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Minnesota Tops New AARP Long-Term Care Scorecard; Other States Lag Behind

More than 3 years after the pandemic started, long-term care is still not recovering

spinner image caregiver pushing an older man in a wheelchair two hands holding a younger and an elderly hand and a woman with a prosthetic leg and crutches to show the range of medicaid long term care
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If you’re a family caregiver who is keeping score — even more than three years since the pandemic walloped the world — the score is still COVID 1, Caregivers 0.

That is the conclusion of AARP’s new comprehensive Long-Term Services and Supports (LTSS) Scorecard, which sprinkles bits of hope along with torrents of recommendations and warns that major gaps in long-term care for older adults persist in all 50 states long since COVID tossed a societal money wrench into the nation’s caregiving system. 

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At issue: The long-term care system has mostly failed to rebound even more than three years after COVID-19 began. This is the first LTSS Scorecard that crunches data — using a variety of publicly available sources, such as the Centers for Medicaid and Medicare Services, the Census Bureau’s American Community Survey and the Bureau of Labor Statistics — from the very height of the pandemic and beyond. Even as the cost of home care has greatly increased, the availability and quality of direct care workers have suffered, the report concludes.

“What’s taking so long?” asks Susan Reinhard, the AARP senior vice president who directs its Public Policy Institute. “If COVID hasn’t taught us that you need to support family caregivers, what more do you want to happen?”

spinner image nationally an average of fifty three percent of nursing staff in nursing homes leave their job within a year some states have even higher turnover such as montana with over sixty two percent new mexico and vermont with  over sixty one percent

Even then, two stalwart states in particular — Minnesota and Washington — and the District of Columbia have continued to innovate with unique ways to support family caregivers at the state level, says the report, which was three years in the making.

The LTSS Scorecard — 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— has been updated every three years since 2011. It is an innovative mechanism to encourage each of the 50 states to carry its own long-term caregiving weight by ranking the states from best to worst in long-term care services. The data-rich report factors in everything from family care services to the long-term care workforce to equity in nursing homes to emergency preparedness.

Minnesota (ranked first), Washington (second) and the District of Columbia (third) led the way, primarily due to their strong support for family caregivers. South Carolina (ranked 49th), West Virginia (50th) and Alabama (51st) are at the very bottom of the LTSS Scorecard.

Urging all states to improve

States ranked at the very top tend to have very strong leadership both inside government and in the private sector who have made the issue of long-term care reform a priority, Reinhard says. Those ranked near the bottom tend to be laggards in caretaking innovation.

“Long-term care is the stepchild of health care,” Reinhard says. “No one likes to think about it. No one likes to think about being a family caregiver.” 

But the LTSS Scorecard, she says, is forcing every state to look at the difficult issue by compiling stats that the states cannot ignore. Then, by ranking the states publicly in so many data-driven categories, AARP is essentially setting off a competition whose ultimate goal is to encourage all to improve.

The overarching problem, of course, is that the U.S. has no national plan for long-term care, says Reinhard. So each state must step in and try to dig into the issue on its own. And, from time to time, signs of progress have sprouted as a result. For example, Reinhard says, since the LTSS Scorecard started, most states now focus their long-term care budgets on home-based and community-based care — where most prefer care and the dollar goes further — not nursing home care. That, she says, is real progress.  And, yes, COVID certainly played a role in directing this change.

spinner image as of twenty twenty fifty three percent of medicaid long term services and support spending for older people and adults with disabilities went to home and community based support services

But in a nation with 48 million family caregivers, the sheer weight of COVID has simply been too oppressive for the long-term caregiving system to quickly recover, Reinhard says. “COVID-19 tested our long-term care systems — and they failed,” she says.

For example, she says, as a result of COVID, adult day care centers nationwide remain in serious decline. Many of these centers, which give adults a safe and familiar place to be during the day, closed during the pandemic and never reopened. These centers not only benefit the clients, they also give family caregivers a break during the day. “When you close a business like this, it’s hard to reopen,” she says.

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She compares this situation to the many restaurants that shuttered during COVID and never resumed service. Not only were they unable to stay financially afloat, but they were also unable to attract staff to return when the pandemic subsided. Adult day care centers — many of which are small businesses — suffered a similar fate, she says.

“We have to reinvest in operations like this that suffered because of COVID,” she says.

Even then, there are improvements to be made. The LTSS Scorecard offers these key recommendations for states to improve their support for long-term care:

  • Bolster the workforce. Nursing homes and in-home care workforces need to improve recruitment and training and increase pay in order to attract and retain skilled workers.
  • Expand innovative models. Effective nursing home models with smaller facilities and private rooms can improve the quality of care and the quality of life.
  • Address inequities. Make investments that close the gaps in access to quality care facilities.
  • Support family caregivers. Prioritize support for family caregivers with paid leave and tax credits to assist with financial needs.
  • Invest in caregiver infrastructure. Increase support and training for home health aides and home visits and update key Medicaid regulations.
  • Build coalitions. Support age-friendly health systems that allow individuals to live independently with things like affordable housing and accessible transportation.
  • Support innovation.  Create comprehensive aging plans that can offer new approaches with things like smaller, more guest-friendly nursing homes.
  • Mandate emergency plans. Develop sound emergency preparedness plans in every state to support nursing home residents in times of crisis.
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Take initiative

So, what can concerned people do?

Make their voice heard, says Reinhard. Perhaps the single most impactful action is to let representatives at your state legislature know if you are unhappy with where your state ranks on the LTSS Scorecard.

Some years ago, when Reinhard was a new mother, she was upset about a toxic site that she read about that was relatively close to her home. She called her state senator to complain — never expecting to hear a response. The next thing she knew, however, he was on the phone speaking with her.

“I was stunned,” she said. “But when it’s your district, they want your vote.”

She came to realize that very few folks take the initiative to do this kind of outreach. “So those who do something can actually have a loud voice,” she says.

Wonder where your state ranks?

The LTSS Scorecard divides states into five tiers based on a series of 50 indicators in areas such as affordability, safety and family caregiver support.

Here are the 2023 AARP Scorecard state rankings:

  • Tier 1: 1) Minnesota; 2) Washington state; 3) District of Columbia; 4) Massachusetts; 5) Colorado.
  • Tier 2:  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 3: 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 4: 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 5: 47) Tennessee; 48) Mississippi; 49) South Carolina; 50) Alabama; 51) West Virginia.

For a deeper dive into how each individual state ranked, go to: Long-Term Services & Supports State Scorecard.

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