Although long-term care receives far less U.S. policy attention than health care does, long-term care matters to many Americans of all ages and affects spending by public programs. Problems in the current long-term care system abound, ranging from unmet needs and catastrophic burdens among the impaired population to controversies between state and federal governments about who bears responsibility for meeting them. As the population ages, the pressure to improve the system will grow, raising key policy issues that include the balance between institutional and noninstitutional care, assurance of high-quality care, the integration of acute and long-term care, and financing mechanisms to provide affordable protection.

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People who are dually eligible for Medicare and Medicaid are the focus of fiscal struggles between federal and state governments. Drawing on a survey of community-based elderly "dual eligibles," this paper examines how well their medical and long-term care needs are being met under the current combination of Medicare and Medicaid policies. While few people report difficulty getting medical care, 58% of people needing long-term care (help with activities of daily living) report unmet needs. As a result, many experience serious consequences, such as falls. Although unmet needs are substantial in all six states surveyed, we find the greater the use of paid home care in a state, the lower the likelihood of unmet needs, suggesting states' policies can make a difference.

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