US: Long-Term Services and Supports

Population, Midyear 2022: 338,289,857
Population Density (Number of Persons per Square Kilometer): 36.98
Life Expectancy at Birth, 2022: 78.20
Projected Population, Midyear 2030: 352,162,301
Percentage of Total Population Aged 65 and Older, Midyear 2022: 17.13%
Projected Percentage of Total Population Aged 65 and Older, Midyear 2030: 20.53%
Projected Percentage of Total Population Aged 65 and Older, Midyear 2050: 23.63%

Source: United Nations, Department of Economic and Social Affairs, Population Division (2023). Data Portal, custom data acquired via website. United Nations: New York. Accessed 12 May 2023.

Share of the population aged 65 and over, 2021: 16.8%
Share of the population aged 65 and over, 2050: 22.0%
Share of the population aged 80 and over, 2021: 3.7%
Share of the population aged 80 and over, 2050: 8.2%
Adults aged 65 and over rating their own health as good or very good, 2021: 77%
Share of adults aged 65 and over receiving long-term care, 2020: 1.7%
(Note: This only includes recipients of long-term care in institutions.)
Estimated prevalence of dementia per 1,000 population, 2021: 15.5
Estimated prevalence of dementia per 1,000 population, 2040: 23.3
Total long-term care spending as a share of GDP, 2021: 1.3%
Long-term care workers per 100 people aged 65 and over, 2021: 4.5
Share of informal carers among the population aged 50 and over, 2021
– Total: 7%
Share of long-term care workers who work part time or on fixed contracts, 2020
– Part-time: 33.9%
– Fixed-term contract: NA
Average hourly wages of personal care workers, as a share of economy-wide average wage, 2018
– Residential (facility-based) care: 51%
– Home-based care: 51%
Long-term care beds in institutions and hospitals per 1,000 population aged 65 years and over, 2021
– Institutions: 28.9
– Hospitals: 0.9
Total long-term care spending by provider, 2021
– Nursing home: 59%
– Home care: 41%

Source: OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, doi.org/10.1787/7a7afb35-en.

Formal Long-Term Care Workers At Home (Nurses and Personal Carers) (FTE), 2020: 588,948
Formal Long-Term Care Workers At Home (FTE) Per 100 Population Aged 65 Years and Older, 2020: 1.1
Formal Long-Term Care Workers In Institutions (Nurses and Personal Carers) (FTE), 2020: 847,593
Formal Long-Term Care Workers In Institutions (FTE) Per 100 Population Aged 65 Years and Older, 2020: 1.6
Long-Term Care Recipients In Institutions Other Than Hospitals, 2018: 2,291,324
Long-Term Care Recipients At Home, 2017: 4,940,259

Source: Organization for Economic Cooperation and Development. OECD.Stat. Last accessed March 23, 2023.

“The WA Cares Fund is a public long-term care insurance program. All working Washingtonians contribute a small percentage of their income into the fund. Then when you need care, you can access your earned benefit of $36,500 (adjusted up to inflation) to pay for services.”

Source: Washington Cares Fund. How the Fund Works. Washington State Department of Social and Health Services. Last accessed March 6, 2025.

“Long-term services and supports (LTSS) vary widely in their intensity and cost depending on an individual’s underlying conditions, the severity of his or her care needs, the setting in which services are provided, and the caregiving arrangement (i.e., paid care versus uncompensated care). The cost of obtaining paid assistance for these services, especially over a long period of time, may far exceed the financial resources of many individuals and their families.¹ Among adults aged 50 and older, 60% feel “mostly” or “somewhat anxious” about affording the cost of LTSS, such as a nursing home, assisted living facility, paid nurse or an aide to assist them in advanced age.² Large personal financial liabilities associated with paid LTSS can leave individuals needing LTSS and their families at financial risk. Among older adults aged 65 with savings ranging from $171,000 to $1.8 million, those with greater long-term care needs were much more likely to deplete their savings than those who did not need long-term care.³

“In the United States, an estimated 14 million adults are in need of LTSS, and over half (56%) are individuals aged 65 and older.⁴ Most individuals who need LTSS are cared for in their own homes with the assistance of informal caregivers such as family members or friends. An estimated 10.6 million people provide uncompensated care to older adults, and, among those, 30% provide care to individuals aged 85 and older.⁵ Moreover, there is unmet need among older adults who need daily assistance. Analysis of Health and Retirement Study data from 2000 to 2021 found that among the 8 million older adults who reported dementia or difficulty with one or more daily personal tasks, 3 million reported not receiving assistance.⁶

Source: Kirsten J. Colello. Long-Term Services and Supports: History of Federal Policy and Programs. R47881. Washington, DC: Congressional Research Service, December 20, 2023. Accessed December 24, 2023.

“While the need for, use of, and costs associated with LTSS vary among individuals over their lifespans, the probability of needing LTSS increases with age. It is estimated that more than half (56%) of Americans who survive to age 65 develop a disability serious enough to need LTSS.⁷ Among those who develop a disability as an older adult, an estimated 10% will need care for less than a year and an estimated 22% will need care for five or more years.⁸ The average duration of LTSS needed is estimated to be 2.8 years overall, with the average duration of LTSS needed being higher for women, at 3.2 years, than for men, at 2.3 years.⁹ As the population ages, the aggregate demand for LTSS is expected to increase. In addition, advances in medical care and supportive care are enabling younger persons with disabilities to live longer lives, requiring the delivery of services and supports for longer periods of time.”

“With the enactment of Titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act in 1965, public financing for post-acute or rehabilitative care and LTSS in long-term care facilities (LTCFs) became part of the U.S. health care delivery system. Over time, states and the federal government became the largest payers of LTSS. In 2021, the United States spent an estimated $467.4 billion on post-acute care and LTSS, representing 13.2% of the $3.6 trillion spent on personal health care.¹⁵ The majority of spending on LTSS is funded by public programs (71.4%), with the Medicaid program being the largest public payer of LTSS (see Figure 1). In 2021, over 44.3% of LTSS was financed by the Medicaid program (combined federal and state spending).¹⁶ Over the past 20 years, the share of public LTSS spending has increased (from 66.8% in 2001 to 71.4% in 2021), primarily due to increases in the proportion of Medicare funding.

“Because the vast majority of LTSS is provided by uncompensated caregivers such as family members, friends, and neighbors, these figures do not account for the total cost of LTSS to the economy. Researchers estimating the opportunity cost of uncompensated caregivers’ time found that the value of this care ranged from $86 billion to $151 billion, depending on various assumptions about leisure time and forgone wages.¹⁷

“LTSS expenditures also make up a growing portion of the U.S. economy, rising from less than 1% of gross domestic product (GDP) in 1990 to more than 1.5% by 2011.¹⁸ Since that time, LTSS expenditures as a percentage of GDP have remained relatively flat, possibly due to policies and programs that have expanded access to less costly interventions that focus on care at home and in the community while restricting public program eligibility to those with low incomes and asset levels.”

“Currently, much of LTSS [Long Term Support Services] is unpaid (or informal) care provided by family members and friends.”

Source: Congressional Budget Office, Key Design Components and Considerations for Establishing a Single-Payer Health Care System. May 2019.

“In 2018, 23 percent of nursing homes used agency nursing staff, accounting for about 3 percent of all direct care nursing hours worked. When used, agency staff were commonly present for ninety or fewer days in a year. By 2022, almost half of all nursing homes used agency staff, accounting for 11 percent of all direct care nursing staff hours. Agency staff were increasingly used to address chronic staffing shortages, with 13.8 percent of nursing homes having agency staff present every day. Agency staff were 50–60 percent more expensive per hour than directly employed nursing staff, and nursing homes that used agency staff often had lower five-star ratings.”

Source: John R. Bowblis, Christopher S. Brunt, Huiwen Xu, Robert Applebaum, and David C. Grabowski. Nursing Homes Increasingly Rely On Staffing Agencies For Direct Care Nursing. Health Affairs 2024 43:3, 327-335

“Contemporary elders’ unprecedentedly long lives fuel concern that they may spend a significant proportion of their lives suffering age-related diseases. A particularly burdensome disease process, both personally and economically, is pathological cognitive decline. To provide a sense of the extent of cognitive impairment, a third of people in the U.S. aged 85 and older have Alzheimer’s disease (Hebert, Weuve, Scherr, & Evans, 2013), the most common cause of pathological cognitive decline (Qian, Schweizer, Munoz, & Fischer, 2016, p. P293). Alzheimer’s disease accounts for 60–80% of dementias, is the sixth leading cause of death in the United States, and the only leading cause of death with no known prevention, efficacious treatment, or cure (Alzheimer’s Association, 2019). Dementia more broadly, which includes Alzheimer’s, Lewy body, cerebrovascular, and mixed dementias, is one of the most expensive diseases, as people with dementia can live for many years cognitively impaired and often require high levels of care (Hurd, Martorell, Delavande, Mullen, & Langa, 2013). Annual estimates for dementia costs in the U.S. in 2010 were between $159 billion and $215 billion (Hurd et al., 2013).”

Source: Hale, J. M., Schneider, D. C., Mehta, N. K., & Myrskylä, M. (2020). Cognitive impairment in the U.S.: Lifetime risk, age at onset, and years impaired. SSM – population health, 11, 100577. doi.org/10.1016/j.ssmph.2020.100577

“Our results show that approximately two out of three Americans experience cognitive impairment, at an average age of approximately 70 years. Women live over 7 years cognitively impaired, men over 5. The educational and racial/ethnic gradients are even larger than the gender differentials and highlight the uneven burden of cognitive impairment. A critical finding is that despite the shorter lives of disadvantaged subgroups (Black and/or lower educated), they experienced a younger age of onset and also spent more years cognitively impaired than their White, highereducated counterparts who experienced a delayed onset. Thus, the early onset does not imply a quick death after onset. A corollary is that for the most advantaged groups (i.e., White and/or higher educated), cognitive impairment is both delayed and compressed toward the very end of life. Further research is required to identify the mechanisms driving these disparities in cognitive impairment.”

“The deinstitutionalization movement and rapid closure of state psychiatric hospitals in the 1960s and 1970s led to rapid growth of admissions of individuals with SMI [Serious Mental Illness] to nursing homes, even those who did not qualify medically for skilled nursing care.¹⁰ To counter this, in 1987, the Omnibus Budget Reconciliation Act (OBRA) was passed, which included mandated screening for SMI among new admissions to all U.S. federally-certified nursing homes (PASRR; Pre-Admission Screening and Resident Review). Although compliance with PASSR was variable,¹¹ the percentage of individuals with SMI in U.S. nursing homes nationally decreased on average between 1985 and 1995.¹²

“The prevalence of SMI in nursing homes and assisted living communities varies significantly by state and facility.^2–4 Data from Minimum Data Set assessments indicated that the average proportion of residents with schizophrenia or bipolar disorder in nursing homes grew from 6.4% to 8.3% between 2000 and 2008, and in 2008, the five percent of facilities with the highest proportion of SMI residents had at least 20%.¹³ In the U.S. Department of Veterans Affairs (VA), nursing homes are known as Community Living Centers (CLCs), which provide long-stay and short-stay skilled nursing, rehabilitation and palliative care. In one study using VA data, the national prevalence of schizophrenia, bipolar disorder, and other psychotic disorders in CLCs rose from 29.4% to 43.8% between 1999 and 2007, though prevalence varies significantly by facility.¹⁴ VA CLCs are not required to conduct PASRR screenings, but they do require that residents have a skilled nursing or functional care need. In both community and VA long-term care communities, residents with SMI likely include some who require the level of care provided and others who would be better served in a less restrictive setting.^14–16“

Source: Muralidharan, A., Mills, W. L., Evans, D. R., Fujii, D., & Molinari, V. (2019). Preparing Long-Term Care Staff to Meet the Needs of Aging Persons With Serious Mental Illness. Journal of the American Medical Directors Association, 20(6), 683–688. doi.org/10.1016/j.jamda.2019.03.018

“Individuals with SMI [Serious Mental Illness] are more likely to be admitted to nursing homes with poorer quality of care indicators.^17, 18 Having a high proportion of SMI residents is associated with inferior quality of care for all residents, including higher rates of hospitalization,¹³ untreated depression, incontinence without a toileting plan, and pain,¹⁹ indicating that attending to the complex care needs of residents with SMI may stretch limited resources in these facilities. In addition, residents with SMI may receive poorer quality of care than other residents, including lower rates of completed advanced directives²⁰ and inadequate pain assessment/treatment, even when controlling for facility level characteristics.^21, 22

“Long-term care residents receive a median of approximately 4 hours of contact from nursing assistants and nursing staff each day.²³ Given the pivotal role of positive social engagement in influencing SMI outcomes, ²⁴ long-term care staff can engender hope and empowerment among this vulnerable resident population. Unfortunately, long-term care staff training curricula most often do not include information regarding caring for residents with SMI,²⁵ state regulations frequently do not stipulate requirements for nursing home staff on this topic,²⁶ and training on this topic is not a requirement for nursing staff in VA CLCs. Without training, nursing home and assisted living staff may be relying on common public misperceptions of these disorders, which are generally inaccurate and stigmatizing.²⁷“

“Private duty home care is an option for individuals who need ongoing nursing or custodial care and whose families have the resources to keep the patient at home. With this type of long-term care, a nurse and / or home health aide goes to the patient’s home for a prescribed period of time and frequency, anywhere from a few hours or a few days a week, to a several hours daily, to round the clock (Harvard Health Letter, 2014; NAHC, 2010). Patients can receive various homemaker services, such as housework, cooking, shopping and transportation (Harvard Health Letter, 2014). They may also receive home health aide services which involve personal care, such as help with bathing, dressing, eating, using the bathroom, walking or transferring and medications.

“Private duty home care has the advantage of allowing the patient to remain at home rather than being institutionalized. One disadvantage is that it can be difficult for family members to arrange their home and schedules to accommodate the person needing care. Another disadvantage is that it can be costly. Unless the patient also needs skilled professional care, Medicare and private health insurance will not cover homemaker or home health aide services. Medicaid may or may not cover the services (coverage is on a stateby-state basis) (Harvard Health Letter, 2014: NAHC, 2010). Long-term care insurance may cover the care. If a patient does not have insurance coverage, the family will have to pay out-of-pocket. For services of a few hours a week, the costs are significantly less than those of a nursing home and this makes private duty home care an attractive alternative to nursing home care. But as the amount of time increases, the costs become significant. At some point, nursing home care is less expensive than home care.”

Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.

“This study provides national estimates of family availability for older adults with dementia and assessed the potential influence of spouse and adult child availability on informal and formal care use. It extends the dementia care literature in significant ways. Most previous studies focused on active family caregivers, which is important for assessing the burden on caregivers. However, it is essential to understand the potential care pool available to older adults with dementia to predict the type of care they will use; their transitions to institutional care; and the associated care costs for them, their families, and the public. For example, a spouse who is an active caregiver provides substantially more hours of care than an adult child who is an active caregiver. However, the majority of adults with dementia do not have a spouse. Spousal availability is especially limited among non-Hispanic Blacks and those with lower socioeconomic status, which may lead to a greater dependence on adult children for ADL care among these groups. In other words, there may be an unequal, intergenerational spillover effect in that children of some vulnerable groups defined by race, ethnicity, and economic status may incur more care responsibility and (opportunity) costs than other groups.

“Our findings from the multivariable models suggest that having a co-resident child reduces the likelihood of using formal care and transitioning to a nursing home among adults with cognitive and physical limitations. Despite the substantial care contribution of a spouse, spousal availability was not independently associated with the likelihood of subsequent formal ADL care use by adults with dementia. Primary responsibility for ADL care may be assigned sequentially, first to a spouse (if physically and cognitively able), followed by an available adult child (if a spouse is unavailable), and then by other informal helpers (for example, siblings, other relatives, and friends) or paid caregivers if a spouse or adult child is not available.²⁷ In other words, for those without a spouse, adult children may step in until they are no longer able to provide the needed level of care. Therefore, the availability of adult children may be more directly linked to the need to use formal care than the availability of a spouse.

“A substantial share of informal care received by adults with dementia was unaccounted for by care provided by either a spouse or an adult child acting alone. This implies that there are multiple informal caregivers and combinations of caregivers (for example, a spouse together with an adult child or an adult child together with other relatives and friends) who may provide help for adults with dementia over the course of their illness.”

Source: HwaJung Choi, Michele Heisler, Edward C. Norton, Kenneth M. Langa, Tsai-Chin Cho, and Cathleen M. Connell, Family Care Availability And Implications For Informal And Formal Care Used By Adults With Dementia In The US, Health Affairs 2021 40:9, 1359-1367

“Having no adult child compared with having at least one adult child was associated with a substantially lower probability of receiving any informal care, at 43 percent versus 62 percent, respectively (exhibit 4). The adjusted probability of receiving ADL care from an adult child was 33 percent. The predicted total monthly hours from all ADL informal helpers was substantially lower for adults who did not have any adult child (95 hours) than for those who had at least one adult child (137 hours) (appendix exhibit A19).²²

“The adjusted probability of any informal ADL care received by adults in this subsample was substantially higher if they had a co-resident adult child (73 percent versus 54 percent if they did not have an adult child within ten miles and 60 percent if they had at least one adult child within ten miles). The adjusted probability of receiving ADL care from an adult child among those who had a co-resident child was 52 percent, similar to that from a spouse (52 percent) (exhibit 4). Predicted total monthly hours from all informal ADL helpers were substantially greater if the subsample adults had a co-resident adult child at 193 hours, versus 104 hours with no adult child living nearby and 119 hours with at least one adult child living nearby but not co-resident (appendix exhibit A19).²²“

“In 2016, 286,300 participants were enrolled in 4600 adult day care centres (ADCCs) in the United States (Caffrey & Lendon, 2019). Adult day care is an option for individuals who need supervision during the day, support with meals, activities to participate in, and opportunities for social interaction. ADCCs may provide medical or social services, or be capable of providing both (Anderson et al., 2013). To provide medical services, centres must have a strong professional healthcare staff, including RNs, LPNs and nursing assistants, as well as physical, occupational and speech therapists, social workers and dietitians. Around 66% of ADCCs provide skilled nursing care and nearly half provide licensed therapeutic services (Happ, DabelkoSchoeny & Shin, 2018). To provide social services centres employ therapists, nutritionists and social workers to organize social activities, recreational activities and nutrition counselling. Some centres provide both medical and social services. All centres offer meals, a certain amount of personal care, and activities. Optional services include transportation to and from the centre, nursing care, counselling, social services and therapies.

“The type of individual that a day care centre will accept depends upon centre capabilities. Centres that can provide medical care can accept individuals needing nursing and custodial care while centres that only provide social activities do not have the capability to take these patients.

“In general, adult day care would not work for individuals who need heavy amounts of custodial or skilled nursing care, such as frequent monitoring of vital signs and invasive treatments. For this reason, centres tend to establish limits in terms of the number and types of deficits in activities of daily living a person can have, and the intensity of medical care the person needs. Adult day care has been a good option for individuals with cognitive impairment. Adult day care is often used by families to keep a family member in the home who otherwise would need institutionalization (Caffrey & Lendon, 2019). This delays institutionalization, gives family care-givers a respite from caring for the individuals, and allows family members to work (Jarrott & Ogletree, 2019). This kind of arrangement, however, means a commitment by the family to ongoing care in the hours that the individual is not in day care (evenings, nights and weekends) – a significant amount of informal care-giving. Families may supplement adult day care with private duty home care services (discussed in Section 5.11.1).”

Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.

“Despite representing a small proportion of total Medicaid enrollees (5.9 percent in 2013), LTSS users represent a substantial proportion of Medicaid benefit spending (41.8 percent, or $167.7 billion in 2013). This includes spending on both institutional and non-institutional services (MACPAC, 2016b).

“As evident in expenditure data, LTSS for these populations can be very costly. Older adults and people with disabilities who rely on Medicaid to finance their care often “spend down” to Medicaid eligibility, meaning that they have exhausted their personal savings by paying out-of-pocket for care. Spending down is common among people using LTSS, particularly among those who require nursing home care. From 1996-1998 to 2008, nearly 10 percent of adults aged 50 and older spent down to Medicaid eligibility; more than half of these beneficiaries utilized personal care services, nursing home services, or both (Wiener, Anderson, Khatutsky, Kaganova & O’Keeffe, 2013).”

Source: Nga T. Thach, BS, and Joshua M. Wiener, PhD. An Overview of Long-Term Services and Supports and Medicaid: Final Report. RTI International for the US Dept. of Health and Human Services. May 2018.

“Medicaid eligibility depends primarily on income and assets. In most states, people who are eligible for SSI are automatically eligible for Medicaid. SSI income levels are about three quarters of the federal poverty level. In general, aged, blind, and disabled beneficiaries may not have more than $2,000 in countable assets for individuals and $3,000 for couples, a level that has not changed since 1989 (Colello, 2017).”

US: Long-Term Services and Supports - Healthcare - National Policies - World Health Systems Facts

World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated March 6, 2025 by Doug McVay, Editor.