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Passing responsibilities down to lower levels of government should be undertaken primarily to place services closer to the people being served and to maximize administrative

When economic conditions permit, states should accumulate budget reserves adequate to maintain services during recessions.

Deficit-reduction efforts should avoid cuts in programs that serve low- and moderate-income populations. 

States should not tie essential spending programs to unstable revenue sources. 

Federal policymakers should develop a comprehensive system for financing Long-Term Services and Supports (LTSS) that includes a new social insurance program to provide a basic level of LTSS.

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

States should require that all beds in a nursing facility be certified for Medicaid and Medicare as a condition for the facility’s participation in Medicaid. 

States should require adequate numbers of appropriately trained staff to ensure a high quality of care.

Quality measures: Participant preferences and satisfaction should be used as key quality measures.

The Centers for Medicare & Medicaid Services, the states, and all other regulators should vigorously enforce all regulations in long-term services and supports (LTSS) facilities and home care w