Ten percent of the Texas population is 65 and older. The state has a large, rapidly growing elderly population, estimated to reach 4.4 million, or 16.1% of the state's total population in 2025. Medicaid spending for long-term care in FY2001 was $3.3 billion -- 28.5% of all Medicaid spending. Medicaid spending for institutions was more than 70% of Medicaid long-term care spending and more than 20% of all Medicaid spending in F Y2001. Spending for home and community-based services has increased rapidly in recent years and represented 29.2% of Texas long-term care spending in FY2001, primarily due to increased use of the Medicaid Section 1915(c) home and community based waiver program. From FY1990 to FY2001 spending for this program increased from less than 1% to over 21% of all Medicaid long-term care spending in Texas. Texas provides a wide range of services in the home and community to about 100,000 adults with disabilities. Despite this, the state has significant overcapacity in its nursing home industry. As a result, the nursing home occupancy rate is quite low -- 68.5% in 2000. The state continues to serve many persons with developmental disabilities in large state institutions and has no plans to close any facilities in the foreseeable future. Interviews with state officials and a review of state reports highlighted a number of issues including: an imbalance in Medicaid financing favoring institutional care, rather than home and community-based care; a shortage of frontline long-term care workers; and waiting lists for home and community-based services.

Illinois is the fifth largest state in the country with 12.4 million people in 2000; the population increased by almost 9% or about one million people in the past decade. About 12% of the state's population is age 65 and older -- 1.5 million people in 2000. By 2025 the Illinois elderly population is expected to increase by over 50% and will be 16.6% of the state's total population. Illinois is one of the few states in the country that provides older persons and younger adults, who meet the eligibility criteria, with state entitlements to home and community-based long-term care services. Both entitlements resulted from court cases that were brought to eliminate waiting lists for services. The state funds the Community Care Program for older adults and the Home Services Program for persons with physical disabilities with a combination of state general revenue funds and Medicaid Section 1915 (c) waiver funds. The Community Care Program uses contracted agencies for the provision of homemaker, adult day care services, and case management services. In contrast, the Home Services Program's relies primarily on personal assistants, whom consumers supervise, to provide services. According to state officials, in 2002 the state had about 3,000 people with developmental disabilities in state-operated development centers (SODCs), 6,500 people in private intermediate care facilities for the mentally retarded (ICFs/MR) and 8,800 people in Section 1915 (c) Medicaid home and community-based services waivers for the developmentally disabled.

Oregon is a recognized leader in home and community-based care and has more than 20 years of experience in moving long-term care clients from institutional settings to home and community-based settings. In 2002, 82 per cent of Oregon's Medicaid long-term care clients were served in the community. Additionally, Oregon was the only state in the nation whose spending for institutional care was less than half of the state's total Medicaid long-term care spending in 2000, with only 37.2 per cent spent on institutional care compared to the national average of approximately 70 per cent. Oregon officials recognize that with the aging population and increasing cost, they may need to rethink the design of their current system. They hope to incorporate a concept of 'bounded choice' where a person's wishes are considered within the boundaries of service capacity and fiscal constraints.

Demographic challenges posed by the growing elderly population and demands for greater public commitment to home and community-based care for persons with disabilities have drawn the attention of federal and state policymakers. Spending on long-term care by both the public and private sectors is significant. In 2001, spending for long-term care services for persons of all ages represented 12.2% of all personal health care spending (almost $152 billion of $1.24 trillion). Federal and state governments accounted for almost two-thirds of all spending. By far, the primary payer for long-term care is the federal-state Medicaid program, which paid for almost half of all long-term care spending in 2001. Maine is one of the smallest states in the country with 13 million people in 2000; it is also one of the oldest states, with 14.4% of its population aged 65 and older. By 2025, over one-fifth of its population will be 65 and older. Medicaid spending for long-term care in Maine in FY2001 was $411 million -- almost one-third of all Medicaid spending. In part due to the aging population and because of a 1993 budgetary crisis involving rapidly escalating Medicaid nursing home costs, Maine has pursued an aggressive policy to decrease dependence on nursing homes. Between 1995 and 2001, the percentage of public long-term care funding devoted to these facilities decreased from 84% to 61%. Moreover, the state has decreased reliance on large state-operated residential facilities for persons with mental retardation in favor of smaller community-based facilities. Maine's efforts to reduce reliance on institutional care has been in part due to expanded use of Medicaid's home and community-based waiver program as well as multiple state-funded programs. PARTIAL

Florida has the largest proportion of elderly in the nation- 2.8 million persons are over age 65, representing 17.6% of its total population. The dramatic rise in the number of persons age 65 and over in Florida over the next 20 years-estimated to total 26.3% of total population-will further stretch the already limited resources of the state. Aware of the pressing demand for long-term care services well into the 21 * century, policymakers in Florida have begun seriously to review options for improving financing and delivery of long-term care for the frail elderly and persons with disabilities. Federal and state Medicaid spending in Florida was $2.6 billion in FY2001, and 30.5% of Medicaid spending was for long-term care. In FY2001, 75.3% of total Medicaid spending was for institutional care. Slightly less than 25% of Medicaid spending was channeled towards home and community-based services. Although institutional care dominated Medicaid spending, there has been slow but steady expansion of home and community-based services funding, both through the use of Medicaid's waiver programs as well as significant support through state sources. Among the major issues facing long-term care in Florida are: the fragmentation of long-term care services among state and local agencies, an imbalance in financing that favors institutional care rather than home and community based care, shortage of health care workers and well-trained staff throughout the long-term care , and disparities in availability of services across the state.

Long-term care issues have high prominence among state officials in Pennsylvania as a result of its large elderly population and concern about the impact of long-term care costs on the state's budget. Its population aged 65 and older is 15.6% of its total population, ranking second only to Florida. By 2025, 21% of its population will be 65 and older. Pennsylvania is federal and state Medicaid spending for long-term care in FY2001 was $5.1 billion -- almost half of all Medicaid spending. Spending for nursing homes was more than one-third of Medicaid spending. While spending for home and community-based services has increased dramatically in recent years, these services represented less than one of every five dollars spent on long-term care in FY2001. Over the last two decades, Pennsylvania has documented issues it has confronted in providing long-term services. Among these issues are: an imbalance in financing favoring institutional care, rather than home and community-based care (which most people prefer); fragmentation in the management and delivery of services; difficult access to services, especially for low and moderate income persons who do not qualify for Medicaid; and disparities in service availability across the state and populations in need of care. According to state officials, Pennsylvania's guiding principles in long-term care are to: control surplus growth of nursing home beds; support consumer choice; encourage expansion of home and community-based services; fund services rather than capital construction; and assure quality of care.