“Home care, meals, help for Alzheimer’s caregivers­—all help the state save money by keeping people out of nursing homes, and that’s a message we want to take to legislators,” says Randy Hunt, CEO of the Senior Resource Alliance, an area office on aging in Orlando. Hunt knows that lawmakers now working on Florida’s 2010 budget are staring at an estimated shortfall of $5 billion.

In the coming months, states will be looking for sources of new revenue—higher taxes on cigarettes, sales taxes on the Internet, increased traffic fines—and trying to find the least harmful cuts they can make. Reluctant to chop a whole program or service, lawmakers may freeze or cut fees to those who provide the services, including not only nursing homes and hospitals, but also agencies that supply home care workers and health aides. Such cuts, though, eventually tend to translate into problems of access and quality of care, says Nick Johnson, director of the state fiscal project for the CBPP.

Unfortunately, even the economic stimulus package assembled by Congress and President Obama—with its billions of dollars of state aid, including more than $87 billion for state aging and Medicaid programs—does not fully protect these home and community long-term care services. “The stimulus money will give states a baseline, so cuts may not have to be so drastic,” says Donna Folkemer, group director for health at the NCSL. “But it probably won’t allow new programs or even help them to hold on to all the current programs.”

And standing still can be moving backward. Consider Florida. While its Community Care for the Elderly escaped cuts this year, for nine years it has gone without a budget increase while its target population of older residents has grown by 700,000, according to Jack McRay, advocacy manager at the AARP Florida state office in Tallahassee. Today, 50,000 older Floridians are on waiting lists for these kinds of home services, state experts say, and 2,272 people died last year while on lists.

Those numbers worry Shirley Miller, who, up until she was 80, earned extra money by working the night shift at the reception desk of her apartment building. “When you’ve been independent all your life, you don’t want to ask for help,” Miller says. “But I just can’t keep up anymore. I need help.”

Barbara Basler is a senior editor at the AARP Bulletin.

Illustration by Gerald Dubois