Reforming Long-Term Care in the United States: Findings from a National Survey of Specialists



Long-term care specialists—including consumer advocates, providers, public officials, and policy experts—who participated in a national survey generally agreed on the need for long-term care reform. Despite some differences, key constituent groups supported the establishment of government-sponsored financing strategies, a shift toward home- and community-based care, offering payment incentives to improve quality, and more effective regulation of nursing homes, home health care agencies, and assisted living facilities.

The Issue

An estimated 10 million older Americans with moderate to severe disabilities have long-term care needs, accounting for a large proportion of health care spending. Furthermore, demand for long-term care services is only expected to increase as the population ages. There is a growing consensus that some type of reform is needed to meet this demand. Giving voice to key stakeholder groups allows those with specialized knowledge of the long-term care system to communicate the importance of this issue to policymakers and the public, say the authors.

Key Findings MillerITL

  • More than 80 percent of respondents agreed that the cost of long-term care should be shared among public and private sources, with government and employers absorbing a large share of the financial burden. Specific strategies include adding a long-term care benefit to Medicare and adopting government incentives to promote savings and to buy long-term care insurance.
  • Most also supported rebalancing the long-term care system away from nursing homes and other institutions toward home- and community-based services (HCBS). Three-quarters of respondents agreed that establishing programs that offer comprehensive HCBS and expanding eligibility for HCBS under Medicaid would effectively accomplish this goal.
  • Only about one-third of participants reported that the federal government does a good job of establishing quality standards for nursing homes. Fewer (15%) were satisfied with the government’s quality standards for home health care agencies, and most (68%) felt that regulations for assisted living facilities should be more stringent.
  • Two-thirds of respondents said they were familiar with the resident-centered "culture change" movement in nursing homes, which allows clients to direct their own care and living choices. However, most agreed that fewer than 10 percent of nursing homes had fully adopted culture change.
  • Valuing workers' contributions and increasing pay were the most frequently mentioned strategies for improving the recruitment and retention of nurse assistants and home health aides. For professional staff, strategies included offering educational assistance, curriculum reform, and higher salaries.

Addressing the Problem

Consumer advocates and provider representatives had diverging views about long-term care reform. Consumers were more likely to favor public payment for family members who provide care, higher staffing requirements, and more aggressive regulatory enforcement as effective quality improvement strategies. There was substantial agreement on many fundamental issues, such as the need for more effective regulation of nursing homes, home health care agencies, and assisted living facilities, the desire to transition toward home- and community-based services, and the importance of payment incentives. Recognizing areas of agreement and disagreement should prove useful in promoting long-term care reform and focusing on solutions that are viable from a policy perspective.

About the Study

The authors conducted a national survey of 1,147 consumer advocates, provider representatives, public officials, policy experts, and other long-term care specialists. The survey was administered between September 2007 and March 2008 and addressed quality and challenges, financing and insurance, individual and family support, organizational change and innovation, and quality improvement and regulation.

The Bottom Line

Long-term care specialists agree on many strategies for reform: establishing government-sponsored financing strategies, shifting toward home- and community-based care, offering payment incentives to improve quality, and formulating more effective strategies for regulating providers.


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Publication Date:
September 9, 2009
Vincent Mor, Edward Alan Miller, Ph.D.,
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Related Topics
Long Term Care Quality