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Chapter 9 - Long-term Care

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NOTE: Charts and graphs for this chapter are listed in the right column of the page.

Content Last Updated: 6/17/2010 8:25:29 PM
Graphics Last Updated: 6/15/2009 9:06:22 AM
Note: Terms in green will show glossary definitions when clicked.

Originally written by Deanna Okrent, Alliance for Health Reform. Updated April 2010 by Deanna Okrent. This chapter was made possible by the Robert Wood Johnson Foundation. 

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  • Two-thirds of people age 65 today will need some long-term care in their lifetimes.1
  • Of the 10 million Americans who need assistance with daily activities, 1.7 million live in the nation’s 16,000 nursing homes and approximately 520,000 live in assisted living facilities.2
  • Fourteen percent of Americans age 85 or older live in nursing homes.3
  • A total of $207 billion was spent on long-term care in the U.S. in 2005.4
  • Of total long-term care spending, Medicaid spending accounts for 49 percent, Medicare accounts for 20 percent, out-of-pocket spending equals 18 percent and private health and long-term care insurance makes up 7 percent.5
  • There are 52 million unpaid caregivers who contribute an estimated $375 billion in value to the U.S. economy. 6
  • The Community Living Assistance Services and Supports (CLASS) Act, enacted in the health reform law of 2010, establishes a new voluntary long-term care insurance program that will be federally administered.7

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”Long-term care” (LTC) generally brings to mind images of nursing homes and older people living in them who can no longer care for themselves. In truth, long-term care comes in many different forms and is provided in many different settings.

It is institutional care. It is assisted living. It is also home- and community-based services, including home health care, adult day care, home delivered meals and other services authorized under Title III of the Older Americans Act.8 (See chart, “Numbers of People Receiving Home and Community-Based Services, 2006.”)

These services are financed by Medicaid, Medicare, private long-term care insurance, private out-of-pocket spending and appropriations under the Older Americans Act. (Despite what many Americans believe, Medicare is not a major payer for LTC, as discussed later.)

Yet the majority of long-term care services aren’t paid for at all. They are provided by 52 million unpaid caregivers -- primarily family members and friends of those needing LTC. Their services, if paid for, would have cost an estimated $375 billion in 2007 – almost double what the federal government spent that year on Medicaid.9 10

LTC serves both people who are over the age of 65 and people under that age (for example, see chart, “Nursing Home Residents by Age & Gender”).

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Cost and Financing of Long-term Care

In 2008, the average annual cost of a private room in a nursing home was more than $76,000.11 The average cost for an assisted living facility in 2007 was $35,628.12 (See Glossary for the differences between the two.) These costs vary widely from region to region and are highest in the Northeast. 13 Costs also vary by certification status, size and type of ownership of the facility.

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Medicaid is a public health insurance program funded by federal and state governments. (See Chapter 8, “Medicaid,” for more.) Medicaid is a major payer for long-term care because federal law requires that Medicaid programs in every state must provide nursing home care and home health care for the qualified poor.

Medicaid accounts for almost half of national long-term care spending.14 (See chart, “Financing of Long-Term Care, 2005.”) Of that amount, most is for institutional care, though spending for non-institutional care is growing and reached 37 percent of Medicaid’s share of LTC spending in 2005.15 Though over half of those who use Medicaid long-term care services are over 65, a third (34 percent) are disabled children and adults under 65. 16

Beyond the basic federal requirements, Medicaid LTC benefits vary from state to state. Home and community-based services (HCBS) are provided under Medicaid waivers in all states but the programs serve limited populations, and vary greatly in scope from state to state. (See Glossary for details about Medicaid waivers.)

Since 2007, under a provision of the Deficit Reduction Act (DRA) of 2005, waivers are no longer required for some home and community-based services, such as case management, homemaker/home health aide services, personal care services, adult day health, and habilitation services.

The health reform law of 2010 (The Patient Protection and Affordable Care Act , orPPACA) contains provisions that may shift more care to home and community-based services in the future. It establishes additional optional HCBS benefits that states may offer under Medicaid and provides financial incentives to states to expand existing HCBS programs.17

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Though many people think that Medicare covers long-term care, in reality it provides only limited coverage of nursing home stays and home health care. Eligibility is based on, and follows, a hospital stay of at least three days. Medicare covers short-term stays in skilled nursing facilities – full coverage for 20 days, partial coverage for up to 80 additional days. This spending, plus spending for home health benefits for eligible Medicare beneficiaries, accounts for 20 percent of long-term care expenditures.18

Private Long-Term Care Insurance

A relatively small number of people purchase long-term care insurance – approximately 7 million policies were in force in 2005. 19 Although it seems entirely logical to minimize the risk of impoverishment from the high cost of long-term care, long-term care insurance has not had broad market appeal.

Younger people don’t yet recognize the need for long-term care insurance, although the cost of it for them is low. When people are closer to the age when they might need long-term care, many cannot afford the then-high priced insurance premiums.

The Robert Wood Johnson Foundation, in 1987, initiated an experimental program called the Program to Promote Long-Term Care Insurance. Also referred to as the Partnership Program, it involves a public-private partnership between Medicaid and private insurance. Those buying long-term care insurance can protect a portion of their assets that otherwise would count against them were they to apply to Medicaid to cover their long-term care expenses. (See the Alliance for Health Reform issue brief on this topic at under “Resources.”)

The Partnership Program began as a demonstration project in four states and is now available for replication in all states. Twenty-nine states had implemented Partnership Programs as of June 2009 and many others are in the process of implementing these programs. 20 All told, long-term care insurance pays for approximately 7 percent of national long-term care spending.21

The Community Living Assistance Services and Supports (CLASS) Act, enacted in the health reform law, establishes a new voluntary long-term care insurance program that will be federally administered. Individuals will be automatically enrolled if their employers agree to participate and premiums will be paid through payroll deductions unless an individual opts out. 22 Though this feature makes participation easy, the program is not projected to make an immediate, sizable difference in the insurance rolls. Many details of the new program have yet to be determined by the Secretary of Health and Human Services.

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Out-of-Pocket Spending

For people without insurance, including those who do not qualify for Medicare or Medicaid benefits, long-term care costs are paid out-of-pocket. This includes payment for nursing home care, assisted living and home health care. The average annual cost of home care by one industry estimate is close to $44,000.23 Out-of-pocket spending accounts for 18 percent of national spending for long-term care.24

The CLASS Act would provide qualified enrollees a cash benefit to help with these expenses.

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As noted, Medicaid serves as the nation’s safety net for individuals with long-term care needs. Many individuals who initially pay for nursing home care out of pocket become impoverished by the high cost of care and later qualify for Medicaid. Can Medicaid continue to fund the largest share of long-term care? Will state budgets hold up under the strain? Will the provisions in PPACA alter the ratio of institutional care to home and community based services and if so, what effect might this have on nursing homes?

Policymakers also wonder how to support family caregiving and other informal caregivers. When family members stay home from work or leave their jobs to care for loved ones, this takes an economic toll on them and on society. How could governments reduce the strain?

Perhaps long-term care insurance can play a greater role. How can we increase its appeal and thereby its market share? Are consumer protections needed to allay fears that the insurance policies of today will cover the needs of tomorrow? Will new products be marketed to supplement the voluntary long-term care insurance program in the CLASS Act?Many states are experimenting with programs that reduce the need for nursing home placements. 25 Such programs require that people needing long-term care be able to live in the most integrated setting appropriate. One innovative effort, Vermont’s “global budgeting,”26 allows Medicaid funds to be spent on whichever service is most appropriate for persons found to be eligible for long-term care. Global budgets do not separate funding for nursing homes or home and community-based services into different “silos.” Will the financial incentives in PPACA encourage the expansion of these and other innovative programs?

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Throughout the health care arena there is a workforce shortage27 and this is dramatically so for direct care workers in long-term care.28 29 Studies have shown that quality of care is directly related to nurse staffing ratios, 30 yet in very few states does the average staffing ratio meet the minimum standard recommended by each state. Questions abound on how to increase recruitment, retention and job satisfaction of direct care workers. The biggest question is: Will the workforce supply be ready to meet the baby boomer demand?

Certified nursing assistants (CNAs), who make up the majority of direct care providers in most facilities (see chart, “Distribution of Direct Care Workers”), currently get minimal training, benefits and opportunity for advancement. PPACA establishes a three-year initiative to strengthen the direct care workforce. It will fund state demonstration projects that train personal or home care aides in 10 core competencies. These projects will be evaluated on job skills mastery, job satisfaction, and beneficiary and family satisfaction with services. 31

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Quality of Care and Resident-directed Care and Services

In 2007, nearly 17 percent of nursing homes inspected by state regulators were cited for serious deficiencies.32 Some say the inspection system is broken. 33 Others say quality of care is the issue, and that nursing home ownership is a contributing factor34 (with most of the criticism lodged against certain for-profit chains). PPACA provisions require disclosure of ownership and governance.35

Medicaid reimbursement and other historical factors have long fostered a bias toward institutional long-term care. In addition to the PPACA provisions mentioned above, some new models of care are being demonstrated across the country.

Among these is the Green House® model, which provides person-centered long-term care in small home-like settings as an alternative to larger, institution-like nursing homes. (For more, see the Alliance issue brief “ Changing the Nursing Home Culture.”)

Studies have shown improved resident and caregiver satisfaction at these types of facilities.36 But the question remains: Are current long-term care providers sufficiently motivated to make the necessary structural changes in older facilities that would be required to create a more individualized, home-like environment? Can they afford to do so?

In a 2008 survey of long-term care opinion leaders,37 84 percent felt that long-term care should be rebalanced away from traditional nursing homes and toward home- and community-based services. Some 61 percent were in favor of expanding consumer-directed programs such as “Cash and Counseling,” a way for those needing long-term care to direct expenditures made on their behalf. (Read more about Cash and Counseling at PPACA provisions referenced earlier will provide financial incentives to states to expand HCBS options.

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A 2007 study showed a relationship between racial segregation and quality disparities in U.S. nursing homes. 38 The study found that blacks were more likely to live in poor quality nursing homes than whites. Blacks were almost three times as likely to live in a nursing home housing predominantly Medicaid residents. The study offered policy recommendations including Medicaid payment reform that would close the gap between Medicaid per diem rates and those paid by private payers.

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  • It is a common misperception that Medicare covers long-term care. It is not well understood that the Medicare “long-term care” benefit is limited to 100 days of skilled care and that it must follow a hospital stay of three days or more. The Center for Medicare Advocacy has information about skilled nursing facility (SNF) care, therapy care, rehab care, and other Medicare issues on its web site, You can also learn about Medicare benefits at
  • There is often confusion between Medicare and Medicaid. It is not well understood that Medicaid covers long-term care for qualified individuals and that it is a means-tested benefit. Most publicly funded long-term care is financed by Medicaid.
  • Gifts to family members or others within the five-year period prior to applying for Medicaid count as assets of the potential beneficiary for purposes of determining Medicaid eligibility. The period in which such gifts are counted as assets is known as the “look-back period.” The “look-back period” for Medicaid changed from three years to five years in February 2006. It is commonly asserted that individuals divest themselves of assets in order to qualify for Medicaid and be eligible for long-term care coverage. However, studies have found little evidence of this phenomenon.39
  • The movement to resident-centered care or person-centered care is often linked with the Green House® movement. (NCB Capital Impact, with support from the Robert Wood Johnson Foundation, is pursuing the development of Green Houses across the country. Click here for more information about this replication initiative.) However, resident-centered care can and should occur in all long-term care facilities, not only ones of a particular architectural design. This movement has many shapes and forms depending on developments on the local and state level and subject to state and federal regulations. A good resource for information about this movement is The movement is also known as “culture change.”
  • Many long-term care facilities require residents to sign admissions agreements with mandatory arbitration clauses. There have been successful cases challenging the legality of such clauses. However, it is still a common occurrence. It is also common to request that a family member accept financial responsibility for their loved one in the facility. Family members are not required to accept such responsibility but often don’t realize what they have signed until much later down the road.  

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  • Long-term care workforce – Is your state conducting a training demonstration for certified nurse assistants(CNAs)? Are there tangible results in lower turnover rates and higher job satisfaction?
  • Long-term care workforce and immigration — What would be the effects of proposed federal immigration reforms? Will tighter restrictions increase the workforce shortage?
  • Long-term care costs and the economic downturn — How are state Medicaid budgets faring in the face of an economic downturn? What will happen to the long-term care safety net for the poor? Will families be able to continue their out-of-pocket spending for long-term care? Will Medicaid enrollment swell?
  • Facility residents’ costs of care are paid for by a variety of sources such as out-of-pocket, private long-term care insurance and Medicaid. The mix of residents by payer source often varies by location of the facility. Is the economic downturn having an effect on the payer source mix of facilities in your community? Will private-pay facilities have to take in more Medicaid residents to fill their beds? Might we see more facility closures due to the economic recession?
  • Are innovative models of care gaining market share? How is the Green House® project progressing? Has the economic downturn slowed progress toward changing institutional models of care into more home-like settings?
  • Are current HCBSs sufficient to meet the increased demand? Will new models develop? Will they be public-private partnerships or depend solely on Medicaid funding? Will some traditional nursing facilities face diminishing occupancy rates and be forced to close their doors?
  • Are baby boomers changing the face of long-term care? Are they requesting/demanding different services, benefits for themselves than their parents demanded? Are more institutions offering email and Internet access to their residents? Will baby boomers find innovative solutions to aging at home? Will this speed the movement away from the current institutional bias? Are baby boomers more aware of “residents’ rights?” For information about residents’ rights contact the National Long-term Care Ombudsman Resource Center. They have an information-packed website at
  • Health reform –Can cost containment efforts be effective without encompassing the share spent by Medicaid and Medicare on long-term care? What effect will the CLASS Act have on the long-term care insurance market?



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Lisa Alecxih , Vice President, The Lewin Group, 703/269-5542

Melanie Bella , Senior Vice President, Center for Health Care Strategies, 609/528-8400,

Randall Brown , Vice President and Director of Health Research, Mathematica Policy Research, 609/799-3535

Stuart Butler , Vice President, The Heritage Foundation, 202/546-4400

Eric Carlson , Attorney, National Senior Citizens Law Center, 213/639-0930 ext.313

Bruce Chernof , Chief Executive Officer, The SCAN Foundation, 562/308-2858,

Steven Dawson , President, PHI, 718/402-7471,

Jennifer Douglas , Assistant Research Scientist, LTC Research, LIMRA International, 860/688- 3358

David Durenberger , Chairman, The National Institute of Health Policy, 651/962-4630

Charles Fahey , Program Officer, Milbank Memorial Fund, 718/817-5356

Judy Feder , Professor, Public Policy Institute, Georgetown University, 202/687-8397

Lynn Friss Feinberg , Deputy Director, National Center on Caregiving, Family Caregiver Alliance, 415/434-3388,

James Firman , President and CEO, National Council on Aging, 202/479-1200,

Len Fishman , President and CEO, Hebrew SeniorLife, 617/363-8211,

Marty Ford , Chairman, Consortium for Citizens with Disabilities, 202/783-2229

Lex Frieden , Senior Vice President, The Institute for Rehabilitation and Research, 713/520-0232,

Robert Friedland , Associate Professor, School of Nursing and Health Studies, Georgetown University, 202/687-1287

Robert Greenwood , Vice President of Public Affairs, National PACE Association, 703/535- 1522

Stuart Guterman , Senior Program Director , Program on Medicare's Future, The Commonwealth Fund, 202/292-6735,

Val Halamandaris , President, National Association for Homecare and Hospice, 202/547-7424

Catherine Hawes , Director, Program on Aging and Long-Term Care Policy, School of Rural Public Health, Texas A&M University System Health Science Center, 979/458-0081,

Antoinette Hays , Dean, Regis College School of Nursing and Health Professions, 781/768-7122,

Alice Hedt , former Director, NCCNHR,

John Holahan , Director of Health Policy Research, Urban Institute, 202/261-5666

Joy Johnson Wils on, Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400,

Mary Jane Koren , Assistant Vice President, Quality of Care for Frail Elders, The Commonwealth Fund, 212/606-3849,

Risa Lavizzo-Mourey , President & CEO, Robert Wood Johnson Foundation, 888/631-9989,

Barbara Lyons , Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270,

Stephen McConnell , Ageing Programme Executive, Atlantic Philanthropies, 212/916-7300,

Mark Meiners , Professor, Department of Health Administration and Policy, George Mason University, 703/993- 1909

Charles Milligan , Executive Director, Hilltop Institute, UMBC, 410/455-6274,

Larry Minnix , President and CEO, American Association of Homes and Services for the Aging, 202/783-2242

Marilyn Moon , Vice President and Director of the Health Program, American Institutes for Research, 301/592-2101,

Vincent Mor , Chair, Department of Community Health, Brown University, 401/863-3172,

Paul Nathanson , Executive Director, National Senior Citizens Law Center, 213/639-0930

Carol O'Shaughnessy , Principal Policy Analyst, National Health Policy Forum, 202/872-0239,

Richard Price , Director of Grassroots and Communications, Hart Health Strategies, 202/783- 2229

Donald Redfoot , Senior Policy Advisor, Public Policy Institute, AARP, 202/434-3840,

Charles Reed , Consultant, C.E. Reed and Associates, 360/943-8188,

Susan Reinhard , Director, AARP Public Policy Institute, 202/434-3841,

Martha Roherty , Executive Director, National Association of State Units on Aging, 202/898- 2578 x138,

John Rother , Executive Vice President for Policy and Strategy, AARP, 202/434-3701,

Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270,

William Scanlon , Senior Policy Advisor, Health Policy R & D, 202/624-3975

Ray Scheppach , Executive Director, National Governors Association, 202/624-5320

Judith Stein , Executive Director, Center for Medicare Advocacy, 860/456-7790,

Paul VandeWater , Senior Fellow, Center on Budget and Policy Priorities, 202/408-1080, vandewater@

Bruce Vladeck , Principal, Ernst & Young, 212/773-3000,

Alan Weil , Executive Director, National Academy for State Health Policy, 202/903-0101

Janet Wells , Director of Public Policy, The National Consumer Voice for Quality Long- Term Care (formerly NCCNHR), 202/332-2276 ext.205

Tim Westmoreland , Visiting Professor of Law, Law Center, Georgetown University, 202/662- 9876

Josh Wiener , Senior Fellow & Program Director, Aging, Disability, and Long-Term Care, RTI International, 202/728-2094

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John Dicken , Director, Health Care, Government Accountability Office, 202/512-7043,

Judith Frye , Director, Office of Family Care Expansion, Wisconsin Department of Health, 608/266-8560,

Stuart Hagen , Principal Analyst, Health and Human Resources Division, Congressional Budget Office, 202/225-2644

Ruth E. Katz , Deputy to the Deputy Assistant Secretary, Office of Disability, Aging and Long-term Care Policy, ASPE,

Laura Lawrence , Chief of the FSA, Life, and Long Term Care Insurances Group, Office of Personnel Management, 202/606-1413,

Frank Titus , Assistant Director for Insurance Services, Office of Personnel Management, 202/606-0745

Edwin Walker , Deputy Assistant Secretary for Program Operaations, Administration on Aging, Department of Health and Human Services, 202/401-4634,

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Mark Cohen , Vice President, LifePlans, Inc, 781/893-7600

Jennifer Cook , Health Policy and Legislative Analyst, National Association of Insurance Commissioners, 202/471-3990,

Irene Fleshner , Vice President for Strategic Nursing Initiatives, Genesis Health Care, 610/925- 4169,

Lee Goldberg , Policy Director, Long Term Care Division, Service Employees International Union, 202/730-7850,

Mary Kennedy , Director of Medicare, Association for Community Affiliated Plans, 202/701-4749,

Robyn Stone , Senior Vice President of Research, American Association of Homes and Services for the Aging, 202/508-1208,

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AARP Public Policy Institute

Administration on Aging, HHS

Alzheimer's Association

American Association for Homes and Services for the Aging

American Association of People with Disabilities

American Institutes for Research

American Network of Community Options and Resources

America's Health Insurance Plans

Bazelon Center for Mental Health Law

CBO, Health and Human Resources Division

Center for Health Care Strategies

Center on an Aging Society, Georgetown University

The Commonwealth Fund

Consortium for Citizens with Disabilities

Disability Policy Collaboration (The Arc of the United States/United Cerebral Palsy)


Families USA

Federal Long Term Care Insurance Program

Genesis Health Care

Georgetown Public Policy Institute

Georgetown University Health Policy Institute

Government Accountability Office

Health Reform GPS

Hebrew Rehabilitation Center for Aged

Heritage Foundation

HHS Office of Disability, Aging and Long-Term Care Policy

The Hilltop Institute, UMBC

Institute for Rehabilitation and Research

John Hancock Long Term Care Insurance

Kaiser Family Foundation

Lewin Group

LifePlans, Inc

Mathematica Policy Research

Metropolitan Life Insurance

Milbank Memorial Fund

National Academy for State Health Policy

National Academy of Social Insurance

National Association for Homecare and Hospice

National Association of Insurance Commissioners

National Association of State Units on Aging

National Center for Assisted Living

National Center on Caregiving, Family Caregivers Alliance

National Conference of State Legislatures

National Council on Aging

National Governors Association

National Institute of Health Policy

National PACE Association

National Senior Citizens Law Center

NCCNHR: The National Consumer Voice for Quality Long-Term Care

Open CRS


Robert Wood Johnson Foundation

RTI International

Rutgers Center for State Health Policy

The SCAN Foundation

Service Employees International Union

Urban Institute


1 AARP Public Policy Institute (2007). “Long-Term Care Trends.” (

2 CDC/NCHS. “National Nursing Home Survey.” Table 1. Number of nursing homes, beds, current residents, and discharges. (

3 AARP Public Policy Institute (2007). “Fact Sheet: Nursing Homes.” (

4 Long-Term Care Financing Project. Georgetown University (2007). “Fact Sheet: National Spending for Long-Term Care.” February. (

5 Long-Term Care Financing Project. Georgetown University (2007). “Fact Sheet: National Spending for Long-Term Care.” February. (

6 AARP Public Policy Institute (2008). “Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update.” November, p. 1. (

7 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. (

8 National Health Policy Forum (2008). “The Basics: Older Americans Act of 1965.” April 21. ( For information on the 2006 amendments to the Older Americans Act, go to

9 AARP Public Policy Institute (2008). “Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update.” November, p. 1. (

10 U.S. Office of Management and Budget (2008). “Analytical Perspectives, Budget of the United States, Fiscal Year 2009.” Table 20-4, p. 334. (

11 Genworth Financial (2008). “Long Term Care Survey: Future Trends in Long Term Care from Genworth Financial.” (

12 AARP. “State-by-State Long-term Health Care Costs.” ( ).

13 AARP. “State-by-State Long-term Health Care Costs.” ( ).

14 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University. (

15 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University. (

16 Kaiser Commission on Medicaid and the Uninsured (2007). “Long-term Services and Supports: The Future Role and Challenges for Medicaid.” September. (

17 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. (

18 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University (

19 AARP Public Policy Institute (2007). “Fact Sheet: Long-Term Care Insurance.” (

20 National Clearinghouse for Long-Term Care Information. “Paying for Long-Term Care.” ( ).

21 AARP Public Policy Institute (2007). “Fact Sheet: Long-Term Care Insurance.” (

22 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. (

23 Genworth Financial (2008). “Long Term Care Survey: Future Trends in Long Term Care from Genworth Financial.”

24 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University (

25 Kitchener, Martin; Willmott, Micky; Wong, Alice; Harrington, Charlene (2006). “Home and Community-Based Services: Medicaid Research and Demonstration Waivers.” UCSF National Center for Personal Assistance Services. (

26 Kaiser Commission on Medicaid and the Uninsured (2006). “Medicaid Facts: The Vermont Choices for Care Long-Term Care Plan.”(

27 The National Academies News Release (2008). “Health Care Work Force Too Small, Unprepared For Aging Baby Boomers; Higher Pay, More Training, And Changes In Care Delivery Needed To Avert Crisis.” ( ).

28 National Center for Health Workforce Analysis, HRSA (2004). “Nursing Aides, Home Health Aides, and Related Health Care Occupations – National and Local Workforce Shortages and Associated Data Needs.” (

29 National Clearinghouse on the Direct-Care Workforce (2005). “Results of the 2005 National Survey of State Initiatives on the Long-Term Care Direct-Care Workforce.” September 2005. (

30 Zhang, Ning Jackie et al. (2006). “Minimum Nurse Staffing Ratios for Nursing Homes.” Nursing Economics. May 2006.

31 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. (

32 OIG Memorandum report (2008). “Trends in Nursing Home Deficiencies and Complaints.” OEI-02-08-00140. (

33 U.S. News and World Report (2008). “GAO Faults State Nursing Home Inspections.” May 2008. ( ).

34 OIG Memorandum report (2008). “Trends in Nursing Home Deficiencies and Complaints.” OEI-02-08-00140. (

35 Healthcare Finance News (2008). “Legislation would increase transparency, penalties for nursing homes.” February 2008.

36 Kane, R.A; Lum, T.Y.; Cutler, L.J. et al. (2007). “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program.” Journal of the American Geriatrics Society, 55(6):832-39. (

37 Miller, Edward Alan; et al. (2005). “The Commonwealth Fund Long-Term Care Opinion Leader Survey: Top-Level Findings.”

38 Health Affairs News Release (2007). “New Study: In many U.S. Cities, Blacks More Likely Than Whites to Live in Poor Quality Nursing Homes.”

39 GAO (2007). “Medicaid Long-Term Care: Few Transferred Assets before Applying for Nursing Home Coverage.” (

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Related Resources

10.09.2010 - St. Petersburg nursing home gets off troubled facilities list, Richard Martin (, St. Petersburg Times (Florida)

A well-known local nursing home is no longer on the list of the worst facilities in the country.

10.05.2010 - Forgotten seniors need time, care , Tom Underwood, Atlanta Journal Constitution

A staggering number of older people — even those with family — spend weekends, birthdays and even holidays in nursing homes by themselves, alone in their memories. While we can’t all afford a monetary donation, we can give the gift of time.

08.25.2010 - State can't exclude felons from in-home care, Bob Egelko, San Francisco Chronicle

An Alameda County judge has blocked Gov. Arnold Schwarzenegger from excluding convicted felons and shoplifters from providing in-home care in a program that serves 430,000 low-income elderly and disabled Californians.

08.21.2010 - Continued budget cuts shred senior safety net, Anita Creamer, Sacramento Bee

Sacramento's safety net for seniors continues to fray, the result of several years' worth of city and county budget cuts.

08.18.2010 - Nursing homes, patients win debt payments, Meredith Cohn, Baltimore Sun

Thousands of low-income nursing home patients in Maryland will have millions in old debts wiped out now that the state has settled a years-long case involving Medicaid payments.


Other Related Resources
  • 01.31.2011 - Weathering the Storm: The Impact of the Great Recession on Long-Term Services and Supports, AARP

    This report documents how the recession continues to affect state programs for older individuals and adults with physical disabilities.


  • Graphics for This Chapter

    Distribution of Direct Care Workers

    Financing of Long-Term Care, 2005

    Number of People Receiving Home and Community Based Services, 2006

    Nursing Home Residents by Age and Gender


    This sourcebook for journalists was made possible with the support of the Robert Wood Johnson Foundation.

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