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As we've often heard, there are 46 million people in the U.S. without health insurance. But more than 200 million have no insurance to cover long-term health care. That includes nursing homes, assisted living centers, home care and other assistance that almost all of us need when we get old. Some proposals to help has quietly made their way into the health care overhaul bills. But as NPR's Joseph Shapiro reports, there is a dispute over the cost.

JOSEPH SHAPIRO: Donna Taylor's father was the rock of the family. He was the primary caregiver for his disabled wife and her elderly mother. But he got sick and went into the hospital for 10 days. When he got out, he couldn't walk. With three elderly, disabled adults in one house, caregiving got expensive. Donna Taylor says her father was surprised at how quickly the family went through its savings.

Ms. DONNA TAYLOR: He said, I worked and I did the right things. I had a pension and I put money away in savings and I had what I thought were the right insurances and the money didn't go far enough. It just wasn't enough.

SHAPIRO: Like most Americans, Taylor's parents believed that their health insurance would pay all the costs of living in a nursing home. It doesn't. But Medicaid does. That's the state and federal insurance for the poor. So Taylor told her father, he'd have to spend through the rest of his savings and go into poverty.

Ms. TAYLOR: If you have ever had to look in the eyes of a 64-year-old man who's now had to go live in a nursing home and - it's horrible. It's - and he never ever made me feel bad about that decision. He never said, Donna, why'd you do this to me? But he told me, this isn't how it was supposed to work out.

SHAPIRO: Donna Taylor's father died in that Phoenix nursing home last year. She thinks he sort of gave up on life. John Rother, of the AARP, says proposals written into health care overhaul legislation would help families like Donna Taylor's. One would encourage states to offer more generous benefits to disabled and elderly people on Medicaid who want to stay in their own homes. And then, says Rother, there's something that could help millions of people.

Mr. JOHN ROTHER (Director of Legislation and Public Policy, AARP): The CLASS Act, which was introduced by the late Senator Ted Kennedy, is a way of putting into place, gradually, an insurance approach to long-term care as opposed to the welfare-based approach we have today.

SHAPIRO: Workers would choose whether to have money deducted from their paychecks. The Congressional Budget Office estimated that deduction would, on average, come to about $65 a month and, when needed, it would pay about $75 a day. That's a little less than half of what one day in the nursing home costs now. John Rother.

Mr. ROTHER: The CLASS Act is not designed to protect people from the costs of nursing home care, very expensive care. It's really designed to help you stay independent at home and to get the services you need: home care, Meals on Wheels, what, you know, a visiting nurse - the kind of thing that people do need very often to be able to continue to live independently. And, you know, I think that's actually what most of us want.

SHAPIRO: So how much is this thing going to cost? That's the dispute. The way it's written, it's supposed to pay for itself. How much gets paid out depends on how much is collected from those voluntary payroll deductions. Frank Keating is president of the American Council of Life Insurers.

Mr. FRANK KEATING (President, American Council of Life Insurers): It sounds good in principle. But it is a huge unfunded liability.

SHAPIRO: The Congressional Budget Office says the CLASS plan would reduce the federal deficit by $58 billion over ten years. That's why it's got a good chance of ending up in final legislation. But Keating says the numbers are wishful thinking that those savings come in the early years when the money's being collected, and hat it's going to cost trillions of dollars when people start needing the benefits. Keating represents companies that sell private long-term care insurance. Less than ten percent of older people have bought one of those private policies. It's been a hard sell. Still, Keating argues it'll be even harder to get young people to buy into the proposed public plan.

Mr. KEATING: It assumes young people will purchase this insurance from the government for a need 40 years down the line. That simply isn't going to happen. Young people aren't going to have to do it unless they're mandated to do it. And they're not mandated to do it in this bill and should not be.

SHAPIRO: There hasn't been a lot of high-profile debate about the proposal to add long-term care to health overhaul. And that reflects the way Americans tend to think about getting old. It's something best not thought about at all.

Joseph Shapiro, NPR News.

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