Now is the opportunity for providers, policymakers and other stakeholders to aggressively reform the long-term services and supports system after its underlying weaknesses were exposed under pandemic conditions, experts argue in a new Health Affairs blog post.

“COVID-19 didn’t create the challenges facing the provision of LTSS, but it did expose them in harsh and compelling ways,” observe Bruce Allen Chernof, MD, president and CEO of the SCAN Foundation, and Cindy Mann, a federal and state health policy expert.

“With state budget cuts looming and the population aging, the system is at risk of continued deterioration — including worsening staffing shortages, less access to needed services, and even more limited oversight,” they added. “COVID-19 tested the system, and despite the heroic efforts of so many, the system failed. It is up to families, policy makers, and other stakeholders to seize the opportunity to make bold and lasting changes.”

Chernof and Mann, however, said it is uncertain whether key players will  “seize the opportunity to make bold and lasting changes.” Because the delivery of services is “typically very fragmented,” the true extent of COVID-19 carnage on patients and their caregivers “may never be known.”


Reform should start with addressing the underfunding of the LTSS system, they wrote. 

“Low reimbursement levels have translated into outdated facilities, with often two or more residents sharing a room and a workforce, which is the backbone of the system, that is poorly paid and lacks benefits such as paid sick leave as well as the training needed to care for people with multiple chronic illnesses that can include dementia and other mental health issues,” they wrote.

The current system is not prepared to withstand future outbreaks, Chernof and Mann believe, so a “reimagined” and person-centered LTSS system is needed. Quick action in light of COVID-19 lessons is needed, they say.

“This includes quickly implementing plans to isolate COVID-19-positive residents, considering wage increases and paid sick leave for staff, ensuring personal protective equipment for all workers, and providing a strategic testing plan for residents and staff,” they wrote.

Possible solutions

Moving forward will require a long-term commitment from states, providers and the federal government who will need to focus on several areas. 

Those include strengthening ties between the long-term care services system and the rest of the healthcare system to allow for more person-centered care planning; replacing and updating outdated facilities, particularly in low-income areas; and reforming state and federal regulatory oversight of nursing homes, to ensure the process promotes transparency and ensures meaningful penalties for noncompliance.

They also called for “seriously exploring sustainable funding models for LTSS,” which could include Medicare and Medicaid more evenly splitting LTSS costs and a social insurance benefit.