WASHINGTON – AARP’s new Long-Term Services and Supports (LTSS) Scorecard finds that more than three years after the COVID-19 pandemic began, care provided in the United States for older adults and people with disabilities is painfully inadequate. The report finds that major gaps persist in every state, especially related to support for family caregivers, the long-term care workforce, equity in nursing homes, and emergency preparedness.

Minnesota (1^st) and Washington state (2^nd) outperformed all other states in the country, particularly due to strong support for family caregivers, and providing many options in terms of health care providers and long-term care settings. The lowest scoring states were in the Southeast, with Alabama and West Virginia ranking 50^th and 51^st, respectively.

“COVID-19 tested our long-term care systems, and they failed. Now is the time to take the lessons we’ve learned to fix them, for the sake of saving lives,” said Susan Reinhard, Senior Vice President, AARP Public Policy Institute. “AARP’s LTSS Scorecard shows some progress and innovation, but there’s still a long way to go before we have systems that allow people to age well and independently for as long as possible and support the nation’s 48 million family caregivers. It’s also clear some emerging issues deserve more attention – from whether nursing homes are prepared to confront natural disasters, to whether they have plans in place to maintain and grow their workforces.”

Additional key findings from the report include:

Family Caregiving

• Only six states — Georgia, Missouri, Montana, New Jersey, North Dakota, and South Carolina — provide a tax credit for family caregivers’ out-of-pocket expenses. Oklahoma enacted a caregiver tax credit bill in June, after data for the Scorecard was collected. Family caregivers on average spend $7,242 per year on out-of-pocket costs.
• Most states do not have statewide laws protecting caregivers from discrimination in the workplace that ensure they are not unfairly treated due to caregiving duties outside of work. Seven states do have statewide laws — Alaska, Connecticut, Maine, Minnesota, New Jersey, New York, and Wisconsin.
• Twelve states have enacted paid family leave laws and 18 states have paid sick day laws, which can be used for caregiving.
• Dozens of states had declines in the number of care choices that help support families managing caregiving. For instance, 21 states experienced declines of 10% or more in adult day services since 2016, and 16 states had declines of 10% or more in access to home health aides since 2019.

Home and Community-Based Services

• There has been a surge in older adults receiving long-term care at home rather than in nursing homes and other institutions. For the first time, more than half (53%) of Medicaid LTSS spending for older people and adults with physical disabilities went to Home and Community-Based Services (HCBS). This is up from 37% in 2009. HCBS includes support for home health care aides, respite services, assistive technology and home modifications, and other services.
  • The average annual per person cost of home care in 2021 was $42,000.
• Eleven states had state policies that improve presumptive eligibility for Medicaid HCBS at the time of data collection, making it possible for people to go home to receive care after being in the hospital rather than having to be admitted to a nursing home while their eligibility for Medicaid payments is being determined.
• Many states have large numbers of people with low care needs living in nursing homes, indicating a lack of HCBS access and services. More than 20% of residents in Montana, Kansas, South Dakota, Oklahoma, and Missouri have residents with low needs, compared to 9% nationally.

Nursing Homes and Institutional Care

• A major workforce crisis exists in nursing home care. Across all states, wages for direct care workers are lower than wages for comparable occupations; wage shortfalls range from $1.56 to $5.03 per hour, with New York, California, Texas, Louisiana, and Washington, D.C. offering the least competitive wages.
  • Nationally, more than half of nursing staff in nursing homes leave their job within a year (53.9% turnover rate). Montana, Vermont, and New Mexico have the highest averages in staffing turnover.
  • Staffing disparities are a significant challenge. Residents of nursing homes with high admissions of Black residents receive almost 200 fewer hours of care per year compared to residents of nursing homes with high admissions of white residents.
• Nationally, only 22% of nursing home residents live in a facility with a 5-star rating. Gaps in workforce and equity result in persistent problems in care. For instance, about 10% of nursing home residents nationwide experienced a pressure sore. Pressure sores can be life-threatening as they can lead to bone or joint infections, cancer, and sepsis.
• Only nine states have enhanced hazard mitigation plans for natural disasters and other emergencies to address the needs of vulnerable older adults and people with disabilities, including for nursing home residents.
• There is some progress toward innovative and effective alternatives to traditional nursing home models. For instance, 10 states made strides in nursing home innovations, such as by supporting Green House® Nursing Home availability and policies, which includes small facilities, private rooms, and other best practices.

“No one should struggle to navigate care and services for a loved one or themselves in the 21st century,” continued Reinhard. “But right now, that’s a reality for far too many individuals and their families, particularly people of color and people with lower incomes. It’s high time we changed this, and that starts with implementing more supportive and equitable policies at the state level that benefit everyone.”

Recommendations

Key recommendations from the report and AARP to strengthen support for long-term care and aging at home:

• Prioritizing support for the 48 million family caregivers, who are the backbone of the long-term care system, providing over $600 billion in unpaid care, such as with paid leave, tax credits, and other mechanisms to address health and financial needs.
• Investing in all aspects of Home and Community-Based Services infrastructure, such as increasing support and training for home health aides and home visits, supporting the ability to access and use medical devices and equipment, and updating key Medicaid regulations and payment models.
• Bolstering the nursing home and in-home care workforce, with improved recruitment and training, increasing pay, and expanding the ability of trained nurses, aides, community health workers and other paraprofessionals to take on some aspects of care. States can choose to enact and enforce staffing and related care standards.
• Expanding the use of innovative, effective models for nursing homes can improve both quality of care and quality of life, such as with smaller facilities and private rooms.
• Addressing inequities by making investments that close the staggering gaps in access to quality care and facilities and staffing shortages.
• Building multisector plans for aging, coalitions and age-friendly health systems, and consider the wider needs to allow individuals to live independently in their homes and communities, such as having affordable and accessible housing and transportation, improved community design, and comprehensive emergency preparedness plans.
• Advancing innovation in cities, counties and states by supporting comprehensive state- and community-wide aging plans and pilo,ting new approaches and programs, like Green House® Nursing Homes and presumptive eligibility, that can then be scaled.
• Ensuring every state in the nation has a sound emergency preparedness plan to support nursing home residents, in particular, in times of crisis – including natural disaster.

The Scorecard includes a series of 50 indicators focused on 1) affordability and access; 2) choice of setting and provider; 3) safety and quality; 4) support for family caregivers; and 5) community integration, using data from a variety of publicly available sources, such as the Centers for Medicaid and Medicare Services, American Community Survey, and Bureau of Labor Statistics.

The LTSS Scorecard is a charitable project made possible by a grant from AARP Foundation, with support from The SCAN Foundation, The Commonwealth Fund, and The John A. Hartford Foundation, and has been updated every three years since 2011.

"Every person, regardless of where they live, their race, or their socioeconomic background, deserves long-term care that is accessible, safe, and prioritizes what matters most to them,” said Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation. “The Scorecard shows that there are significant regional and racial disparities in the care a person receives. State policymakers can and should take steps now to close the gap in access to quality care.”

"The LTSS Scorecard indicates progress in some state programs, but opportunities exist for both public and private sectors to enhance LTSS,” said Sarita A. Mohanty, MD, President and Chief Executive Officer of The SCAN Foundation. “Most older adults prefer home and community-based care that meets their needs, but it remains financially out of reach for many working-class families, particularly those who are part of the 'forgotten middle'. TSF is committed to identifying, highlighting, and elevating innovative policies and programs to ensure all older adults can age well in home and community."

“Equity is an essential component of high-quality health care, and is especially important in LTSS,” said Melinda Abrams, Executive Vice President, Programs, The Commonwealth Fund. “I am thrilled AARP was able to add race and ethnicity data for several indicators. This year and going forward, this new data will shed light on the experiences people of color in LTSS and draw attention to individuals with the greatest need.”

To view the full Scorecard and state-by-state information visit ltsschoices.aarp.org.

State Rankings:

• Tier One: 1: Minnesota; 2: Washington state; 3: District of Columbia; 4: Massachusetts; 5: Colorado.
• Tier Two: 6: New York; 7: Oregon; 8: Hawaii; 9: Vermont; 10: New Jersey; 11: California; 12: Rhode Island; 13: Connecticut; 14: Maryland; 15: Wisconsin; 16: Maine.
• Tier Three: 17: Delaware; 18: Nebraska; 19: North Dakota; 20: New Mexico; 21: Pennsylvania; 22: Arizona; 23: Iowa; 24: New Hampshire; 25: Illinois; 26: Alaska; 27: Indiana; 28: Virginia; 29: Utah; 30: Kansas; 31: Michigan; 32: Ohio; 33: Montana; 34: Texas; 35: Idaho.
• Tier Four: 36: South Dakota; 37: Arkansas; 38: Missouri; 39: Georgia; 40: Wyoming; 41: North Carolina; 42: Kentucky; 43: Florida: 44: Nevada; 45: Louisiana; 46: Oklahoma.
• Tier Five: 47: Tennessee; 48: Mississippi; 49: South Carolina; 50: Alabama; 51: West Virginia.

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About AARP
AARP is the nation's largest nonprofit, nonpartisan organization dedicated to empowering people 50 and older to choose how they live as they age. With a nationwide presence, AARP strengthens communities and advocates for what matters most to the more than 100 million Americans 50-plus and their families: health security, financial stability and personal fulfillment. AARP also produces the nation's largest circulation publications: AARP The Magazine and AARP Bulletin. To learn more, visit www.aarp.org/about-aarp/, www.aarp.org/español or follow @AARP, @AARPenEspañol and @AARPadvocates on social media.

About AARP Foundation

AARP Foundation works to end senior poverty by helping vulnerable people over 50 build economic opportunity. Our approach emphasizes equitable outcomes for populations that have faced systemic discrimination. As AARP's charitable affiliate, we serve AARP members and nonmembers alike. Through vigorous legal advocacy and evidence-based solutions, and by building supportive community connections, we foster resilience, advance equity, and restore hope. To learn more, visit aarpfoundation.org or follow @AARPFoundation on social media.

About The SCAN Foundation

The SCAN Foundation envisions a society where all of us can age well with purpose. We pursue this vision by igniting bold and equitable changes in how older adults age in both home and community. For more information, visit www.TheSCANFoundation.org.

About The Commonwealth Fund

The Commonwealth Fund, among the first private foundations started by a woman philanthropist—Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. For more information, visit: https://www.commonwealthfund.org.

About The John A. Hartford Foundation

The John A. Hartford Foundation, based in New York City, is a private, nonpartisan, national philanthropy dedicated to improving the care of older adults. The leader in the field of aging and health, the Foundation has three areas of emphasis: creating age-friendly health systems, supporting family caregivers, and improving serious illness and end-of-life care. For more information, visit: https://www.johnahartford.org.