Mary Bethel is associate state director for advocacy of AARP North Carolina. She spent 29 years working in the state Division of Aging and Adult Services. Excerpts from a recent interview with Q editor Jane Ruffin:

ON THE NATURE OF THE PROBLEM: I think it's a big issue for folks, and it's not only an issue of institutional care, but it's also an issue of home- and community-based services. If you look at the whole continuum of care -- from keeping people in their homes to people going to skilled nursing care -- you hope that people have choices and options. In many cases, people don't have choices and options because the funding sources dictate where they'll pay for.

Right now, Medicare will pay 20 days of skilled care in a long-term care facility after you have a stroke or something like that, but it won't pay any more, so then you're dependent on Medicaid. Medicaid is funded by the state and federal government with a county share in North Carolina. ... If you look at trying to keep people in their homes, you've got some Medicaid money going there, but we're relying more and more on state funding for those types of things.

So the funding stream in many ways dictates where people get services. The other thing that the funding stream dictates is whether they have eligibility criteria and whether you consider income and assets.

ON WHAT SHOULD BE DONE: I think the big issue is, if you look at anything regarding funding, whether it's Medicaid, Medicare or whatever, you want to try to move policy in the direction of giving people more choices and options. And sometimes that is a hard thing to move toward when you have a system that's very ingrained to operate the way it has for the last 40 years.

ON PEOPLE WHO ARE TOO WELL OFF TO QUALIFY FOR MEDICAID: If you've got programs that are means tested, they're saying if people are able to pay, they should pay, and then we'll pay when they aren't able to anymore. What you see happening most of the time, and this is particularly true with nursing home and adult-care home level of care, is people end up spending down their money very quickly and becoming eligible for public funding. So it's a question of what type of decisions do you make as far as eligibility for programs.

ON TAX BREAKS FOR PEOPLE WHO BUY LONG-TERM CARE INSURANCE: We had in North Carolina a tax credit for long-term care insurance, which is something that's being promoted as an alternative to going into a nursing home. It can pay for nursing home care, but it also can pay for someone to receive care in their home. But [the tax credit] expired in December 2003. So one of the things AARP has on our agenda is reinstatement of that tax credit.

With the deficit reduction [act] signed at the federal level in January, there was a provision to allow states to begin to do what is called long-term care partnership programs, which encourage people to purchase long-term care insurance and then protect a certain amount of assets before they are eligible for Medicaid. And if we had a tax credit in North Carolina, that would tie in nicely with that.

ON PLANNING FOR LONG-TERM CARE: One of the big situations with families sometimes is they do wait until the last minute to think about options for care and how you can finance things of that nature. The time to think about what you're going to do with long-term situations is not when Mom's in the hospital suffering from a stroke and she's going to be discharged in 24 hours and you don't know what you're going to do.

It certainly would be beneficial for families to have heart-to-heart discussions. What does Mom want? Ask Mom what Mom wants. What do the children think about the whole situation? What type of resources and assets do you have that can be utilized? What are the resources and assets available in your community ... that you can apply for?

Long-term care in many cases ends up being a crisis decision process and not a lot of thought or preplanning is going into it.

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