A broad consensus of Americans concluded long ago that health care spending in our country — especially spending involving Medicare and Medicaid — cannot be sustained. [IMGCAP(1)]Over the years, many medical professionals and policymakers have suggested ideas and solutions on how to resolve this problem. But because of a host of reasons including a lack of resolve; lack of understanding of the magnitude of the problem; or, perhaps, insufficient political will, the United States has not adequately addressed the health care delivery and spending issues that have become our country’s most prominent domestic challenge. As broad solutions to health care reform are being developed in Washington, D.C., I am concerned that all the important discussions and ideas do not look broadly enough in considering an important and rapidly growing sector that is a significant user of health care. I’m speaking, of course, of our elders who depend upon care and services in the final years of their lives.These individuals have lived productive lives, defended our country and raised today’s leaders. Yet they are, at worst, threatened to be left behind or, at best, diminished in the health care reform discussions.We must ask ourselves, “Where is the soul’ in our efforts to ensure elders are cared for in a manner they so rightly deserve?—Keeping our nation’s elderly individuals independent as long as possible is an important objective, and, appropriately, emphasis is being placed on health care services that allow more elders to stay in their homes. However, skilled care facilities will continue to play an important role for those individuals that require a higher level of care than can be provided in the home in the latter years of life.It is equally important to note that skilled care facilities provide a tremendous benefit to seniors who need post-acute therapy as they transition back home. Additionally, such services are being provided in a quality-driven, cost-effective manner resulting in lower costs to our nation’s health care delivery systems. The United States has approximately 15,700 licensed skilled nursing facilities. That number is decreasing as the largest number of retirees in our country’s history (77 million baby boomers) is beginning to utilize Medicare and Social Security. In 2008, 1.4 million Americans resided in nursing homes. Thanks to modern medicine, healthier lifestyles and other factors, our elders are living longer. Census projections indicate that the population group that will have the greatest percentage increase between the years 2000 and 2050 is the 85 and older group — at 389 percent! — followed by the 65-84 age group at 114 percent. Many elderly individuals are cared for at home by family. Almost 80 percent of Americans have not made adequate plans or financial arrangements for the time if and when they or their loved ones are unable to care for themselves and need assistance with daily living activities such as feeding, bathing or dressing. Many have the misconception that health insurance or Medicare alone will pay for long-term care. Funding for nursing home care comes from many sources. Medicare pays for long-term care under certain circumstances, such as post-acute rehabilitation. Many military veterans live in nursing homes when a Veterans Affairs nursing home is unavailable or if an arrangement exists between a provider and the VA. A modest, diminishing number of individuals pay for nursing home care privately, while a smaller number rely on long-term care insurance payments.However, Medicaid remains the major payer of nursing home care (approximately 60 percent of the total nursing home population). A recent study shows that Medicaid falls about $4.2 billion — or about $12.50 per resident every day — short of reimbursing providers for the cost of supplying qualified individuals with quality care in America’s nursing homes. Despite all these funding and aging statistics, the health care debate in recent weeks has included little mention about how to reform long-term care. In fact, some major reform proposals declare that significant long-term care funding cuts need to be made to pay for needed change to our nation’s health care system. My fear is that what is being forgotten and lost in the important debate about needed health care reform in this country are those who are now, or will soon be, in the twilight of life — our nation’s elderly. As Hubert Humphrey once said, how we treat those individuals is a true “moral test— of our government.The long-term care profession has many sensible, cost-effective suggestions to address the problems faced by our elders who require care. More importantly, our seniors deserve and have earned the right for their voices to be heard in the health care reform debate. They must not be the forgotten generation.It is critical that solutions to reforming health care in this country include the voices, the needs and the souls of our nation’s growing senior population. It is not only ethically the right thing to do, but also an effective way for this country to watch over limited health care resources.David J. Horazdovsky is president and CEO of the Evangelical Lutheran Good Samaritan Society, based in Sioux Falls, S.D. Founded in 1922, the society is the nation’s largest not-for-profit provider of senior housing and services, operating in 24 states, employing 22,000 staff members and serving more than 28,000 seniors.