Which States Provide The Best—And Worst—Long-Term Care Services?

Minnesota and Washington are the states that provide the best services and supports for frail older adults, younger people with disabilities, and their families, according to a new study by AARP. The worst performers: Alabama and West Virginia.

AARP defines superior supports and services as those that are affordable and accessible, give families a choice of high-quality and safe care settings including their own homes, provide assistance for family caregivers, and are well-integrated with their communities.

50 Indicators

Overall, AARP looked at 50 indicators over five broad dimensions, based on publicly available data. The seniors’ group has been periodically analyzing a wide—but evolving—range of services since 2009. Many of these, such as Medicaid benefits, are provided by states. Others, such as cost of care or nursing home quality, reflect circumstances within states. These can sometimes, but not always, be affected by state regulation.

The group found a wide variation among the states. Overall, the highest performers were in the Northeast from Maryland to Maine and on the West Coast. The worst were in the Southeast and South Central US in a block from Oklahoma to Florida and the Carolinas.

Not surprisingly, the highest-performing states scored well across all dimensions AARP measured. Thus, among the best performers, a state that provided frail older adults a high-level of access and affordability also was likely to provide the best support to family caregivers.

However, even the best performers fell short in some domains. For example, while Washington State ranked in the top tier for affordability and access, safety and quality, and caregiver support, it was only average for integrating long-term care with other community services.

Poor Is Poor

By contrast, the lowest-rated states generally were poor performers across the board. Alabama and West Virginia were rated in the lowest or second-lowest tiers across all dimensions.

Not surprisingly, most states ranked in the middle were average across most domains. But a few showed a lot of variability, depending on what was being measured.

For example, Pennsylvania was among the highest rated states for providing a choice of care settings but below average for supporting family caregivers. Alaska scored above average for safety and quality but was among the worst for integrating care into local communities.

Evolving Services

Because AARP changed some indicators from the last time it published this survey in 2020, the group said it is not useful to compare top-line results. However, it did spot some overall trends. The use of Medicaid home and community-based services grew significantly. It found 35 states expanded programs that allowed Medicaid long-term care recipients to direct their own care and 34 expanded their Aging and Disability Resource Centers.

The bad news: Home care costs rose by more than 10 percent (relative to incomes) in 23 states, the supply of home health aides fell in 16, and availability of adult day services declined in 21.

Since data were collected for years 2020 and 2021, many of these results may have been affected by the COVID-19 pandemic. And I’m surprised, for example, that only 23 states reported sharply higher home care costs.

Nursing Homes

The study also looked at the share of Medicaid patients living in nursing homes who have what AARP describes as “low care needs.” It found the national average is about 9 percent. In seven states, the rate is less than 5 percent. But in five, (Montana, Kansas, South Dakota, Oklahoma, and Missouri) it exceeds 20 percent.

Another area of wide variation: COVID-19 vaccinations in nursing homes. The report found that the share of staff up to date on their COVID boosters as of February 2023 ranged from nearly 45 percent in Washington, DC to below 11 percent in Alabama.

The study identified similar dramatic variation for residents, where booster rates ranged from nearly 77 percent in South Dakota to 34 percent in Arizona.

The AARP study shows how state variation in services can be a two-edged sword. Often, it allows for important experimentation from which we all can learn. For instance, Washington State’s public long-term care insurance program is a valuable test. On the other hand, it lets some states encourage, and even provide, poor quality care for their most vulnerable residents.

AARP does a valuable service by shining a light on it all.