State strategies to support community based long term care for the elderly.

States play a principal role in designing and implementing publicly funded long term care programs. They are in a key position to determine what setting, from whom, and under what philosophy of care individuals can access long term care. State long term care systems have evolved over the past 25 years to support increased availability of community based care for older individuals. States have pursued three broad strategies to increase availability. One set of strategies aims to increase capacity through expanding the supply, public funding and eligibility for a wide array of home and community based services (HCBS). A second set of strategies seeks to constrain institutional growth in order to increase the dollars available for HCBS. Managed/capitated long term care is a third strategy that is a hybrid of the other two approaches. Empirically, increased capacity through use of Medicaid and Medicare resources and growth in the supply of community based care providers, combined with moderation of institutional bed supply, are associated with enhanced access and expenditures for community based long term care. The effectiveness of capitated or managed systems of care varies by model and in some cases is still under study. State fiscal resources are key to the ability to support community based care for the elderly. Targeted federal support may be critical to the continued expansion of community based care, given heterogeneity in state resources, coupled with an increasing demand for long term care.