Who can afford to be old and sick?

Those too 'wealthy' for aid and too poor to pay their own way are legion

William Marshall made a good living working for a railroad company in South Carolina and draws a modest pension. But the high cost of ongoing care eventually forced Marshall, 86, to give up his home and everything he had accumulated after he developed mild dementia and had several heart attacks.

"He's middle [class]," said Marshall's daughter, Donna Jones of Cary. "He can't get any assistance whatsoever from the government."

Increasingly, middle-income retirees with chronic illness or disabilities face the same struggle when it comes to paying for long-term care, such as nursing homes, rest homes, assisted living and in-home aides.

They are too well-off to qualify for Medicaid and other public services that cover the health-care costs of people with low incomes. But they aren't wealthy enough to pay the expenses out of their own pockets, and they can't afford special private insurance for long-term care.

In the Triangle, nursing homes cost an average of $62,780 a year, according to a survey last year by the MetLife Mature Market Institute. But contrary to what many people assume, Medicare -- the federal health insurance program for people 65 and older -- doesn't pay for such long-term care. Neither do most routine health-care plans.

Marshall's railroad pension is too high for him to qualify for assisted-living care paid for by a joint state/county fund and Medicaid. So he used some of the proceeds from the sale of his house for a place in an assisted-living facility. After that money ran short, he moved into a less expensive spot at Parkway Retirement Home in Cary.

Situations such as Marshall's can have a big effect on other family members. Jones visits her father often, leads Bible services and makes sure to keep in touch with the staff and management.

But Jones, who owns her own cleaning business, has barely given a thought to her own retirement; she's tied up helping her dad.

"If something happened to me, he'd be homeless if we didn't have family here," she said.

With 70 million baby boomers at or nearing retirement age nationally, the specifics of long-term care -- who gets what and who pays for it -- are likely to take up increasing amounts of public attention and money. In North Carolina, those over 65 will increase from 12 percent to about 18 percent of the population by 2030, according to the state Division of Aging and Adult Services.

"There will be a large group of our senior population who will never qualify for public assistance, and yet will never be able to manage the costs they face on a daily basis," said the writers of "Growing Older Living with Dignity," a report released this year by a Wake County task force on aging.

"Our system fails these people utterly."

Who qualifies for help?

Many people reach retirement age and beyond without a calamity that requires long-term care. But for those who do suffer an injury or chronic illness that requires long-term services, the expense can be catastrophic.

"Half of people turning 65 will have no private out-of-pocket expenditures for long-term care, while more than one in 20 are projected to spend $100,000 or more of their own money (in present discounted value)," said the authors of a study published this year in the scholarly journal "Inquiry."

Out-of-pocket payments accounted for only 28 percent of the $115 billion Americans spent on nursing homes in 2004, according to a commission financed by the Henry J. Kaiser Family Foundation. Private insurance covered even less: 7.8 percent. Medicaid, by contrast, paid for 44 percent, the largest share.