If you had $9,000 a month to spend on housing, would you choose a beachfront property — or an average shared room in a nursing home? If you or a loved one needs long-term care, that price tag becomes an expensive reality — one that many physicians aren’t aware of until it becomes personal. Unlike most medical expenses, insurance rarely helps. Aside from Medicaid recipients and veterans, long-term care is largely paid out of pocket, often until savings run dry.
I learned this hard lesson just before my medical training began. At age 22, I toured more nursing homes and assisted living facilities than I did college campuses just four years earlier. When my father’s MS progressed, my mom and I tried our best to provide around-the-clock care at home. When I was accepted to medical school, we knew this plan wasn’t sustainable. We couldn’t afford to pay $9,000 a month without selling nearly everything. Our experience wasn’t unusual — we were unpaid family caregivers like more than 1 in 5 adults in the U.S. –part of an unrecognized workforce of 53 million Americans holding up a patchwork long-term care system dependent on altruism and availability. But what options exist for those without family or friends to provide care at home like we did for my father?
Years later, as an internal medicine resident, I saw the other side of this dilemma. Discharging patients from the hospital — often just a single checkbox on my daily list of tasks — frequently represented an enormous, undesired milestone for them. During care coordination rounds, we discussed the destinations that few people envision for themselves until illness or injury strikes. It felt like learning a new language: skilled nursing facility (SNF), long-term acute care hospital (LTACH), short-term rehab (STR), and long-term care (LTC) — one that doesn’t routinely appear in medical school curricula. We discussed barriers that kept patients in the hospital — not because they still needed our care — but because they needed time to exhaust their savings so they would qualify for Medicaid and could then afford placement.
This strategy, known as Medicaid spend down, seemed unimaginable until I met the tearful gaze of a patient on day 57 of their admission. They wanted to recover, but also needed to sacrifice their financial security just to have somewhere to go for care they could not manage independently, and couldn’t afford home health care. I found myself grappling with an ethical question: was I acting in my patients’ best interest, or participating in a system that requires financial ruin as a prerequisite for care?
Now, a decade later, as a palliative care physician, I commonly see patients’ goals of care dictated not solely by their values, but by their insurance coverage, or lack thereof. This is true for both long-term and end-of-life care. When medical students and residents rotate with me, there’s always a moment of stunned silence when they learn how few options are available to care for our patients, outside of relying on family. It’s a poignant learning moment that comes too late in our training.
Physicians, by virtue of our income, may feel shielded from this reality. But our economic privilege isn’t a free pass. Our long work hours make it difficult to serve as unpaid caregivers. Without planning, we may face the same impossible options as our patients: spend down our assets or pay the same hefty price. The difference is that we have an opportunity for earlier access to information and the ability to act on it—but this shouldn’t be information hidden in our plain sight.
Long-term care planning should be treated as a core component of financial wellness, alongside retirement savings, which placement costs can quickly deplete. It’s never too early to learn about long-term care insurance, understand its costs, and consult agents or advisors rather than waiting until disaster strikes. We must acknowledge in medical training that long-term care isn’t a social afterthought, but a central factor in care outcomes. Clinical rotations are an ideal opportunity for medical students to observe and understand long-term care costs through patients’ experiences.
The $9,000 question asks us to face an uncomfortable truth. Autonomy, dignity, and a lifetime of savings can all quickly be swept away by illness. If physicians don’t confront this reality — for our patients and our families — we will continue practicing medicine that ignores the financial conditions that determine how and where patients live and die.
How did you learn about the costs of long-term care for patients? Share in the comments.
Lindsey Ulin is a palliative care physician in Dallas, TX. She enjoys writing in indie coffee shops and bookstores and spoiling her dog Winston. She tweets at @LindseyUlin. Dr. Ulin is a 2025-2026 Doximity Op-Med Fellow.
Image by enisaksoy / Getty
