Long-Term Services and Supports: Case Studies from Four States


Cover of the reportEvery day, 10,000 Americans turn 65 years old and estimates suggest that roughly half of this group will need some form of long-term services and supports (LTSS) during their lifetime. Longer lifespans, particularly for aging baby boomers, contribute to an extraordinary demand for LTSS for older adults and people with disabilities or chronic illness. This is also an issue for younger generations, including millennials and Generation X, both as today’s caregivers and tomorrow’s care receivers.

Long-term services and supports include a broad range of day-to-day assistance needed by people with chronic health conditions and challenges with daily living activities—for example, dressing, bathing, housework, money management and transportation. Services are provided in the home or in institutional settings such as nursing homes, supportive housing or assisted living facilities. People who require LTSS represent a diverse group, including those older than 65 and younger adults with different types of physical, cognitive and mental disabilities, as well as children who are medically fragile.

Demand for these services is projected to grow in the coming years, as are the associated costs, which are often paid for with public money. Medicaid, the largest single payer of long-term services and supports across age groups, accounts for about half of all LTSS spending. Studies suggest that home- and community-based services (HCBS) are cost-effective compared to institutional care. To qualify for Medicaid HCBS, individuals must meet a state’s criteria for an institutional level of care. Medicaid spending on HCBS outpaced spending on institutional long-term care for the first time in 2013 and continues to increase. In fact, 55 percent of Medicaid spending on LTSS was for home- and community-based services in 2015.

In addition, unpaid caregivers, such as family or friends, provide a significant amount of care, often filling in the care gaps. In 2013, approximately 40 million Americans provided care to adults with varying levels of needs, translating to a value of an estimated $470 billion in unpaid LTSS.

This report discusses the experiences of four states as they aim to improve systems of long-term care.

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