How Can Adult Children Influence Parents’ Long-Term Care Insurance Purchase Decisions?

Abstract

Purpose of the Study:

Long-term care (LTC) poses a significant strain on public health insurance financing. In response, there is policy interest in bolstering the private long-term care insurance (LTCI) market. Although families are central to LTC provision, their role in LTCI demand remains unclear. The purpose of this study was to obtain in-depth information concerning: (a) How do older parents evaluate the need for LTCI, (b) what role do adult children play? and (c) How do families communicate about parents’ LTC preferences and plans, including LTCI purchase?

Design and Methods:

We conducted focus groups with older parents and adult children in diverse markets. Two groups were conducted with older parents who had purchased LTCI and two with parents who had not purchased LTCI. Four groups were conducted with adult children, mixed as to whether their parents had purchased LTCI. Probes were informed by published reasons for purchasing or not purchasing LTCI. We analyzed transcriptions using directed content analysis and constant comparative method.

Results:

Older parents valued autonomy for themselves and their children. Older parent purchasers regarded LTCI as supporting this value while nonpurchasers perceived limitations. Adult children described unstated expectations that they would care for their parents. Though discussions between parents and children about LTCI were rare, successful influence occurred when children appealed to shared values, specifically avoiding burden and remaining home.

Implications:

Messages that emphasize autonomy over LTC decisions and interventions that start the LTC conversation among families, with attention to shared values, could increase private LTCI uptake.

Long-term care (LTC) poses a significant strain on public health insurance financing (Wiener, 2013). In response, there has been policy interest in bolstering the market for private long-term care insurance (LTCI), especially after demise of the Community Living Assistance Services and Supports (CLASS) Act, which would have provided publicly administered LTCI as part of the Affordable Care Act. The private LTCI market is currently small, covering only about 13% of adults 65 years of age and older (Doty & Shipley, 2012). Moreover, its long-run viability is uncertain. Premiums, which consumers already perceive as costly, have been increasing, and products have been decreasing, with insurers losing profitability and exiting the market (Wiener, 2013). The Commission on Long-Term Care in its Report to the Congress proposed strategies for restructuring LTC financing through a balance of private and social insurance and additionally asserted the need for educational campaigns to improve participation in private LTCI (Commission on Long Term Care, 2013).

Although supply-side imperfections need to be addressed, the LTCI market will not improve without also addressing the demand side, for example by educating individuals about risk of needing LTC and benefit of having LTCI (Brown & Finkelstein, 2009). People may be less likely to purchase LTCI because they do not foresee themselves needing LTC (Brown, Goda, & McGarry, 2012; Finkelstein & McGarry, 2006; Liebman & Zeckhauser, 2008; Stum, 2001). However, their expectations may be incorrect, as LTCI purchase is less common among adults who are older and less healthy, less educated, and lower income – precisely those more likely to need LTC (“Who Buys Long-Term Care Insurance in 2010–2011?,” 2012). Consumers may also choose not to buy LTCI because they feel they cannot afford it or do not see the value, being concerned not only about the high cost of products, but also about the possibility of insurers raising premiums, going bankrupt, or denying claims (Frank, Cohen, & Mahoney 2013). Studies indicate that Medicaid crowd-out may be substantial and that tax subsidies, and partnership programs for purchase of private LTCI have limited scope for increasing coverage (Greenhalgh-Stanley, 2012; Lin & Prince, 2012; Sun & Webb, 2013). Researchers also have long hypothesized that purchase decisions are influenced by beliefs about family involvement, such as availability of informal caregivers and importance of bequests, though findings on these factors from empirical studies have been mixed (Brown & Finkelstein, 2009; Brown et al., 2012; Costa-Font, 2010; Cramer & Jensen, 2006; Curry, Robison, Shugrue, Keenan, & Kapp, 2009; Konetzka & Luo, 2011; Lockwood, 2012; McCall, Mangle, Bauer, & Knickman, 1998; Mellor, 2001; Pauly, 1990; Schaber & Stum, 2007; Zweifel & Strüwe, 1998). Thus, there are multiple potential leverage points for improving uptake.

Because family plays a central role in LTC, with informal care surpassing the value of paid health providers, it is particularly important to understand how family can influence LTCI purchase (Feinberg, Reinhard, Houser, & Choula, 2011); however, underlying mechanisms remain unclear. One potential mechanism is the bequest, or exchange, motive, whereby parents forgo LTCI, so their children will provide care in order to receive an inheritance; having LTCI might deter their children from providing care (Lockwood, 2012; Norton & Houtven, 2006; Pauly, 1990; Zweifel & Strüwe, 1998). Recent evidence, though, challenges the assumption that parents prefer informal care from their children (Brown et al., 2012). Further, because adult children tend not to play an active role in parents’ LTCI purchase decisions, there may be a disconnect between parents and children in their understanding of each other’s preferences and plans (“Who Buys Long-Term Care Insurance in 2010–2011?,” 2012). To address this knowledge gap, we solicited, with open-ended questions, in-depth, nuanced information from older parents and adult children concerning: (a) How do older parents evaluate the need for LTCI? (b) What role do adult children play? and (c) How do families communicate about parents’ LTC preferences and plans, including LTCI purchase? This evidence can be used to begin to design communication strategies (Atkin & Rice, 2013) to stimulate uptake of private LTCI and that take into account potential influence of adult children.

Study Methods

Because the study objective was to understand and compare distinct experiences of older parents and adult children, the individual older parent or adult child constituted our unit of analysis. We thus conducted data collection separately with older parents and adult children via focus groups in geographically diverse markets: Boston, MA; Charlotte, NC; and Chicago, IL (downtown and suburb). We conducted a total of eight focus groups. Two groups were conducted with older parents who had purchased LTCI and two with parents who had not purchased LTCI, and four adult child groups were mixed as to whether their parents had or had not purchased LTCI. The number of groups was sufficient to achieve both variety and consistency of responses from each segment (older parent purchaser, older parent nonpurchaser, and adult child). A national market research firm conducted recruitment by calling individuals from their database who had previously agreed to participate in market research studies. Recruiters used a screening questionnaire developed by the research team to establish eligibility. They invited individuals who met eligibility criteria to participate in a scheduled focus group to discuss planning and decision making about LTC, with incentives of $75–100 depending on the market. The firm also provided the focus group facilities in each location. This study was approved by the Duke University Medical Center Institutional Review Board.

Participants and Recruitment

Eligibility criteria were designed to recruit older parents and adult children with parents who could reflect experiences of consumers and potential consumers of LTCI. Accordingly, parents were recruited who were aged 50–75 and who either already had purchased LTCI or had considered how they would obtain LTC. Parents were also eligible if they had primary or shared responsibility in their family for deciding how their LTC needs would be met, because of our interest in understanding their LTCI decision-making experience, and if they had living children, because of our interest in exploring how their adult children may have influenced their purchase decisions. Individuals receiving Medicaid and users of the Veterans Affairs health system with a service-connected disability rating of 70% or greater were ineligible because access to public LTCI would eliminate their need for private LTCI. (Veterans who are disabled by an injury or illness that was incurred or aggravated during active military service are classified as having a service-connected disability, and eligible for long-term care services in the VA and disability compensation.) Additionally, recruiters screened out individuals who had applied for long-term disability benefits, because underwriting practices for private LTCI would make them ineligible for purchasing LTCI. Eligible adult children had parents, who were at least 50 years of age, had not applied for long-term disability benefits, did not receive Medicaid, and were not users of the VA health system. Additionally, adult children were eligible if they had thought about how their parents would obtain help should they need it. Recruiters asked adult children if their parents had LTCI, with the goal to recruit a mix for each adult child focus group of individuals whose parents did and did not have LTCI. Parents and adult children were not recruited from within the same families.

Focus Group Procedures

Focus groups were led by one moderator with a second researcher present to conduct informed consent and take notes. Each discussion lasted 1–1.5 hr. A brief self-report survey was distributed to collect demographic characteristics.

Focus group questions are presented in Table 1. Older parents were asked about factors that had influenced their purchase decisions and how having or not having LTCI could affect family members’ roles in their care. Probes were informed by previously published reasons for purchasing or not purchasing LTC insurance (e.g., beliefs about value of LTCI or perceived availability of informal care). Adult children were asked about their roles in parents’ decisions regarding LTCI purchase. The moderator probed respondents in all groups to elaborate on family discussions regarding LTCI.

Table 1.

Questions for Focus Groups on Family Dynamics and Long-Term Care Insurance (LTCI) Purchase Decisions, 2012

Research Questions 1 and 2: How do older parents evaluate the need for LTCI? What role do adult children play?

Older parents

• What are reasons they decided to purchase LTCI or not?

• How could having LTCI affect what their family would do?

Adult children

• What was their knowledge of (and role in) parents’ decisions?

• How could LTCI affect their roles in their parents’ care?

Research Question 3: How do families communicate about parents’ long-term care preferences and plans, including LTCI purchase?

• Describe family discussions

Data Analysis

We analyzed transcriptions using directed content analysis, a systematic process of interpreting text by applying descriptive labels (codes) and identifying thematic patterns (Hsieh & Shannon, 2005). All transcripts were coded independently by at least three researchers, who met to discuss each transcript and resolve disagreements through negotiated consensus (Hill et al., 2005). A priori codes were developed to reflect the same reasons for purchasing or not purchasing that we asked as probes. Data-derived codes were developed from initial reading of transcripts to reflect notions that developed from focus group discussions, and were not covered by a priori codes. In order to identify patterns within the data related to our research questions about how older parents and adult children interact with each other about LTC plans, we organized these initial codes according to the following categories that we regarded as relevant for family dynamics: roles, values, and communication. For example, we grouped the codes having children available to help and children encouraging purchase under the category of roles, and the codes wanting to avoid being a burden and avoiding family conflict under the category of values. After organizing coded data according to this initial framework, we iteratively reviewed and compared the grouped data to identify themes. This technique derives from a grounded theory approach to inductively analyze and interpret data known as “constant comparative method” (Charmaz, 2006). We additionally developed a matrix to compare themes between participant segments (older parent purchasers, older parent nonpurchasers, or adult children) (Miles & Huberman, 1994). Data were managed and coded with qualitative software (NVivo).

Study Results

We spoke to 40 older parents and 40 adult children, with about 10 participants in each focus group. Demographic characteristics are displayed in Tables 2 and 3. The average age of older parents was 65 years, and about half were male. Most of the older parents were White, with at least one Black or Hispanic participant in each group. Purchasers in our sample had more education than nonpurchasers, consistent with the general population. The average age of adult children was 44, and almost half were male. Most adult children were White, with some Black, Hispanic, and Asian participants.

Table 2.

Characteristics of Older Parents Participating in Focus Groups on Family Dynamics and Long-Term Care Insurance Purchase Decisions (N = 40), 2012

	Purchasers (N = 21)	Nonpurchasers (N = 19)
	M (SD) or N (%)	M (SD) or N (%)
Age	65 (7) (range 51–73)	65 (6) (range 52–73)
Male	11 (52%)	8 (42%)
Race/ethnicity
White	19 (90%)	16 (84%)
Black	1 (5%)	2 (11%)
Hispanic	1 (5%)	1 (5%)
Married or partnered	15 (71%)	14 (74%)
College educated	18 (86%)	5 (26%)
Working for pay	11 (52%)	10 (53%)
Children
Average no. of children	2 (1)	3 (2)
Average no. of children within an hour	2 (1)	3 (2)

Table 3.

Characteristics of Adult Children Participating in Focus Groups on Family Dynamics and Long-Term Care Insurance Purchase Decisions (N = 40), 2012

	M (SD) or N (%)
Age	44 (11) (range: 28–69)
Male	18 (45%)
Race/ethnicity
White	27 (68%)
Black	7 (18%)
Hispanic	3 (8%)
Asian	2 (5%)
Married or partnered	19 (48%)
College educated	25 (78%)
Working for pay	34 (85%)

An overview of themes relevant to the research questions (How do older parents evaluate the need for LTCI? What role do adult children play? How do families communicate about parents’ LTC preferences and plans, including LTCI purchase?) is presented in Table 4. In the next pages we discuss these themes in more detail with supporting examples. We describe similarities and differences between older parent purchasers and nonpurchasers, and illuminate how statements from adult children compare with those of older parents.

Table 4.

Summary of Key Findings and Implications From Focus Groups (N = 8) With Older Parents and Adult Children on Parents’ Long Term Care Insurance Purchase Decisions

Finding	Implication
Older parents valued autonomy for their children and themselves, and purchasers regarded LTCI as supporting autonomy while nonpurchasers perceived limitations	Messages emphasizing independence over long-term care decisions and avoidance of family burden could stimulate interest in LTCI.
Though older parents said that they valued autonomy, adult children described unstated expectations that they would care for their parents	Intervention to help improve communication between parents and children about their roles prior to actually needing LTC could help bring attention to potential implications for family members and activate individuals not inclined to plan for LTC, including consideration of LTCI.
When they discussed LTC, adult children successfully influenced parents to purchase LTCI by framing in terms of autonomy.	Tailoring interventions to focus on values shared by older parents and adult children, such as desire for autonomy, could improve quality of parent–child communication about LTC and LTCI.

Note: LTCI = Long-Term Care Insurance.

Older Parents Valued Autonomy for Their Children and Themselves; Among These Older Parents, Purchasers Regarded LTCI as Aupporting Autonomy While Nonpurchasers Perceived limitations

Older parents generally said that they wanted to have their children’s support if they needed LTC, without imposing financial or caregiver burden on them. This motivation stemmed from having seen how devastating informal care could be for caregivers. Some older adult purchasers described rebuffing their children’s offers to care for them, knowing that their children, although well intended, might end up feeling “resentment” from losing a measure of control over their own lives. Conversely, some nonpurchasers said that they were open to having their children involved in their care if that was what they wanted to do. Regardless of whether they had purchased LTCI, older parents indicated that they would want their children to assume roles as advocates rather than health care providers. Furthermore, purchasers said that they had obtained LTCI to establish this boundary.

Ideally, if I needed care, what is it you can’t do two out of the five daily bodily things or whatever, that’s how they determine you could qualify for the long-term care, so assuming that’s the case, then I mean that would be the first line of defense. Then the kids would be the second-line of defense if needed. The long-term care, my wife and then the kids would fill in, if necessary. But not personally, they’d fill in by getting resources there to help. I wouldn’t want them there changing diapers and cleaning up after me and that sort of thing, no way. (older parent purchaser)

Purchasers described LTCI as a way for them to buy time and weigh options, so they could make autonomous, thoughtful decisions. They said that LTCI provided a way for them to ensure that they would not only have care available to them, but also “freedom of choice” to determine the nature of their care. Older parents also said that by having LTCI they believed they would have choice about the type of care that they could receive, whether at home or in a facility. Also, they would be able to choose how they could spend their time with their children, rather than having to rely on them to provide care. Though older parents generally expressed uncertainty about their future need for long-term care, purchasers described taking proactive steps to plan for the future.

Everything’s going to fall on the son who’s here. I do not want that. So I thought, number one, my mother’s in my house. I see what it does. This will not happen, if I can do anything about it. Number two, I want to be the one to make the decision. I want to be independent…I thought, I can do this and it will buy me time. No matter what happens, this little policy- I’m OK for X amount of time. So, you can think about it. We can research it. If I have a mind, I can think about it. But it’s independence, in a way. I like that a lot. (older parent purchaser)

Nonpurchasers also valued autonomy, but they focused on the (perceived) limitations of the types of services covered by LTCI or how it could constrain their budgets. For example, some regarded LTCI as specific to skilled nursing facilities. Nonpurchasers also said that they had prioritized spending their money on more immediate family needs, such as raising their children or purchasing life insurance; now they said it was too costly for them to purchase LTCI because the price of premiums had increased as they aged.

It was presented to me by my life insurance agent when I was talking to him about insurance for me primarily, and [my wife] a close second because she’s got to take care of the family, and also something for the children that they could build upon when they got into their twenties. We talked- I think I might have even asked him because I had heard about it, but when you are in your thirties it just made no sense to me to buy it. We kept [my wife] home for a long time to take care of the girls, the house, and me. It was wonderful for our family, and the money just wasn’t there. Then as they got older, girls are expensive. And I have not pursued it since. This is like me wanting to go get a quarter million dollar whole life policy today. I couldn’t afford it. And I can’t afford long-term care either. That’s where I’m at. (older parent nonpurchaser)

Though Older Parents Said that They Valued Autonomy, Adult children Described Unstated Expectations That They Would Care for Their Parents

In contrast to older parents’ assertions about wanting to maintain autonomy with limited involvement from their children, adult children described how they sensed unstated expectations, in large part due to family or cultural norms, that they would contribute to or pay for their parents’ LTC. These expectations were described as unstated, because families delayed discussions about LTC. Nonpurchasers said that they did not feel ready or see a need to discuss their LTC preferences and plans with their children, and purchasers bought LTCI on their own volition. Family discussions about LTC, when they did occur, were commonly triggered by a health or financial event, either from within or outside of their own family. Respondents described discussions as being cursory and brief, with nonpurchasers and adult children of nonpurchasers broaching the topic of planning for LTC but not making decisions. Older parents said that it was difficult to discuss LTC plans with their children, because their children did not want to consider that their parents might need LTC. However, adult children described how ambiguity about their role in their parents’ LTC presented a quandary for them. Adult children wanted to respect their parents’ needs and expectations and at the same time consider what their role in their parents’ care might mean for their own obligations, such as taking care of their own financial or family needs: interestingly, it was because of similar constraints that nonpurchasers did not purchase LTCI for themselves in the past and now say they cannot afford it because of high premiums.

My parents are still pretty healthy. They’re in their midsixties, but culturally they make the decisions. So its my culture [Asian]. My parents will make all the decisions. Or the oldest son. There’s only two of us. So if anything happens, it’s going to be between the oldest son and the parents deciding it. So I’ll try to bring it up but they don’t want to talk about it. They don’t want to be a burden to us. But at the end of the day, they will probably end up just being with us because that’s how it’s usually done for Asian culture. The kids will take care of the parents. So that’s – we really don’t have really big conversations with our parents. There’s some concerns. Obviously, I don’t know what’s going on completely. I know they have health insurance and life insurance but at the end of the day, I’m still concerned that we’ll have to cover whatever expectations that they think. I know they’re both diabetic and that could lead to a lot more serious complications in the long run, I would say. So, yes, it’s just strange not to know everything about what they want to do if that situation comes up. (adult child)

When They Discussed LTC, Adult Children Successfully Influenced Parents to Purchase LTCI by Framing in Terms of Autonomy

Adult children were unable to influence their parents’ LTCI purchase decisions by simply appealing to the need for LTC. This was true for families in which siblings were in agreement as well as in conflict about parents’ LTC needs. For example, an adult child said she believed that her mother would “buy into the idea” of LTC planning if her siblings would get on board with her, but that they were in denial about her likelihood of needing it. In another family, seven siblings were in agreement about helping their mother purchase LTCI, but the mother also refused, saying that she did not need it and that it was too expensive. Instead, successful influence occurred when framing LTCI in line with parents’ values, specifically with respect to values concerning autonomy for themselves and their children. In one case, an adult child described having sold the idea of LTCI to his parents as a way for them to avoid being a burden to him and his brother. Just as parents had noted advantages of advanced planning, some adult children mentioned the benefit of discussing preferences and plans when parents are younger and healthier, before there is a need to make quick decisions.

We’re extremely fortunate. My parents are fairly young. They’re in their 60’s, you know, and they actually listen to me. So we had the chat last year and [they] actually bought the long-term care…The first thing that comes up is the expense. Because actually it is very expensive. It was actually more expensive than I thought. I should have had the chat after I found out. But you have to do it. I mean, you know, and I think they re at the age when we can actually buy it, and it’s not that expensive. You know, the premiums are a little lower, because they’re in their 60s. It was absolutely imperative that we get it. It’s just one of those things. Because if they got ill then, you know, some of the burden would fall on us, and I think it would be more of a burden on them, you know, because they would feel like we’re burdening our children. So we actually spun it that way, like look, you know, you wouldn’t want to impose. Some of the culture dictates some of that. So it was actually much easier for us. I mean, in the way we put it, that you have to have long-term care, because otherwise you may have to come live with us. (adult child)

Discussion and Conclusion

As advanced by the Commission on Long-Term Care, an important part of protecting the public against LTC costs includes not only product innovation in both the public and private sectors, but also education about why and how individuals should prepare for financing LTC, with a goal of increasing participation in private LTCI. Because parent–child relationships are integral to LTC, we explored the role of adult children in parents’ LTCI purchase decisions as a potential leverage point for increasing LTCI demand. We found that, though older parents commonly valued maintaining autonomy for themselves and their children when considering LTC, there were striking differences between LTCI purchasers and nonpurchasers in how this motivation impacted their decisions to obtain LTCI. Our results about what consumers value can be used to develop educational campaigns to increase public awareness and, in turn, demand of private LTCI as a viable option for future health needs (see Table 4 for summary of key findings and implications).

Messages that emphasize older parents’ independence over LTC decisions and avoidance of family burden could stimulate interest in LTCI. Older parents in general held in common personal goals of wanting to maintain autonomy for themselves and for their children. LTCI purchasers said that they had purchased LTCI in order to have choice of LTC and autonomy over decision-making. In contrast, although nonpurchasers also valued autonomy, they mostly discussed limitations of LTCI consistent with known barriers such as perceived cost or lack of future need for LTC (Brown et al., 2012). The concern with autonomy that we found reflects Americans’ attitudes toward aging in general (Tompson et al., 2013). Stum (2001) found from interviewing families already dealing with LTC that families wanted independence and control over the process; although respondents in that study were commenting on independence as a family unit while respondents in our groups were commenting on independence as individual decision makers, prior to needing LTC. It is notable that, though often hypothesized as a factor in family influence on LTCI purchase, bequests were not mentioned as a reason to purchase or not purchase LTCI; instead, autonomy was the most salient motivator discussed in our groups. If promoted as a mechanism for maintaining autonomy, then perceived pros of having LTCI might outweigh cons resulting in greater likelihood of purchase.

In addition to informing message concept, our findings indicate that intervention to help initiate family discussion prior to actually needing LTC could be a strategy for influencing individuals not inclined to plan. One possibility is a Web-based tool, such as that developed by the AARP, targeted at women in their 40s, 50s, and 60s to help them consider their LTC preferences, develop personal plans, and share their decisions with others (AARP). Families, even in the midst of making decisions about LTC use, can find it overwhelming and difficult to communicate about complex financial or health issues (Stum, 2001); however, parents need to communicate their preferences and plans. Parents indicated that they valued the ability to make their own care decisions, without having to rely on their children; however, adult children said that they believed that their parents expected them to provide care, with their beliefs based on normative expectations rather than direct communication. This type of intervention can thus be developed to have an affect at the family-level; a first step for parents who might be less inclined to take a high-control approach to communicating their LTC preferences, as was exhibited by purchasers in our study, might be to encourage them to ask their children if or how they want to be involved in their LTC (Lewis, DeVellis, & Sleath, 2002).

The quality of communication between older parents and adult children around LTC planning could be important for stimulating LTCI demand, specifically with attention to identifying where children and parents’ values intersect. Interpersonal communication is most effective in relationships characterized by responsiveness to each other’s concerns and correspondence of goals (Lewis et al., 2002). Among our focus group participants, maintaining autonomy was important for both older parents and adult children, indicating potential for correspondent LTC goals, yet there was general lack of family discussion about planning for this. Adult children may be able to influence their parents’ decisions about LTCI, in spite of commonly reported reasons for not purchasing, such as perceived cost and need (Brown et al., 2012), if they know what their parents primarily value (e.g., avoiding burden, remaining at home). By targeting interventions at a family level to facilitate LTC planning with emphasis on shared values, there may also be a spillover effect in which adult children begin to consider LTCI as an option for themselves, avoiding the difficulty that many older parents face when they delay consideration of LTCI only to find that the cost is prohibitive.

In conclusion, we provide new evidence for how family context affects LTCI purchase decisions that can be used in early stage, conceptual development of a communication campaign (Atkin & Rice, 2013) or an expansion of the “Own Your Future” LTC awareness campaign by HHS (ASPE, 2012). We found that maintaining autonomy was a driving motivator for older parents who had purchased LTCI and, though not enough in and of itself to stimulate LTCI purchase, also an important value for nonpurchasers. Because adult children are likely to be impacted by their parents’ lack of LTC coverage, public policy can support development of intervention strategies to facilitate effective communication between parents and children about expectations for parents’ LTC, including potential benefit of LTCI. Our results indicate that adult children want to know their parents’ preferences and plans and that, though discussions are rare or inefficient, there is overlap between parents’ and children’s goals, namely balance between supporting family members and maintaining individual autonomy. This information can be used to develop strategies for helping consumers consider private LTCI in their LTC planning; future work could focus on defining specific communication channels and intervention activities. Finally, the Long-Term Care Commission report reflects a comprehensive approach, with a balance of public and private resources, and, though our work focuses on how to improve uptake of private LTCI, based on currently available products, it would also be important to consider how these strategies might be relevant for social insurance.

Funding

NIH/National Institute of Nursing Research (IR01NR13583-1, PI: Van Houtven).