These are the Best, Worst States for Long-Term Care

Washington is the No. 1 state in the nation for long-term services and supports (LTSS), while Indiana lies at the bottom of the list.

That’s according to a new “State Scorecard” report from AARP, the SCAN Foundation and Commonwealth Fund, which examined the factors that determine long-term care for seniors and people with disabilities. AARP released similar reports in 2011 and 2014.

The report ranked each state and the District of Columbia based on LTSS performance in five main categories: affordability and access; choice of setting and provider; quality of life and quality of care; support for family caregivers; and effective transitions between nursing homes, hospitals and homes.


Washington was in the top quartile of performance for all but one of the five categories. Runner-up Minnesota, which beat Washington to become the top-ranked state in 2014, also scored in the top quartile in four of the five categories. Vermont, Oregon and Alaska rounded out the top five states.

Kentucky, Alabama, Mississippi and Tennessee were at the other end of the list, with Indiana at the very bottom. The Hoosier State scored in the last quartile in three of the five categories.

Funding disparities


The lion’s share of Medicaid LTSS funding for seniors and adults with physical disabilities went to nursing homes, the report also found. Furthermore, the amount of Medicaid dollars that states put toward home- and community-based services varied significantly.

Minnesota, for instance, devoted 69% of Medicaid dollars to home- and community-based services, while Alabama put just 14% toward the same services. Overall, just 10 states spent more on home- and community-based services than on nursing homes.

Still, states have made steady, albeit slow, progress in increasing the share of Medicaid spending going toward home- and community-based services. The share increased from 39 percent in 2011 to 41 percent in 2014, the most current year of available data among the states.

More than half of the states (29) showed significant improvement in the percentage of new LTSS users who first received home- and community-based services. Specifically, Montana, Pennsylvania, Maryland, Iowa, Delaware, Louisiana, Vermont and Nebraska showed the most improvement.

But that metric also varied widely, with 30% of new Medicaid beneficiaries first receiving services in their homes and communities in the bottom five states compared with 80% in the top five states.

Slow going across the board

Although most states showed at least some progress in each of the five main categories, the pace wasn’t enough to keep up with demographic demands, the report noted.

The majority of states logged no “meaningful change” related to affordability and access, for instance. The cost of LTSS over time remains significantly more than what middle-income families can afford. Additionally, most adults lack private long-term care insurance.

Another problem relates to the ongoing direct care labor shortage. The number of direct care workers is insufficiently growing to meet the demands of seniors and adults with disabilities who are living at home.

At the current national rate of improvement, the bottom five states for the number of home health and personal care aides would need 34 years to hire enough workers to equal the median state. And the median state would need another 34 years to reach the number of workers in the top five states.

“Overall, states have made incremental improvements, but must pick up the pace of change to meet the needs of a growing number of people aging and living with disabilities,” the report found.

Written by Tim Regan

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