The still-rising death toll of nursing home residents from the poorly controlled spread of the COVID-19 virus has reignited criticism of Medicaid’s care quality, payment adequacy, and even its existence. Over the years, the federal-state program created to provide healthcare for poor people during the Johnson administration has quietly evolved into de facto long-term care coverage for the middle class. Low state payment rates often result in low-quality care. More vigorous regulation might move the dial a bit. But it cannot alter the fundamental cost/quality economics.

Unfortunately, the long-standing argument that private long-term care insurance would adequately fill the gap left by gutting Medicaid coverage now could do much harm, both to older U.S. citizens and the country. If Medicaid coverage were withdrawn, very few more people would or could buy long-term care insurance.