Citation URL: http://www.urban.org/SusanMGoldenson

Alabama is a fairly small Southern state with substantial low-income and minority populations. The Medicaid program is heavily dependent on intergovernmental transfers and provider taxes to fund the state share and funding crises have been routine. By and large, Alabama's Medicaid program relies on minimum federal requirements to determine eligibility and coverage policy. Most of Alabama's social programs are severely constrained because of the relatively limited tax base, the fact that most tax revenues are earmarked for education, and the strong anti-tax sentiment of the state. The low levels of revenue leave policymakers with little choice but to provide health and welfare benefits at fairly minimal levels.

During 1993 and 1994, the United States debated but did not enact major health reform. Many proposals included substantial long-term care initiatives. In designing its long-term care proposal, the Clinton Administration addressed many of the basic policy choices that must be decided in all long-term care efforts. (Milbank Quarterly 2001 June; 79(2); 207-252).

The need for long-term care assistance affects people of all ages, not just elderly populations. Accordingly, this chart book provides relevant information on long-term care assistance for all people with disabilities, using a variety of state and federal data sources. Using this chart book, policymakers, researchers, advocates, and practitioners will be able to understand the scope of the long-term care system. Information is organized into three major categories: consumers, providers, and financing.

Indiana, a midwestern state with about 6 million people in 1999, provides home and community services to about 2,300 beneficiaries through its Aged/Disabled Medicaid waiver and an additional 10,000 persons with disabilities through its state-funded Community and Home Options to Institutional Care for the Elderly (CHOICE) program. The Medicaid waiver and the CHOICE program rely on an agency-based model for provision of home care services; with CHOICE providing a particularly flexible set of services. The state also funds two small programs that provide supplemental payments to people in board and care homes.

This paper analyzes the ability of rural communities to maintain health care services for their residents in a changing health care environment. In addition to the constantly evolving health care marketplace, factors that influence the structure and strength of the rural health care safety net include demography, geography, and policies at the federal, state, and local levels. The safety net in rural areas generally includes almost all local providers. Therefore, maintaining the safety net in rural communities strengthens the entire health care infrastructure. The study describes the health care safety net in 11 rural counties in five states (AL, MN, MS, TX, and WA).

Initiatives to increase the purchase of private long-term care insurance have achieved only modest success. Affordability is arguably the principal barrier to purchase, but lack of knowledge about the need for long-term care, misinformation about Medicaid coverage, and competing priorities also play a role. While private insurance can do more than it does now, the authors conclude that it is unlikely to finance more than a small proportion of long-term care expenses. The public policy question becomes: What should society do about the large majority of disabled older persons who have no private long-term care insurance?

Initiatives to increase the purchase of private long-term care insurance have achieved little success. Affordability is arguably the principal barrier to purchase, but lack of knowledge of the need for long-term care, misinformation about Medicare coverage, and competing priorities play a role. While private insurance can do more than it does now, the authors conclude that it is unlikely to finance more than a small proportion of long-term care expenses. (The Elder Law Journal 2000 January; 8(1); 57-102).

Many states have responded to growing Medicaid long-term care expenditures by limiting the number of nursing home, home health, and nonmedical residential facilities through certificate-of-need (CON) programs and moratoria on new construction. This report focuses on the use of CON programs and moratoria as a long-term care cost-control strategy in the 13 states which are the focus of the ANF study. These programs typically focus on nursing home beds. While this strategy may be effective in the short-to-medium term, states must also consider the needs of an aging population.

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