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Best and Worst States for Long-Term Care

A new ranking shows big variations in affordability, quality and choices

By Richard Eisenberg and SCAN Foundation

Editor's note: This article is part of a year-long project about aging well, planning for the changes aging brings and shaping how society thinks about aging.

Most Americans over 65 will need long-term care at some point. But its affordability, where they’ll get the care (for instance, nursing home or at home) and — most important — the quality of their care? Well, that depends on the state they live in, according to a new study by AARP, the SCAN Foundation and The Commonwealth Fund.

“Where you live is still the best predictor of the services you will receive when and where you need them,” according to the 2014 State Long-Term Services and Supports (LTSS) Scorecard, an updated version of the researchers’ 2011 ranking.

The Best and Worst States

Residents in Minnesota, Washington, Oregon, Colorado, Alaska, Hawaii, Vermont and Wisconsin have the best long-term care services and supports (LTSS), based on the scorecard’s number crunchers.

The worst states? They’re mostly in the South: Kentucky, Alabama, Mississippi, Tennessee and, the outlier, Indiana.

You can find the full ranking at

(MORE: Are You Set to Pay a $262,800 Nursing Home Bill?)

“Overall, about eight states are doing very well and the rest have a long way to go,” said Susan Reinhard, one of the study’s authors, who is Senior Vice President of Public Policy at AARP. “Even the top eight can do much better.”

Our Lack of Long-Term Care Planning

Most of us in our 40s, 50s and 60s can do a much better job planning for, and talking about, potential long-term care needs, too.

Some 65 percent of Americans 40 and older have done little or no planning for their own needs for ongoing living assistance, according to a recent poll by the AP-NORC Center for Public Affairs Research.

That survey also found that just 41 percent of people over 40 have discussed with their family their preferences for the kinds of ongoing living assistance they want and only 35 percent have set aside money to pay for long-term care.

Never mind that the median annual rate of a private room in a nursing home is now $87,600; an assisted-living room costs $42,000 a year and a home health aide for long-term care runs $45,188 annually, on average, according to the recent Genworth Cost of Care Survey. Or that some long-term care insurers have been reducing benefits, denying claims and socking policyholders with double-digit annual rate hikes. (Next Avenue has a series of articles to help you make long-term care plans: SPECIAL REPORT: Transforming Life As We Age. The report is supported by a grant from The SCAN Foundation.)

How States Were Ranked

To come up with its ranking of the 50 states and Washington, D.C., the Scorecard analysts reviewed data for 26 indicators in five broad categories: Affordability & Access; Choice of Setting and Provider; Quality of Life and Quality of Care; Support for Family Caregivers and — a new category for 2014, Effective Transitions (how disruptive it is for someone to move between care settings such as home, hospital and nursing home).

(MORE: Why Long-Term Care Is Headed for a Crisis)

“We wanted to see if we could get a great system going in the states, what would it look like,” said Reinhard. “And we wanted to put a spotlight on the areas that states should zero in on.”

Overall, the study found that states relying heavily on nursing homes for long-term care also “demonstrate less effective transitions across care settings.” Translation: “People with complex needs getting care at home or in nursing homes are more likely to experience inappropriate and costly hospitalizations and inadequate support in moving from a nursing home back into the community,” the report said.

Best and Worst By Category

The top and bottom locales for each category:

Affordability and Access: Washington, D.C. was best; Kentucky was worst

Choice of Setting and Provider: Minnesota was best; Alabama was worst

Quality of Life and Quality of Care: Minnesota was best; Oklahoma was worst

Support for Family Caregivers: Hawaii was best; Indiana was worst

Effective Transitions: Oregon was best: Louisiana was worst


Medicaid 'Safety Net' Fraying

The strength of the Medicaid “safety net” also varies wildly among states, the report found.

“If you spend all your money for long-term care services that Medicare doesn’t pay, the Medicaid safety net is supposed to catch you,” said Reinhard. But, her report noted, “each state has extensive flexibility with regard to eligibility and services provided by the Medicaid safety net, including both the level of income and assets a beneficiary can retain and still qualify for coverage.”

(MORE: How to Get Good Long-Term Care Coverage)

Where There's Been Improvement

Compared to 2011, Reinhard said, there have been a lot of “positive, incremental changes.” For example, the number of home health and personal care aides per 1,000 residents age 65+ rose in 36 states since the last survey and nursing home staffing turnover got better in 31 states.

Also, more states have been enacting laws to support family caregivers. Just today, Oklahoma signed into law the CARE Act, legislation that would, among other things, requiring hospitals and rehab centers to record the names of family caregivers when their loved ones are admitted and notify them if they’ll be discharged to another facility or released to their home. (Other states, such as Hawaii, Illinois and New Jersey are working to get similar laws passed.)

Affordability Still A Big Problem

But the affordability of long-term care did not improve in any state since 2011. The original survey found that the cost of long-term care services and supports was unaffordable for middle-income families in all states and the same is true today. The cost of nursing home care “remains far out of reach for middle-income Americans in every state,” the report noted.

Reinhard said the states at the top of the ranking score so well for a variety of reasons. “They have a strong philosophy” about long-term care and “take to heart that people want to live at home and that caregivers need training,” she said. Also, Reinhard added, these states are “committed to getting out information to help people make long-term care choices” and they’ve made funding for services and supports a priority.

What the Ranking Means for You

So what should you and your parents make of this ranking? Is it a clarion call to move to Minnesota or Washington? “It’s not so much about moving, but what you should be pushing your state legislators for,” said Reinhard.

The report’s authors would like to see the creation of minimum long-term care services and supports performance standards, so no one anywhere would fear that his or her state didn’t offer at least that level of assistance.

“Until our nation improves [in supporting family caregivers, improving the quality of care and establishing mechanisms for financing it], families will continue struggling to pay for long-term care services and supports, often impoverishing themselves — at great personal and family distress — to get the services they need,” the report said.

What the Future Holds

I asked Reinhard whether she was optimistic or pessimistic based on the new report and long-term care services and support trends she’s seeing.

“I’m optimistic. I see more positive change than negative,” she said. “It’s just that we need to go faster and push harder. We’re kind of in denial about what’s going to happen in this aging society.”

Photograph of Richard Eisenberg
Richard Eisenberg is the former Senior Web Editor of the Money & Security and Work & Purpose channels of Next Avenue and former Managing Editor for the site. He is the author of "How to Avoid a Mid-Life Financial Crisis" and has been a personal finance editor at Money, Yahoo, Good Housekeeping, and CBS MoneyWatch. Read More
By SCAN Foundation
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