The Best and Worst States for Long-Term Care

Report: Even Among the Top Performing States There Is Room for Improvement

Reviewed by Laura J. Martin, MD on September 08, 2011

Sept. 8, 2011 -- Geography determines the type of long-term care available to Americans, a new report suggests.

The "scorecard" report finds that states vary widely in the services they provide to the elderly, to disabled adults, and to the family caregivers who support them.

"Our intention is that this scorecard will begin a dialogue among key stakeholders so that lagging states can learn from top performers and all states can target improvements where they are most needed," the authors write.

The scorecard is a collaboration between the AARP's Public Policy Institute, the Commonwealth Fund, and the Scan Foundation. It ranks states' performance according to four categories:

  1. Affordability and access
  2. Patient choice of both provider and setting
  3. Quality of life and care
  4. Support for family caregivers

The Best and the Worst

Overall, the five states that scored the highest were:

  1. Minnesota
  2. Washington
  3. Oregon
  4. Hawaii
  5. Wisconsin

The lowest scores went to:

  1. Mississippi
  2. Alabama
  3. West Virginia
  4. Oklahoma
  5. Indiana

A list of all the states can be found at

The authors of the report point out that even the states with the highest scores need to improve the services they provide. They also note that each of the lowest ranked states performed well in at least some of the categories measured.

"There was wide variation across the states as well as within states," Bruce Chernof, MD, FACS, president and CEO of The SCAN Foundation, told reporters during a telebriefing.

Affordability and Accessibility

Long-term care is unaffordable for middle income families, according to the report. Even in states where nursing home care is most affordable, such care averages 171% of an older person's household income. The national average is 241%.

For home care, the numbers are less staggering. But at an average of 88% of income nationwide, they still put a great stress on household means.

"We looked at affordability, and it's just not affordable," Susan Reinhard, senior vice president for public policy at AARP, told reporters.

Accessibility is also an issue. As the report points out, states have a great amount of flexibility when it comes to determining Medicaid eligibility.

The numbers reveal how well their different systems work. The top five states cover an average of 63% of their low- to moderate-income population that requires long-term care. The worst states cover only 20%. The nationwide average is 37%.

"States need to streamline eligibility rather than make it complicated to get into the system," Reinhard told reporters.

Most people, the authors write, prefer receiving care in their home or in a home-like setting in their community that affords them some measure of independence.

Choice, however, is in short supply in the worst states. In those states, only 26% of new Medicaid recipients benefit from home or community-based support (HCBS). By contrast, more than three-quarters of those receiving Medicaid in the five best states opt for HCBS.

Quality of Life and Care

Ninety-one percent of adults with disabilities report that they are satisfied with their quality of life in South Dakota, Alaska, North Dakota, Hawaii, and Nebraska -- the top five states for this category. The lowest scoring states had an 81% satisfaction rate. In North Dakota, 57% of such adults held a job, the highest rate in the country. In the worst states, less than a fifth of disabled adults were employed.

Quality of care also varied greatly. One marker of nursing home care quality is the presence of pressure sores, which develop on the skin due to lying in bed without moving for extended periods. They can lead to dangerous, sometimes fatal infections. In 2008, 16% of long-stay nursing home patients in the five worst states had such pressure sores, compared to 7% in the top states. The national average was 12%.

Another measure of the quality of care is nursing home staff turnover. In the bottom states, nearly three-quarters of staff at such institutions changes each year. That's compared to 27% in the top states (Connecticut, Illinois, South Carolina, Rhode Island, and Hawaii).

Supporting Family Caregivers

The report's authors believe that support for caregivers, whether social, emotional, or legal, is an essential part of long-term care. They write that states that score highly in this category generally score highly in most other measures.

The authors urge states to offer more sick leave to caregivers than required by the federal Family and Medical Leave Act as well as adopting services that will help make their work less burdensome.

"We hope that this scorecard serves as a baseline or tool for improvement," Mary Jane Koren, MD, MPH, vice president of long-term care quality improvement at the Commonwealth Fund, told reporters.

The improvements the authors envision could be quite significant. For example, if all states performed as well as Minnesota, more than 120,000 hospitalizations would be avoided. That translates to $1.3 billion in health care savings. And if they all had public safety nets as effective as that of Maine, more than 667,000 people would be covered by Medicaid or other publicly funded programs.

The authors acknowledge that the report leaves many questions unanswered. For example, they were unable to address such issues as access to transportation and how well long-term services and support are coordinated with both primary and acute care. For many such questions, there was inadequate data.

"You can't improve what you can't measure," Koren told reporters.

Show Sources


Bruce Chernof, MD, FACS, president and CEO, The SCAN Foundation.

Susan Reinhard, senior vice president for public policy, AARP.

Mary Jane Koren, MD, MPH, vice president of long-term care quality improvement, Commonwealth Fund.

Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers.

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