Many influential advocates and legislators remember the CLASS Act, which was part of the Affordable Care Act in 2010. Advocates and political leaders had to put a great deal of effort into having the ACA include the CLASS insurance scheme to support people living with disabilities. The final law required that CLASS be fiscally neutral, but the fact that it would be voluntary led to estimates that only a few percent of the population would buy in, and that the group paying in would include a disproportionate number of people with high risks, including many already having disabling conditions. This made the premiums prohibitively expensive and the program unsustainable. Thus, the CLASS Act was never implemented and was repealed in 2013. The disappointments of advocates and legislators might lead them to ask how the WISH Act would be different. The most striking difference is that WISH would not be voluntary and thus would maintain the largest possible pool of contributors and beneficiaries, with no opportunity for the adverse selection that afflicted CLASS. The table below is meant to illuminate the array of differences.
| DOMAIN | The WISH Act proposal | The CLASS Act, withdrawn |
| Federal vs. State program | Federal | Federal |
| Participation | Mandatory | Voluntary (mandatory with opt out) |
| Underwriting | None | None |
| Eligible population | All U.S.workers | Anyone 18+ choosing to participate. They also must receive wages or income that are subject to the Social Security tax and meet minimum work-quarter requirements, except for patients in a hospital or nursing facility, ICF/MR, IMD, or Medicaid beneficiary |
| Vesting requirements | Full benefits with 10 years contributing, partial down to 5 quarters | Contributed into the program for at least 5 years |
| Benefit eligibility triggers | Uses HIPAA triggers | Uses HIPAA triggers |
| Type and Amount of Benefit Payment | Cash benefit paid monthly, roughly $120/day, indexed to inflation and wage costs in long-term care | Cash benefit paid monthly, TBD but roughly $50/day. Might be based on degree of disability. Benefit rolls over month to month but not beyond a calendar year. |
| Covered Services | Not applicable because it is a cash benefit | Not applicable because it is a cash benefit |
| Coverage Duration (front vs. back vs. comprehensive) | Catastrophic/Back End, unlimited duration once disability trigger(s) are met and after an up-front waiting period | As long as the qualifying disability lasts |
| Waiting Period Before Benefits Begin | Varies from 1 year to 5 years, based on lifetime income | None |
| Premium estimate | 0.3% of wages from employee, matched by employer (or 0.6% for self-employed) | Premium estimates averaged $123/month for a $75/day benefit, but the CMS actuaries later estimated $240/month. Premiums could have increased, except for older retirees. |
| Finance source | Mandatory premiums from payroll deductions | Financed through monthly premiums paid by voluntary payroll deductions |
| Opportunity for private market supplement | Front-end coverage with private LTCI and caregiver support programs easily fit and carriers would be relieved of most of the “tail” risk | LTC insurance could “top off” CLASS coverage or continue to sell to individuals who opt-out and pass underwriting. |
| Coordination with other programs | Income from WISH would not count against eligibility for other federal programs, but income from WISH could mitigate the level of benefits for low-income programs such as Medicaid nursing home care. | Eligibility for CLASS program benefits would have no effect on eligibility for Medicaid, Medicare, Social Security retirement, survivors, or disability benefits or Supplemental Security Income (SSI) benefits. Medicaid is the payer of last resort where there is duplication but enrollees can retain a small portion of their CLASS cash benefit when both payment sources apply. |
| Inflation Protection | Adjusted for inflation and direct service worker wages. | Adjusted for inflation but details not specified. |
Since a decade has passed since the enactment and withdrawal of CLASS, advocates for federal catastrophic long-term care insurance should generally use this comparison only with people for whom the effort and disappointment of CLASS are still salient, and who ask about the merits of the WISH Act in comparison.
Dr. Joanne Lynn 
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