many individuals in need of LTSS receive care at home from family caregivers, these individuals are often unpaid and untrained. Taxpayer-funded programs that support LTSS will also experience strain. Currently, Medicaid is the largest payer for LTSS in the United States. In 2012, the US spent $220 billion on LTSS, approximately 61 percent of which was paid by the Medicaid program.22 Yet whereas Medicaid spending on LTSS grew by 1 percent per year between 2002 and 2012, the Congressional Budget Office estimates a growth rate of 5.5 percent per year between 2013 and 2023.23 Access to long-term care insurance remains limited. Few individuals have access to the kind of insurance products that would allow them to pay for the kind of LTSS they are likely to need. Currently, Medicare covers only short-term skilled nursing for 100 days and home healthcare needs after an acute care episode. Medicaid pays for a majority of long term care in the US and provides a safety net for those who are impoverished by the cost of long term care. Because of this financing structure, a great deal of policy activity in long term care is happening at the state level, as state leaders use policy levers such as Medicaid waivers to deliver LTSS in innovative ways. However, many significant gaps remain. Few resources are directed toward supports for family caregivers. In the private marketplace, the combination of financial risks and adverse-selection problems has made premiums for long-term care insurance prohibitively high. Moreover, the poor performance of the short-lived Community Living Assistance Services and Supports (CLASS) program suggests major challenges for achieving comprehensive long-term care reform at the federal level. Finally, the existence of Medicaid as a “second payer” for long-term care services has contributed to the crowding out of demand for long-term care insurance.24 While meaningful LTSS reform is a major policy priority for many organizations in the study, the evidence base on the effects of proposals to reform the system for insuring long-term care is limited particularly at the federal level. All states are engaged in some effort to rebalance their long term care systems to care for beneficiaries at home rather than in an institutional setting. Addressing the Health Needs of an Aging America | 29 25S. Eiken et al., Medicaid Expenditures for Long-Term Services and Supports in FFY 2012, CMS and Truven Analytics, April 2014, available from: p-program-information/by-topics/long-term-services-and-supports/downloads/ltssexpenditures-2012.pdf 26 R.L. Kane et al. Patterns of utilization for the Minnesota senior health options program. J Am. Geriatr. Soc. 2004; 52(12):2039– 2044; R.L. Kane et al. The quality of care under a managed-care program for dual eligibles. Gerontologist 2005; 45(4):496–504; R.L. Kane, Outcomes of managed care of dually eligible older persons. Gerontologist 2003; 43(2): 165–174; W.G. Weissert et al. Cost sav-ings from home and community based services: Arizona’s capitated Medicaid long-term care program. J. Health Polit. Policy Law 1997; 22(6):1329–1357. 27 H.S. Kaye et al. Do noninstitutional long-term care services reduce Medicaid Spending?, Health Affairs 2009; 28(1):262–272. In 2012, close to half of all Medicaid LTSS spending was for home and community based services (HCBS).25 A number of states are using managed care as a strategy to promote greater integration and efficiency in Medicaid LTSS delivery systems, but evidence on the effectiveness of these programs is limited. Fewer than 10 states have had a managed Medicaid LTSS program in place for over a decade. Studies of long running, well-established MLTSS program have shown mixed results on indicators such as cost savings, utilization and quality, though some programs have demonstrated modest improvements in preventable hospitalizations and emergency room visits.26 To date, over 20 states have implemented or are considering implementation of a Medicaid MLTSS program. Some evidence indicates that states with a long-running, extensive HCBS programs are able to slow Medicaid long term care spending growth more effectively than states which