Eight years ago, Gloria Zane faced the same challenge thousands of Hawai'i residents confront on a regular basis today.

She wasn't sure how her family would manage to cover the high cost of long-term care for their aging parents.

Zane, then 53, decided to retire early from her government management job and become a caregiver for her folks. Some of her siblings helped pay the bills. But it was still a financial strain, one that in the ensuing years virtually depleted her parents' assets.

"It was tough," she said.

Zane's experience reflects what has become a crisis in Hawai'i: middle-class families are struggling to cope with long-term-care bills, and some elders are going without needed services because of the high costs.

It is a crisis that is expected to worsen as Hawai'i's senior population grows at a rapid clip and people live longer, eventually requiring more intensive care as they get into their 80s, 90s and beyond.

Worse, no one has come up with a way to effectively address the problem. Efforts to establish Hawai'i tax credits or a public financing plan for long-term-care insurance have fizzled in recent years. A commission has been formed to explore ways to reform Hawai'i's long-term-care system.

But with the state facing a serious budget deficit, no big-picture solutions are on the horizon. Some elder-care programs already are dealing with service cuts because of the budget squeeze.

"For those in their senior years who need help, it's absolutely a crisis," said Barbara Kim Stanton, executive director of AARP Hawai'i. "Alarms are already sounding."

The difficult issues associated with long-term care hit the headlines recently when a Nu'uanu nursing home evicted an 81-year-old, wheelchair-bound woman a week before Christmas and left her at a Honolulu hospital emergency room because her family stopped paying the bill.

The case of Florence Ko, who was dropped off at Straub Clinic & Hospital wearing only a hospital gown, with none of her regular medications and less than $3 in her purse, underscored the need for people to plan for long-term care well before it is needed, experts said. Few, however, do so.

Ko had accumulated a tab of more than $40,000 when she was evicted from Nu'uanu Hale, had no long-term-care insurance and did not qualify for Medicaid, a government benefits program for the poor. She had twice been denied Medicaid coverage, presumably because of a Portlock property — valued at more than $1 million — that was held in a family trust and was transferred to her New York daughter in 2008. Ko has since moved to a private apartment with a relative.

"I think there's this false sense of security in this state that people are going to be OK," Stanton said. "But people are going to be in for a rude awakening."

DWINDLING ASSETS

Zane, a retired Family Court manager, said her mother couldn't qualify for Medicaid because her assets were worth too much. After the elder woman died in 2002 at age 75, Zane's father, then 84, started having more health problems. By the time he had a stroke and needed full-time nursing care in 2005, his assets had dwindled to the point he was eligible for Medicaid, Zane said.

Despite a severe shortage of nursing-home beds, Zane was able to find her father, Ted Redoble, a spot at Leahi Hospital.

Until then, Zane's experience in dealing with Hawai'i's network of elder-care services was largely negative, making her realize how ill-prepared the community is to deal with caring for its aged.

"The whole elder-care system really sucks," she said. "Everything is so fragmented."

The financial part of the crisis, for the most part, is not affecting the wealthy who can afford to pay for top-notch care. And those on the other end of the spectrum, the poor, have Medicaid to rely on, though their choices may be limited.

But the majority of families fall in between, experts say, and only about one in 10 are believed to have private insurance to cover long-term care.

If someone needs institutional care, Hawai'i has among the highest costs in the country.

For a semi-private room in a nursing home, the annual tab is nearly $100,000, according to an April 2008 study by Genworth Financial. That's about twice Hawai'i's median annual household income. A private room averages more than $107,000.

Even for less intensive care, such as a room in an assisted-living facility, the average annual rate is more than $41,000, the Genworth report says.

The cost of institutional care, however, can be somewhat misleading.

"People's biggest fear is the cost of nursing homes, but the reality is only 5 to 10 percent of the senior population go to nursing homes," said Valerie Taylor, program director for Child & Family Service's gerontology program.

CHEAPER ALTERNATIVES

Because living at home or in a residential setting is a cheaper alternative for less complicated cases, and usually more desirable from the senior's perspective, government programs in recent years have provided more resources to help seniors live at home as long as possible.

That trend has fueled a dramatic jump in residential care homes, which now number about 900 in Hawai'i, up 48 percent since 2005, according to state figures.

But even the cost of residential care can be prohibitive for some families.

The average annual tab for adult daycare in Hawai'i, for instance, is $15,249, according to the Genworth report.

Jade Young said her brother, Carl Young, had decent medical insurance when he was diagnosed with pancreatic cancer in March 2008 and she started caring for him.

Young and her extended family were more prepared than many to deal with a catastrophic illness. She has a background in hospice care, her older brother is a retired physician and her niece is a gerontologist.

At the time, Carl was living in the family home in Kapahulu and needed full-time care, provided in shifts by Young and other family members, including Carl's wife. Though Carl's insurance covered most of the expenses, maintaining around-the-clock care was a challenge, Young said.

"It's not just the finances," she said. "Your personal well-being gets drained. When it's your own family, it's kind of overwhelming emotionally."

Young, a high school teacher, died in June at the age of 66.

SHORTAGE OF HELP

If money isn't an issue, finding quality help often is because of a shortage of qualified caregivers, experts say. The shortage affects institutions, such as nursing homes, as well as residential care homes and individuals looking for caregivers.

The tight fiscal times also mean many agencies are having difficulty meeting the demand for services.

Catholic Charities Hawai'i, which provides household chores to O'ahu seniors through the Kupuna Care program, used to have a wait list averaging about 30 people. The wait to get into the chore program typically would be one to two months. Now the list has grown to roughly 120 people, and the wait averages about six months, according to Diane Terada, Catholic Charities' community and senior services division administrator.

As resources get more scarce, "services are being provided much thinner than we would like," Terada said. "We've already spread out the safety net very, very thin."

And with costs projected to keep rising, elder advocates are worried about even more cuts as demand continues to soar.

"We've got an infrastructure right now that is just a patchwork of services," said Cullen Hayashida, long-term-care coordinator at Kapi'olani Community College.

The high prices already can be so prohibitive that some seniors who have difficulty with daily activities, such as cooking, laundry and personal care, are not getting the help they need at home.

In a January 2008 survey of more than 200 seniors who needed such help, nearly 77 percent said they weren't using any services because of the cost — the most common reason cited by the respondents.

The second-most common reason, mentioned by nearly 69 percent, was not knowing where to go for help, according to the University of Hawai'i and Pacific Research and Planning Associates survey.

Hayashida said thousands of at-home elderly are not getting the care they need, resulting in such incidents as seniors falling and not being tended to for days, or elders with dementia wandering away from their residences.

"It's going to get much worse," he said. "People are not just paying attention to this."

Deborah Jackson, founder of eldercare hawaii.com, agreed. "It's a huge problem," she said.

To address gaps in the long-term-care system, the Legislature last year established a commission to recommend reforms and develop a five-year plan, including a proposal for financing long-term-care services. The plan is due by September 2010.

The commission has started its work with $50,000 from AARP. But a $100,000 state appropriation has not been released by the Lingle administration.