Achieving Comprehensive Long-Term Services and Supports Reform


The U.S. needs a system that provides universal access to a comprehensive range of health care services and long-term services and supports (LTSS).

The LTSS component of the system, provide affordable, coordinated, high-quality LTSS to offer consumers choices and give support to family caregivers. New sources of both public and private financing are critically important to develop a new system.


Developing a comprehensive long-term services and supports system

In this policy: FederalState

A long-term services and supports (LTSS) program should be part of a comprehensive system that provides universal access to a range of LTSS and health care services and supports family caregivers.

Federal policymakers should develop a comprehensive system for financing LTSS that includes a new social insurance program that provides a basic level of LTSS. To ensure an adequate level of comprehensive services, the program should be designed to function seamlessly with a mix of other financing sources, including private long-term care insurance, individuals’ out-of-pocket expenditures, and Medicaid for individuals with low incomes.

The public and private sectors, including the Social Security Administration, the Centers for Medicare & Medicaid Services (CMS), and health insurance carriers should educate consumers and their families about their risk for needing LTSS, the lack of coverage for LTSS through Medicare and health insurance, and all options for financing LTSS.

With better education, consumers can understand their options and responsibilities and make informed choices that are best suited to their needs and circumstances.

New funding sources, including a new publicly financed social insurance program

In this policy: FederalState

The cost of a new social insurance LTSS program should be paid for with premiums, individual contributions through cost-sharing requirements, and general revenues.

The criteria for evaluating LTSS financing proposals should include the extent to which they are progressive, broad-based, stable, affordable, and capable of growing with enrollment.

The federal government should finance LTSS through a universal, comprehensive, publicly administered program such as Medicare, or a similar social insurance program of shared risk.

Such a program should be part of a comprehensive system that provides universal access to a range of health care services and LTSS. The program should emphasize the independence, dignity, autonomy, and privacy of individual consumers so that they can maximize their physical and psychosocial potential.

Progressive financing and low-income protections

In this policy: FederalState

Because a contribution equal to the full actuarial cost of the LTSS benefit is too expensive for many Americans, the financing provisions must take into account affordability and must be sustainable for the program overall.

Beneficiary cost-sharing for either community or institutional services should be modest and not favor one type of service over another. Public funds should pay for individuals who cannot afford to contribute to cost-sharing in order to protect people with low incomes.

Adequate financing and reserves

In this policy: FederalState

Some tax revenues for a new LTSS program should be earmarked for an LTSS trust fund to build adequate reserves to cover later generations. The new LTSS program should require some maintenance of states’ current spending on LTSS to help defray the federal government’s costs.

A financing package should adequately deal with transition costs as a new program is phased in since many older adults and people with disabilities would be eligible for benefits before a large reserve fund could be built up.

Ensuring essential features of a long-term services and supports social insurance program

In this policy: FederalState

Benefits should be designed to enable consumers to choose services they deem most appropriate for their needs.

Strong federal and state oversight should be provided to ensure the equitable treatment of all people eligible to receive services. People must have equal access to services regardless of payer.

Care management should be used to coordinate health care and LTSS for people who need both types of services. Care management should be conflict-free, multidisciplinary, and available to all, regardless of payer.

The system should build on states’ experiences or require state and local agencies to have a major role in running any new program.

States should be required to implement a single point of entry for LTSS that can determine financial and program eligibility and authorize services in a prompt and timely fashion.

Assessments to determine eligibility for services should measure the need for assistance caused by functional limitations and the need for assistance with activities ofADLs or Activities of Daily Living are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. IADLs or Instrumental Activities of Daily Living are activities related to independent living and include preparing meals, managing money, shopping for… daily living and instrumental activities ofADLs or Activities of Daily Living are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. IADLs or Instrumental Activities of Daily Living are activities related to independent living and include preparing meals, managing money, shopping for… daily living without regard to whether the person being assessed has family who can assist with the care. It should also measure the need for supervision due to cognitive or mental impairment and behavioral problems, long-term nursing services, and medical management.

Federal and state governments should use a standardized assessment in a consistent manner to determine beneficiaries’ needs.

A full range of home- and community-based services should be provided to delay or prevent institutionalization and help to control overall LTSS costs. These services include but are not limited to personal care in the home, case management, respite care, adult day services, accessible transportation, and supportive housing.

Consumer-directed LTSS should always be available, promoted, and supported, regardless of payer or provider. Federal and state agencies should offer consumers the option of a cash payment to select and manage their LTSS.

The program must have strong consumer protection standards and enforcement mechanisms.
There is evidence that many consumers who receive a cash benefit manage their LTSS more economically than those who receive benefits under an agency-administered model.

Services from all providers should be designed and delivered in a way that promotes independence.

The program should not provide financial incentives to use one type of care over another.

If federal and state governments use capitated payment systems, they should require strong consumer protection standards. Capitated rates must be sufficient to meet the needs of those served and allow consumers to choose the services that best meet their needs.

Intermediate steps for achieving comprehensive reform

In this policy: FederalState

Until a comprehensive national LTSS program is implemented, there are intermediate steps which should be taken.

The federal government should create a public social insurance benefit, either within Medicare or in a new public program that provides some level of coverage to protect consumers who need LTSS.

States should implement LTSS programs that are affordable for those who do not meet Medicaid’s eligibility requirements but who still cannot afford LTSS.

Coordination should be improved among LTSS programs and between the health care and LTSS systems for people who need services from both.

Services in consumer-preferred settings—primarily in the home and community—should be expanded. Services that support family caregivers’ ability to continue providing care should be included in the expansion.

Adequate oversight

In this policy: FederalState

The federal and state government should conduct regular, thorough, and consistent oversight to ensure consumers’ quality of care and quality of life, and to protect their rights in all LTSS settings. Oversight should include evaluation of clients’ outcomes to the extent feasible.

Consumer focus

In this policy: FederalState

Consumers and their family caregivers, as appropriate, should be the focus of all LTSS programs and services.

LTSS consumers, including those from diverse communities, should participate in all aspects of program development, implementation, and oversight.

Consumersto the extent they are capableor their caregivers or legal representatives should have the option to make decisions about the LTSS they receive and manage their own services and supports.

Improving coordination with other health programs

In this policy: FederalState

Medicare coverage of health services for those with chronic illnesses and disabling conditions should be improved (see also Chapter 7, Health - Health Care Coverage—Medicare and Chapter 7, Health - Reforming the Delivery of Health Care Services—Chronic Care Coordination, Accountable Care Organizations) and medical care management should be used to coordinate health care and LTSS for people who need both types of services. Care management should be conflict-free, multidisciplinary, and available to all, regardless of payer.

Covered services should be fully portable so people can receive them in a wide range of settings.

The effects of integrating other public LTSS programs, such as state-funded and Department of Veterans Affairs programs, into a new system should be carefully considered to ensure that program changes enhance participant access. Existing programs should receive adequate federal funding to ensure veterans’ access to LTSS.

Flexible, innovative, and efficient administration

In this policy: FederalState

A reformed LTSS system must have an administrative structure capable of meeting the needs of diverse and growing numbers of beneficiaries.

Expanded access to home-and community-based services

In this policy: FederalState

Eligibility for services should be based on how LTSS relate to an individual’s functional needs, chronic illness, and medical conditions.

Medicare’s potential role in meeting beneficiaries’ LTSS and medical needs should be reexamined and expanded to assist people who depend on family caregivers. It should include improved home health care and skilled-nursing facility benefits, personal care designed to help people with ADLs, and adult day care and other caregiver support services, such as assessment of caregiver needs, education and training, and respite care.

Improved Medicaid benefits should serve as an LTSS safety net for vulnerable populations with low incomes and few assets and for those who become impoverished because of medical or LTSS needs.

Services provided through the Older Americans Act and Social Services Block Grants should receive adequate funding because they are important to the home- and community-based LTSS system.

Conflict-free care management should be available through public agencies to help individuals and their families access the full range of LTSS.

Improved long-term care insurance

In this policy: FederalState

Long-term care insurance should be subject to stronger consumer protections and greater standardization so that consumers can make informed comparisons among policies.

Phased-in coverage

In this policy: FederalState
A comprehensive new program can be introduced gradually. The program should cover people who currently need services and build an adequate program for future generations through a range of financing resources.

Appropriate services

In this policy: FederalState

Avoiding unnecessary institutionalization by providing home- and community-based services—such as home care, conflict-free care management, personal care, respite care, adult day services, and supportive housing—is one of the most important and effective ways to control the costs associated with LTSS (see also Expanding Home- and Community-Based Services in this chapter).

In order to help control LTSS costs, federal and state governments should use a standardized assessment in a consistent manner to determine the beneficiary’s needs. The assessment should inform the care plan in addressing the person’s goals and needs. Longitudinal information from this assessment should be used to evaluate client outcomes and monitor quality of care. A universal core of assessment items should be developed and implemented across health care and LTSS systems so that consumer outcomes can be tracked.

Improving data collection

In this policy: FederalState

Federal and state governments should ensure that standardized systems collect data on service use, costs, and quality, particularly for Medicaid and Medicare. Accurate and timely LTSS data are central to evaluating services and client outcomes and making sound policy decisions regarding the cost-effective allocation of financial resources.

Curbing fraud and abuse

In this policy: FederalState

Federal and state governments should adequately fund Medicaid fraud and abuse units, as well as investigate and prosecute providers in any services and supports setting who defraud Medicaid or abuse beneficiaries.

Conflict-free care management

In this policy: FederalState

Conflict-free care management should ensure effective and efficient coordination of high-quality client services.


In this policy: FederalState

Organizations and governmental agencies that provide any care management, including health maintenance organizations and social health maintenance organizations, should share the financial risk of cost overruns and the financial rewards of effective cost containment. Effective governmental oversight (e.g., periodic audits and look-back surveys) must be in place to help prevent conflicts of interest within the care management system.

Private payments

In this policy: FederalState

Any social insurance program should be supplemented by private payments and ensure protections for people with low incomes.