The demand for community-based long-term support and services (LTSS) continues to be a critical issue in the 21st century. However, the nation has lacked a comprehensive, proactive, national public-private system of delivery. The current system is a patchwork of inadequate funding, with the largest source of federal funds provided by the Medicaid program which requires most people to be impoverished to receive services. Furthermore, there is an institutional bias in Medicaid that directs these funds to institutional services while community services are primarily available through waivers. With increased numbers of baby boomers retiring, the need for qualified support workers and family caregivers will exacerbate severe inequities in the ability of individuals with disabilities of all ages to live in integrated settings of their choice.
In order to meet this national challenge, the federal government must take the lead in developing a system that reflects sustainability, financial stability, diverse options of community supports and services, and a quality well-paid workforce that supports consumer self-determination and personal responsibility. Since Medicaid has become the core of federally supported LTSS, the philosophy of the Medicaid program must be changed to reflect the preference for individualized community-based services over institutional services. In addition, the need for supports outside of the Medicaid program must be addressed, including possibilities of incorporating an LTSS benefit into Medicare.