Need long-term care? Many families are out of luck.

The family took out a home equity line of credit on Eyres’s house, and Webster contributed financially. She estimates the care plus medical equipment cost $1 million over three years, none of it covered by insurance.

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The family’s experience highlights a challenge facing many families in Massachusetts that’s likely to get worse: There’s no system to help middle-class residents pay for long-term care. Washington state recently created the first state-based, payroll tax-funded long-term care insurance program. Now, some Massachusetts policy makers are discussing whether to create a similar program here. While a new tax-funded benefit is not the only possible solution, how to pay for long-term care is a vital conversation that policy makers need to have.

As Robin Lipson, the state secretary of Aging and Independence, said at a recent State House panel discussion that I attended, the lack of a way to pay for long-term care impacts families across generations. If an older adult lacks paid care, family members often become unpaid caregivers, which can affect their mental health or their ability to work.

According to the UMass Donahue Institute, 20.4 percent of Massachusetts residents were over age 65 in 2025 and 5 percent were over age 80, figures that are expected to increase to 22.9 percent and 7.7 percent, respectively, by 2040. One national estimate suggests that more than half of people who turn age 65 will at some point require long-term support. In Massachusetts, a home health aide costs a median of $91,520 a year, according to CareScout, while a private room in a nursing home costs nearly $190,000.

Medicare, the insurance system that covers US adults over age 65, doesn’t cover long-term care. Medicaid, the federal system for low-income adults (MassHealth in Massachusetts), is the biggest long-term care payer. But the patient must spend down their money before they qualify. It hurts families by leaving no money for the next generation to inherit and drains state budgets when people join Medicaid because it’s the only way to pay for a nursing home.

There is private long-term care insurance, but only about 10 percent of Massachusetts residents over age 60 had this type of insurance in 2023, according to a report by the consulting firm Milliman and commissioned by the state Executive Office of Health and Human Services. Private long-term care insurance is expensive — the average annual premium for someone buying a policy in 2023 was $3,342, according to Milliman — and insurers can deny coverage based on health status. Richard Frank, director of the Center on Health Policy at Brookings, told me that people who buy long-term insurance tend to be “rich, worried, and healthy.”

That leaves the middle class — those too wealthy to qualify for Medicaid and too poor to pay out of pocket or buy insurance — in the lurch.

These are people like the 77-year-old Newton realtor I spoke to, who asked that her name not be used, whose husband has Parkinson’s disease and Lewy body dementia. Her husband applied for long-term care insurance but was denied because of a preexisting condition. He needs a home health aide 12 hours a day, costing around $200,000 a year. The realtor said she works as much as possible, with no hope for retirement. “As soon as I wake up, I start worrying about money,” she told me.

Washington state imposed a mandatory 0.58 percent payroll tax that funds up to $36,500 in long-term care benefits. Workers began contributing in 2023; the first benefits pay out this July. The program is controversial. Republicans opposed it as a financial burden on all workers, especially for those who may never receive the benefit. But a ballot campaign to let workers opt out failed, with 55 percent voting to maintain the program.

In Massachusetts, Milliman’s study of publicly funded long-term care insurance identified myriad ways programs could be structured with different costs, benefit caps, and eligibility. For example, it projects a 0.68 percent payroll tax on all workers could pay an insured worker’s first $75,000 in costs. An estimated 2.74 percent payroll tax could fund a “catastrophic” plan that pays an unlimited amount, but only after someone covers their own expenses for three years.

Marc Cohen, codirector of the LeadingAge LTSS Center at UMass Boston, said a mandatory social insurance program, similar to Social Security, is the only way to keep a program affordable since it spreads risk among healthier and sicker people.

The challenge of creating a sustainable, voluntary program became evident nationally when the late Senator Ted Kennedy advocated for inclusion of the CLASS Act in the Affordable Care Act, creating a voluntary program where workers could opt into paying a payroll tax for long-term care insurance. President Obama suspended the program and Congress repealed it because officials couldn’t make it affordable and financially solvent without making it mandatory.

To be sure, Washington’s model isn’t the only solution. MIT health economist Jonathan Gruber said one problem with social insurance is it’s politically tricky to require people to pay a tax when many won’t realize the full benefit. Gruber and other economists at Brookings have advocated for creating a home health care benefit through Medicare. But the think tank is vague on how Medicare would pay for it.

There are ways to make private insurance cheaper — authorizing state tax credits or tax-deferred savings accounts to help people purchase private insurance, or offering government-backed reinsurance policies to long-term care insurers. Some states let people retain more assets when qualifying for Medicaid if they have insurance. Allowing a worker, for example, to set aside money for long-term care in a tax-advantaged savings account like a 401(k) could help some people. These types of policies are more politically palatable. But Cohen said they are unlikely to move the needle significantly because the incentives aren’t large enough to change behavior.

There’s no easy answer. But maintaining the status quo means families like Eyres’s are out of luck, burning through retirement savings, forced to quit work to provide care, or delaying retirement to pay for care. Society needs a more sustainable solution.

Shira Schoenberg can be reached at shira.schoenberg@globe.com. Follow her @shiraschoenberg.