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How the Affordable Care Act Can Help Move States Toward a High-Performing System of Long-Term Services and Supports


With its promise of enhanced federal funding, the Affordable Care Act can help states reorient their systems of long-term care away from nursing homes and institutional care and toward a greater emphasis on home- and community-based services. In this way, states will be better able to meet diverse needs and preferences while recognizing and supporting the important role of family caregivers.


IMPORTED: __media_1562D43267B84C9185B9491CB2C13420_w_220_h_241_as_1.gif Long-term services and supports used by seniors and people living with disabilities are largely administered and paid for at the state level, resulting in significant variations across the United States in overall quality, types and amounts of services offered, eligibility, and system navigability. Recent economic troubles have driven many states to cut services, although a survey by AARP found that many others are maintaining and even expanding long-term services. To help states assess their current systems and plan for the future, researchers from AARP, The Commonwealth Fund, and The SCAN Foundation are developing a state-level performance scorecard of long-term services and supports (due out mid-2011). In a Health Affairs article, the research team set out to define long-term services and supports, outline the key characteristics of a high-performing system, and discuss new options and incentives in the Affordable Care Act that can support cost-effective programs to help people with limitations or disabilities remain in their homes and communities.

A High-Performing System of Long-Term Services and Supports

The authors define long-term services and supports as assistance with activities of daily living—such as eating, dressing, and bathing—for older people and adults with disabilities. These include direct human assistance, assistive technologies or devices, health maintenance tasks, and care coordination. These also include support provided to family members and other unpaid caregivers.

The team identified the following five key elements of a high-performing long-term services and supports system: 

  • Support for family caregivers. In 2005, 88 percent of community-based seniors who received help with two or more activities of daily living relied on unpaid caregivers. For these helpers, the accumulated physical and emotional strain over time can be overwhelming. It is crucial to recognize these individuals by involving them in decision-making and helping them to maintain their own well-being. 
  • Ease of access and affordability. The information needed to make decisions about long-term services and supports must be readily available, timely, and clear. In addition, services should be affordable for those with moderate and even higher incomes, with a safety net available for those who cannot afford the cost.
  • Choice of settings and providers. People requiring long-term services should receive them in the setting and from the providers they choose, including family members hired as caregivers. In addition, the system should offer a range of housing and transportation choices. Beneficiaries should be involved in making such decisions, whenever possible.
  • Quality of care and life. Social and emotional needs—not just health requirements—must be addressed. Beneficiaries’ personal preferences and dignity must be respected.
  • Effective transitions and organization of care. Long-term services and supports must be integrated with health-related services, like clinician visits and physical therapy, as well as with social assistance like transportation. It is also important to ensure the smooth coordination of necessary transfers—from hospital to home, for instance—while avoiding unnecessary transfers.

How the Affordable Care Act Can Help

The Affordable Care Act offers states several incentives and programs to help reach these goals, including: 

  • the Community First Choice option, which increases the federal share of Medicaid costs for states that offer person-centered home and community-based services;
  • Money Follows the Person grants, which help people move out of institutions or avoid unwanted institutionalizations;
  • the “no wrong door” policy, which creates a single point of entry for services and eligibility; and
  • a new Medicaid option, featuring enhanced federal matching payments, to establish health homes (medical homes) for beneficiaries with chronic conditions.

The Bottom Line

Using the incentives and options offered in the Affordable Care Act, states can improve their systems of long-term services and supports, moving away from institutional care and embracing options that keep more people in their homes and communities.

Publication Details



S. C. Reinhard, E. Kassner, and A. Houser, “How the Affordable Care Act Can Help Move States Toward a High-Performing System of Long-Term Services and Supports,” Health Affairs, March 2011 30(3):447–53.