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In Brief: A Balancing Act: State Long-Term Care Reform

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Positive transformational change of Medicaid's LTSS system requires a philosophy that embraces the right of people with disabilities to live in the least restrictive environment; effective leadership; a creative problem-solving attitude that can find innovative ways to work within existing laws; and innovative ways to encourage federal policy makers to waive or overturn rules that hinder states' ability to balance their service delivery in favor of HCBS.


The ability of some states to accomplish substantial reforms demonstrates that obstacles to change can be overcome.

Change can be accelerated and supported by adopting federal and state policies that:

  • Allow consumers to receive services in the setting of their choice.
  • Adopt nursing home diversion programs that prevent people from ever entering a nursing home.
  • Eliminate waiting lists for HCBS.
  • Offer a range of residential choices.
  • Support family caregivers.
  • Facilitate states' ability to establish a unified global budget for funding LTC.
  • Consolidate LTC programs, policies, and budgets in one state agency.
  • Put a moratorium on Medicaid regulations that hinder states' ability to help individuals leave nursing homes and transition to HCBS.
  • Eliminate Medicaid's institutional bias.
  • Increase affordable public and private financing options to give people more choice and control over the services they need.
  • Explore offering states financial incentives to accelerate the pace of change in shifting more Medicaid spending to HCBS.


Written by Enid Kassner, Susan Reinhard, Wendy Fox-Grage, Ari Houser and Jean Accius, AARP Public Policy Institute; Barbara Coleman and Dann Milne, Consultants.
July 2008
©2008 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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