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Long-Term Care in the United States- A Timeline

Long-Term Care in the United States- A Timeline

Data from the United States Census Bureau shows that there has been a consistent rise in the proportion of Americans over the age of 65 years. This figure was 14% in 2010 and is estimated to be at 20% by 2030. According to Holt (2017), about 66 million people in the U.S. were providing Long-Term Care (LTC) to the elderly, ill, or physically challenged in the U.S. Over the last century, LTC services have evolved to better cater to persons’ needs. This paper traces the evolution of the chief programs of LTC from institutionalized Care Homes and Home-based services and the medical funding services Medicaid and Medicare in the United States. It highlights the timeline and important legislative changes that caused the evolution.

The Era of Nursing Homes

The history of nursing homes can be traced to the 17th-century almshouses for the elderly, orphaned, and mentally ill. Over the years, the service has evolved subject to policy, culture, and medicine. The enactment of the Social Security Act of 1935 was the first time the Federal Government of the U.S. became involved in nursing homes. The act provided the establishment of the Old Age Assistance (OAA) to provide funds to improve the quality of care in nursing homes. Consequently, this led to many voluntary and for-profit nursing care homes and the increased hiring of skilled nursing personnel to provide these services (Feder et al., 2015). Amendments to the Social Security Act in 1950 modified the reimbursement method for medical care provided to patients. Payments were now directed to public institutions and straight payments to care providers. The amendment also provided the establishment of programs for licensure of these nursing homes. However, there were no standardized requirements or procedures to enforce these providences. There was a growing need for skilled nursing facilities, and the Hill-Burton Act of 1954 was amended to make funds available for non-profit organizations to fill this demand (Feder et al., 2015). Additional Social Security Act amendments increased the OAA payments and set up matching programs for required services for patients.

The Medical Assistance replaced the OAA for the Aged (MAA) after the enactment of the Kerr-Mills Act. The MAA was more extensive, and by 1965, it was available in 47 states. Concerns over the adequacy of licensure standards and enforcement efforts led to the development of the Medicaid and Medicare Act of 1865 due to the amendment of the Social Security Act. These programs dramatically expanded federal funding to nursing home services, whereby Medicare only covered acute care, and Medicaid covered institutional LTC. Amendments responded to the public outcry over abuse and fraud in nursing homes. Intermediate Care Facilities (ICFs) were developed, which served residents who did not require 24-hour care services but needed more than custodial care. It was reported that ICFs would reduce the overall care of LTC. The Moss Committee had held hearings in 1965 about the deviations in standards of care in nursing homes and had recommendations to exert more control over LTC facilities. However, many states protested the proposed ICF regulatory requirements, and the U.S. Department of Health, Education, and Welfare withdrew its intentions. By 1968 after several hearings by the Moss Committee, a series of federal regulatory efforts, and other investigations that unraveled the unscrupulous undertakings of many nursing homes, standardized regulations were passed whereby Medicare and Medicaid could withhold funding to nursing homes if standards set by comprehensive regulations were not met.

The Era of Community-Based Services

By 1974, different SSA amendments authorized federal funding to states to facilitate community-based services such as protective services, health support, nutritional assistance, and daycare for adults. Further, there was a series of attempts to enforce compliance of skilled nursing facilitates to regulations. Focused assessments were done on staffing levels and qualifications, safety, and service delivery. Title XIX was created in 1975 to consolidate all federal assistance for LTC social services. It aimed at reducing inappropriate institutionalized care and promoted community-based services. Amendments to the OAA of 1978 led to the adoption and implementation of the nursing home ombudsman program and emphasized community changes over LTC. The Mental Health Systems Act enacted in 1980 funded the support and development of mental health programs and favored the deinstitutionalization of these programs. The HCBS waiver program was enacted in 1980 to offer home and community-based services, including non-medical services. A Tax Equity and Fiscal Responsibility Act in 1981 permitted states to cover children living with disabilities in the community. Accordingly, this is under the Katie Beckett Plan. These children were previously being referred to institutionalized care.

Between 1984 and 2010, HCBS experienced diverse changes that significantly modified LTC. The Nursing Home Reform Act of 1987 imposed quality requirements for Medicare and Medicaid to cover nursing homes to improve care standards. Later, a Medicare Catastrophic Act of 1988 removed time limits for LTC service coverage. However, this act was repealed in 1989. Legislative and other changes in the 1990s mainly expanded Home and Community-Based Services for people living with disabilities. In 2005, there were increased efforts to support and promote community-based services and increased removal of barriers for people living with disabilities. The Deficit Reduction Act of 2005 supported the transfer of assets for nursing home applications through Medicaid and encouraged individuals to purchase LTC insurance.

After 2010 and to the present day, this period is referred to as the era of Health Reforms. The Affordable Care Act (ACA) incentivized the improvement of LTC facilities and the expansion of home and community-based services. In 2013, the Commission on LTC made recommendations regarding service delivery and workforce improvements. Since then, the CMS has finalized new rules for quality of care for home and community-based care. Accordingly, this is evident in the five-star quality rating system for nursing homes, which has improved care standards in these nursing homes.


LTC services have significantly evolved, including skilled nursing facilities and home and community-based services. All these have modified funding, quality of care, professionalism in care, the scope of care, inclusiveness, and models of care. Several factors have limited the growth of long-term care services in the United States. These factors include complex program designs such as payment methods, difficult policy issues from the state and federal government, inadequate infrastructure, and the long time required for planning. However, LTC remains popular in the United States and will continually grow in the future.


Feder, J., Komisar, H. L., & Niefeld, M. (2015). Long-Term Care in the United States: A Timeline | KFF. KFF.

Holt, J. D. (2017). Navigating Long-Term Care. Gerontology and Geriatric Medicine, 3, 233372141770036.


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Create a 700- to 1,050-word timeline showing the evolution of programs and services for aging populations over the past 50 years. Include in your timeline:

Long-Term Care in the United States- A Timeline

Long-Term Care in the United States- A Timeline

An overview of how programs and services have evolved
Two examples of programs and services that have evolved and an explanation of the changes that have taken place
At least 2 references

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