 

This Brief was prepared through intramural research by the U.S. Department of Health and Human 

Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and 

Long-Term Care Policy. For additional information about this subject, visit the DALTCP home page at 

http://aspe.hhs.gov/office_specific/daltcp.cfm or contact HHS/ASPE/DALTCP, Room 424E, H.H. 

Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, Helen.Lamont@hhs.gov, 

William.Marton@hhs.gov, or Samuel.Shipley@hhs.gov.